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Cognitive and affective reassurance and patient outcomes in primary care: A systematic review

Pincus, Tamara,*; Holt, Nicolaa; Vogel, Stevenb; Underwood, Martinc; Savage, Richardd; Walsh, David Andrewe; Taylor, Stephanie Jane Carolinef

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doi: 10.1016/j.pain.2013.07.019
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Abstract

1 Introduction

In primary care, where a large proportion of consultations are for self-limiting or medically unexplained disorders, delivering effective reassurance is a core skill for all practitioners. Doing this effectively has the potential to improve health outcomes and, by reducing onward referrals, reduce health care costs. The effects of patient–practitioner interactions, including reassurance, on patient outcomes are most likely to be demonstrable in groups with conditions that are defined by subjective symptoms [35]. Amongst the commonest of these groups are patients with nonspecific pain conditions, in which a clear cause cannot be established [30]. With such uncertainty, the consultation can be challenging for practitioners and patients, yet a primary goal of the consultation is to reassure patients and to support them to manage their condition. Delivering reassurance to those with nonspecific pain is advised by many guidelines, including low back pain [1,48], neck pain [4,47], and irritable bowel syndrome [38].

Most models of good practice during consultations are based on the principles of patient-centred care, which typically include an element of reassurance [59]. The method of ‘reassurance’ is in the behaviour of the health care provider. Thus, data gathering in relation to signs, symptoms, and concerns as well as the impact of the problem is a prerequisite to reassurance, but reassurance itself is in the response of the health care provider to the data gathered.

We were able to identify only one evidence-informed model that explicitly focuses on reassurance [8]. The model is deduced from studies of persuasion and categorizes reassurance into affective communication, which aims to reduce worry, create rapport, and reassure patients through a sense of being cared for, respected, and understood; and cognitive reassurance, which aims to change patients’ perceptions and beliefs through education.

Coia and Morley [6] argue that affective reassurance is heuristic and rapid, and produces an immediate response in reducing concerns and worry. However, such responses are transient, and when problems return to impact on patients in the absence of the reassuring practitioner, the patient has not been empowered with new tools to deal with them. In contrast, the authors argue, cognitive reassurance is systematic and time-consuming, but its impact in changing beliefs and increasing understanding is preserved, which in turn will improve adherence and self-management. Crucially, this model asserts that the 2 processes are mutually exclusive. Once affective reassurance has taken place, the patient has insufficient motivation or capacity to engage properly with processing information to enable cognitive reassurance to take place.

If this hypothesis is correct, it requires a substantial shift in training and delivery of care. We therefore carried out a review of the evidence from prospective cohorts of patients consulting in primary care in which practitioners’ communication could be categorized as affective or cognitive, and was measured in relation to outcomes. We focused on consultations in primary care in which uncertainty is commonly high [41], and where expressions of psychological need for emotional support are high [55].

2 Methods

2.1 Defining and coding reassurance

For the purposes of this review, we used Linton and colleagues’ definition of reassurance [40] and the categorization into affective and cognitive components outlined by Coia and Morley [6]. According to these, ‘reassuring’ is defined as behaviour carried out by the practitioner. Reassurance is achieved if the patient changes his or her behaviour, understanding, or thoughts. Hence, effective reassurance should be measured through patient outcomes, including self-report of change in beliefs and mood and measures of change in behaviour, resulting in improved coping and management of the problem.

2.2 Search strategy

Our search focused on observational prospective study designs that provide detailed measurement of the components carried out during consultations and that measure subsequent patient outcomes. Specifically, we were interested in patients presenting with pain and discomfort, with poorly understood aetiology, and for whom further tests and referrals are not indicated (Table 1). We included groups with nonspecific disorders typified by pain (eg, low back pain, fibromyalgia, irritable bowel syndrome, unexplained chest pain, alone or in combination), mixed clusters of these populations defined in the original studies in reference to a lack of a clear pathological cause (such as medically unexplained syndromes), and mixed undefined groups attending primary care consultations, as these include large proportions of our target groups [11,27,29,31]. We did not address studies investigating the impact of delivery of test results and educational material on patient outcomes; these have been reported elsewhere [3,26,36].

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Table 1:
Inclusion and exclusion criteria.

