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A systematic review of evidence
on the links between patient experience
and clinical safety and effectiveness
Cathal Doyle,
1
Laura Lennox,
1,2
Derek Bell
1,2
To cite: Doyle C, Lennox L,
Bell D. A systematic review of
evidence on the links
between patient experience
and clinical safety and
effectiveness. BMJ Open
2013;3:e001570.
doi:10.1136/bmjopen-2012-
001570
▸
Prepublication history and
additional material for this
paper are available online. To
view these files please visit
the journal online
(http://dx.doi.org/10.1136/
bmjopen-2012-001570).
Received 18 June 2012
Revised 2 November 2012
Accepted 12 November 2012
This final article is available
for use under the terms of
the Creative Commons
Attribution Non-Commercial
2.0 Licence; see
http://bmjopen.bmj.com
1
NIHR CLAHRC for North
West London, Chelsea and
Westminster Hospital,
London, UK
2
Department of Medicine,
Imperial College London,
Chelsea and Westminster
Hospital, London, UK
Correspondence to
Dr Cathal Doyle;
c.doyle@imperial.ac.uk
ABSTRACT
Objective:
To explore evidence on the links between
patient experience and clinical safety and effectiveness
outcomes.
Design: Systematic review.
Setting: A wide range of settings within primary and
secondary care including hospitals and primary care
centres.
Participants: A wide range of demographic groups
and age groups.
Primary and secondary outcome measures: A
broad range of patient safety and clinical effectiveness
outcomes including mortality, physical symptoms,
length of stay and adherence to treatment.
Results: This study, summarising evidence from
55 studies, indicates consistent positive associations
between patient experience, patient safety and clinical
effectiveness for a wide range of disease areas,
settings, outcome measures and study designs. It
demonstrates positive associations between patient
experience and self-rated and objectively measured
health outcomes; adherence to recommended clinical
practice and medication; preventive care (such as
health-promoting behaviour, use of screening services
and immunisation); and resource use (such as
hospitalisation, length of stay and primary-care visits).
There is some evidence of positive associations
between patient experience and measures of the
technical quality of care and adverse events. Overall, it
was more common to find positive associations
between patient experience and patient safety and
clinical effectiveness than no associations.
Conclusions: The data presented display that patient
experience is positively associated with clinical
effectiveness and patient safety, and support the case
for the inclusion of patient experience as one of the
central pillars of quality in healthcare. It supports the
argument that the three dimensions of quality should
be looked at as a group and not in isolation. Clinicians
should resist sidelining patient experience as too
subjective or mood-oriented, divorced from the ‘real’
clinical work of measuring safety and effectiveness.
INTRODUCTION
Patient experience is increasingly recognised
as one of the three pillars of quality in health-
care alongside clinical effectiveness and
patient safety.
1
In the NHS, the measurement
of patient experience data to identify
strengths and weaknesses of healthcare deli-
very, drive-quality improvement, inform
ARTICLE SUMMARY
Article focus
▪ Should patient experience, as advocated by the
Institute of Medicine and the NHS Outcomes
Framework, be seen as one of the pillars of
quality in healthcare alongside patient safety and
clinical effectiveness?
▪ What aspects of patient experience can be linked
to clinical effectiveness and patient safety
outcomes?
▪ What evidence is available on the links between
patient experience and clinical effectiveness and
patient safety outcomes?
Key messages
▪ The results show that patient experience is con-
sistently positively associated with patient safety
and clinical effectiveness across a wide range of
disease areas, study designs, settings, popula-
tion groups and outcome measures.
▪ Patient experience is positively associated with
self-rated and objectively measured health out-
comes; adherence to recommended medication
and treatments; preventative care such as use of
screening services and immunisations; health-
care resource use such as hospitalisation and
primary-care visits; technical quality-of-care
delivery and adverse events.
▪ This study supports the argument that patient
experience, clinical effectiveness and patient safety
are linked and should be looked at as a group.
Strengths and limitations of this study
▪ This study demonstrates an approach to design-
ing a systematic review for the ‘catch-all’ term
patient experience, and brings together evidence
from a variety of sources that may otherwise
remain dispersed.
▪ This was a time-limited review and there is
scope to expand this search based on the results
and broaden the search terms to uncover further
evidence.
Doyle C, Lennox L, Bell D. BMJ Open 2013;3:e001570. doi:10.1136/bmjopen-2012-001570 1
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commissioning and promote patient choice is now man-
datory.
2–4
In addition to data on harm avoidance or
success rates for treatments, providers are now assessed
on aspects of care such as dignity and respect, compas-
sion and involvement in care decisions.
4
In England,
these data are published in Quality Accounts and the
Commis sioning for Quality and Innovation payment
framework which makes a proportion of care providers’
income conditional on the improvement in this domain.
5
The inclusion of patient experience as a pillar of
quality is often justified on grounds of its intrinsic
value—that the expectation of humane, empathic care is
requires no further justification. It is also justified on
more utilitarian grounds as a means of improving
patient safety and clinical effectiveness.
67
For example,
clear information, empathic, two-way communication
and respect for patients’ beliefs and concerns could lead
to patients being more informed and involved in
decision-making and create an environment where
patients are more willing to disclose information.
Patients could have more ‘ownership’ of clinical deci-
sions, entering a ‘therapeutic alliance’ with clinicians.
This could support improved and more timely diagnosis,
clinical decisions and advice and lead to fewer unneces-
sary referrals or diagnostic tests.
89
Increased patient
agency can encourage greater participation in personal
care, compliance with medication, adherence to recom-
mended treatment and monitoring of prescriptions and
dose.
910
Patients can be informed about what to expect
from treatment and be motivated to report adverse
events or complications and keep a list of their medical
histories, allergies and current medications.
11
Patients’ direct experience of care process through
clinical encounters or as an observer (eg, as a patient on
a hospital ward) can provide valuable ins ights into every-
day care. Examples include attention to pain control,
assistance with bathing or help with feeding, the envir-
onment (cleanliness, noise and physical safety) and
coordination of care between professions or organisa-
tions. Given the organisational fragmentation of much
of healthcare and the numerous services with which
many patients interact, the measurement of patient
experience may help provide a ‘whole-system’ perspec-
tive not readily available from more discrete patient
safety and clinical effectiveness measures.
