Unannounced standardized patient assessment of the roter interaction analysis system: the challenge of measuring patient-centered communication.

Abstract

Despite wide-spread endorsement of patient-centered communication (PCC) in health care, there has been little evidence that it leads to positive change in health outcomes. The lack of correlation may be due either to an overestimation of the value of PCC or to a measurement problem. If PCC measures do not capture elements of the interaction that determine whether the resulting care plan is patient-centered, they will confound efforts to link PCC to outcomes. To evaluate whether one widely used measure of PCC, the Roter Interaction Analysis System (RIAS), captures patient-centered care planning. RIAS was employed in the coding of unannounced standardized patient (USP) encounters that were scripted so that the failure to address patient contextual factors would result in an ineffective plan of care. The design enabled an assessment of whether RIAS can differentiate between communication behavior that does and does not result in a care plan that takes into account a patient's circumstances and needs. Eight actors role playing four scripted cases (one African American and one Caucasian for each case) in 399 visits to 111 internal medicine attending physicians. RIAS measures included composites for physician utterance types and (in separate models) two different previously applied RIAS patient-centeredness summary composites. The gold standard comparison measure was whether the physician's treatment plan, as abstracted from the visit note, successfully addressed the patient's problem. Mixed effects regression models were used to evaluate the relationship between RIAS measures and USP measured performance, controlling for a variety of design features. None of the RIAS measures of PCC differentiated encounters in which care planning was patient-centered from care planning in which it was not. RIAS, which codes each utterance during a visit into mutually exclusive and exhaustive categories, does not differentiate between conversations leading to and not leading to care plans that accommodate patients' circumstances and needs.