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REVIEW

Patient-centered care and adherence: Definitions and


applications to improve outcomes
Janice H. Robinson, MSN, FNP (MSN Graduate), Lynn C. Callister, RN, PhD, FAAN (Associate Professor), Judith A.
Berry, DNSc, APRN, FNP (Associate Professor), & Karen A. Dearing, PhD, APRN (Associate Professor)
College of Nursing, Brigham Young University, Provo, Utah

Keywords Abstract
Patient-centered care; adherence; patient
involvement; patient perspective. Purpose: The implementation of patient-centered care (PCC) has been ham-
pered by the lack of a clear definition and method of measurement. The purpose
Correspondence of this review is to identify the fundamental characteristics of PCC to clarify its
Janice H. Robinson, MSN, FNP, College of definition, propose a method for measurement of PCC, and recommend effective
Nursing, Brigham Young University, 400 SWKT, PCC practices.
Provo, UT 84602
Data sources: Review of literature related to PCC, adherence and communication
Tel: 801-762-7472; Fax: 801-422-0536;
from Cinahl, PubMed Academic Search Premier, and Cochrane Library databases.
E-mail: janicehrobinson@gmail.com
Conclusions: Research has shown that patient-centered interactions promote
Received: August 2007; adherence and lead to improved health outcomes. The fundamental character-
accepted: January 2008 istics of PCC were identified as (a) patient involvement in care and (b) the
individualization of patient care. The use of a numeric rating scale to measure the
doi:10.1111/j.1745-7599.2008.00360.x presence of these characteristics allows quantification from the patient perspec-
tive. Effective PCC practices were related to communication, shared decision
making, and patient education.
Implications for practice: PCC is a measure of the quality of health care.
Understanding the characteristics of PCC facilitates its implementation and
measurement. Promoting PCC activities will improve adherence and encourage
patient responsibility for health status.

PCC improves communication, promotes patient involve-


Introduction
ment in care, creates a positive relationship with the pro-
Patient-centered care (PCC) is recognized as a measure of vider, and results in improved adherence to treatment plan
the quality of health care. Healthcare advocacy groups as (Agency for Healthcare Research and Quality [AHRQ],
well as government and regulatory agencies are promoting 2005; Anderson, 2002; Beck, Daughtridge, & Sloane,
the use of PCC as a desirable component of quality health 2002; Stewart et al., 2000).
care. Public funds are used for 44% of all healthcare In spite of the reported benefits of PCC, there are prob-
expenditures, with private insurance accounting for lems in implementing its use. In the latest National Health-
36%, and consumers for 20% (National Center for Health care Quality Report by the AHRQ (2005), PCC was
Statistics, 2005). Financial interests necessitate public and reportedly always used in only 45%62% of patient
private organizations take part in determining standards of encounters. Patient-centeredness was always or usu-
quality of care. While PCC is not a criterion for reimburse- ally evident in 89% of total encounters, with 6%18% of
ment, it influences policies associated with credentialing, patients reporting they have never experienced PCC.
licensure, medical education, and assessment of quality of There is variation of almost 12% between surveyed groups
care (Epstein et al., 2005). In 2001, the Institute of Med- based on race, age, level of education, income, perceived
icine (IOM) included PCC as one of the six essential aims of health status, and health insurance coverage. Of the
the healthcare system (IOM, 2001a). Studies relate that four dimensions of healthcare quality, patient safety

600 Journal of the American Academy of Nurse Practitioners 20 (2008) 600607 2008 The Author(s)
Journal compilation 2008 American Academy of Nurse Practitioners
J.H. Robinson et al. PCC and adherence