11
Focusing on such utilitarian arguments, this study
reviews evidence on links that have been demonstrated
between patient experience and clinical effectiveness
and patient safety.
METHODS
Identifying variables relevant to patient experience
Patient experience is a term that encapsulates a number
of dimensions, and in preliminary database searches,
this phrase, on its own, uncovered a limited number of
useful studies. To broaden and structure the search for
evidence, identify search terms and provide a framework
for analysis, it was necessary to identify what patient
experience entails and outline potential mechanisms
through which it is proposed to impact on safety and
effectiveness. As such, we combined common elements
from patient experience frameworks produced by The
Institute of Medicine,
1
Picker Institute
12
and NICE.
13
Table 1 delineates different dimensions of patient
experience and distinguishes between ‘relational’ and
‘functional’ aspects.
10 14
Relational aspects refer to inter-
personal aspects of care—the ability of clinicians to
empathise, respect the preferences of patients, include
them in decision-making and provide information to
enable self-care.
10
It also refers to patients’ expectations
that professionals will put their interest above other con-
siderations and be honest and transparent when some-
thing goes wrong.
815
Functional aspects relate to basic
expectations about how care is delivered, such as atten-
tion to physical needs, timeliness of care, clean and safe
environments, effective coordination between profes-
sionals, and continuity.
Using these frameworks and discursive documents in
this area of research
9101617
as a guide, we identified
Table 1 Identifying aspects of patient experience and search terms
Relational aspects Functional aspects
Emotional and psychological support, relieving fear and anxiety,
treated with respect, kindness, dignity, compassion, understanding
Effective treatment delivered by trusted professionals
Participation of patient in decisions and respect and understanding
for beliefs, values, concerns, preferences and their understanding
of their condition
Timely, tailored and expert management of physical
symptoms
Involvement of, and support for family and carers in decisions Attention to physical support needs and environmental
needs (eg, clean, safe, comfortable environment)
Clear, comprehensible information and communication tailored to
patient needs to support informed decisions (awareness of
available options, risks and benefits of treatments) and enable
self-care
Coordination and continuity of care; smooth transitions
from one setting to another
Transparency, honesty, disclosure when something goes wrong
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words and phrases commonly used to denote aspects of
patient experience, examples of which are listed in box 1.
These were combined with search terms representing
patient safety and clinical effectiveness outcomes,
hypothesised to be associated with patient experience in
discursive literature. We searched for a broad range of
outcome measures, including both self-rated and ‘objec-
tive’ measurements of health status, physical health and
mental health and well-being, the use of preventive
health services, compliance or adherence to health-
promoting behaviour and resource use.
Combining these two sets of search terms in the
EMBASE database, we identifi ed 5323 papers whose
abstracts were then reviewed. If deemed relevant, the
full article was retrieved to assess whether it met the
inclusion criteria.
Given conce rns about the sole use of protocol-driven
search strategies for complex evidence,
18
for the full-text
articles retrieved for review, we used a ‘snowballing’
approach to identify further studies. This involved sour-
cing further articles in these studies for assessment and
using the ‘related articles’ function in the Pubmed data-
base. We repeated this for new articles identified until
the approach ceased to identify new studies.
Inclusion criteria, assessment of quality
and categorisation of evidence
We included studies that measured associations between
patients’ reporting of their experience and patient safety
and clinical effectiveness outcomes. These included
studies measuring associations between patient experience
and safety or effectiveness outcomes either at a patient
level (ie, data on both types of variables for the same
patients) or at an organisational level (ie, associations
between aggregated measures of patient experience and
safety and effectiveness outcomes for the same type of
organisation such as a hospital or primary-care practice).
We included studies where the variables denoting
patient experience and patient safety and clinical effect-
iveness were measured in a credible way, through the use
of validated tools. For patient experience variables, these
include surveys covering several aspects of experience
(such as Picker surveys and the Hospital Consumer
Assessment of Healthcare Providers and Systems survey)
and specific aspects (such as a ‘Working Alliance Scale’,
19
Multidimensional Health Locus of Control Scale scale
20
or
Usual Pr o vider Continuity index
21
). For patient safety and
clinical effectiveness, these include, for example, generic
health and quality of life surveys (such as Short-Form 36),
disease-specific surveys (such as the Seattle Angina
Questionnaire
22
), measures of the technical quality of care
(such as the Hospital Quality Alliance (HQA) score),
reviews of medical records and care provider data.
23
Details of the methods used to measure variables in each
study are included in tables 5 and 6.
We included studies where the sample size of patients
or organisations appeared sufficiently large to conduct a
meaningful statistical analysis (excluding studies with
fewer than 50 subjects). When extracting data relevant
to our study from systematic reviews, we selected only
those studies that met these criteria.
We then searched the studies’ results for positive asso-
ciations (where a better patient experience is associated
with safer or more effective care), negative associations
(where a better patient experience is associated with less
safe or less effective care) and no associations.
Associations refer to cases where one meas ure of patient
experience (typically an overall rating of patient experi-
ence for a care provider) has a statistically significant
association with one or more clinical effectiveness or
patient safety variable. If a study showed associations
between several aspects of patient experience that
appeared to be closely related (eg, ‘listening’, ‘empathy’,
or ‘respect’) and an aspect of effectiveness or safety, this
was counted as one association found. This was to avoid
exaggerating the weight of the evidence by ‘over count-
ing’ associations.
Two main types of studies emerged in the search—
those focusing on interventions to improve aspects of
patient experience and those exploring associations
between patient experience variables and patient safety
and clinical effectiveness variables. To manage the scope
of this time-limited review, we decided to restrict analysis
of the large number of interventions to the evidence
contained within systematic reviews.
RESULTS
Overall, the evidence indicates positive associations
between patient experience and patient safety and clin-
ical effectiveness that appear consistent across a range of
disease areas, study designs, settings, population groups
and outcome me asures. Positive associations found out-
weigh ‘no associations’ by 429–127. Of the four studies
where ‘no associations’ outweigh positive associations,
there is no suggestion that these are methodologically
superior. Negative associations were rare. Of the 40 indi-
vidual studies assessed in table 5 negative associations
(between patient experience of clinical team interac-
tions and continuity of care and separate assessment of
the quality of clinical care) were found in only one
study.
