Chronic obstructive pulmonary disease (COPD) remains a major public health problem. It is the fourth leading cause of chronic morbidity and mortality in the United States, and is projected to rank fifth in 2020 in burden of disease worldwide, according to a study published by the World Bank/World Health Organization. Yet, COPD remains relatively unknown or ignored by the public as well as public health and government officials. In 1998, in an effort to bring more attention to COPD, its management, and its prevention, a committed group of scientists encouraged the U.S. National Heart, Lung, and Blood Institute and the World Health Organization to form the Global Initiative for Chronic Obstructive Lung Disease (GOLD). Among the important objectives of GOLD are to increase awareness of COPD and to help the millions of people who suffer from this disease and die prematurely of it or its complications. The first step in the GOLD program was to prepare a consensus report, Global Strategy for the Diagnosis, Management, and Prevention of COPD, published in 2001. The present, newly revised document follows the same format as the original consensus report, but has been updated to reflect the many publications on COPD that have appeared. GOLD national leaders, a network of international experts, have initiated investigations of the causes and prevalence of COPD in their countries, and developed innovative approaches for the dissemination and implementation of COPD management guidelines. We appreciate the enormous amount of work the GOLD national leaders have done on behalf of their patients with COPD. Despite the achievements in the 5 years since the GOLD report was originally published, considerable additional work is ahead of us if we are to control this major public health problem. The GOLD initiative will continue to bring COPD to the attention of governments, public health officials, health care workers, and the general public, but a concerted effort by all involved in health care will be necessary.

https://www.who.int/respiratory/copd/GOLD_WR_06.pdf

Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary.

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Global strategy for asthma management and prevention

According to W. Edwards Deming, American companies require nothing less than a transformation of management style and of governmental relations with industry. In Out of the Crisis, originally published in 1982, Deming offers a theory of management based on his famous 14 Points for Management. Management's failure to plan for the future, he claims, brings about loss of market, which brings about loss of jobs. Management must be judged not only by the quarterly dividend, but by innovative plans to stay in business, protect investment, ensure future dividends, and provide more jobs through improved product and service. In simple, direct language, he explains the principles of management transformation and how to apply them.

Out of the Crisis

Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) Workshop summary.

OBJECTIVE: To ascertain whether the quality of physician-patient communication makes a significant difference to patient health outcomes. DATA SOURCES: The MEDLINE database was searched for articles published from 1983 to 1993 using "physician-patient relations" as the primary medical subject heading. Several bibliographies and conference proceedings were also reviewed. STUDY SELECTION: Randomized controlled trials (RCTs) and analytic studies of physician-patient communication in which patient health was an outcome variable. DATA EXTRACTION: The following information was recorded about each study: sample size, patient characteristics, clinical setting, elements of communication assessed, patient outcomes measured, and direction and significance of any association found between aspects of communication and patient outcomes. DATA SYNTHESIS: Of the 21 studies that met the final criteria for review, 16 reported positive results, 4 reported negative (i.e., nonsignificant) results, and 1 was inconclusive. The quality of communication both in the history-taking segment of the visit and during discussion of the management plan was found to influence patient health outcomes. The outcomes affected were, in descending order of frequency, emotional health, symptom resolution, function, physiologic measures (i.e., blood pressure and blood sugar level) and pain control. CONCLUSIONS: Most of the studies reviewed demonstrated a correlation between effective physician-patient communication and improved patient health outcomes. The components of effective communication identified by these studies can be used as the basis both for curriculum development in medical education and for patient education programs. Future research should focus on evaluating such educational programs.

Effective physician-patient communication and health outcomes: a review

Background: We designed this observational cohort study to assess the association between patient-centered communication in primary care visits and subsequent health and medical care utilization. 

Methods: We selected 39 family physicians at random, and 315 of their patients participated. Office visits were audiotaped and scored for patient-centered communication. In addition, patients were asked for their perceptions of the patient-centeredness of the visit. The outcomes were: (1) patients' health, assessed by a visual analogue scale on symptom discomfort and concern; (2) self-report of health, using the Medical Outcomes Study Short Form-36; and (3) medical care utilization variables of diagnostic tests, referrals, and visits to the family physician, assessed by chart review. The 2 measures of patient-centeredness were correlated with the outcomes of visits, adjusting for the clustering of patients by physician and controlling for confounding variables. 

Results: Patient-centered communication was correlated with the patients' perceptions of finding common ground. In addition, positive perceptions (both the total score and the subscore on finding common ground) were associated with better recovery from their discomfort and concern, better emotional health 2 months later, and fewer diagnostic tests and referrals. 

Conclusions: Patient-centered communication influences patients' health through perceptions that their visit was patient centered, and especially through perceptions that common ground was achieved with the physician. Patient-centered practice improved health status and increased the efficiency of care by reducing diagnostic tests and referrals.

