EXHORTATIONS to promote greater engagement of patients in their own health care pepper the rhetoric of health care leaders and policy documents, but the practical implications are rarely spelled out. The focus on patient engagement stems from a belief that the actions of health professionals constitute only part of the effort necessary to help people cope with the effects of illness or disability and restore them to the best possible state of health. An equally, if not more, important part is played by patients themselves, their families, and communities as coproducers of health (Table 1).
Several themes emerge whenever patients are asked about their priorities. Most people want the security of knowing that they will be able to access timely, reliable, effective, and safe health care when they need it; that they will be given adequate information and support to participate in decisions that affect them; that clinical staff will accord them empathy, dignity, and respect; that they will be told about the options for treating or managing their condition and their preferences will be taken into account; and that they will not have to worry about the financial consequences of being ill (Coulter, 2005). Care that achieves these goals is deemed to be patient centered (Mead & Bower, 2000). These attributes are important, not just because people prefer to be treated by clinicians who are good listeners and good at informing, advising, and educating them, but also because it is hoped that this type of care may contribute to better health outcomes. There are indications that patient-centered care may indeed improve outcomes. For example, studies have found that patients whose treatment is deemed patient centered are more likely to trust their clinicians, (Keating et al., 2002) more likely to adhere to treatment recommendations, (Haynes et al., 2008) and less likely to die following a major event such as acute myocardial infarction (Meterko et al., 2010).
So the goal is to support and strengthen patients' determinations of their health care needs and self-care efforts with a view to obtaining maximum value and improved health outcomes. If patients are to play a more effective role they must be better supported, be better informed, be more discriminating about the effects of medical treatment, and have more opportunities for participation. Those working in ambulatory care have a key part to play in enabling greater patient engagement, but the evidence that should guide their efforts is widely dispersed in a broad range of disciplines and journals. There is a need to make it more accessible to busy practitioners to ensure that effective strategies are prioritized. This article summarizes key points from 3 linked sources that have attempted that task: an overview of systematic reviews looking at the effects on informing, educating, and involving patients (Coulter & Ellins, 2007), a summary of the evidence on patient engagement strategies originally published as part of a Web tool, (Picker Institute Europe, 2010a) and a book that reviewed theories, concepts, and evidence on the broad topic of patient engagement (Coulter, 2011). The Web tool included tables summarizing the “best buys” derived from this overview. Extracts from these are reproduced here in a revised and updated format.
IMPROVING HEALTH LITERACY
Health literacy is the ability to read, understand and act upon health information, essential skills for making appropriate health decisions (Institute of Medicine of the National Academies, 2004). Low health literacy is associated with more hospitalizations, greater use of emergency care, lower use of screening and vaccination programs, less adherence to treatment recommendations, worse health status, and higher mortality rates (Berkman et al. 2011). Improving health literacy is critically important in tackling health inequalities (“Health Literacy”, 1999). Even people with good basic literacy and numeracy skills may struggle to understand and interpret health information in a way that prompts them to act appropriately to protect or enhance their health. Although tackling low levels of health literacy requires carefully developed approaches targeted at those with special needs, it is also important to address the health information needs of the whole population. Because health literacy is central to enhancing involvement of patients in their care, all strategies designed to strengthen patient engagement should focus on improving health literacy.
Efforts to improve levels of health literacy among disadvantaged groups take many forms, including formal health education in schools, colleges, and adult learning centers, educational courses for small groups, peer support groups, and one-to-one counseling with health professionals. The good news is that people's knowledge and capability to manage their own health can be improved, especially when it is tailored to their particular needs (Hibbard et al., 2009). The bad news is that relying on educational programs on their own is insufficient to narrow the gap in health outcomes (Pignone et al. 2005). For example, despite the fact that group educational programs are routinely provided for pregnant women, there is very little evidence that the effects of these extend beyond minor knowledge gains and social contact with other mothers, which in itself can be useful but is unlikely to impact on health inequalities (Gagnon & Sandall, 2007). Part of the problem lies in the fact that educational programs have tended to use traditional didactic methods that may not be well received by people who struggled with these when they were at school. Directive styles of teaching and advice giving tend to generate resistance or a sense of hopelessness in those on the receiving end. More engaging methods, such as motivational interviewing, may prove more successful (Rollnick et al., 2010). A systematic review of 72 studies found that using motivational interviewing to stimulate healthy behaviors worked much better than traditional advice giving (Rubak et al., 2005). This calls for greater emphasis on encouraging patients to determine their own goals for behavior change instead of simply complying with the professional's agenda.