24
Box 1 Search terms denoting patient experience
Pa tient-centr ed care; patient engagement; clinical inter a ction; patient–
clinician; clinician–patient; patient–doctor; doctor–patient; phys-
ician–patient; patient–phy sician; patient–provider; interpersonal
trea tment; physician discussion; trust in physician; empathy; com-
passion; r espect; responsiv eness; patient pr efer ences; shared
decision-making; therapeutic alliance; participation in decisions;
decision-making; autonomy; caring; kindness; dignity; honesty;
participation; right to decide; physical comfort; involv ement (of
family, carers, friends); emotional support; continuity (of care);
smooth transition; emotional support.
Doyle C, Lennox L, Bell D. BMJ Open 2013;3:e001570. doi:10.1136/bmjopen-2012-001570 3
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Table 2 shows surveys to be the predominant method
used to measure variables for individual studies (figur e 1).
Table 3 presents the frequency of positive associations
and ‘no associations’ categorised by type of outcomes
(for 378 of the 556 cases where sufficient information
was available to categorise). These include objectively
measured health outcomes (eg, ‘mortality’, ‘blood
glucose levels’, ‘infections’, ‘medical errors’); self-
reported health and well-being outcomes (eg, ‘health
status’, ‘functional ability’‘quality of life’, ‘anxiety’);
adherence to recommended treatment and use of pre-
ventive care services likely to improve health outcomes
(eg, ‘medication compliance’, ‘adherence to treatment’
and screening for a variety of conditions); outcomes
related to healthcare resource use (eg, ‘hospitalisations’,
‘hospital readmission’, ‘emergency department use’,
‘primary care visits’); errors or adverse events and mea-
sures of the technical quality of care.
Table 4 shows associations categorised by type of care
provider (for the subset of studies focusing on one
setting) and for studies focused on chronic conditions.
Tables 5 and 6 present details of all studies identified,
specifying the analytical focus of each study, methods to
measure variables and positive associations and ‘no ass-
coiations’ found.
DISCUSSION
Overall, the evidence indicates associations between
patient experi ence, clinical effectiveness and patient
safety that appear consistent across a range of disease
areas, study designs and settings.
As table 3
indicates,theevidenceshowspositiveassocia-
tions found outweigh those not found for both self-
assessment of physical health and mental health (61 vs 36)
and ‘objective’ measures of health outcomes (eg, where
measures are taken by a clinician or by reviewing medical
records) (29 vs 11). For objective measures, one study
25
shows positiv e associations for ulcer disease, hypertension
and breast cancer. Two studies on myocardial infarction
show positive associations with survival 1 year after dis-
charge
26
and inpatient mortality.
27
Objective measurement
is less fr equently ex plor ed than self-rated health and is an
area that could benefit from further research.
Evidence is strong in the case of adherence to recom-
mended medical treatment. A meta-analysis included in
this study showed positive associations between the
quality of clinician–patient communications and adher-
ence to medical treatment in 125 of 127 studies analysed
and showed the odds of patient adherence was 1.62 times
higher where physicians had communication training.
28
Regarding compliance with medication, positive associa-
tions found to outweigh those not found.
20 29–35
A review
of interventions to increase adherence to medication
(not included in this study) showed communication of
information, good provider–patient relationships and
patients’ agreement with the need for treatment as
common determinants of effectiveness.
36
There is evi-
dence of better use of preventive services, such as screen-
ing services in diabetes, colorectal, breast and cervical
cancer; cholesterol testing and immunisation.
24 25 37–39
There is also evidence of impacts on resource use of
primary and secondary care (such as hospitalisations,
readmissions and primary care visits).
21 29 40–45
For studies exploring associations between patient
experience and technical quality of care measured by
other means, the evidence is mixed. Two studies in
acute care showed positive associations between overall
ratings of patient experience and ratings of the technical
quality of care (using HQA measures) for myocardial
infarction, congestive heart failure, pneumonia and
complications from surgery.
23 46
Another found an asso-
ciation with adherence to clinical guidelines for acute
myocardial infarction.
27
A similar study in primary care
found positive associations between patient experience
of processes and measurement of care quality (from the
Healthcare Effectiveness Data and Information Set
(HEDIS) system measuring care quality for disease pre-
vention and management in chronic conditions).
24
Table 2 Methods used to measure variables
Number
of studies
Patient experience variables
Survey 31
Interviews 2
Medical records 1
Effectiveness and safety variables
Survey for self-rated healthcare 12
Other survey 14
Medical records 3
Data-monitoring quality of care
delivery (eg, audit, HQA, HEDIS)
3
Care provider outcome data 3
Physical examination 1
Patient interviews 2
HQA, Hospital Quality Alliance; HEDIS, Healthcare Effectiveness
Data and Information Set.
Figure 1 Outlines the disease areas covered.
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However, two other studies found no associations
between patients’ ratings and ratings based on an assess-
ment of medical records.
47 48
Some studies show positive associations between
patients’ perspective or observations of processes of care
and the safety of care recorded through other means.
Isaac
46
found positive associations between ratings of
patient experience and six patient-safety indicators
(decubitus ulcer; failure to rescue; infections due to
medical care; postoperative haemorrhage, respiratory
failure, pulmonary embolism and sepsis). Two studies
examining evidence for patients’ ability to identify
medical errors or adverse events in hospital showed posi-
tive associations between patients’ accounts of their
experience of adverse events and the documentation of
events in medical records.
49 50
But another study shows
only 2% of patient-reported errors were classified by
medical reviewers as ‘real clinical medical errors’ with
most ‘reclassified’ by clinicians as ‘misunderstandings’
or ‘behaviour or communication problems’.
51
Overall,
there is less evidence available on safety compared to
effectiveness and this should be a priority for future
research in this area.
Research from other studies not included in this review
support these findings. For example, research on ‘deci-
sion aids’ to ensure that patients are well informed about
their treatments, and that decisions reflect the prefer-
ences of patients indicates that patient engagement has a
beneficial impact on outcomes. For example, awareness
of the risks of surgical procedures resulted in a 23%
reduction in surgical interventions and better functional
status.
52
Another review showed that provision of good
information and emotional support are associated with
better recovery from surgery and heart attacks.
