Family Presence in Adult Patients’
Routine Physician Visits:
A Review and Synthesis of the Literature
Jennifer L. Wolff and Debra L. Roter
June 2010
Background
• F
Families
ili are iinvolved
l d iin h
health
lth care processes
 Proxy decision-makers in end-of-life care
 Personal care and household task assistance
g
disabilityy
for short- or long-term
 Help patients transition from hospital to home
• Although less studied,
studied growing awareness that
chronically ill adults are commonly accompanied
to routine physician visits
Questions
1. How frequently are adults accompanied to
routine p
physician
y
visits?
2. Do accompanied patients differ from
unaccompanied patients,
patients and if so
so, how?
Who are accompanied patients’
companions?
3. Does patient accompaniment to physician
visits have a bearing for communication
processes or outcomes?
p
Methods: Identification of Studies
PsychInfo and PubMed 1949
1949-July
July 2009 along with
hand search of bibliographies
Literature Review Inclusion Criteria:
• English language journal
patient-health p
professional medical visit
• Describe adult p
interactions that occurred in office or outpatient setting
• Present quantitative information regarding patient
accompaniment
i
t
Exclusion Criteria: Studies of pediatric patients, end-oflife or terminally ill patients
patients, emergency visits
visits, genetic
counseling, specialty mental health visits
Methods: Data Extraction
Type of data: Observational (audio or videotaped) versus
patient report (survey)
Study sample: Sample size, study setting, provider type,
g criteria, country
y in which study
y conducted
age
Patient and companion attributes: age, gender, physical
and mental health status, relationship of companion to
patient
Visit structure: duration of visit (minutes); patient,
companion, physician verbal activity
C
Communication
i ti process measures: (social
(
i l conversation,
ti
positive talk, negative talk, biomedical and
psychosocial information giving, information seeking)
Patient outcomes: activation, satisfaction with care,
knowledge, confidence, motivation, skills proficiency,
adherence
Methods: Combining Findings
Average standard normal deviate (Z) and effect
size (r) extracted or computed from each study
– Studies that contributed more than one result in given
category we entered average
Pooled weighted and unweighted effect sizes (r)
calculated using Fisher transformation
Weighted effect size, r = quantify the strength of
the mean difference in patient attribute,
communication process measure or outcome
for accompanied patients relative to
unaccompanied
p
p
patients
– Positive r indicates communication process occurred more
commonly among accompanied patient visits relative to
unaccompanied patients
Summary of Contributing
Studies
Type of Study
Number
of
Studies
Observational
Studies
9
93
Patient-Reported
Studies
7
457
(129-12,018)
2,177
Observational
Ob
ti
l
AND Patientp
Studies
Reported
16
139
(21-12,018)
1,018
Median # Patients
(Range)
(21-473)
Mean #
Patients
116
Question 1:
How frequently
q
y are adults
accompanied to routine
physician
h i i visits?
i it ?
Rates of Adult Patient Accompaniment to
Routine Physician Visits
Visits,
Summary of Contributing Studies
60%
57.1%
50%
38.5%
40%
37.4%
38.8%
37.2%
34.0%
30%
20%
10%
0%
Ob
Observational
ti
l (n=5)
( 5)
Median
S
Survey
(n=7)
( 7)
Weighted Mean
C bi d ((n=12)
Combined
12)
Question 2:
Do accompanied patients differ from
unaccompanied patients,
patients and if so
so,
how? Who are accompanied patients’
companions?
i
?
Profile of Accompanied and
Unaccompanied Patients
Accompanied
Profile (# contributing studies)
No
Yes
D
P-value
Mean Age (years; n=12)
66.6
70.1
3.5 <0.0001
Caucasian (%; n=5)
72.9
70.1
-2.8
Female Gender (%; n=10)
53 0
53.0
58 6
58.6
5 6 <0.0001
5.6
<0 0001
High school education (%; n=9)
59.7
42.8 -16.9 <0.0001
Excellent/Very Good Self Rated
Health (%; n=8)
41.4
28.2 -13.3 <0.0001
0.115
Profile of Companions During Adults’
Adults
Routine Physician Visits
Family
y Companion
p
Profile Median ((Range)
g )
Mean Age (years; n=5)
Mean
62.0 (58-68)
63.0
Female (%; n=7)
78.0 (63.0-93.0)
79.4
Relationship to patient (%)
Spouse (n=12)
Child (n=10)
54.0 (38.5-71.0)
35.5 (10.0-53.8)
54.7
32.2
16.0 (0.0-45.0)
18.7
Other (n=13)
Question 3:
Does patient accompaniment
to physician visits have a
bearing for communication
processes or outcomes?
