Family presence in routine medical visits: A meta-analytical review

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Abstract

Older adults are commonly accompanied to routine physician visits, primarily by adult children and spouses. This is the first review of studies investigating the dynamics and consequences of patient accompaniment. Two types of evidence were examined: (1) observational studies of audio and/or videotaped medical visits, and (2) surveys of patients, families, or health care providers that ascertained experiences, expectations, and preferences for family companion presence and behaviors in routine medical visits. Meta-analytic techniques were used to summarize the evidence describing attributes of unaccompanied and accompanied patients and their companions, medical visit processes, and patient outcomes. The weighted mean rate of patient accompaniment to routine adult medical visits was 37.6% in 13 contributing studies. Accompanied patients were significantly older and more likely to be female, less educated, and in worse physical and mental health than unaccompanied patients. Companions were on average 63 years of age, predominantly female (79.4%), and spouses (54.7%) or adult children (32.2%) of patients. Accompanied patient visits were significantly longer, but verbal contribution to medical dialog was comparable when accompanied patients and their family companion were compared with unaccompanied patients. When a companion was present, health care providers engaged in more biomedical information giving. Given the diversity of outcomes, pooled estimates could not be calculated: of 5 contributing studies 0 were unfavorable, 3 inconclusive, and 2 favorable for accompanied relative to unaccompanied patients. Study findings suggest potential practical benefits from more systematic recognition and integration of companions in health care delivery processes. We propose a conceptual framework to relate family companion presence and behaviors during physician visits to the quality of interpersonal health care processes, patient self management and health care.

Introduction

There is little dispute that families are relevant to health and health care. Family involvement has been articulated as one of six dimensions of patient-centered care (Gerteis, Edgman-Levitan, & Daley, 1993), and a central tenant of chronic care processes (The MaColl Institute). Numerous studies empirically demonstrate the relevance of family to patients’ engagement in medical decision-making (Clayman, Roter, Wissow, & Bandeen-Roche, 2005), satisfaction with physician care (Wolff & Roter, 2008), treatment adherence (DiMatteo, 2004), quality of health care processes (Glynn et al., 2006, Vickrey et al., 2006), physical and mental health (Seeman, 2000), and mortality (Christakis & Allison, 2006). Yet despite a broad appreciation that families matter, specific knowledge regarding which actions and behaviors undertaken by family members are most helpful, or efficacious in improving health, is limited. The complexity of family attributes and dynamics and capacity to both benefit and exacerbate health and health care (DiMatteo, 2004, Seeman, 2000), complicate measurement and intervention efforts. A better understanding of the pathways by which families and friends exert their influence within routine medical visits could inform efforts to improve the patient-physician partnership as well as chronic care innovations, such as the patient-centered medical home.

Building on the conceptual underpinnings of high quality chronic care, innovative approaches have been developed to equip patients with the tools, skills, and information to self manage health care (IOM, 2008). However these approaches may be less applicable to older, less literate, and chronically ill patients, who are less assertive and less interested in shared decision-making, (Arora and McHorney, 2000, Ende et al., 1989, Levinson et al., 2005) and for whom primary care visit time constraints are especially problematic (Fiscella & Epstein, 2008). That older, less literate, and sicker patients are most likely to be accompanied to routine physician visits (Wolff & Roter, 2008), raises the possibility that optimizing family involvement in routine medical visits may present a viable strategy for improving chronic care processes for this challenging patient population.

The term “family” is used throughout this manuscript given evidence that it is most often spouses and adult children who accompany patients to health care encounters (Wolff & Roter, 2008), however the term is used broadly, and meant to encompass friends who may also be present and involved in physician visits. The importance and implications of family as providers of assistance in the home and community (e.g., as “family caregivers”) and in negotiating health system logistics, has been established (IOM, 2008). In this paper, we focus more narrowly on the presence and behaviors of family within older adults’ routine face-to-face medical encounters. The salience of family involvement in medical visit dialog is considered conceptually and empirically in relation to interpersonal processes, patient self management and quality of care.

We have developed a framework that depicts how patients, families, and professional caregivers interact and the pathways by which family companions influence interpersonal processes and outcomes of medical encounters (Fig. 1). The context within which health care is delivered is shaped by patients’ homes, communities, and local health care and community service systems. Patient, family, and provider attributes are brought to bear on interpersonal processes during physician office visits, shown at the center of the model. Coordination of care is shown in our model as emanating from triadic patient-family-provider exchanges that span time and place. The replication of linked triadic dialog is depicted across health care settings that include but are not limited to: physician office visits, pharmacy and outpatient services, and hospital and other post-acute care settings. Although the model depicts patient outcomes and quality of care as emanating from physician office visit processes, we believe that the collective replication and linkages of triadic communication processes across a range of health care settings, and with a variety of health care professionals has a bearing in regard to whether quality outcomes are achieved.

To further elaborate on our framework, three defined, albeit interrelated, aspects of interpersonal processes (1) relationship rapport, (2) information exchange, and (3) medical decision-making, are described in relation to accompanied patients’ medical visits. Relationship rapport refers to trust, empathy, respect, genuineness, and mutuality to support the establishment of a productive alliance among all parties (patient, family companion, provider). In general, physician communication patterns that are less dominant and more participatory and empathetic engender positive rapport (Schmid Mast et al., 2008, Street et al., 2009). However, physicians employ more paternalistic, biomedical communication with the types of patients who tend to be accompanied --- older, sicker, and socially disadvantaged patients (Fiscella and Epstein, 2008, Hall et al., 1993, Hall et al., 2002, Roter et al., 1997).