2.3 Database- and citation-based searches

We undertook an initial scoping exercise by searching Medline and PsycInfo databases from 1979 to November 2010 using the terms ‘pain and reassurance,’ ‘pain and communication skills,’ and ‘pain and practitioner–patient relationship’ in the title and abstract. A start date of 1979 was selected on the basis of the year of publication of Kessel’s seminal article on consultation-based reassurance [37]. We did a backward citation search, followed by forward citation search on the pool of selected articles. We supplemented this with a second systematic search, following the recommendations from the Centre for Reviews and Dissemination [4]. The following databases were searched for relevant studies published from 1979 to October 2012: Medline, PsycInfo, PsycExtra, and ProQuest Dissertations and Theses. Full details of the search strategy are shown in the Supplemental data. We used EPPIreviewer 4.0 [64] systematic review–dedicated software for coding. Finally, we hand-searched the reference lists of the 2 most recent review articles that our search identified [8,50] (Fig. 1).

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Fig. 1:
Literature searches and screening results.

Titles and abstracts were screened according to the criteria presented in Table 1.

2.4 Data extraction

We extracted data on patient samples, country, practitioner sample, details of baseline measures, details of consultation measures, details of outcome measures, analysis, and findings (Table 2; Supplementary Table E1). We coded the consultation into affective/cognitive components, excluding measures of data gathering, and communications from patients to practitioners. Affective reassurance included verbal and nonverbal communication showing caring, empathy, and confidence, recognising and responding to distress cues, being warm and friendly, and offering generic reassuring statements, such as ‘I don’t think you should worry.’ Cognitive reassurance included explanation of symptoms, explicit exclusion of serious disease, agreeing goals, negotiating treatment options, discussing prognosis and future care, checking understanding, discussing obstacles, and summarizing. The clarification into cognitive and affective reassurance was carried out by the researchers through scrutiny of the description of the measures used as presented in the original articles. All studies were extracted and coded by 2 independent researchers, and agreement was achieved through discussion. Outcomes were categorized into short term (consultation exit) and follow-up.

T2A-23
Table 2:
Findings from empirical studies.
T2B-23
Table 2:
Findings from empirical studies.
T2C-23
Table 2:
Findings from empirical studies.

2.5 Data analysis

Because of the known heterogeneity in samples, measures of consultation, and outcome measures, statistical pooling of results was not planned. Methodological quality coding was carried out by 2 researchers independently according to recommendations for evaluation of the quality of prognosis studies in systematic reviews [25] (Supplementary Table E2). There are no established cut points to define adequate or high methodology; thus, we present the total score for each study but refer to high methodology as those studies that scored above 10 of 13.

3 Results

We considered 16,059 abstracts and read 58 publications describing 53 studies. From these we identified 16 studies that met our entry criteria (Fig. 1) and that measured and analysed both cognitive and affective reassurance (Table 2). Composite components of both types of reassurance were excluded.

3.1 Coding

All studies were independently double coded. Intercoder agreement was 93% for inclusion/exclusion at the final stage. There was disagreement about 2 studies, both of which were excluded after discussion. Agreement on the coding of the methodological quality of the studies was estimated from the number of criteria (13) multiplied by the number of studies (16). There was disagreement on 3 items (1%); this was resolved by discussion.

3.2 Findings

3.2.1 Affective reassurance

Affective reassurance was associated with higher satisfaction and enablement in 3 studies [51,52,63] and with lower satisfaction and increased concerns in 1 study with high methodology [19] and 1 with lower methodology [66]. One study [27] found no association between affective reassurance and improved satisfaction. Importantly, in the following studies, all rating high for methodological quality, affective reassurance was associated with higher symptom burden/less improvement [15,41,57], with lower rates of return to work in one [57] and with reduced adherence in another [15]. Two of these studies [14,41] adjusted for clinical status at baseline, and the third [57] found no significant correlation between patients or practitioners’ communication and pain intensity at baseline.

3.2.2 Cognitive reassurance

Four high-quality [39,41,53,60] and 4 lower-quality studies [32,33,51,63] found an association between cognitive reassurance and immediate (consultation exit) outcomes, including increased satisfaction and enablement, and reduced concerns.