Various strategies for improving patients' health literacy have been evaluated in systematic reviews (Table 2). There is evidence that patient information materials (printed and electronic) can have a beneficial effect on patients' knowledge and understanding of their condition (Kinnersley et al., 2007; Stacey et al., 2011). Specially targeted interventions can help to increase knowledge and understanding in people with low health literacy if they are well designed (Pignone et al., 2005). The impact is greater when written information is personalized and reinforced by verbal information from clinicians (Clement et al., 2009; Haynes et al., 2008; Johnson et al., 2003). The provision of written and electronic information can help to increase patients' sense of empowerment. It can also improve their ability to cope and may help to reduce anxiety in certain cases (Bessell et al., 2002; Eysenbach, 2003; Eysenbach et al., 2004; Wofford et al., 2005). Preoperative and predischarge information may help to reduce consultations, length of stay in hospital, and follow-up visits (Chan et al., 2011; Johansson et al., 2004, 2005; McDonald et al., 2004; McDonnell, 1999; Santo et al., 2005). There is also some evidence of a beneficial impact on health behavior, uptake of screening, and improved clinical outcomes resulting from e-learning programs and “virtual” support (Murray et al., 2005). Well-designed printed and electronic information materials can help to improve patients' knowledge and understanding of their condition, but these must be well targeted and available at the right time (Murray et al., 2005; Skinner et al., 1999). Information has greater impact when it is personalized and reinforced by verbal information from clinicians. There is also evidence that different components of telehealth (telephone helplines, telecoaching, and telemonitoring) can reduce social isolation, increase decision-making confidence, and improve satisfaction (Jennett et al., 2003; Mair & Whitten, 2000). One review concluded that structured telephone support and telemonitoring are effective in reducing mortality and hospitalizations for patients with chronic heart failure (Inglis et al., 2010).
HELPING PATIENTS MAKE APPROPRIATE HEALTH DECISIONS
Shared decision making is a process in which clinicians and patients work together to select tests, treatments, management, or support packages, based on clinical evidence and the patient's informed preferences. It involves the provision of evidence-based information about options, outcomes, and uncertainties, together with decision support counseling and a system for recording and implementing patients' informed preferences (see Barry, this issue). Patient decision aids have been developed to support the process. These take a variety of forms, spanning everything from simple 1-page sheets outlining the options, through more detailed leaflets or computer programs, to DVDs or interactive Web sites that include filmed interviews with patients and professionals to help patients understand their choices.
Much of the research evidence about shared decision making has focused on major health decisions where there is more than one feasible option, and on screening tests and preventive strategies, and self-management support for chronic conditions (Table 3). Evaluations of various types of support for shared decision making show it can contribute to more participation, improved knowledge and understanding, more accurate risk perceptions, greater comfort with decisions, fewer patients choosing major surgery, better treatment adherence, improved confidence and coping skills, improved health behaviors, and more appropriate service use (Bodenheimer et al., 2002; Loveman et al., 2008; Mosen et al., 2007; Murray et al., 2005; Ryan et al., 2010; Stacey et al., 2011; Wennberg et al., 2010). “Active” patients are better equipped to make informed and personally relevant decisions about their care, but those with lower levels of activation, low levels of health literacy, and inadequate encouragement and support tend to defer to clinicians as decision makers and often remain at low levels of activation. It may also be cost-effective, but the evidence on this is limited at present (Kennedy et al., 2002; Wennberg et al., 2010).
Other types of interventions have been developed to enhance patients' confidence to play a more active role in clinical consultations, including the provision of prompt sheets to encourage patients to ask questions about their treatment options. Question prompts can help to increase the number of questions asked in consultations. This does not always lead to improvements in patients' knowledge; however, studies have produced mixed results (Gaston & Mitchell, 2005; Harrington et al., 2004; Kinnersley et al., 2007; Wetzels et al., 2008).