demonstrated the greatest improvement of 10.2%, effec- related to management of hypertension, hyperlipidemia,
tiveness improved by 3%, while PCC and timeliness were diabetes, cardiac disease, and renal disease. Studies focus-
combined for a total rate of improvement of only 1.9% ing on the treatment of chronic disease were felt to be more
when compared with measures from the previous year useful in determining the effectiveness of the intervention
(AHRQ, 2005, p. 4) on adherence because treatment of chronic illness requires
Some of the factors slowing implementation of PCC are more patient involvement with the management of mul-
related to difficulty in changing traditional patterns of inter- tiple interventions. Chronic care also provides the practi-
action (Ponte et al., 2003), perceptions of increased time and tioner more opportunity for interaction with the patient to
cost (Bechel, Myers, & Smith, 2000), and vagueness about work on adherence issues. Successful adherence would be
what constitutes PCC (Mead & Bower, 2000). The inability evidence of effective, patient-centered interactions.
to define and measure patient-centeredness in a uniform Articles related to psychiatric interactions, HIV/AIDS, and
way seriously decreases its scientific utility. Finding ways to end-of-life care were excluded because of increased psy-
overcome the barriers to PCC is important in improving the chosocial implications. Studies pertaining to short-term
quality of health care, increasing patient satisfaction, pro- adherence were excluded because they would not reflect
moting patient adherence, and advancing research. persistence in the maintenance of long-term adherence.
Examining the relationship between adherence and
PCC can increase understanding of PCC and establish its
Results
usefulness in clinical practice. Adherence is a key factor in
health promotion as well as cost-effective use of health
Definition of PCC
care. It is estimated that the cost of nonadherence is
approximately $300 billion a year (DiMatteo, 2004). In Patient-centeredness has its roots in holistic health care
addition to economic benefits, adherence contributes to an and is a shift from the traditional disease-oriented model
improved quality of life and greater productivity (Thorpe, (Epstein, 2000). Its popularity began to increase in the
2005). As clinicians, advanced practice registered nurses 1970s, coming to prominence as healthcare organizations,
(APRNs) can become caught in the daily routine and stress institutions, and public agencies have more recently
of patient interactions and overlook the importance of endorsed patient-centeredness. Given the interest in
PCC. Understanding and utilizing PCC consistently in PCC, efforts to define and measure the outcomes of PCC
clinical interactions aid the APRN in establishing a positive have become more important. The definition of PCC varies
patient relationship, which promotes patient satisfaction depending upon the setting or perspective being repre-
and encourages adherence, ultimately improving patient sented. An examination of the literature revealed four
health status. Additionally, the focus of health care has sources of definitions for PCC. These include a public
moved from a traditional model of paternalistic care by the policy perspective, an economic perspective, clinical per-
provider to one that involves more patient participation in spective, and patient perspective.
care. Understanding PCC allows the practitioner to facil-
PCC and public policy perspective
itate that transition. The purposes of this review were
twofold: (a) to examine the literature to define PCC and The IOM defines PCC as a partnership among practi-
adherence and (b) to identify elements of PCC that are tioners, patients, and their families (when appropriate) to
effectively being used to improve treatment adherence. ensure that decisions respect patients wants, needs, and
preferences and that patients have the education and
support they need to make decisions and participate in
Method
their own care (IOM, 2001b, p.7). This definition is used
An electronic search was conducted to identify studies by the Agency for Healthcare Research and Quality
from 2000 to 2006 in the following databases: CINAHL, (AHRQ), which measures healthcare quality in the United
PubMed, Academic Search Premier (EBSCO), and States. This position regarding patient-centeredness helps
Cochrane Library. Search terms were adherence, PCC, shape the vision of health care, provides the basic concepts
patient-centered communication, providerpatient rela- for building a quality healthcare system, and is the foun-
tionship, healthcare communication, patient goals, and dation of other definitions of PCC.
compliance. References from all articles were reviewed for
PCC in economic perspective
additional relevant studies.
Inclusion criteria for this article focusing on PCC and Another definition of PCC examines the patient as
adherence include an adult population, aged 18 years and consumer in the healthcare environment. A consumerist
older, and studies from the United States and Great Britain view, or patient-centered view, recognizes the patients
published in English. Specific studies to be examined were ability to make informed healthcare choices that balance