The impact of patient-centered care on outcomes.

Preface. About the authors. List of contributors. Acknowledgments. Part one: overview. Introduction. The evolution of clinical method. Part two: the four components of the patient-centered clinical method. Introduction. The first component: exploring health, disease and the illness experience. 'I don't want to die': case illustrating component 1. 'I should write a letter to the editor!': case illustrating component. The second component: understanding the whole person. Part 1: individual and family. Trauma, tragedy, trust and triumph: case illustrating component 2. The second component: understanding the whole person. Part 2: context. Mary T: case illustrating component 2. 'Doctor, I need you to give me a test to check if I am a lesbian': case illustrating component 2. The third component: finding common ground. 'I'd sooner take my chances!': case illustrating component 3. The fourth component: enhancing the patient-clinician relationship. When we first saw eye to eye: case illustrating component 4. The flag for undefined pain: case illustrating component 4. Part 3: learning and teaching the patient-centered clinical method. Introduction. Becoming a physician: the human experience of medical education. A messenger: case illustrating becoming a physician. Learner-centered teaching. Being there: case illustrating being learner-centered. Challenges in learning and teaching the patient-centered clinical method. Teaching the patient-centered clinical method - practical tips. The case report as a teaching tool for patient-centered care. Margaret L: case illustrating a patient-centered case report. Part 4: the health care context and patient-centered care. Introduction. Team-centered approach: how to build and sustain a team. The team was the container for her story: case illustrating a team-centered approach. Health care costs and patient-centered care. Part 5: research on patient-centered care. Introduction. Using qualitative methodologies to illuminate patient-centered care. Evidence on the impact of patient-centered care. Measuring patient perceptions of patient-centeredness. Measuring patient-centeredness. Conclusions. References. Index.

Patient-Centered Medicine: Transforming the Clinical Method

Primary care p 468 

Key messages about patient centred care can be drawn from the paper by Little et al in this issue of the BMJ (p 468).1 Firstly, strong agreement exists between the definition of patient centredness that arises empirically from this observational study of patients in the United Kingdom and another definition arising from reflections on practice in South Africa and Canada,2 suggesting an international definition of patient centred medicine. Secondly, the premise of the observational study is correct—that the best way of measuring patient centredness is an assessment made by the patients themselves.

Patient centredness is becoming a widely used, but poorly understood, concept in medical practice. It may be most commonly understood for what it is not—technology centred, doctor centred, hospital centred, disease centred. Definitions of patient centred care seek to make the implicit in patient care explicit. Such definitions are, we recognise, oversimplifications which help in teaching and research but fail to capture the indivisible whole of a healing relationship. Perhaps qualitative research comes closer to conveying the qualities of such care.

Acknowledging these limitations, researchers seek answers to crucial questions …

https://www.bmj.com/content/bmj/322/7284/444.full.pdf

Towards a global definition of patient centred care.

Objectives. —To use audiotape analysis to describe communication patterns in primary care, to relate these to ideal relationship types as described in the literature, and to explore the patterns' relationships with physician and patient characteristics and satisfaction. Design. —Description of routine communication in primary care based on audiotape analysis and patient and physician exit questionnaires. Setting. —A total of 11 ambulatory clinics and private practices. Participants. —The participants were 127 physicians and 537 patients coping with ongoing problems related to disease. Main Outcomes Measures. —Roter Interactional Analysis System (RIAS) and patient and physician exit satisfaction questionnaires. Results. —Cluster analysis revealed 5 distinct Communication patterns: (1) "narrowly biomedical," characterized by closed-ended medical questions and biomedical talk occurring in 32% of visits; (2) "expanded biomedical." like the restricted pattern but with moderate levels of psychosocial discussion occurring in 33% of the visits; (3) "biopsychosocial," reflecting a balance of psychosocial and biomedical topics (20% of the visits); (4) "psychosocial," characterized by psychosocial exchange (8% of visits); and (5) "consumerist," characterized primarily by patient questions and physician information giving (8% of visits). Biomedically focused visits were used more often with more sick, older, and lower income patients by younger, male physicians. Physician satisfaction was lowest in the narrowly biomedical pattern and highest in the consumerist pattern, while patient satisfaction was highest in the psychosocial pattern. Conclusions. —Primary care communication patterns range from narrowly biomedical to consumerist patterns and parallel the ideal forms of patient-physician relationships described in the literature.

Moira Stewart

Papers

Effective physician-patient communication and health outcomes: a review

The impact of patient-centered care on outcomes.

Patient-Centered Medicine: Transforming the Clinical Method

Towards a global definition of patient centred care.

Communication patterns of primary care physicians.