Personalized care planning is another form of shared decision making. In this case, people who live with long-term conditions are offered scheduled appointments to discuss the treatment, care, and support they want to optimally manage their own health. Relevant support can be given in clinical consultations, but it can also be provided outside the consultation by offering counseling provided by trained health coaches, face-to-face, on the telephone, or on the Internet. Health coaches use motivational interviewing techniques that respect patients' autonomy and help them make health choices that fit with their preferences and situation (Rollnick et al., 2002). There is evidence that targeted health coaching can have a beneficial effect on risk factors and health outcomes, leading to lower mortality rates and improvements in health behaviors (Clark et al., 2010; Hutchison & Breckon, 2011; Neubeck et al., 2009).
A great many studies have been carried out to evaluate different types of self-management support in specific groups of patients; for example, those with arthritis, asthma, cancer, heart disease, chronic obstructive pulmonary disease, diabetes, epilepsy, HIV/AIDS, hypertension, mental illness, and stroke (Picker Institute Europe, 2010b). People with chronic conditions have benefited from short self-management courses where they learn from other people with the same chronic condition (Lorig et al., 2001). This type of self-help education can bring benefits in terms of improvements in knowledge, coping behavior, adherence to treatment recommendations, and self-efficacy, and modest short-term improvements in pain, disability, fatigue, and depression (Chodosh et al., 2005; Foster et al., 2007). Complex collaborative care techniques have been shown to reduce depression, but there is only limited evidence that educational programs have a beneficial effect on people with psychological problems. One-to-one support or group support that is professionally led and integrated into primary care may be more effective for some conditions than lay-led courses, but studies have shown mixed effects. Most trials have looked at short-term outcomes only, so there are still questions about what needs to be done to ensure results are sustained over the longer term.
IMPROVING THE QUALITY OF CARE PROCESSES
Gathering systematic feedback on patients' experiences is a key element in monitoring and improving the quality of health care (Table 4). Feedback can be obtained using quantitative (surveys) or qualitative (narrative) methods gathered during or after an episode of care. Asking patients to respond to surveys is a relatively passive form of engagement, but these can be a useful for pinpointing problems that may lead to more active involvement. The Consumer Assessment of Health Plans Surveys are a good example of carefully designed instruments that capture the essence of what patients deem to be important and also correlate with indicators of clinical quality (Isaac et al., 2010; Schneider et al., 2001). The bodies that fund or coordinate these surveys hope that patients will use them to select providers, thereby incentivizing quality improvements, but evidence on the likely effectiveness of this strategy is mixed (Faber et al., 2009; Fung et al., 2008). Although some patients seek out information about the quality of care, it is not evident that provider choice per se drives up quality standards. However, the fact that performance data are now publicly available does seem to have had an impact on providers, in some cases stimulating them to implement quality improvements (Friedberg et al., 2011).
In addition to measuring the quality of care delivery, patients' reports can be used to measure the outcomes of clinical care. Patient-reported outcome measures are standardized, validated instruments to measure patients' perceptions of their health status (impairment), their functional status (disability), and their health-related quality of life (well-being). Often used alongside clinical indicators and measures of patients' experience, they fill an important gap in the measurement of the impact of symptoms and treatments on social functioning and quality of life (Bream & Black, 2009). Feedback from patient-reported outcome measures can improve diagnosis and management of patients' conditions, particularly in mental health, and can help to increase patient participation in consultations (Haywood et al., 2006; Marshall et al., 2006).
Simply gathering performance data and publishing it or presenting it to staff appears insufficient to stimulate change; stronger incentives are required (Davies & Cleary, 2005). Factors that can help include committed and engaged leadership; regular monthly or quarterly feedback reports; an organization-wide approach with strong quality improvement structures; adoption of clear, focused goals; involvement of patients and families in developing action plans; and financial incentives (Davies et al., 2008). Pay-for-performance incentives linked to primary care patient surveys have been shown to lead to significant improvements in communication and care coordination (Rodriguez et al., 2009).