601
PCC and adherence J.H. Robinson et al.

cost, quality, convenience, and other service characteristics patient needs, setting patient goals based on patient pref-
(Robinson, 2005). Greater media coverage of healthcare erence, and increasing the humaneness of care. Activities
issues, direct-to-consumer marketing of pharmaceuticals, to achieve these goals include involving the patient in
and Internet access to information has influenced the role treatment decisions, improving patientprovider commu-
patients now have in the relationship with their healthcare nication, and including family members in care.
provider. Patients are now more actively involved in a rela-
tionship of shared decision making and empowerment PCC from the patient perspective
(Dontje, Corser, Kreulen, & Teitelman, 2004). Patients, Patient perspective is essential in defining patient-cen-
using information from multiple sources, now look to the teredness. While a formal definition of PCC from a patient
provider to supply care based on patient wants. This results perspective has not been developed, research has identi-
in PCC that resembles a supply and demand model of care. fied patient preferences for healthcare interactions. Patient
The concept of managed consumerism in health care looks priorities for care include the following characteristics:
to balance these two components, supply of services by respect, courtesy, competence, efficiency, patient involve-
providers with the demands of patients (the PCC compo- ment in decisions, time for care, availability/accessibility,
nent), and is the goal of a market-oriented health policy information, exploring patients needs, and communica-
(Robinson). tion (Jennings, Heiner, Loan, Hemman, & Swanson, 2005;
The Economic and Social Research Institute (ESRI) Wanzer, Booth-Butterfield, & Gruber, 2004; Wensing,
disputes the idea that consumer-driven care is PCC. The Jung, Mainz, Olesen, & Grol, 1998). A survey of patient
focus of PCC is on meeting the patients needs rather than preferences in the primary care setting determined that
simply providing diagnostic services and advice without communication, partnership, and health promotion were
support for following recommendations (ESRI, 2006). It is the most important patient needs, particularly among
argued that patient-centeredness means putting the patients with psychosocial issues or who were symptom-
patient at the center of the healthcare system not balancing atic (Little et al., 2001). Additionally, a study by Jennings
two economic interests. Patient-centeredness involves et al. showed that patients want to be treated respectfully,
more than meeting consumer demands and is more than with competence, and given information to create a more
just giving the patient what is wanted or asked for. Alter- patient-centered healthcare system.
natively, PCC recognizes the values, needs, and wants of
the patient. Patient expectations of health care include
Measurement of PCC
consumer-minded factors regarding the time, cost, and
quality of care. These patient values need to be addressed Measurement of PCC has generally been conducted
as part of PCC. through the use of patient questionnaires reporting the
patients perception of PCC practices or patient satisfaction
PCC defined from a clinical practice perspective
with the interaction. This was the method used in the
In the clinical setting, the patientprovider relationship National Healthcare Quality Report which asked patients to
historically has been controlling or paternalistic in nature respond to survey questions related to: (a) the provider
(Teutsch, 2003). Traditional practice with a provider- listens carefully, (b) the provider explains things clearly,
centered focus of delivery meant patients received care (c) the provider respects what the patient has to say, and
without regard to their preferences. An early definition of (d) the provider spends enough time with the patient
PCC referred to the providerpatient relationship as one (AHRQ, 2005). The questions focused on the use of
that integrates the patient perspective and preferences patient-centered communication as well as examining
while involving the patient in decision making and self- time as a component of PCC. Patient surveys have weak-
care (Gerteis, Edgman-Levitan, Daley, & Delbanco, 1993). nesses because of variations in perceptions of terminology
Stewart et al. (2000) defined PCC as providing a relation- and limitations in understanding responses. A patient may
ship that focuses on the well-being of the individual. respond that the provider listens carefully but that does not
Additionally, the psychosocial context and the patients identify what constitutes listening carefully.
experience of the illness should be integrated into the pro- The other method generally used to determine the pre-
cess (Stewart et al., 2000). PCC recognizes the belief that sence of patient-centeredness is analysis of taped patient
healing involves knowing the patient as a person while provider interactions. Focusing on patientprovider commu-
accurately diagnosing his or her illness (Epstein, 2000). nication patterns alone has not correlated with health out-
The terms patient-focused, patient-based, and patient- comes or the determination of the presence of PCC
centered are used by Bechel et al. (2000) to distinguish independent of patient perception (Epstein, 2000; Howie,
different aspects of implementing the patient perspective. Heaney, & Maxwell, 2004). The patients perception is the
The three terms are used to describe tailoring treatment to most reliable measure of patient-centeredness regardless of

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J.H. Robinson et al. PCC and adherence