Information exchange, the giving and receiving of knowledge about patients’ health, symptoms, values, preferences, beliefs, and treatments, is a central function of health care encounters (Makoul, 2001). Providers require information from patients for accurate diagnosis and relevant treatment. Patients require information from providers regarding the nature and expected course of their condition as well as treatment options, benefits, side effects, and uncertainty. Information exchange is especially challenging for medically complex patients with more extensive physical symptoms and psychosocial stresses; the types of patients who tend to be accompanied. Given constraints on physician time and limited flexibility in visit length (Chen et al., 2009, Tai-Seale et al., 2007), there is less opportunity for medically complex patients to adequately disclose and discuss their health information. Older and less literate patients have been shown to prefer physician-directed care (Arora and McHorney, 2000, Ende et al., 1989, Levinson et al., 2005), and to ask fewer questions, express fewer concerns, and to be less apt to seek clarification of information (Arora and McHorney, 2000, Eggly et al., 2006). These communication patterns may suggest to physicians that patients are uninterested in visit dialog, or unwilling to engage in discussion.

Although patients vary in their preferences for sharing health care decision-making responsibilities with health care providers (Ende et al., 1989, Levinson et al., 2005) the “shared” medical decision-making paradigm has been embraced in recent years as particularly relevant to chronic care, where patient responsibilities and actions largely determine success (Murray, Charles, & Gafni, 2006). At its most basic level, the paradigm implies that clinical issues and options are defined and explained in an understandable manner and in sufficient detail (relative merits, drawbacks, and uncertainties) so that the patient may assess them within the context of their own preferences and values (Charles et al., 1999, Murray et al., 2006). While beginning to change (Edwards & Elwyn, 2009), much of the decision-making literature has focused on a single treatment in light of a well-defined serious or life threatening illness (Charles et al., 1999). The chronic care decision-making paradigm is in many ways less straightforward due to the greater number of potential issues for discussion, the fact that decision-making occurs iteratively across time and in consultation with a variety of stakeholders (such as family), and ambiguity regarding which decisions are most urgent (Murray et al., 2006). Given limited time and competing issues, negotiation to establish a visit agenda may be an important part of the chronic care decision-making process.

It is our hypothesis that family companions exert a largely positive influence on medical visit dialog by improving patient-provider relationship rapport, facilitating information exchange, and engaging patients in medical decision-making. We further surmise that family companions’ involvement extends beyond the medical encounter to health care management at home and in the community. We believe that family involvement in interpersonal health care processes has a bearing on the quality of patients’ health care, as defined by indices specified by the IOM. For example, family companions’ facilitate information transfer and coherent service use across time and health care settings, such as among patients discharged from the hospital to home (efficiency). Families motivate patients to adhere to treatment regimens on a daily basis (effectiveness), initiate contact with health professionals to report on emerging conditions or symptom exacerbation (timeliness; safety), and advocate on behalf of patients for services, benefits, and provider attentiveness to patients’ preferences and needs (patient-centeredness; equity). The extent to which families are acknowledged and supported by providers may also be influential to their own well being; it has been suggested that most patients would amend intended treatment goals to encompass the experiences and perspectives of their families (Berwick, 2009).

While the broad and reciprocal pathways by which family involvement in interpersonal health care processes influence a wide range of health and health care outcomes, the focus of this paper is limited to family companions and their behaviors during office visits. Studies describing family companions’ contributions to medical visit dialog are relatively few in number and have not been systematically reviewed to date. To this end, we review empirical evidence from the published literature to describe what is currently known regarding whether and how the presence of a family companion has a bearing on interpersonal processes within the context of routine medical encounters, as well as patient outcomes and quality of health care. Our goal is to construct a unifying framework for considering this body of work, to evaluate and summarize methods and findings from relevant studies, and to consider implications of study findings with regard to future directions in chronic care endeavors.

Section snippets

Search strategies and inclusion criteria

To be included in this review, studies had to: (1) have been published in an English language journal, (2) describe medical visit interactions between adult patients and health care professionals, and (3) present quantitative information regarding patient accompaniment as it relates to any of the following: patient or family companion attributes, visit structure, communication processes, and/or outcomes of care. Studies restricted to pediatric patients, to hospitalized or terminally ill

How frequently are adult patients accompanied to physician office visits?

The mean rate of accompaniment to routine adult physician visits was 46.1% in 13 studies that reported on the presence of a family companion (top panel of Table 2). The proportion of patients who were accompanied to medical visits was lower in studies that relied on patient surveys or interviews (37.3%) as compared with observational studies (56.3%; of 6 contributing studies, 4 were oncology patient populations). The mean, weighted mean, and median rate of patient accompaniment was comparable

Discussion

This study finds that family companions are commonly present in older adults’ routine medical visits and that they typically accompany patients who are older, less educated, and who have more extensive physical and mental health needs than patients who are unaccompanied. Drawing from studies that were conducted in a range of settings and that employed a variety of methodological approaches, 37% of adult patients were found to be accompanied to routine medical visits by a family companion, most

Acknowledgments

This study was supported by National Institute of Mental Health grant K01MH082885 "Optimizing Family Involvement in Late-Life Depression Care" (JLW).

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