Four high-quality [14,41,60,65] and 3 lower-quality studies [32,33,52] found associations with improvement in symptoms at follow-up. Associations were also found with reduced further health care utilization in 3 studies [33,52,60], one of which [60] was of high methodology. The relationship between cognitive reassurance and adherence remains unclear. One study found an association with improved adherence [52], but another found no association with pill count [58]. One study [45] found no association between cognitive reassurance and improved satisfaction, and 2 studies [53,57] found no associations between cognitive reassurance and symptom resolution at follow-up.

4 Discussion

4.1 Principal findings

The findings suggest that cognitive reassurance improves patients’ outcomes immediately after the consultation and at follow-up. Associations were found in 7 studies with improvements in symptoms, and with reduced subsequent health care utilization in 3 studies. In contrast, affective reassurance was associated at best only with improved satisfaction and at worst with poorer outcomes. Three studies with good methodology found an association between affective reassurance and reduced recovery/higher symptom burden.

4.2 Strengths and weaknesses of this review

To our knowledge, this is the first review investigating reassurance in primary care on the basis of a model that explicitly codes practitioners’ behaviour into cognitive and affective components. Although this coding enabled a direct comparison between the 2 types of reassurance, it resulted in exclusion of many studies that used composite measures of patient-centred consultations in association with outcomes. Although agreement between coders was high, there is a possibility of errors in coding, especially when coding is based indirectly on previous direct coding by study authors.

In addition, despite the associations found, causality cannot be established in observational studies. Not all the studies adjusted for severity of symptoms, mood, and function at baseline, which could have affected practitioners’ behaviour. As outcomes in some of these groups are likely to be poorer, it is impossible to know whether increases in affective reassurance reduced or increased the likelihood of poor outcomes.

However, of the 3 studies with high methodology that found [15,41,57] worse outcomes associated with affective reassurance, 2 adjusted for clinical status, and the third found no correlations between pain intensity at baseline and communications at the consultation.

The majority of studies identified in this review included consecutive mixed groups of patients, which are likely to be extremely heterogeneous. However, primary care samples are reported to include large proportions of our target groups [11,27,29,31]. The majority of the identified studies included follow-up in durations up to 4 months. The long-term impact of reassurance remains therefore unknown. Further work is needed for the following: to determine whether similar associations between reassurance and outcomes may be found in groups with a clear aetiology, prognosis, and choice of treatment; to explore other aspects of patient-centred approaches, including empathy and sensitivity, both of which may be necessary to elicit the comprehensive picture of patients’ problems and concerns; and to explore potential differences in reassuring new patients and those known to the practitioners. A systematic review published after our analyses were complete reports evidence for a relationship between empathy and patient’ outcomes [8], but interpretation of the findings in relation to our review are not clear, as measures of empathy do not distinguished between data gathering and information giving, and often include items that measure a combination of affective and cognitive reassurance (eg, [46]). We also note that studies that measured only cognitive or affective components of the consultation might be compromised, as the presence of the other (unmeasured) component may nonetheless affect patients’ outcomes. We therefore consider the stronger evidence to be forthcoming from studies that measures both components in the same consultation.

4.3 How the findings fit with other studies

The low number of studies examining the impact of practitioner–patient interactions on patient outcomes was surprising, even before we applied the inclusion criterion for studies that explicitly measured cognitive and affective reassurance. Our systematic searches were comprehensive and together included over 16,000 abstracts, yet we identified only 53 empirical prospective cohorts in primary care that met our inclusion criteria. Existing narrative reviews (eg, [7,12,17]) and publications on how to improve consultations [eg, 2,5,13] far exceed the empirical evidence. The assumption that all aspects of patient-centred consultations have a positive impact on all outcomes, in all patients, demonstrates a case in which implementing a theory may have galloped ahead of evidence.

Other reviews of the impact of consultation-based factors in broader groups have provided inconclusive and inconsistent findings [5,22,28,44]. Practitioner–patient collaboration has been found to predicts treatment adherence, but the effect size is small [2,23,24]; meeting patient expectations has a modest effect on satisfaction, but the evidence is inconclusive for other outcomes [54]. The current review advances the field by categorizing consultations into affective and cognitive components, and addressing groups in which reassurance is considered to be a primary goal of the consultation.

We did not include randomized controlled trials (RCTs) in our analysis. The research question within RCTs—will this intervention change outcome?—is distinctly different from that in the observational studies we have included, where we are looking for the characteristics that predict a good outcome after the consultation. Others have systematically reviewed the literature on studies to improve the consultation and have not found a convincing benefit on patient outcomes; they have also failed to adequately draw out the components of effective reassurance [9,10,21,34].