the analysis of the communication pattern. A study by adherence is seen as being more patient-centered than
Stewart et al. (2000) found a difference in health outcomes compliance (Vlasnik, Aliotta, & DeLor, 2005).
based on patient-reported perception of patient-centeredness
versus the use of audiotapes to identify patient-centeredness. Measurement of adherence
Diagnostic tests and referrals were one half as frequent if the
Like PCC, adherence is difficult to measure because of
visit was perceived to be patient-centered as reported by
confusing terminology and the use of different methods of
the patient when compared with those based on the use
measurement with variable degrees of reliability. Direct
of audio-taped interviews alone. Essentially, the patient is
measures are considered more accurate and involve ob-
the sole determinant of patient-centeredness. Although
servable data such as blood or urine testing. Indirect meas-
observable characteristics may indicate the presence of
ures are less reliable and include pill counts, diaries,
a patient-centered interaction, unless that is the patients
pharmacy refill records, and outcome measures such as
perception, it really is not patient-centered (Stewart, 2001).
blood pressure and weight change. Self-report, surveys,
Effortstomeasuretheeffectivenessofpatient-centeredness
questionnaires, interviews, and physician estimate are sub-
using direct health outcomes such as lipid levels, body mass
ject to errors of over- or underestimation (Bartels, 2004;
index (BMI), hemoglobin A1c (HgbA1c) levels, and blood
Vermeire, Hearnshaw, Van Royen, & Denekens, 2001).
pressure have provided inconclusive results (Kinmonth,
The accurate measurement of adherence serves two
Woodcock, Griffin, Spiegal, & Campbell, 1998). Difficulties
purposes. First, it is important as a means of motivating
in methods for measurement include measures that are not
patients to continue adherence. Second, it is also impor-
appropriate, are poorly designed, and lack reliability and
tant in determining the efficacy of prescribed treatment.
consistency (Howie et al., 2004). Franks et al. (2005) also
The question of the appropriateness of treatment remains
point out the limitations of measuring effectiveness based on
unclear if it has not been implemented correctly.
patient satisfaction because of patient confounding.
Patient-centered practices to improve adherence
Definition of adherence
Multiple variables have been examined without strong
Adherence and compliance have previously been used correlation or predictive value of adherence. Findings are
interchangeably to refer to a patients efforts to follow inconsistent whether social class, age, sex, marital status,
healthcare advice. The term compliance was initially de- education, and disease factors influence adherence (Lutfey
fined as the extent to which a persons behavior (in terms & Wishner, 1999; Vermeire et al., 2001). Differences in
of taking medications, following diets, or executing life- patient values and perceptions account for some of this
style changes) coincides with the clinical advice (Sackett variability. Practical issues of time, money, transportation,
& Haynes, 1976, p. 11). Compliance suggests that the physical or mental handicaps, difficulty managing the
patient obeys or conforms to the providers instructions healthcare system, poor communication, and unpleasant
without regard to the patients independence, autonomy, side effects also contribute to nonadherence (Popa-Lisseanu
and ability to take an active role in their health care (Lutfey et al., 2005; Resnik, 2005). The factor that appears to most
& Wishner, 1999). There is a connotation of control that strongly correlate with adherence is the patients own
condemns a patients behavior as flawed for the inability beliefs influenced by personal knowledge and experience
to conform to treatment. When a providers healthcare as well as that of family and friends (Vermeire et al.).
goals are not met, the patient is labeled as noncompliant Understanding the patient perspective allows the provider
and treatment goals lowered, to the detriment of patient to give treatment options congruent with patient needs and
health (Lutfey & Wishner). An important aspect of adher- values. A patient-centered approach is essential to promot-
ence is recognizing the patients right to choose whether or ing adherence. Elements of patient-centeredness applied to
not to follow treatment recommendations. The difference adherence include communication, shared decision mak-
between refusal of treatment and nonadherence is the ing, and support for self-management.
patients involvement in the decision-making process.
Communication
Nonadherence occurs only if the patient does not follow
treatment recommendations that are mutually agreed Communication skills are considered to be as important
upon (Resnik, 2005). as the providers technical skills in providing quality health
Adherence focuses more on patient involvement and care (United States Department of Health and Human
the patientprovider relationship. The term adherence is Services, Office of Disease Prevention and Health Promo-
preferred as having a broader interpretation and under- tion, 2000). A great deal of research has focused on com-
standing of factors that affect a patients ability to follow munication, particularly patient-centered communication.
treatment recommendations. Because of these factors, Two aspects of communication that are of interest to PCC

