Medical Decision Making
Analyzing the effects of shared decision-making, empathy and team interaction on patient satisfaction and treatment acceptance in medical rehabilitation using a structural equation modeling approach

https://doi.org/10.1016/j.pec.2012.12.007Get rights and content

Abstract

Objectives

The aims of the study are: (1) To develop and test a theory-based model for the predictive power of “Shared decision making (SDM)”, “Empathy” and “Team interaction” for “Patient satisfaction” and “Treatment acceptance”. (2) To identify mediating effects of “Compliance” and “Satisfaction with decision”.

Methods

Within a multi-center cross-sectional study (11 inpatient rehabilitation clinics at different indication fields), the model was evaluated in descriptive and structure analytical terms based on survey data of N = 402 inpatients.

Results

The structural equation model proved to exhibit an appropriate data fit. A high proportion of variance of “Patient satisfaction” (61%) and “Treatment acceptance” (67%) can be predicted by “SDM”, “Empathy”, “Satisfaction with decision” and “Team interaction”. While no mediating effects were found for the two subcomponents of “Compliance” (“Patient cooperation”, “Adherence”), “Satisfaction with decision” showed a full mediation for “Treatment acceptance” and a partial mediation for “Patient satisfaction”.

Conclusion

“Team interaction” should be considered as an important predictor of process and patient-centered outcome characteristics.

Practice implications

The current findings can be used to derive measures as well as interventions to optimize the organization of participatory care within teams in order to strengthen patient centeredness and to ensure a high quality of care.

Introduction

The concept of “Shared decision-making (SDM)” provides a promising approach for strengthening patient centeredness in medical rehabilitation [1], [2]. SDM is mostly described as a form of physician–patient interaction, which is characterized by an interactive decision-making process conducted on an equal footing [3], [4], [5], [6]. A joint determination of treatment goals and the selection of treatment measures, can lead to enhanced patient satisfaction with the treatment, an improved collaboration, a more effective transfer to everyday life, and ultimately better treatment outcomes [1], [7]. To implement SDM in practice, a sustainable physician–patient relationship and specific communication structures are required, which encourage the patient to express his expectations, goals and preferences. Patients show a high need for information [8], [9], [10] and an increasing desire to be involved into medical decision-making processes [11], [12]. The level of desire for participation differs between patients [12], [13], can change throughout the course of illness [14], [15] and is dependent on the desire for information [1], [13], [16]. It was shown that a good physician–patient relationship may be advantageous not only for subjectively perceived psychosocial criteria (e.g., quality of life, depression, anxiety), but also objective medical criteria (e.g., symptom alleviation, lowering of blood pressure and blood sugar [2], [17], [18], [19], [20], [63]). Besides physiological outcome parameters (e.g., reduced symptoms, improved functional capacity and pain control), positive effects of SDM have also been mentioned for mental health outcomes [1], [13], [18], [64]. Study findings show an increase in patients’ satisfaction, compliance and treatment acceptance [7], an increase in transfer to everyday life [1], [13] and an improvement in quality of life and medication adherence [65], [66], as well as a reduction of decision conflicts, anxiety [6] and medication costs [65]. Additionally, improvements in physician–patient communication, risk perception, and patient knowledge have been reported [15].

The degree of physicians’ empathy, which supports a better exchange of information between physician and patient, proved to be a further important component of a trustful relationship between physician and patient [43]. Positive effects of physician empathy include an increase in compliance, patient satisfaction, diagnostic precision [22], [23] and self-efficacy [24]. Furthermore, it is associated with a reduction in emotional distress [24], and an increase in professional satisfaction and a reduction of stress on the part of the physicians [23], [25], [26].