Accompanied and Unaccompanied
P ti t ’ Vi
Patients’
Visit
it D
Duration
ti
(k=6 observational studies; n=883 patient visits)
Length of Visit (Minutes)
35
29 8
29.8
30
Weighted Mean r1=0.19
24.6
25
Pooled Significance:
g
Combined Z1=4.28
=4 28
20
P-Value2 = < 0.01
15
P-Value for
Heterogeneity3 = 0.21
10
5
0
Not Accompanied
Notes:
1.
Accompanied
Positive effect indicates accompanied visits longer.
2. P-value of combined Z. P-values are two-tailed.
3. P<0.10 is evidence of considerable heterogeneity.
Accompanied and Unaccompanied Physician
Visits’ Verbal Activity by Contributing Party
Visits
(k=3 observational studies; n=307 patient visits)
60%
50%
54.4% 53.3%
45.5% 47.3%
45.5%
Pooled Significance
Patient Verbal Activity:
Weighted Mean r1= 0.16
40%
32.4%
30%
Combined Z1= -2.45
20%
P-Value2 = < 0.01
10%
P-Value for
Heterogeneity3 = 0.92
0%
Patient
Patient &
Companion
Not Accompanied
Notes:
1.
Physician
Accompanied
Positive effect indicates greater verbal activity in accompanied visits.
2. P-value of combined Z. P-values are two-tailed.
3. P<0.10 is evidence of considerable heterogeneity.
Accompanied and Unaccompanied Physician
Vi it & C
Visits
Communication
i ti P
Processes
(k=5 observational studies)
Positive Talk – laughter, friendliness, solidarity, agree,
show approval
Negative Talk – disagree, express tension or disapproval
Biomedical Information Giving – present symptoms,
answer questions, respond to instructions, provide
suggestions, opinion, information
Psychosocial Information Giving – statements regarding
stress, feelings, emotions, values, beliefs, psychological
outlook
Information Seeking – ask questions or opinion
Accompanied Vs. Unaccompanied Physician
Visit Communication Processes
(k=5 observational studies)
0 20
0.20
0.17 *
Effect Size r
0.15
0.10
0.04
0 05
0.05
0 03
0.03
0.01
0.00
-0.05
-0.06
-0.10
-0.05
-0.08
Positive Talk
Negative Talk
Patient
*P=0.01
-0.06
Biomedical
Information
Giving
Patient & Companion
-0.05
Psychosocial
Information
Giving
Physician
Information
Seeking
Accompanied
p
Versus
Unaccompanied Patient Outcomes
Results Average
Largest
Adjusted Effect Size Effect Size
Study
Outcome(s)
N
Prohaska
Patient-reported satisfaction,
knowledge, anxiety (6 items)
129
No
-0.09
-0.21
Greene
Patient-reported satisfaction
(1 item)
30
No
0.00
0.00
Labrecque
Patient-reported
Patient
reported satisfaction
(1 item)
473
Yes
0.00
0.00
Wolff
Patient-reported satisfaction with
usual provider (12 items)
12 018
12,018
Yes
0 09 *
0.09
0 10 *
0.10
Jansen
Objective data; Information recall
(11 items)
100
No
0.31 *
0.58 *
* Statistically significant at p<0.05
S
Summary
off Findings
Fi di
• 37% of adults are accompanied
p
to routine p
physician
y
visits by a companion.
• Accompanied patients are older, more likely to be
female, less educated, and in worse physical health
than unaccompanied patients
• Companions
C
i
are ttypically
i ll middle-aged,
iddl
d ffemale
l
spouses or adult children
• Physician visits are longer
longer, patients less verbally
active, physicians provide more biomedical
information when accompanied.
• Although not conclusive, results favored
p
((vs. unaccompanied)
p
)p
patient outcomes.
accompanied
Li it ti
Limitations
• R
Relatively
l ti l few
f
contributing
t ib ti studies
t di
• Secondary data analysis of published
information (existing measures, cut-points,
results)
• Limited information regarding companion
characteristics, reasons for involvement, and
family dynamics
• Heterogeneity of studies (patient populations,
study design, measures, outcomes)
I li ti
Implications
• P
Potential
t ti l role
l ffor companions
i
iin ffacilitate
ilit t
information exchange, activate patients,
i
improve
provider
id understanding
d t di off patient
ti t
health needs
• Ambiguity in role raises bioethical
considerations regarding patient autonomy
• Interventions to clarify companions’ role or
p
p
physician
y
skills
improve
• Patient centered medical home
THANKS!!