603
PCC and adherence J.H. Robinson et al.

are the impact of provider style on the patientprovider the patient perspective (Harmon et al., 2006). Patient
relationship and the issue of time for the patient visit. involvement in care can be affected by cultural differences,
Provider styles that are based on using open-ended age, level of education, gender, and socioeconomic status
questions, paying attention to patient concerns, and allow- (Popa-Lisseanu et al., 2005; Street, Gordon, Ward, Krupat,
ing patients the time to express themselves are considered & Kravitz, 2005; Tennstedt, 2000). Methods to improve
patient-centered (Howie et al., 2004). Maintaining patient involvement involve teaching the patient what to
patient-centered communication throughout the visit do, assessing the patients ability and resources to follow
appears to be problematic. In looking at provider styles treatment, and understanding the patients attitude
that were informational or controlling, researchers found toward treatment (DiMatteo, 2004).
that most providers used an informational style that Patient-centeredness should not exclude the promotion
became a controlling style when making decisions and of evidence-based practice by the provider. If health care is
planning patient care (Lawson, 2002). Patient satisfaction more than just giving the patient what is wanted, then care
with provider style also varies with the type of visit. must integrate both evidence-based and patient-centered
Patients with simple complaints preferred a directing style, approaches (Sidani, Epstein, & Miranda, 2006). Methods
while those with chronic illness preferred a sharing (or to achieve the complementary use of both concepts
patient-centered) style (Mead & Bower, 2000). include identification of effective interventions, presenta-
Another focus of PCC is time spent with the patient. The tion of pros and cons of treatment options, and incorpo-
patient perception of enough time with the provider is ration of patient preferences for treatment (Coyler &
more directly related to having patient needs addressed Kamath, 1999).
than actual amount oftimeinthe visit.Mechanic, McAlpine,
Support for self-management
and Rosenthal (2001) found that the time of a healthcare
visit has actually increased by 12 min in the past 10 years. Patient education alone has been largely ineffective in
The perception of a shorter provider visit may be because of improving adherence. When combined with other inter-
compressing more information into the visit. Female physi- ventions, education does enable a patient to participate
cians spend almost 2 min more time with patients and are more effectively in managing care (Roter et al., 1998). The
more positive, attend to more psychosocial issues, and are need for education is especially important for patients
more active in listening. There was no difference in patient living with chronic conditions. Complexity of treatment
satisfaction or report on health outcomes related to in- is a factor in poor adherence. Education combined with
creased time of healthcare visit (Roter & Hall, 2004). Using timely follow-up visits, progress reports, and psychosocial
enough time to understand and meet patient needs, not support have produced positive results (Davidson, 2005;
a specified amount of time, is the critical determinant of Mason, 2005).
effective patientprovider communication. Education methods involve patientprovider interac-
Communication is essential in establishing a high-quality tion, non face-to-face communication, and disease man-
patientprovider relationship. In turn, the quality of the agement programs. The patientprovider interaction
patientprovider relationship is a key factor in improving should be understandable, at the level of interest of the
adherence (Harmon, Lefante, & Krousel-Wood, 2006). patient, and focus on what the patient needs to know
Healthcare education needs to provide greater emphasis rather than teaching the patient what the provider knows
on the development of communication skills. The ESRI (Lowes, 1998). Almost one half of the adults in the
(2006) suggests an examination of nursing curricula to United States cannot understand and apply health infor-
identify methods for teaching PCC communication techni- mation because of low literacy levels (Nielsen-Bohlman,
ques. Currently, the effectiveness of nursepatient commu- Panzer, & Kindig, 2004). The use of analogies or visual
nication has not been established. displays of information can help improve understanding.
Non face-to-face communication methods are useful
Shared decision making
to educate, motivate, remind, reinforce, and respond
Understanding the patients goal in treatment will to patient concerns. These include print, Internet, and
increase the probability of adherence. The patient may be telephone interactions (Hughes, 2003). Disease man-
concerned about issues related to symptom management, agement programs provide education from a variety of
side effects, cost, quality of life, and complexity of treatment different health professionals to assist in the daily man-
(Vermeire et al., 2001). Providing options allows the patient agement of chronic illness. They are often offered
to address concerns and choose a treatment that reflects his through medical centers or health systems. Patients par-
or her ability and propensity to adhere to treatment. ticipating in these programs have improved health out-
Shared decision-making enables the provider to identify comes, greater self-efficacy, and improved quality of life
barriers to adherence and offer solutions that incorporate (Sweet, 2004).

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J.H. Robinson et al. PCC and adherence

Discussion involvement and personalization of care, would be rated


independently on an NRS scale of 05. Combining those
Understanding PCC two scores would then determine the level of PCC on
a scale of 010. The use of such a tool would provide
The primary difference between PCC and the biomed-
feedback, from the patient perspective, in a clinical setting
ical, or traditional, healthcare model is the providers focus
as well as enable quantitative research into the correlation
on the patient versus the health concern or problem. In
between PCC and adherence.
a traditional model, the focus is on treating the condition,
resulting in the provider taking responsibility for care of
Definition and measurement of adherence
the problem, consequently taking care of the patient. In
PCC, the patient maintains responsibility for his or her The definition of adherence while similar to compliance
health care with help from the provider. This is a funda- must include the patient perspective. Adherence can be
mental principle of PCC that has not been addressed in the defined as a patients efforts to follow treatment recom-
literature. mendations that are mutually agreed upon. This acknowl-
edges the patients ability to participate in making
Definition and measurement of PCC healthcare decisions.
Measurement of adherence must reflect the patients
Attempts to define PCC have resulted in multiple terms
efforts to adhere to treatment. Although less reliable, the
and descriptions often obscuring the core concepts. Table 1
most valid measurement of adherence would be those
provides the descriptors from definitions of PCC from the
measures that track patient behavior, such as pill counts,
four sources of PCC perspective addressed earlier (i.e.,
weight change, or interviews. Conversely, direct meas-
public policy, economic, clinical, and patient perspective).
ures, while preferred for reliability, lack validity if a corre-
The descriptors have been classified into two categories
lation between the proposed treatment the patient adheres
that represent fundamental principles of PCC. As Table 1
to and the outcome is not established. For example,
shows, the various definitions of PCC condense into the
a patient with type 2 diabetes agrees to lose 30 pounds
two concepts of (a) a patientprovider relationship that
to achieve an HgbA1c level of 7.0. In spite of losing the
promotes patient involvement and (b) care that individu-
weight, the HgbA1c level is above 7.0. The patient was
alizes patient treatment. Simply defined, PCC promotes
100% adherent with their behavior but appears nonad-
patient involvement and individualization of care.
herent based on the outcome of the direct measure of
Because a major focus of PCC is patient perspective,
HgbA1c level. In this example, the efficacy of a specific
measurement of PCC should be based on patient percep-
weight loss to a specific HgbA1c is not established and
tion of PCC. An approach similar to using a numeric rating
therefore should not be linked to a measure of adherence.
scale (NRS) to measure a patients pain may be useful in
measuring PCC. Pain has been defined as being a personal
PCC and adherence
and subjective experience (Katz & Melzak, 1999). PCC
could also be viewed as being a personal and subjective Adherence is an outcome of PCC but is often addressed
experience. Using an NRS can help determine the degree of in the same manner as compliance, with provider expect-
involvement or personalization of care from the patient ations that patients will follow prescribed treatment based
perspective. on the traditional delivery of health care. Communication
Figure 1 provides an example of using an NRS to quan- is critical in both facets of patient involvement and per-
tify the degree of PCC. The two components of PCC, patient sonalization of care. The provider must thoughtfully