Sustaining quality improvement requires organization-wide cultural change. For example, a study of 6 academic medical centers looked at how they tackled the task of implementing patient and family-centered care across their organizations. The process was triggered by entirely different events in each organization, never followed a straight line, was led at different levels in the organization and moved at different paces, yet they shared several important characteristics, including visionary leadership, integration of patient-centered principles into recruitment and other human resource policies, and active involvement of patients and families in the process of planning and implementing change (Shaller & Darby, 2009).
The training (or retraining) of health professionals is key to achieving improvements in health care quality. In addition to biomedical knowledge and technical skills, health professionals must learn how to interact with and care for patients. This may involve transforming traditional consulting styles to enable greater patient involvement (Stevenson et al., 2004). Patient-centered communication and longer consultations are associated with improved care management and greater clinical effectiveness in primary care (Wilson & Childs, 2002). There is evidence that, with effective teaching and ample opportunity to practice, effective interpersonal skills can be learnt and reproduced, resulting in better, more participative consultations. For example, trainees can be taught how to express empathy (Bonvicini et al., 2009), how to break bad news (Makoul et al., 2010), and how to practice shared decision making (Bieber et al., 2009). Well-designed training programs can increase the patient centeredness of consultations leading to improved patient satisfaction (Gysels et al., 2004; Lewin et al., 2001). There remains a question mark, however, about the extent to which these skills can be sustained when faced with the real world of a busy clinic.
This review is, of necessity, selective rather than comprehensive, and broad brush in its approach. Some studies have produced conflicting or negative results and the evidence of benefit is not always clear-cut. Nevertheless what I have tried to do is to give an honest account of the balance of the evidence drawn, wherever possible, from high quality systematic reviews. The important points to note are (a) contrary to popular belief there is a great deal of published evidence on the likely effectiveness of patient engagement strategies and (b) there is a compelling case for reviewing and, where necessary, adapting health care delivery and practice styles to enable active engagement of patients in planning and shaping their health care.
Berkman N. D., Sheridan S. L., Donahue K. E., Halpern D. J., Crotty K. (2011). Low health literacy and health outcomes: an updated systematic review. Annals of Internal Medicine, 155(2), 97–107.
Bessell T. L., McDonald S., Silagy C. A., Anderson J. N., Hiller J. E., Sansom L. N. (2002). Do Internet interventions for consumers cause more harm than good? A systematic review. Health Expectations, 5(1), 28–37.
Bieber C., Nicolai J., Hartmann M., Blumenstiel K., Ringel N., Schneider A., Loh A. (2009). Training physicians in shared decision-making-who can be reached and what is achieved? Patient Education and Counseling, 77(1), 48–54.
Bodenheimer T., Wagner E. H., Grumbach K. (2002). Improving primary care for patients with chronic illness: the chronic care model, Part 2. JAMA, 288(15), 1909–1914.
Bonvicini K. A., Perlin M. J., Bylund C. L., Carroll G., Rouse R. A., Goldstein M. G. (2009). Impact of communication training on physician expression of empathy in patient encounters. Patient Education and Counseling, 75(1), 3–10.
Bream E., Black N. (2009). What is the relationship between patients' and clinicians' reports of the outcomes of elective surgery? Journal of Health Services Research and Policy, 14(3), 174–82.
Chan R. J., Webster J., Marquart L. (2011). Information interventions for orienting patients and their carers to cancer care facilities. Cochrane Database of Systematic Reviews, 12, CD008273. doi:10.1002/14651858.CD008273.pub2
Chodosh J., Morton S. C., Mojica W., Maglione M., Suttorp M. J., Hilton L., Shekelle P. (2005). Meta-analysis: Chronic disease self-management programs for older adults. Annals of Internal Medicine, 143(6), 427–438.
Clark A. M., Haykowsky M., Kryworuchko J., MacClure T., Scott J., DesMeules M., McAlister F. A. (2010). A meta-analysis of randomized control trials of home-based secondary prevention programs for coronary artery disease. European Journal of Cardiovascular Prevention and Rehabilitation, 17(3), 261–70.