4.4 Unanswered questions and future research

Provisional evidence from this review suggests that some aspects of reassurance are more beneficial than others. In light of practitioners having to prioritize behaviours under time pressure, offering clear explanations and information about prognosis, explicit exclusion of serious disease, and discussion of treatment plan should take priority. We note that receiving information has been rated as a more important aspect of patient-centred care by patients, in comparison with clinicians prioritizing receptiveness and affective components [49].

We have developed a model to guide future research (Fig. 2). The model is based on the findings from the current review in combination with other theories, in reference to sequence [42,43], content and components of the consultations [13,16,56] and paths to outcomes [62].

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Fig. 2:
Model of reassurance in relation to outcomes.

We aim to provide guidance for future research rather than providing a definitive model of evidence-based reassurance.

Specifically, the model includes measurement of known predictors of outcomes outside of consultation-related factors, details the consultation components at the different stages of the consultation, and divides outcomes into short, medium, and long term. Following from left to right in Fig. 2, the block arrows at the bottom of the figure denote that patients’ characteristics and those of their problem (eg, psychosocial factors; previous experience, education, and knowledge; general health and fitness; pain; symptom burden; function) affect all aspects of the consultation and outcomes at all stages. There is a plethora of evidence to support the association between patient characteristics and their behaviour during consultations (eg, [61]), and their prognosis (eg, [18]). The block arrows at the top of Fig. 2 denote that practitioner and setting characteristics (eg, personal characteristics, orientation, perceived roles, patient-related beliefs, work-related factors such as consultation duration and stress) affect all aspects of the consultation [20].

The first stage of the consultation is data gathering. The practitioner is involved in exploring symptoms, eliciting concerns/feelings, elicit illness perceptions/causal attributions, exploring expectations, and, where appropriate, carrying out examinations. The patient is involved in exposition, describing the problem and its impact, and voicing beliefs, concerns, and requests. This stage of the consultation affects the next stage (denoted by thin arrows in Fig. 2) both in terms of the practitioners’ behaviour and the patients’ behaviour.

The next stage, information giving, involves the practitioner offering affective and cognitive reassurance. These communications affect immediate outcomes, which in turn affect medium and long-term outcomes. Cognitive reassurance results in changes in knowledge and understanding, increased sense of control, and change in beliefs. The questions that remain to be addressed (denoted by question marks) are whether changes in short-term outcomes such as satisfaction, perceived support and reduced anxiety (for which there is some evidence for an association with affective reassurance) improve or worsen medium and long-term outcomes; and whether cognitive reassurance can be effectively delivered independently of affective reassurance. Thus, the 2 paths from affective reassurance to outcomes (a direct path, and a path via cognitive reassurance) form priorities for research.

4.5 Conclusion

We have shown that some, but not all, patient–practitioner interactions during the consultation are related to patients’ outcomes. There is sufficient evidence to suggest that cognitive reassurance is an important aspect of the consultation, and that giving clear explanations and information improve patients’ outcomes in the short term and in the long term. The findings also raise questions about the impact of affective reassurance on patient outcomes, which at best appears to be related only to short-term outcomes. Future research should, in the first instance, establish comprehensive, reliable, and valid measures of both affective and cognitive reassurance. Experimental and longitudinal observational studies are necessary to compare the impact of cognitive and affective reassurance on patients’ outcomes, including their recall of information given during the consultation, their compliance with advice, and their shift in their beliefs, in addition to symptom resolution, well-being, and utilization of health care services. There is a need to investigate these in distinct subgroups. How to effectively reassure patients in the context of uncertainty remains a primary goal for future research.

Conflict of interest

The authors report no conflict of interest.

Acknowledgements

Assistance with the scoping citation search was provided by Emma McHarg, PhD, at the Department of Psychology, Royal Holloway, University of London. Coding of titles and abstracts for inclusion or exclusion in this review was provided by Saz Ahmed, Jennifer Mills, and Jennah Hylton-Edwards, Royal Holloway, University of London. NH was supported by a PhD studentship from the Economic and Social Science Research Council, UK.

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Appendix A Supplementary data

Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.pain.2013.07.019.

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Keywords:

Primary care; Reassurance; Systematic review

© 2013 Lippincott Williams & Wilkins, Inc.