Table 1 Categorization of PCC descriptors from four definitions

Public policy definitions Economic definitions Clinical practice definitions Patient definitions

Patient involvement Partnership Shared decision making Self-care Involvement in treatment


Education Empowerment Patient goals Information provided
Participation in care Family Involvement Partnership
Participate in decisions
Individualized care Respect for patient Patient demand for cost, Psychosocial experience Respectful treatment
wants needs, and preferences quality, convenience, Knowing patient Time for care
and other concerns Tailoring treatment Communication
Humane care Patient as priority
Communication Accessible care

605
PCC and adherence J.H. Robinson et al.

1. Degree of patient involvement in care

0 1 2 3 4 5
No Mod. Involvement Shared Decision Making
Involvement Clearly understands care
Maximal support for patient

2. Degree of individualized care

0 1 2 3 4 5
Standardized care Some Care reflects personal
No personalization Personalization needs, wants and preferences

3. Combined patient involvement/individualized care scores---PCC score

0 1 2 3 4 5 6 7 8 9 10
No PCC Moderate PCC Maximal PCC
(Low potential (Moderate potential (Strong potential
for adherence) for adherence) for adherence)

Figure 1 NRS for PCC: A combination of patient involvement and individualized care ratings.

organize time with the patient to effectively meet diag- correlation to reported adherence would establish the
nostic, psychosocial, and educational needs of the patient. utility of such a tool. Assuming a high level of PCC
Provider education for the patient as well as supplemental corresponds to a high level of adherence, specific outcomes
resources such as non face-to-face communication and that rely on adherence, such as blood pressure control,
community or healthcare programs can improve a could be investigated to determine if improved PCC con-
patients involvement in adherence. Providers also sup- tributes to improved outcomes.
port patient adherence by identifying individual patient Research in the implementation of PCC is needed as well
circumstances that are barriers to adherence and tailoring to identify methods for improvement in communication,
treatment to those needs. patient education, shared decision making, and support for
patient needs. PCC is a key factor in improving the quality
of health care, increasing patient adherence, and eventu-
Conclusions ally reducing healthcare costs. Efforts to improve its imple-
The purpose of PCC is to improve the quality of health. mentation in practice will benefit the patient, the provider,
Developing a concise definition of what is or is not patient- and the healthcare system.
centered can help in determining appropriate methods to
implement PCC in both clinical practice and for research
purposes. PCC involves enabling patient responsibility for References
health care by promoting patient involvement and indi- Agency for Healthcare Research and Quality. (2005). National Healthcare Quality
vidualization of patient care. Report, 2005. 79-82. Retrieved June 30, 2006, from http://www.ahrq.gov/qual/
nhqr05/nhqr05.pdf
Providers need a method to measure the patients per-
Anderson, E. B. (2002). Patient-centeredness: A new approach. Nephrology News and
ception of the providerpatient interaction in order to Issues, 16(12), 8082.
improve the quality of that interaction. A provider may Bartels, D. (2004). Adherence to oral therapy for type 2 diabetes: Opportunities for
be more patient-centered with some patients than others enhancing glycemic control. Journal of the American Academy of Nurse Practitioners,
16, 816.
or may believe their actions are patient-centered when
Bechel, D., Myers, W. A., & Smith, D. G. (2000). Does patient-centered care pay off?
they are not perceived that way by the patient. The method Joint Commission Journal on Quality Improvement, 26, 400409.
used to assess PCC needs to be simple and understandable Beck, R., Daughtridge, R., & Sloane, P. D. (2002). Physician-patient communication
to the patient. Use of an NRS individualizes the assessment in the primary care office: A systematic review. Journal of American Board of Family
Medicine, 15, 2538.
of PCC, making it an invaluable tool in research and
Coyler, H., & Kamath, P. (1999). Evidence-based practice: A philosophical and
clinical practice. A pilot study to determine the effective- political analysis: Some matters for consideration by professional practitioners.
ness of an NRS in determining the level of PCC and its Journal of Advanced Nursing, 29, 188193.