53
STUDY STRENGTHS AND LIMITATIONS
This review builds on other studies
9101617
exploring
links between these three domains. This study also
demonstrates an approach to designing a systematic
search for evidence for the ‘catch-all’ term patient
experience, bringing together evidence from a variety of
sources that may otherwise remain dispersed. This
approach can be used or adapted for further research in
this area.
This was a time-limited review and there is scope to
expand this search, based on our results. There may be
scope to broaden the search terms and this may uncover
further evidence. The first search was confined to one
database and the review focused primarily on peer-
reviewed literature excluding grey literature. To manage
the scope of this review, we restricted the analysis of
interventions to improve patient experience to evidence
within systematic reviews. While we used some quality cri-
teria to filter studies (including the use of validated tools
to measure experience, safety and effectiveness out-
comes and sample size), with more time a more detailed
formal quality assessment may have added value to the
study. Although all positive associations included in the
study are statistically signifi cant, the strength of associa-
tions vary. Because of time constraints and the hetero-
geneity of measures used, we did not systematically
compare the strengths of positive associations in differ-
ent studies, but this may be an area for future work.
There may also be scope to explore whether future
research in this area could go beyond the counting of
associations in this study through, for example,
meta-analysis. As always, there may be a publication bias
in favour of studies showing positive associations
between patient experience variables and safety and
effectiveness outcome s.
54
In addition, 28 of the 40 indi-
vidual studies assessed were conducted in the USA and
caution is needed about their applicability to other
healthcare systems.
CONCLUSION
The inclusion of patient experience as one of the pillars
of quality is partly justified on the grounds that patient
experience data, robustly collected and analysed, may
help highlight strengths and weaknesses in effectiveness
Table 4 Weight of evidence by provider and for chronic
conditions
Weight of evidence
by provider and for
chronic conditions
Associations
found
No of
associations
Primary care 110 48
Hospital 43 17
Chronic conditions 53 9
Table 3 Associations categorised by type of outcome
Objective’
health
outcomes
Self-reported
health and
wellbeing
Adherence
to
treatment
(including
medication)
Preventive
care
Healthcare
resource
use
Adverse
events
Technical
quality of
care
All
categories
No of positive
associations found
29 61 152 24 31 7 8 312
‘No associations’ 11 36 7 2 6 0 4 66
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Table 5 Individual studies
Author
Type of study,
sample size,
country Setting Disease focus
Unit of
analysis
(patient
(P) or
org (O)
Patient experience
focus and method
used
Safety and
effectiveness
measure
Association
demonstrated
Association not
demonstrated
Assoc.
Found
vs NOT
found
Chang et al
48
Cohort study,
236 patients,
USA
Managed
care
organisation
22 clinical
conditions
P Providers
communication (The
Consumer Assessment
of Healthcare Providers
and Systems survey
and ‘Quality of care’)
Technical quality and
patient global ratings
(medical records and
patient interviews)
None Technical quality
of care
0/1
Sequist
et al
24
Cross-sectional
study, 492
settings, USA
Primary care Cervical, breast
and colorectal
cancer,
chlamydia,
cardiovascular
conditions,
asthma,
diabetes
P Doctor–patient
communication, clinical
team interactions,
organisational features
of care (The
Ambulatory Care
Experiences survey)
Clinical quality focusing
on disease prevention,
disease management
and outcomes of care
(Healthcare
Effectiveness Data and
Information Set
(HEDIS))
Cervical cancer, breast
cancer and colorectal
cancer screening,
Chlamydia screening,
Cholesterol screening
(cardiac), LDL
cholesterol testing
(diabetes), eye exams
(diabetes), HbA1c
testing, nephropathy
screening
Cholesterol
management,
HbA1c control,
LDL cholesterol
control, blood
pressure control
9/4
Burgers
et al
55
Survey, 8973
patients, Range
Range of
settings
Chronic lung,
mental health,
hypertension,
heart disease,
diabetes,
arthritis, cancer
P Coordination of care
and overall experience
(Commonwealth Fund
International Health
Policy Survey)
Death score Death score None 1/0
Kaplan
et al
25
Randomised
control trial, 252
patients, USA
Range of
settings
Ulcer disease,
hypertension,
diabetes, breast
cancer
P Physician–patient
communication
(assessment of audio
tape and questionnaire)
Physiological measures
taken at visit and
patients’ self-rated
health status survey.
Follow-up blood
glucose and blood
pressure, functional
health status,
self-reported health
status.
None 4/0
Jha et al
23
Cross-sectional
study, 2429
settings, USA
Hospital Acute
myocardial
infarction,
congestive heart
failure,
pneumonia
complications
from surgery
O Patient communication
with clinicians,
experience of nursing
services, discharge
planning (Hospital
Consumer Assessment
of Healthcare Providers
and Systems
(HCAHPS) survey)
Technical quality of
care using Hospital
Quality Alliance (HQA)
score
Technical quality of
care in AMI, congestive
heart failure (CHF),
pneumonia, surgical
care
None 4/0
Continued
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Table 5 Continued
Author
Type of study,
sample size,
country Setting Disease focus
Unit of
analysis
(patient
(P) or
org (O)
Patient experience
focus and method
used
Safety and
effectiveness
measure
Association
demonstrated
Association not
demonstrated
Assoc.
Found
vs NOT
found
Rao et al
47
Cross-sectional
study, 3487
patients, UK
Primary care Hypertension,
Influenza
vaccination
P Older patients’
experience of technical
quality of care (General
Practice Assessment
survey)
Technical quality of
care—(medical
records)
None Hypertension
monitoring and
control, influenza
vaccination.