Clement S., Ibrahim S., Crichton N., Wolf M., Rowlands G. (2009). Complex interventions to improve the health of people with limited literacy: A systematic review. Patient Education and Counseling, 75(3), 340–351.
Coulter A. (2005). What do patients and the public want from primary care? BMJ, 331(7526), 1199–1201.
Coulter A. (2011). Engaging patients in healthcare. New York, NY: McGraw-Hill Education.
Coulter A., Ellins J. (2007). Effectiveness of strategies for informing, educating, and involving patients. BMJ, 335(7609), 24–27.
Davies E., Cleary P. D. (2005). Hearing the patient's voice? Factors affecting the use of patient survey data in quality improvement. Quality & Safety in Health Care, 14(6), 428–432.
Davies E., Shaller D., Edgman-Levitan S., Safran D. G., Oftedahl G., Sakowski J., Cleary P. D. (2008). Evaluating the use of a modified CAHPS survey to support improvements in patient-centred care: lessons from a quality improvement collaborative. Health Expectations, 11(2), 160–176.
Eysenbach G. (2003). The impact of the Internet on cancer outcomes. CA: A Cancer Journal for Clinicians, 53(6), 356–371.
Eysenbach G., Powell J., Englesakis M., Rizo C., Stern A. (2004). Health related virtual communities and electronic support groups: Systematic review of the effects of online peer to peer interactions. BMJ, 328(7449), 1166.
Faber M., Bosch M., Wollersheim H., Leatherman S., Grol R. (2009). Public reporting in health care: How do consumers use quality-of-care information? A systematic review. Medical Care, 47(1), 1–8.
Foster G., Taylor S. J., Eldridge S. E., Ramsay J., Griffiths C. J. (2007). Self-management education programmes by lay leaders for people with chronic conditions. Cochrane Database of Systematic Reviews, (4), CD005108.
Friedberg M. W., SteelFisher G. K., Karp M., Schneider E. C. (2011). Physician groups' use of data from patient experience surveys. Journal of General Internal Medicine, 26(5), 498–504.
Fung C. H., Lim Y. W., Mattke S., Damberg C., Shekelle P. G. (2008). Systematic review: the evidence that publishing patient care performance data improves quality of care. Annals of Internal Medicine, 148(2), 111–123.
Gagnon A. J., Sandall J. (2007). Individual or group antenatal education for childbirth or parenthood, or both. Cochrane Database of Systematic Reviews, (3), CD002869.
Gaston C. M., Mitchell G. (2005). Information giving and decision-making in patients with advanced cancer: A systematic review. Social Science and Medicine, 61(10), 2252–2264.
Gysels M., Richardson A., Higginson I. J. (2004). Communication training for health professionals who care for patients with cancer: A systematic review of effectiveness. Supportive Care in Cancer, 12(10), 692–700.
Harrington J., Noble L., Newman S. (2004). Improving patients' communication with doctors: A systematic review of intervention studies. Patient Education and Counseling, 52(1), 7–16.
Haynes R. B., Ackloo E., Sahota N., McDonald H. P., Yao X. (2008). Interventions for enhancing medication adherence. Cochrane Database of Systematic Reviews, (2), CD000011.
Haywood K., Marshall S., Fitzpatrick R. (2006). Patient participation in the consultation process: A structured review of intervention strategies. Patient Education and Counseling, 63(1–2), 12–23.
Health literacy: Report of the Council on Scientific Affairs, Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, American Medical Association. (1999). JAMA, 281(6), 552–557.
Hibbard J. H., Greene J., Tusler M. (2009). Improving the outcomes of disease management by tailoring care to the patient's level of activation. American Journal of Managed Care, 15(6), 353–360.
Hutchison A. J., Breckon J. D. (2011). A review of telephone coaching services for people with long-term conditions. Journal of Telemedicine and Telecare, 17(8), 451–8.
Inglis S. C., Clark R. A., McAlister F. A., Ball J., Lewinter C., Cullington D., Cleland J. G. (2010). Structured telephone support or telemonitoring programmes for patients with chronic heart failure. Cochrane Database of Systematic Reviews, (8), CD007228.