606
J.H. Robinson et al. PCC and adherence

Davidson, J. (2005). Strategies for improving glycemic control: Effective use of National Center for Health Statistics. (2005). Health, United States, 2005: With chartbook
glucose monitoring. American Journal of Medicine, 118(Suppl. 9A), 27S32S. on trends in the health of Americans. Table 123, Personal health care expenditures according
DiMatteo, M. R. (2004). Evidence-based strategies to foster adherence and improve to type of expenditure and source of funds: United States, selected years 1960-2003.
patient outcomes. Journal of the American Academy of Physician Assistants, 17, 1821, Retrieved July 1, 2006, from http://www.cdc.gov/nchs/data/hus/hus05.pdf#123
33, 34. Nielsen-Bohlman, L., Panzer, A., & Kindig, D. (Eds.). (2004). Health literacy: A
Dontje, K., Corser, W., Kreulen, G., & Teitelman, A. (2004). A unique set of prescription to end confusion. Washington, DC: National Academics Press.
interactions: The MSU sustained partnership model of nurse practitioner primary Ponte, P. R., Conlin, G., Conway, J. B., Grant, S., Medeiros, C., Nies, J., et al. (2003).
care. Journal of American Academy of Nurse Practitioner, 16, 6369. Making patient-centered care come alive: Achieving full integration of the
Economic and Social Research Institute. (2006, January). Patient-centered care for patients perspective. Journal of Nursing Administration, 33, 8291.
underserved populations: Definition and best practice. Retrieved June 29, 2006, from Popa-Lisseanu, M. G., Greisinger, A., Richardson, M., OMalley, K. J., Janssen, N. M.,
http://www.esresearch.org/documents_06/Overview.pdf Marcus, D. M., et al. (2005). Determinants of treatment adherence in ethnically
Epstein, R. (2000). The science of patient-centered care. Journal of Family Practice, 49, diverse, economically disadvantaged patients with rheumatic disease. Journal of
805807. Rheumatology, 32, 913919.
Epstein, R. M., Franks, P., Fiscella, K., Shields, C. G., Meldrum, S. C., Kravitz, R. L., Resnik, D. B. (2005). The patients duty to adhere to prescribed treatment: An ethical
et al. (2005). Measuring patient-centered care in patient-physician consultation: analysis. Journal of Medicine and Philosophy, 30, 167188.
Theoretical and practical issues. Social Science and Medicine, 61, 15161528. Robinson, J. C. (2005). Managed consumerism in healthcare. Health Affairs, 24,
Franks, P., Fiscella, K., Cleveland, G. S., Meldrum, S., Duberstein, P., Jerant, A. F., 14781489.
et al. (2005). Are patients ratings of their physicians related to health outcomes? Roter, D. L., & Hall, J. A. (2004). Physician gender and patient-centered
Annals of Family Medicine, 3, 229234. communication: A critical review of empirical research. Annual Review of Public
Gerteis, M., Edgman-Levitan, S., Daley, J., & Delbanco, T. L. (Eds.). (1993). Through Health, 25, 497519.
the patients eyes: Understanding and promoting patient-centered care. San Francisco: Roter, D. L., Hall, J. A., Merisca, R., Nordstrom, B., Cretin, D., & Svarstad, B. (1998).
Jossey-Bass. Effectiveness of interventions to improve patient compliance: A meta-analysis.
Harmon, G., Lefante, J., & Krousel-Wood, M. (2006). Overcoming barriers: The role Medical Care, 36, 11381161.
of providers in improving patient adherence to anti-hypertensive medications. Sackett, D., & Haynes, R. (1976). Compliance with therapeutic regimens. Baltimore, MD:
Current Opinion in Cardiology, 21, 310315. Johns Hopkins University Press.
Howie, J. G., Heaney, D., & Maxwell, M. (2004). Quality, core values and the general Sidani, S., Epstein, D., & Miranda, J. (2006). Eliciting patient treatment preferences:
practice consultation: Issues of definition, measurement and delivery. Family A strategy to integrate evidence-based and patient-centered care. Worldviews on
Practice, 21, 458468. Evidence-Based Nursing. Third Quarter, 2006, 116123.
Hughes, S. (2003). The use of non face-to-face communication to enhance Stewart, M. (2001). Towards a global definition of patient-centred care. British