0/3
Meterko
et al
26
Cohort study,
1858 patients,
USA
Veteran
Affairs
Medical
Centres
Acute
myocardial
infarction
P Patient-centred care,
access, courtesy,
information,
coordination, patient
preferences, emotional
support, family
involvement, physical
comfort (VA Survey of
Healthcare
Experiences of Patients
(SHEP))
Survival 1-year
postdischarge
Survival 1-year post
discharge
None 1/0
Vincent
et al
56
Cohort survey
227 patients,
UK
Range of
settings
Varied P Accountability,
explanation, standards
of care, compensation
(questionnaire)
Legal action Legal action None 1/0
Agoritsas
et al
57
Cohort patient
survey, 1518
patients,
Switzerland
Hospital Varied P Global rating of care
and respect and dignity
questions (Picker
survey)
Patient reports of
undesirable events
(survey)
Neglect of important
information by
healthcare staff, pain
control, needless
repetition of a test,
being handled with
roughness
None 4/0
Flocke et al
37
Cross-sectional
study, 2889
patients, USA
Primary care Varied P Interpersonal
communication,
physician’s knowledge
of patient, coordination
(Components of
Primary Care
Instrument (CPCI))
Use of preventive care
services (screening,
health habit counselling
services, immunisation
services)
Screening, health habit
counselling,
immunisation
None 3/0
Jackson,
J. et al
58
Quantitative
cohort study
500 patients,
USA
General
medicine
walk-in clinic
Varied P Patient satisfaction
(Research and
Development (RAND)
9-item survey)
Functional status
(Medical Outcomes
Study Short-Form
Health Survey (SF-6)),
symptom resolution,
(RAND 9-item survey),
follow-up visits
Symptom resolution,
repeat visits, functional
status
None 3/0
Continued
Doyle C, Lennox L, Bell D. BMJ Open 2013;3:e001570. doi:10.1136/bmjopen-2012-001570 7
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Table 5 Continued
Author
Type of study,
sample size,
country Setting Disease focus
Unit of
analysis
(patient
(P) or
org (O)
Patient experience
focus and method
used
Safety and
effectiveness
measure
Association
demonstrated
Association not
demonstrated
Assoc.
Found
vs NOT
found
Clark et al
41
Randomised
control trial 731
patients, USA
Range of
settings
Asthma P Patient experience of
physician
communication (patient
interviews and Likert
scale)
Emergency department
visits, hospitalisations,
office phone calls and
visits, urgent office
visits (survey+medical
chart review of 6% of
patients to verify
responses)
Number of office visits,
emergency visits,
urgent office visits,
phone calls,
hospitalisations
None 5/0
Raiz et al
20
Quantitative
cohort study,
357 patients,
USA
Primary care Renal transplant P Patient faith in doctor
(Multidimensional
Health Locus of Control
Scale (MHLC))
Medication compliance Remembering
medications, taking
medications as
prescribed
None 2/0
Kahn et al
32
Cohort study,
881 patients,
USA
Hospitals Breast cancer P Level of physician
support, participation in
decision-making and
information on side
effects (survey)
Medication adherence Ongoing tamoxifen use None 1/0
Plomondon
et al
22
Cohort study,
1815 patients,
USA
Hospital Myocardial
infarction
P Satisfaction with
explanations from their
doctor, overall
satisfaction with
treatment (Seattle
Angina questionnaire)
Presence of angina
(Seattle Angina
Questionnaire)
Presence of angina None 1/0
Fuertes
et al
19
Survey, 152
patients, USA
Hospital Neurology P Physician–patient
communication,
physician–patient
working alliance,
empathy, multicultural
competence
(questionnaire)
Adherence to medical
treatment (adherence
Self-Efficacy Scale and
Medical Outcome
Study (MOS)
adherence scale)
Adherence to treatment None 1/0
Lewis et al
31
Qualitative
cohort study,
191 patients,
USA
Primary care Pain P Doctor–patient
communication (survey)
Medication adherence
(Prescription Drug Use
Questionnaire (PDUQ))
Use of prescribed
opioid medications
None 1/0
Safran et al
59
Cross-sectional
study, 7204
patients, USA
Primary care Varied P Accessibility, continuity,
integration, clinical
interaction,
interpersonal aspects,
trust (The Primary Care
Assessment Survey)
Adherence to
physician’s advice,
health status, health
outcomes (Medical
Outcomes Study
(MOS), Behavioural risk
factor survey)
Adherence, health
status
Health outcomes 2/1
Continued
8 Doyle C, Lennox L, Bell D. BMJ Open 2013;3:e001570. doi:10.1136/bmjopen-2012-001570
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Table 5 Continued
Author
Type of study,
sample size,
country Setting Disease focus
Unit of
analysis
(patient
(P) or
org (O)
Patient experience
focus and method
used
Safety and
effectiveness
measure
Association
demonstrated
Association not
demonstrated
Assoc.
Found
vs NOT
found
Alamo et al
60
Randomised
study, 81,
Spain
Primary care Chronic
musculoskeletal
pain (CMP),
fibromyalgia
P Patient-centreed-care
(‘Gatha-Res
questionnaire’ and
follow-up phone call)
Pain (Visual Analogue
Scale (VAS) anxiety
(Oldberg scale of
anxiety and depression
(GHQ))
Anxiety, number of
tender points (pain)
Pain, pain
intensity, pain as
a problem,
number of
associated
symptoms,
depression,
physical mobility,
social isolation,
emotional
reaction, sleep
2/10
Fan et al
61
Survey, 21 689
patients, USA
Primary care Cardiac care,
diabetes,
congestive
obstructive
pulmonary
disorder
(COPD)
P Communication skills
and humanistic
qualities of primary
care physician (Seattle
Outpatient Satisfaction
Survey)
Physical and emotional
aspects, coping ability
and symptom burden
for angina, COPD and
diabetes (Seattle
Angina Questionnaire
(SAQ), Obstructive
Lung Disease
Questionnaire
(SOLDQ), Diabetes
Questionnaire (SDQ))
Patient ability to deal
with all 3 diseases,
education for diabetes
patients, angina
stability, physical
limitation due to angina
Self-reported
physical limitation
for angina and
COPD, symptom
burden for
diabetes,
complications for
diabetes
7/4
O’Malley
et al
38
Cross-sectional
study, 961
patients, USA
Primary care Varied P Patient trust (survey) Use of preventive care
services
Blood pressure
measurement, height
and weight
measurement,
cholesterol check,
papanicolaou test (pap)
tests, breast cancer
screening, colorectal
cancer screening,
discussion of diet,
discussion on
depression
None 8/0
Little et al
62
Survey, 865
patients, UK
Primary care varied P Patient centredness
(Survey)
Enablement, symptom
burden, resource use
Enablement, symptom
burden, referrals
Re-attendance,
investigations
3/2
Levinson
et al
63
Qualitative
cohort study,
124 physicians,
USA
Primary care Varied P Physician–patient
communication
(assessment of
audiotape)
Malpractice Malpractice claims None 1/0
Continued
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Table 5 Continued
Author
Type of study,
sample size,
country Setting Disease focus
Unit of
analysis
(patient
(P) or
org (O)
Patient experience
focus and method
used
Safety and
effectiveness
measure
Association
demonstrated
Association not
demonstrated
Assoc.