Funding:
g
NIMH grant K01MH082885, “Optimizing
Family Involvement in Late-Life
Late Life Depression
Care”
Contact:
Jennifer Wolff; jwolff@jhsph.edu
Summary of Visit Duration and Participant
Verbal Activity from Observational Studies
Pooled
Mean
Pooled Effect, r 3 Significance
PP-Value for
p
Accompanied
Unwtd
Wtd
Value Heterogeneity
4
5
Mean r; Mean r;
Z3
No
Yes
Duration of Visit k n
Length of Visit
(Mi t )
(Minutes)
6 883 24.6
24 6
29 8
29.8
0 13
0.13
0 19
0.19
4 28 <0.01
4.28
<0 01
0 21
0.21
Verbal Activity, by Participant (%)
Patient
3
0 45.5% 32.4%
-0.14
-0.16
-2.45 0.01
0.92
Patient &
C
Companion
i
3 307 45.5%
45 5% 47.3%
47 3%
0 02
0.02
0 02
0.02
0 35
0.35
0 73
0.73
0 88
0.88
Physician
3 307 54.4% 53.3%
-0.01
-0.02
-0.28 0.78
0.87
Note: Positive effect indicates accompanied visits longer or that activity longer in accompanied visits.
P-value of combined Z. P-values are two-tailed
P<0.10 is evidence of considerable heterogeneity.
Accompanied Patient Outcomes: Verbally
Active vs
vs. Less Active Companions
Study
Sample
Number
Items
Type of
Data
Results
Adjusted
Average
Effect Size
(95% CI)
Largest
Effect Size
(95% CI)
Studyy
Outcome(s)
()
Clayman
Patient decision
making
93
--
Objective
Yes
0.05
0.24
(-0.16,0.25) (0.03,0.41)
Street
Patient satisfaction
84
1
Patient
Report
No
0.18
0.18
(-0.04,0.38) (-0.04,0.38)
Wolff
Patient satisfaction
3,794
12
Patient
Report
Yes
00.15
15
(0.11,0.18)
00.19
19
(0.16,0.22)
Methods: Combining Findings
Average standard normal deviate (Z) and effect
size (r) extracted or computed from each study
– If not presented and could not be calculated but
conventional p-value reported, then associated onetailed z entered
– When study only stated estimated differences “not
significant” z designated as 0
Studies that contributed more than one result in
given category we entered average
R  Zr pooled weighted and unweighted
effect sizes ((r)) calculated
Positive r indicates communication process occurred
more commonly among accompanied patient visits
relative to unaccompanied patients
Methods: Data Extraction
Type of data: Observational (audio or videotaped) versus
patient report
p
p ((survey)
y)
Study sample: Sample size, study setting, provider type,
age criteria, country in which study conducted
Patient and companion attributes: age,
age gender
gender, physical
and mental health status, relationship of companion to
patient
Visit structure: duration of visit (minutes); patient,
companion, physician verbal activity
Communication process measures: (social conversation
conversation,
positive talk, negative talk, biomedical and
psychosocial information giving, information seeking)
Patient outcomes: activation,
activation satisfaction with care
care,
knowledge, confidence, motivation, skills proficiency,
adherence
Visit Dialogue (n=5 Observational Studies)
Visit Dialogue Profile by Category
Positive Talk/Social Role Function
Patient
Patient/companion (vs. patient)
Physician
Negative Talk
Patient
Patient/companion (vs. patient)
Physician
Information Giving
Biomedical
Patient
P ti t/
Patient/companion
i (vs.
( patient)
ti t)
Physician
Psychosocial
Patient
e
Patient/companion (vs. patient)
Physician
Information Seeking
Patient
Patient/companion (vs. patient)
Physician
n
P-Value for
Heteroneity3
2 175
1 145
3 648
0.68
--0.79
-0.06
---0.08
-0.87
---1.50
0.38
--0.13
--- --2 277
--- ---
--0.06
---
---0.05
---
---0.81
---
--0.42
---
3 205
3 205
3 648
0.65
0 63
0.63
0.18
0.04
0 00
0.00
0.17
0.68
0 35
0.35
2.57
0.50
0 73
0.73
0.01
3 205
05
3 205
2 175
0.
0.22
0.19
0.81
-0.06
0.06
-0.05
0.01
-1.27
. 7
-0.99
0.01
0. 0
0.20
0.32
0.99
--- --2 277
--- ---
--0.74
---
--0.03
---
--0.44
---
--0.66
---
k
Wtd Pooled Combined
PMean r 4
Z 4 Value 5