preventive strategies. Journal of Cardiovascular Nursing, 18, 267273. Medical Journal, 322, 444445.
Institute of Medicine. (2001a). Crossing the quality chasm: A new health system for the 21st Stewart, M., Brown, J. B., Donner, A., McWhinney, I. R., Oates, J., Weston, W. W.,
century. Retrieved July 1, 2006, from http://iom.edu/object.File/Master/27/184/ et al. (2000). The impact of patient-centered care on outcomes. Journal of Family
Chasm-8pager.pdf Practice, 49, 796804.
Institute of Medicine. (2001b). Envisioning the national health care quality report. Street, R. L., Gordon, H. S., Ward, M. M., Krupat, E., & Kravitz, R. L. (2005). Patient
Retrieved July1, 2006, from http://newton.nap.edu/execsumm_pdf/10073.pdf participation in medical consultations: Why some patients are more involved than
Jennings, B. M., Heiner, S. L., Loan, L. A., Hemman, E. A., & Swanson, K. M. (2005). others. Medical Care, 43, 960969.
What really matters to healthcare consumers. Journal of Nursing Administration, 35, Sweet, M. G. (2004). A patient-centered approach to chronic disease management.
173180. Journal of the American Academy of Physician Assistants, 17(11), 2534.
Katz, J., & Melzak, R. (1999). Measurement of pain. Surgical Clinics of North America, Tennstedt, S. L. (2000). Empowering older patients to communicate more effectively
79, 231252. in the medical encounter. Clinics in Geriatric Medicine, 16, 6170.
Kinmonth, A. L., Woodcock, A., Griffin, S., Spiegal, N., & Campbell, M. J. (1998). Teutsch, C. (2003). Patient-doctor communication. Medical Clinics of North America,
Randomised controlled trial of patient centred care of diabetes in general practise: 87, 11151145.
Impact on current well-being and future disease risks. British Medical Journal, 317, Thorpe, K. E. (2005). The rise in health care spending and what to do about it.
12021208. Health Affairs, 24, 14361445.
Lawson, M. T. (2002). Nurse practitioner and physician communication styles. United States Department of Health and Human Services, Office of Disease
Applied Nursing Research, 15, 6066. Prevention and Health Promotion. (2000). Healthy People 2010: Understanding and
Little, P., Everitt, H., Williamson, I., Warner, G., Moore, M., & Gould, C. (2001). Improving Health. Retrieved July 1, 2006, from http://www.Healthypeople.gov/
Preferences of patients for patient-centred approach to consultation in primary document/HTML/Volume1/11HealthCom.htm
care: Observational study. British Medical Journal, 322, 468472. Vermeire, E., Hearnshaw, H., Van Royen, P., & Denekens, J. (2001). Patient
Lowes, R. (1998). Patient-centered care for better patient adherence. Family Practice adherence to treatment: Three decades of research. A comprehensive review.
Management, 5, 4657. Journal of Clinical Pharmacy and Therapeutics, 31, 331342.
Lutfey, K. E., & Wishner, W. J. (1999). Beyond compliance is adherence. Diabetes Vlasnik, J. J., Aliotta, S. L., & DeLor, B. (2005). Medication adherence: Factors
Care, 22, 635639. influencing compliance with prescribed medication plans [Abstract]. Case
Mason, C. M. (2005). The nurse practitioners role in helping patients achieve lipid Manager, 16(2), 47.
goals with statin therapy. Journal of the American Academy of Nurse Practitioners, 17, Wanzer, M. B., Booth-Butterfield, M., & Gruber, K. (2004). Perceptions of health
256262. care providers communication: Relationships between patient-centered
Mead, N., & Bower, P. (2000). Patient-centeredness: A conceptual framework and communication and satisfaction. Health Communication, 16, 363384.
review of the empirical literature. Social Science and Medicine, 5, 10871100. Wensing, M., Jung, H. P., Mainz, J., Olesen, F., & Grol, R. (1998). A systematic review
Mechanic, D., McAlpine, D. D., & Rosenthal, M. (2001). Are patients office visits of the literature on patient priorities for general practice care. Part 1: Description of
with physicians getting shorter? New England Journal of Medicine, 344, 198204. the research domain. Social Science and Medicine, 47, 15731588.

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