Found
vs NOT
found
Carcaise-
Edinboro and
Bradley
39
Cross sectional
study, 8488
patients, USA
Primary care Colorectal
cancer
P Patient-provider
communication
(Consumer
Assessment of
Healthcare Providers
and Systems (CAHPS)
survey)
Colorectal Cancer
screening, fecal occult
blood testing and
colonoscopy (Medical
Expenditure Panel
Survey)
CRC screening, fecal
occult blood testing,
colonoscopy
None 3/0
Schneider
et al
33
Cross-sectional
analysis study,
554 patients,
USA
Primary care HIV P Physician–patient
relationship (survey)
Adherence (survey) Adherence to
antiretroviral therapy
None 1/0
Schoenthaler
et al
34
Cross-sectional
study, 439
patients, USA
Primary care Hypertension P Patients’ perceptions of
providers’
communication (survey)
Medication adherence
(Morisky self-report
measure)
Medication adherence None 1/0
Slatore
et al
64
Cross-sectional
study, 342
patients, USA
Range of
settings
COPD P Patient–clinician
communication (Quality
of communication
questionnaire (QOC))
Self-reported breathing
problem confidence
and general self-rated
health (survey)
Confidence in dealing
with breathing problems
Self-rated health 1/1
Lee and
Lin
65
Cohort study,
480 patients,
Taiwan
Range of
settings
Type 2 diabetes P Trust in physicians
(survey)
Self-efficacy,
adherence, health
outcomes
(Multidimensional
Diabetes Questionnaire
and 12-Item
Short-Form Health
survey (SF-12))
Physical HRQoL,
mental HRQoL, body
mass index HbA1c,
triglycerides,
complications,
self-efficacy, outcome
expectations,
adherence
None 9/0
Heisler
et al
35
Survey, 1314
patients, USA
Primary care Diabetes P Physician
communication,
physician interaction
styles, participatory
decision-making
(Questionnaire)
Disease management
(surveys and national
databases)
Overall
self-management,
diabetes diet,
medication compliance,
exercise, blood glucose
monitoring, foot care.
Exercise 6/1
Lee and
Lin
66
Cohort study,
614 patients,
Taiwan
Range of
settings
Type 2 diabetes P Patients’ perceptions of
support, autonomy,
trust, satisfaction
(Healthcare Climate
Questionnaire and
Autonomy Preference
Index (API))
Glycosylated
haemoglobin (HbA1C)
(medical records)
Physical and mental
health-related quality of
life (HRQoL) (SF-12)
Physical HRQoL,
mental HRQoL
Information
preference
interaction,
HbA1C
2/2
Continued
10 Doyle C, Lennox L, Bell D. BMJ Open 2013;3:e001570. doi:10.1136/bmjopen-2012-001570
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Table 5 Continued
Author
Type of study,
sample size,
country Setting Disease focus
Unit of
analysis
(patient
(P) or
org (O)
Patient experience
focus and method
used
Safety and
effectiveness
measure
Association
demonstrated
Association not
demonstrated
Assoc.
Found
vs NOT
found
Kennedy
A. et al
67
Randomised
control trial, 700
patients, UK
Hospital Inflammatory
bowel Disease
P Patient-centred-care
(interviews)
Resource use,
self-rated physical and
mental health,
enablement (patient
diaries, questionnaires,
medical records)
Ability to cope with
condition, symptom
relapses, hospital visits,
appointments made
Physical
functioning, role
limitations, social
functioning,
mental health,
energy/vitality,
pain, general
health perception,
anxiety, number
of relapses,
number of
medically-defined
relapses, average
relapse duration,
frequency of GP
visits, delay
before starting
treatment
4/13
Stewart
et al
42
Observational
cohort study,
315 patients,
Canada
Primary care General P Patient-centred
communication
(assessment of
audiotape and
Patient-Centred
Communication Score
tool)
Discomfort (VAS)
symptom severity
severity (Visual
Analogue Scale),
Health Status (Short
Form-36 SF-36) Quality
of care provision (chart
review by doctors)
Symptom discomfort
and concern,
self-reported health,
diagnostic tests,
referrals and visits to
the family physician
None 5/2
Kinnersley
et al
68
Observational
study, 143
patients, UK
Primary care Varied P Patient-centredness
(assessment of
audiotape and
questionnaires)
Symptom resolution,
resolution of concerns,
functional health status
(Questionnaire)
None Resolution of
symptoms,
resolution of
concerns,
functional health
status
0/3
Solberg
et al
51
Survey, 3109
patients, USA
Primary care
—
multispecialty
group
Varied P Patient experience of
errors (survey)
Review of errors (chart
audits and physician
reviewer judgements)
None None 1/0
Isaac et al
6
Cross-sectional
study, 927
hospitals, USA
Hospital Acute
myocardial
infarction,
O General patient
experiences (Hospital
Consumer Assessment
Processes of care
(Health Quality Alliance
Decubitus ulcer rates,
infections, processes of
care for pneumonia,
Failure to rescue 11/1
Continued
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Table 5 Continued
Author
Type of study,
sample size,
country Setting Disease focus
Unit of
analysis
(patient
(P) or
org (O)
Patient experience
focus and method
used
Safety and
effectiveness
measure
Association
demonstrated
Association not
demonstrated
Assoc.
Found
vs NOT
found
congestive heart
failure,
pneumonia
complications
from surgery.
of Healthcare Providers
and Systems survey
(HCAHPS))
(HQA) database) and
patient safety indicators
CHF and myocardial
infarctions, surgical
composites,
hemorrage, respiratory
failure, DVT, pulmonary
embolism, sepsis
Glickman
et al
27
Cohort study,
3562 patients,
USA
Hospital Acute
myocardial
infarction
P Patient satisfaction
(Press-Ganey survey)
Adherence to practice
guidelines, outcomes
(CRUSADE quality
improvement registry).