Institute of Medicine of the National Academies. (2004). Health Literacy: A prescription to end confusion. Washington, DC: The National Academies Press.
Isaac T., Zaslavsky A. M., Cleary P. D., Landon B. E. (2010). The relationship between patients' perception of care and measures of hospital quality and safety. Health Services Research, 45(4), 1024–1040.
Jennett P. A., Affleck Hall L., Hailey D., Ohinmaa A., Anderson C., Thomas R., Scott R. E. (2003). The socio-economic impact of telehealth: A systematic review. Journal of Telemedicine and Telecare, 9(6), 311–320.
Johansson K., Salanterä S., Heikkinen K., Kuusisto A., Virtanen H., Leino-Kilpi H. (2004). Surgical patient education: Assessing the interventions and exploring the outcomes from experimental and quasi-experimental studies from 1990 to 2003. Clinical Effectiveness in Nursing, 8, 81–92.
Johansson K., Nuutila L., Virtanen H., Katajisto J., Salanterä S. (2005). Preoperative education for orthopaedic patients: Systematic review. Journal of Advanced Nursing, 50(2), 212–223.
Johnson A., Sandford J., Tyndall J. (2003). Written and verbal information versus verbal information only for patients being discharged from acute hospital settings to home. Cochrane Database of Systematic Reviews, (4), CD003716. doi:10.1002/14651858.CD003716
Keating N. L., Green D. C., Kao A. C., Gazmararian J. A., Wu V. Y., Cleary P. D. (2002). How are patients' specific ambulatory care experiences related to trust, satisfaction, and considering changing physicians? Journal of General Internal Medicine, 17(1), 29–39.
Kennedy A. D., Sculpher M. J., Coulter A., Dwyer N., Rees M., Abrams K. R., Stirrat G. (2002). Effects of decision aids for menorrhagia on treatment choices, health outcomes, and costs: A randomized controlled trial. JAMA, 288(21), 2701–2708.
Kinnersley P., Edwards A., Hood K., Cadbury N., Ryan R., Prout H., Butler C. (2007). Interventions before consultations before helping patients address their information needs. Cochrane Database of Systematic Reviews, (3), CD004565. doi:10.1002/14651858
Lewin S. A., Skea Z. C., Entwistle V., Zwarenstein M., Dick J. (2001). Interventions for providers to promote a patient-centred approach in clinical consultations. Cochrane Database of Systematic Reviews, (4), CD003267.
Lorig K. R., Ritter P., Stewart A. L., Sobel D. S., Brown B. W. Jr., Bandura A., Holman H. R. (2001). Chronic disease self-management program: 2-year health status and health care utilization outcomes. Medical Care, 39(11), 1217–1223.
Loveman E., Frampton G. K., Clegg A. J. (2008). The clinical effectiveness of diabetes education models for Type 2 diabetes: a systematic review. Health Technology Assessment, 12(9), 1–116, iii.
Mair F., Whitten P. (2000). Systematic review of studies of patient satisfaction with telemedicine. BMJ, 320(7248), 1517–1520.
Makoul G., Zick A. B., Aakhus M., Neely K. J., Roemer P. E. (2010). Using an online forum to encourage reflection about difficult conversations in medicine. Patient Education and Counseling, 79(1), 83–86.
Marshall S., Haywood K., Fitzpatrick R. (2006). Impact of patient-reported outcome measures on routine practice: a structured review. Journal of Evaluation in Clinical Practice, 12(5), 559–68.
McDonald S., Hetrick S., Green S. E. (2004). Pre-operative education for hip or knee replacement. Cochrane Database of Systematic Reviews, (1), CD003526.
McDonnell A. (1999). A systematic review to determine the effectiveness of preparatory information in improving the outcomes of adult patients undergoing invasive procedures. Clinical Effectiveness in Nursing, 3, 4–13.
Mead N., Bower P. (2000). Patient-centredness: A conceptual framework and review of the empirical literature. Social Science and Medicine, 51(7), 1087–1110.