Additionally, a good collaboration of the various health care professionals within a team is also seen as a key factor for an effective and efficient health care [27], [28], [29]. Team interaction is associated with an improvement in treatment outcomes [30], [31], [32] and a reduction of morbidity [33], as well as an increase in patient satisfaction [30], [31], employee satisfaction [27] and a reduction of health economic costs [31], [32]. Nevertheless “Team interaction” is not systematically regarded in existing models addressing outcome related models of clinical communication and interaction structures and processes. To fill this gap, the “Model of Integrated Patient Centeredness (MIPC)” was developed to meet the necessity of consistently integrating the aspect of team interaction into the common model of Shared Decision Making [34], [35]. It is assumed that improved collaboration within a team can help to avoid non-integrated processes in the treatment process. Furthermore, joint decisions between physicians, treatment team and patients can be better accepted by all involved and implemented more consistently into practice [34], [35], [36].

Thus, the main aim of the study was to empirically define and test a theory based model and consequently create the basis for a model-oriented investigation of important theory-oriented relationships.

The goal of this work was to examine the described model using structural analysis with regard to empirically (a) assess model variables and (b) estimate the associations and predictive relationships. To this aim, the following hypotheses were formulated regarding (a) the data fit of the complete model and (b) the construct relationships:

Hypothesis I

The data information of the variables can be adequately modeled by a theory-based structural equation model.

Hypothesis II

The constructs “SDM”, “Empathy” and “Team interaction” have a predictive value for the constructs “Patient satisfaction” and “Treatment acceptance”.

Hypothesis III

“Team interaction” is an independent predictor of “Patient satisfaction” and “Treatment acceptance”.

Hypothesis IV

The effects of the independent variables “SDM”, “Team interaction” and “Empathy” on the dependent variables “Patient satisfaction” and “Treatment acceptance” are mediated by the variables “Compliance” and “Satisfaction with decision”.

Section snippets

9-item Shared Decision Making Questionnaire (SDM-Q-9)

To measure the extent to which patients are included in decision-making processes, the “9-item Shared Decision Making Questionnaire (SDM-Q-9)” was used [38]. The questionnaire can be applied across different diseases and is oriented toward the nine treatment steps of SDM [5], [38], [39]. The items are rated on a 6-point Likert scale from 0 (“completely disagree”) to 5 (“completely agree”). High values correspond to a high shared decision; e.g., “My doctor and I selected a treatment option

Descriptive statistics

The descriptive statistics are summarized for all scales in Table 2. “Empathy” (M = 4.15) proved to be “high” from the patient perspective, and “Team interaction” (M = 3.20) and “SDM” (M = 3.89) were rated as “relatively high” on average. Substantially lower values prevailed for “Patient satisfaction” (M = 2.48) and for “Satisfaction with decision” (M = 2.08). Generally, the “Treatment acceptance” (M = 3.04), “Patient cooperation” (M = 3.60) and “Adherence” of the patients (M = 1.76) was evaluated from their

Discussion

Based on the theoretical Model of Shared Decision Making (e.g., [3], [4]) and empirical findings on SDM (e.g., [2], [18]), physician empathy [20], [22], [23] and team interaction (e.g., [30], [32]), a model was developed which assumes the importance of these key factors for patient satisfaction and treatment acceptance of patients in medical rehabilitation. In addition to the empirical operationalizations, the assumed predictive relationships proved to be compatible with the data in the

Conflict of interest

All authors are requested to disclose any actual or potential conflict of interest including any financial, personal or other relationships with other people or organizations within three years of beginning the submitted work that could inappropriately influence, or be perceived to influence their work.

Acknowledgements

The study is part of the German grant program “Chronic illness and patient orientation” and is supported by the German Federal Ministry of Research and Education and the German statutory pension insurance scheme. We thank all of the providers in the rehabilitation clinics (AOK-Klinik Korbmattfelsenhof, AOK-Klinik Stöckenhöfe, Askepios Triberg, DAK-Haus Schwaben, Kliniken Dr. Vötisch, Rehabilitationsklinik Birkenbuck, Rehaklinik St. Landelin, Reha-Zentrum Todtmoos, Rheintalklinik,

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