Inpatient mortality,
composite clinical
measures, acute
myocardial infarction
(AMI) survival
None 3/0
Fremont
et al
69
Survey, 1346
patients, USA
Hospital Cardiac P Patient-centred care
(Picker survey)
Processes of care,
functional health status,
cardiac symptoms
(Medical Outcomes
Study questionnaire,
London School of
Hygiene measures for
cardiac symptoms)
Overall health, chest
pain, patient reported
general physical and
mental health status
Mental health,
shortness of
breath
5/2
Riley et al
70
Survey, 506
patients,
Canada
Hospital Cardiac care—
acute coronary
P Continuity of care (The
Heart Continuity of
Care Questionnaire,
Medical Outcome
Study Social Support
Survey, Illness
Perception
Questionnaire)
Participation in cardiac
rehabilitation,
perception of illness,
functional capacity
(Duke Activity Status
Index (DASI))
Cardiac rehabilitation
participation,
perceptions of illness
consequences
None 2/0
Weingart
et al
49
Cohort study,
228 patients,
USA
Hospital Varied P Patient experience of
adverse events
(interviews)
Adverse events
(mMedical records and
patient interviews)
Adverse events None 1/0
Weissman
et al
50
Survey, 998
patients, USA
Hospital Varied P Patient experience of
adverse events
(interviews)
Adverse events
(medical records)
Adverse events None 1/0
HRQoL, health-related quality of life.
12 Doyle C, Lennox L, Bell D. BMJ Open 2013;3:e001570. doi:10.1136/bmjopen-2012-001570
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Table 6 Systematic reviews
Authors
Time span and
studies
meeting
inclusion
criteria
Healthcare
setting
Disease areas
covered
Unit of
analysis
Patient experience
focus (and
measurement
methods)
Safety and effectiveness
measure—association
demonstrated -
Safety and effectiveness
measure—association not
demonstrated
Assocs
found vs
not
found
Blasi et al
71
1974–1998,
4of25
Range of
settings
Asthma, hypertension,
cancer, insomnia,
menopause, obesity,
tonsillitis
P Provider behaviour
and communication
(grading of
consultations)
Health status, symptom
improvement, treatment
effectiveness, fear of injection,
anxiety, ratings of pain, number
of doctor visits, pain, speed of
recovery
Comfort, recovery time, return
visits
9/3
Drotar
29
1998–2008,
4of22
Range of
settings
Asthma, cystic
fibrosis, diabetes,
epilepsy, inflammatory
bowel disease,
juvenile rheumatoid
arthritis
P Physician and staff
behaviour (surveys,
interviews, medical
records)
Treatment adherence,
compliance, office visits, phone
calls, hospitalisations
Medication adherence 5/1
Hall et al
72
1990–2009,
10 of 14
Range of
settings
Brain injury,
musculoskeletal
conditions, cardiac
conditions, trauma,
back, neck and
shoulder pain
P Therapist-patient
relationship,
therapeutic alliance
(surveys, audio/video
taped session)
Adherence, employment sta tus,
physical training, ther apeutic
success, perceived effect of
treatment, pain, physical
function, depression, general
health status, attendance,
floor-bench lifts, global
assessment scores, ability to
perform activities of daily living
(ADLs), mobility
Weekly physical training,
disability, productivity,
depression, functional status,
adherence
18/6
Stevenson
et al
73
1991–2000,
7 of 134
Range of
settings
Hypertension, asthma,
chronic obstructive
pulmonary disorder,
ovarian cancer,
epilepsy,
hyperlipidaemia
P Doctor–patient
communication
(surveys)
Self-reported adherence, blood
pressure control, general
physician practice visits,
hospitalisations, emergency
room visits for children with
asthma, quality of life for COPD
patients, oral contraceptive
adherence, adherence to
antiepileptic drugs, pain control
following gynaecological
surgery, adherence to
medication for depression
Length of visits to doctor for
asthma patients, health status
and use of healthcare services
for epilepsy patients,
adherence to Niacin and bile
acid sequestrant therapy
9/5
Saultz and
Lochner
44
1967–2002,
41 studies
Range of
settings
Varied P Continuity of care —
ongoing relationship
between individual
doctor and patient
Hospitalisation rate, hospital
readmission, length of stay,
influenza immunisation,
preventive care, antibiotic
compliance, intensive care unit
Diabetes (HbA1C, lipid
control, blood pressure control,
presence of diabetic
complications), blood glucose
control, functional ability of
51/30
Continued
Doyle C, Lennox L, Bell D. BMJ Open 2013;3:e001570. doi:10.1136/bmjopen-2012-001570 13
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Table 6 Continued
Authors
Time span and
studies
meeting
inclusion
criteria
Healthcare
setting
Disease areas
covered
Unit of
analysis
Patient experience
focus (and
measurement
methods)
Safety and effectiveness
measure—association
demonstrated -
Safety and effectiveness
measure—association not
demonstrated
Assocs
found vs
not
found
(surveys, continuity
of care index)
days, Neonatal morbidity, Apgar
score, Birth weight, rates and
timeliness of childhood
immunisations, health-related
quality of life, recommended
diabetes care measures,
glucose control, PAP tests,
mammogram rate, breast
exams, surgical operation rates,
hypertension control, presence
of depression, relationship
problems, adverse events in
hospitalsed patients, degree of
patient enablement, rheumatic
fever incidence
elderly patients, compliance
with antibiotic therapy,
well-child visits, blood
pressure checks in women,
pregnancy complications,
newborn mortality,
immunization rates, NICU
admissions, Apgar scores,
caesarean rate, length of
labour, indications for
tonsillectomy
Hall, Roter and
Katz
74
Meta-analysis
41 studies
Range of
settings
Varied P Clinician–patient
communication
(surveys, interviews,
observations,
assessment of video
or audio)
Compliance (with 4 variables of
PE), recall/understanding (with
4 variables of PE)
Compliance (with 1 variable of
PE), recall/understanding (with
1 variable of PE)
8/2
Jackson,
C. et al
40
1984–2008,
3of17
Range of
settings
Inflammatory bowel
disease
P Trust in physician,
Patient–physician
agreement,
adequacy information
(surveys)
Adherence to treatment Compliance 2/1
Sans-Coralles
et al
43
1984–2005,
9of20
Primary
care
No specific disease
focus
P Continuity of care,
coordination of care,
consultation time,
doctor–patient
relationship
(validated tools in
these different
domains)
Hospital admissions, length of
stay, compliance, recovery from
discomfort, emotional health,
diagnostic tests, referrals,
quality of care for asthma,
diabetes and angina, symptom
burden, receipt of preventive
services
Enablement 13/1
Hsiao and
Boult
45
1984–2003,
3of14
Primary
care
No specific disease
focus
P Continuity with