Meterko M., Wright S., Lin H., Lowy E., Cleary P. D. (2010). Mortality among patients with acute myocardial infarction: The influences of patient-centered care and evidence-based medicine. Health Services Research, 45(5, Pt. 1):1188–1204.
Mosen D. M., Schmittdiel J., Hibbard J., Sobel D., Remmers C., Bellows J. (2007). Is patient activation associated with outcomes of care for adults with chronic conditions? Journal of Ambulatory Care Management, 30(1), 21–29.
Murray E., Burns J., See T. S., Lai R., Nazareth I. (2005). Interactive Health Communication Applications for people with chronic disease. Cochrane Database of Systematic Reviews, (4), CD004274.
Neubeck L., Redfern J., Fernandez R., Briffa T., Bauman A., Freedman S. B. (2009). Telehealth interventions for the secondary prevention of coronary heart disease: A systematic review. European Journal of Cardiovascular Prevention and Rehabilitation, 16(3), 281–289.
Pignone M., DeWalt D. A., Sheridan S., Berkman N., Lohr K. N. (2005). Interventions to improve health outcomes for patients with low literacy. A systematic review. Journal of General Internal Medicine, 20(2), 185–192.
Rodriguez H. P., von Glahn T., Elliott M. N., Rogers W. H., Safran D. G. (2009). The effect of performance-based financial incentives on improving patient care experiences: A statewide evaluation. Journal of General Internal Medicine, 24(12), 1281–1288.
Rollnick S., Butler C. C., Kinnersley P., Gregory J., Mash B. (2010). Motivational interviewing. BMJ, 340, 1242–1245.
Rollnick S., Miller W. R., Butler C. C. (2002). Motivational interviewing: Preparing people to change (Vol. 2). New York, NY: Guilford Press.
Rubak S., Sandbaek A., Lauritzen T., Christensen B. (2005). Motivational interviewing: a systematic review and meta-analysis. British Journal of General Practice, 55(513), 305–312.
Ryan R., Santesso N., Hill S., Lowe D., Kaufman C., Grimshaw J. (2010). Consumer‐oriented interventions for evidence‐based prescribing and medicines use: An overview of systematic reviews. Cochrane Database of Systematic Reviews (Online), (5):CD007768. doi:10.1002/14651858.CD007768.pub2
Santo A., Laizner A. M., Shohet L. (2005). Exploring the value of audiotapes for health literacy: A systematic review. Patient Education and Counseling, 58(3), 235–243.
Schneider E. C., Zaslavsky A. M., Landon B. E., Lied T. R., Sheingold S., Cleary P. D. (2001). National quality monitoring of Medicare health plans: The relationship between enrollees' reports and the quality of clinical care. Medical Care, 39(12), 1313–1325.
Skinner C. S., Campbell M. K., Rimer B. K., Curry S., Prochaska J. O. (1999). How effective is tailored print communication? Annals of Behavioral Medicine, 21(4), 290–298.
Stacey D., Bennett C. L., Barry M. J., Col N. F., Eden K. B., Holmes-Rovner M., Thomson R. (2011). Decision aids for people facing health treatment or screening decisions. Cochrane Database of Systematic Reviews, (10), CD001431.
Stevenson F. A., Cox K., Britten N., Dundar Y. (2004). A systematic review of the research on communication between patients and health care professionals about medicines: The consequences for concordance. Health Expectations, 7(3), 235–245.
Wennberg D. E., Marr A., Lang L., O'Malley S., Bennett G. (2010). A randomized trial of a telephone care-management strategy. New England Journal of Medicine, 363(13), 1245–1255.
Wetzels R., Harmsen M., Van Weel C., Grol R., Wensing M. (2008). Interventions for improving older patients' involvement in primary care episodes. Cochrane Database of Systematic Reviews (Online), (1), CD004273.
Wilson A., Childs S. (2002). The relationship between consultation length, process and outcomes in general practice: A systematic review. British Journal of General Practice, 52(485), 1012–1020.
Wofford J. L., Smith E. D., Miller D. P. (2005). The multimedia computer for office-based patient education: A systematic review. Patient Education and Counseling, 59(2), 148–157.
© 2012 Lippincott Williams & Wilkins, Inc.