Can Patient–Provider Interpersonal Interventions Achieve the Quadruple Aim of Healthcare? A Systematic Review
Human connection is at the heart of medical care, but questions remain as to the effectiveness of interpersonal interventions. The purpose of this review was to characterize the associations between patient–provider interpersonal interventions and the quadruple aim outcomes (population health, patient experience, cost, and provider experience).
We sourced data from PubMed, EMBASE, and PsycInfo (January 1997–August 2017). Selected studies included randomized controlled trials and controlled observational studies that examined the association between patient–provider interpersonal interventions and at least one outcome measure of the quadruple aim. Two abstractors independently extracted information about study design, methods, and quality. We characterized evidence related to the objective of the intervention, type and duration of intervention training, target recipient (provider-only vs. provider–patient dyad), and quadruple aim outcomes.
Seventy-three out of 21,835 studies met the design and outcome inclusion criteria. The methodological quality of research was moderate to high for most included studies; 67% of interventions targeted the provider. Most studies measured impact on patient experience; improvements in experience (e.g., satisfaction, patient-centeredness, reduced unmet needs) often corresponded with a positive impact on other patient health outcomes (e.g., quality of life, depression, adherence). Enhanced interpersonal interactions improved provider well-being, burnout, stress, and confidence in communicating with difficult patients. Roughly a quarter of studies evaluated cost, but the majority reported no significant differences between intervention and control groups. Among studies that measured time in the clinical encounter, intervention effects varied. Interventions with lower demands on provider time and effort were often as effective as those with higher demands.
Simple, low-demand patient–provider interpersonal interventions may have the potential to improve patient health and patient and provider experience, but there is limited evidence that these interventions influence cost-related outcomes.
KEY WORDSinterpersonal interventions quadruple aim systematic review patient–provider communication
We would like to acknowledge Ted Miclau, Laura Jacobson, Shreyas Bharadwaj, and Isabella Romero for their assistance in data analysis and synthesis. We would also like to acknowledge Amrapali Maitra, Sheila Lahijani, and Lars Osterberg for their insightful contributions to this research study.
This study was supported by a grant from the Gordon and Betty Moore Foundation (#6382, Zulman & Verghese, PIs) and a grant from the Arthur Vining Davis Foundation. Drs. Haverfield and Schwartz are supported by VA Palo Alto Center for Innovation to Implementation (Ci2i) HSR&D postdoctoral fellowship.
Compliance with Ethical Standards
Conflict of Interest
There are no conflicts to disclose.
- 1.Verghese A, Charlton B, Cotter B, Kugler J. A history of physical examination texts and the conception of bedside diagnosis. Trans Am Clin Climatolo Assoc. 2011;122:290–311.Google Scholar
- 8.Hoerger M, Epstein RM, Winters PC, Fiscella K, Duberstein PR, Gramling R, et al. Values and options in cancer care (VOICE): study design and rationale for a patient-centered communication and decision-making intervention for physicians, patients with advanced cancer, and their caregivers. BMC Cancer 2013;13:188.PubMedPubMedCentralCrossRefGoogle Scholar
- 17.Wood JT. Interpersonal Communication: Everyday Encounters. 7th ed. Boston: Cengage Learning; 2013.Google Scholar
- 18.Cochrane Effective Practice and Organisation of Care (EPOC). EPOC Resources for review authors, 2017. Available at: https://www.epoc.cochrane.org/epoc-resources-review-authors
- 19.Phillips B BC, Sackett D, Badenoch D, Straus S, Haynes B, Dawes M. Oxford Centre for Evidence-Based Medicine—Level of Evidence [Internet]. Oxford: Oxford Centre for Evidence-Based Medicine; 1998 1998 Nov [updated 2009 Mar; cited 2018 Mar 29].Google Scholar
- 21.Aboumatar HJ, Carson KA, Beach MC, Roter DL, Cooper LA. The impact of health literacy on desire for participation in healthcare, medical visit communication, and patient reported outcomes among patients with hypertension. J Gen Intern Med 2013;28(11):1469–76.PubMedPubMedCentralCrossRefGoogle Scholar
- 26.Altiner A, Brockmann S, Sielk M, Wilm S, Wegscheider K, Abholz HH. Reducing antibiotic prescriptions for acute cough by motivating GPs to change their attitudes to communication and empowering patients: a cluster-randomized intervention study. J Antimicrob Chemother 2007;60(3):638–44.PubMedCrossRefGoogle Scholar
- 29.Bakker IM, Terluin B, van Marwijk HW, van der Windt DA, Rijmen F, van Mechelen W, et al. A cluster-randomised trial evaluating an intervention for patients with stress-related mental disorders and sick leave in primary care. PLoS Clinical Trials. 2007;2(6):e26.PubMedPubMedCentralCrossRefGoogle Scholar