physician (surveys,
interviews, medical
Hospitalisations for all
conditions and ambulatory
care-sensitive conditions, odds
of hospitalisation(2), healthcare
Acute ambulatory
care-sensitive conditions,
mobility, pain, emotion,
activities of daily living,
21/15
Continued
14 Doyle C, Lennox L, Bell D. BMJ Open 2013;3:e001570. doi:10.1136/bmjopen-2012-001570
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Table 6 Continued
Authors
Time span and
studies
meeting
inclusion
criteria
Healthcare
setting
Disease areas
covered
Unit of
analysis
Patient experience
focus (and
measurement
methods)
Safety and effectiveness
measure—association
demonstrated -
Safety and effectiveness
measure—association not
demonstrated
Assocs
found vs
not
found
records, chart
reviews)
costs(2), emergency department
visits, emergent hospital
admissions(2), length of stay,
diabetes recognition, mental
health(2), pain, perception of
health, well-being, BMI,
triglyceride concentrations,
recovery, clinical outcomes,
self-reported health
smoking, BMI, hypertension,
hypercholesterolaemia,
self-reported health, glycaemic
control, diabetes control,
frequency of hypoglycaemic
reactions, blood sugar, weight
Arbuthnott
et al
30
Meta analysis,
1955–2007,
All 48 studies
included
Range of
settings
Asthma, bacterial
infection, flbromyalgia,
diabetes, renal
disease,
hypertension,
congestive heart
failure, inflammatory
bowel disease, breast
cancer, HIV and
tuberculosis
P Physician–patient
collaboration
(Observation,
surveys)
Medication adherence,
behavioural adherence
Appointment adherence 2/1
Stewart
75
1983–1993,
21 studies
Range of
settings
Peptic ulcers, breast
cancer, diabetes,
hypertension,
headache, coronary
artery disease,
gingivitis, tuberculosis,
prostate cancer
P Physician–patient
communication
(surveys, evaluation
of audio- or
videotape recording)
Peptic ulcer physical limitation,
blood glucose levels, blood
pressure, headache resolution,
physician evaluation of
symptom resolution for coronary
artery disease, gingivitis and
tuberculosis, anxiety level in
gynaecological care, radiation
therapy, breast cancer care,
functional status following
radiation therapy for prostate
cancer, anxiety after radiation
therapy, pain levels and hospital
length of stay after
intra-abdominal surgery,
physical and psychological
complaints in breast cancer care
Details not included 16/5
Zolnierek and
DiMatteo
28
Range of
settings
No specific disease
focus
P Physician–patient
communication
Adherence to treatment
recommended by clinician
Adherence (2 observational
studies)
125/2
Continued
Doyle C, Lennox L, Bell D. BMJ Open 2013;3:e001570. doi:10.1136/bmjopen-2012-001570 15
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Table 6 Continued
Authors
Time span and
studies
meeting
inclusion
criteria
Healthcare
setting
Disease areas
covered
Unit of
analysis
Patient experience
focus (and
measurement
methods)
Safety and effectiveness
measure—association
demonstrated -
Safety and effectiveness
measure—association not
demonstrated
Assocs
found vs
not
found
Meta analysis
1949–2008,
127 studies
(observation,
surveys)
Beck et al
76
1975–2000,
5of14
Primary
care
No specific disease
focus
P Physician–patient
communication
(observation,
evaluation of audio
and video tapes)
Compliance with doctors’
advice, blood pressure, pill
count
None 10/0
Cabana and
Lee
21
1966–2002,
7of18
Range of
settings
Rheumatoid arthritis,
epilepsy, breast
cancer, cervical
cancer, diabetes
P Continuity of care
(validated measures
of continuity eg,
SCOC)
Hospitalisations, length of stay,
emergency department visits,
intensive care days, preventive
medicine visits, drug or alcohol
abuse, outpatient attendance,
glucose control for adults with
diabetes
None 18/5
Richards
et al
77
1997–2002,
2of33
Range of
settings
Psoriasis P Patient’s perception
of care, satisfaction,
interpersonal skills
(surveys, interviews)
Treatment adherence,
medication use
None 2/0
BMI, body mass index.
16 Doyle C, Lennox L, Bell D. BMJ Open 2013;3:e001570. doi:10.1136/bmjopen-2012-001570
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and safety and that focusing on improving patient
experience will increase the likelihood of improvements
in the other two domains.
3
The evidence collated in this study demonstrates positive
associations between patient experience and the other two
domains of quality. Because associations do not entail caus-
ality, this does not necessarily prove that improvements in
patient experience will cause improvements in the other
two domains. However, the weight of evidence across dif-
ferent areas of healthcare indicates that patient experience
is clinically important. There is also some evidence to
suggest that patients can be used as partners in identifying
poor and unsafe practice and help enhance effectiveness
and safety. This supports the argument that the three
dimensions of quality should be looked at as a group and
not in isolation. Clinicians should resist sidelining patient
experience measures as too subjective or mood-orientated,
divor ced from the ‘real’ clinical work of measuring and
delivering patient safety and clinical effectiveness.
Acknowledgements The authors of this work thank Mandy Wearne at NHS
Northwest who commissioned this work and provided comments on earlier
drafts, We are also grateful to Jocelyn Cornwell who provided comments on
an early draft of this article. This article presents independent research
commissioned by the National Institute for Health Research (NIHR) under the
Collaborations for Leadership in Applied Health Research and Care (CLAHRC)
programme for North West London. The views expressed in this publication
are those of the author(s) and not necessarily those of the NHS, the NIHR or
the Department of Health.
Contributors CD and DB conceived of the study and were responsible for the
design and search strategy. CD and LL were responsible for conducting the
search. CD and LL conducted the data analysis and produced the tables and
graphs. Derek Bell provided input into the data analysis and interpretation.
The initial draft of the manuscript was prepared by CD then circulated among
all authors for critical revision. All authors helped to evolve analysis plans,
interpret data and critically revise successive drafts of the manuscript.
Funding This research received no specific grant from any funding agency in
the public, commercial or not-for-profit sectors.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement There are no additional data available.
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