- 30.Bashour HN, Kanaan M, Kharouf MH, Abdulsalam AA, Tabbaa MA, Cheikha SA. The effect of training doctors in communication skills on women’s satisfaction with doctor-woman relationship during labour and delivery: a stepped wedge cluster randomised trial in Damascus. BMJ Open. 2013;3(8).PubMedPubMedCentralCrossRefGoogle Scholar
- 34.Bieber C, Muller KG, Blumenstiel K, Schneider A, Richter A, Wilke S, et al. Long-term effects of a shared decision-making intervention on physician-patient interaction and outcome in fibromyalgia. A qualitative and quantitative 1 year follow-up of a randomized controlled trial. Patient Educ Couns. 2006;63(3):357–66.PubMedCrossRefGoogle Scholar
- 37.Blodt S, Mittring N, Schutzler L, Fischer F, Holmberg C, Horneber M, et al. A consultation training program for physicians for communication about complementary medicine with breast cancer patients: a prospective, multi-center, cluster-randomized, mixed-method pilot study. BMC Cancer. 2016;16(1):843.PubMedPubMedCentralCrossRefGoogle Scholar
- 39.Briel M, Langewitz W, Tschudi P, Young J, Hugenschmidt C, Bucher HC. Communication training and antibiotic use in acute respiratory tract infections. A cluster randomised controlled trial in general practice. Swiss Medical Wkly. 2006;136(15–16):241–7.Google Scholar
- 43.Cals JW, Ament AJ, Hood K, Butler CC, Hopstaken RM, Wassink GF, et al. C-reactive protein point of care testing and physician communication skills training for lower respiratory tract infections in general practice: economic evaluation of a cluster randomized trial. J Eval Clin Pract. 2011;17(6):1059–69.PubMedCrossRefGoogle Scholar
- 44.Cals JW, de Bock L, Beckers PJ, Francis NA, Hopstaken RM, Hood K, et al. Enhanced communication skills and C-reactive protein point-of-care testing for respiratory tract infection: 3.5-year follow-up of a cluster randomized trial. Ann Fam Med. 2013;11(2):157–64.PubMedPubMedCentralCrossRefGoogle Scholar
- 45.Cooper LA, Ghods Dinoso BK, Ford DE, Roter DL, Primm AB, Larson SM, et al. Comparative effectiveness of standard versus patient-centered collaborative care interventions for depression among African Americans in primary care settings: the BRIDGE Study. Health Serv Res. 2013;48(1):150–74.PubMedCrossRefGoogle Scholar
- 47.Curtis JR, Back AL, Ford DW, Downey L, Shannon SE, Doorenbos AZ, et al. Effect of communication skills training for residents and nurse practitioners on quality of communication with patients with serious illness: a randomized trial. JAMA. 2013;310(21):2271–81.PubMedPubMedCentralCrossRefGoogle Scholar
- 54.Epstein RM, Duberstein PR, Fenton JJ, Fiscella K, Hoerger M, Tancredi DJ, et al. Effect of a patient-centered communication intervention on oncologist-patient communication, quality of life, and health care utilization in advanced cancer: the VOICE randomized clinical trial. JAMA Oncol. 2017;3(1):92–100.PubMedPubMedCentralGoogle Scholar
- 55.Finnema E, Droes RM, Ettema T, Ooms M, Ader H, Ribbe M, et al. The effect of integrated emotion-oriented care versus usual care on elderly persons with dementia in the nursing home and on nursing assistants: a randomized clinical trial. Int J Geriatr Psychiatry. 2005;20(4):330–43.PubMedCrossRefGoogle Scholar
- 60.Griffey RT, Shin N, Jones S, Aginam N, Gross M, Kinsella Y, et al. The impact of teach-back on comprehension of discharge instructions and satisfaction among emergency patients with limited health literacy: a randomized, controlled study. J Commun Healthc. 2015;8(1):10–21.PubMedPubMedCentralCrossRefGoogle Scholar
- 69.Kinmonth AL, Woodcock A, Griffin S, Spiegal N, Campbell MJ. Randomised controlled trial of patient centred care of diabetes in general practice: impact on current wellbeing and future disease risk. The Diabetes Care From Diagnosis Research Team. BMJ. 1998;317(7167):1202–8.PubMedPubMedCentralCrossRefGoogle Scholar
- 73.Lonsdale C, Hall AM, Murray A, Williams GC, McDonough SM, Ntoumanis N, et al. Communication skills training for practitioners to increase patient adherence to home-based rehabilitation for chronic low back pain: results of a cluster randomized controlled trial. Arch Phys Med Rehabil. 2017;98(9):1732–43.e7.PubMedCrossRefGoogle Scholar
- 77.Mercer SW, Fitzpatrick B, Guthrie B, Fenwick E, Grieve E, Lawson K, et al. The CARE Plus study—a whole-system intervention to improve quality of life of primary care patients with multimorbidity in areas of high socioeconomic deprivation: exploratory cluster randomised controlled trial and cost-utility analysis. BMC Med. 2016;14(1):88.PubMedPubMedCentralCrossRefGoogle Scholar
- 80.Moral RR, Torres LA, Ortega LP, Larumbe MC, Villalobos AR, Garcia JA, et al. Effectiveness of motivational interviewing to improve therapeutic adherence in patients over 65 years old with chronic diseases: a cluster randomized clinical trial in primary care. Patient Educ Couns. 2015;98(8):977–83.PubMedCrossRefGoogle Scholar
- 94.Ackley BJ SB, Ladwig G, Tucker S. Evidence-Based Nursing Care Guidelines: Medical-Surgical Interventions. 1 ed. St. Louis: Mosby Elsevier; 2007.Google Scholar