What does this article add?
- Empathy of physicians working in an Internal Medicine ward appears
inversely correlated to 30-days readmission rate of the patients they
cared of
- This remains true in the big subgroup of patients with heart failure,
a disease in which adherence to treatment is considered important
INTRODUCTION
The idea of the importance of an empathic patient-doctor relationship is
deeply rooted in medical tradition[1] and teaching, but is
surprisingly supported by only scanty evidence.[2]
Between 2011 and 2012, two studies were carried out to demonstrate the
fact that the empathy of family doctors can improve the clinical outcome
of patients on strong endpoints. Those studies were limited to Family
practice and included only Diabetic patients, demonstrating lower
glycated hemoglobin and lower rates of hospitalization for metabolic
decompensation in patients of higher empathy doctors.[3, 4]
Currently, the number of studies supporting the importance of
physician’s empathy is limited and doesn’t focus on patient outcomes,
but on patient’s and physician’s satisfaction.[5–12] Furthermore,
the clinical impact of empathy in a hospital setting has never been
studied. This actual gap of knowledge contrasts with the great
importance that is traditionally credited to the doctor-patient
relationship at the patient bedside.[13]
We therefore aimed to measure the clinical impact of physician’s Empathy
on the outcome of their patients in the Internal Medicine departments in
our hospital.
To this end, we have considered the correlation between the physician’s
Empathy and the readmission rate of his patients in the 30 days
following discharge, one of the most used indicators of hospitalized
patients’ outcome.[14–18] We measured the empathy of the physicians
with validated self-administered scales. We obtained the readmission
rate data through a combined analysis of the Emergency Room (ER) and
Hospital Discharge Form (HDF) databases.
Since the readmission rate is probably influenced by other variables
contained in the HDF database, we have measured these effects to control
their interference on the correlations under study.
METHODS AND MATERIALS
Participation was asked to all the doctors of the Istituto di Ricovero e
Cura a Carattere Scientifico (IRCCS) Policlinico “San Matteo”
Foundation, who had worked in Internal Medicine wards in the years
2013-2017.
Any doctor who had filled the HDF relating to any hospitalization in
Internal Medicine in the index period was considered as the discharging
physician of that index case. We decided to use the doctor filling up
the HDF, rather than the doctor signing the Hospital Discharge Letter
(HDL), after a brief analysis of a convenience sample of three hundred
HDF and HDL. In the rare cases of discrepancy, the doctor in charge of
the HDF (rather than the one signing HDL) was invariably the one who had
really taken care of the patient for the longest part of the
hospitalization and considered himself responsible for all the effects
of the case.
Subsequently we excluded doctors who had made less than 100 ordinary
discharges during the period under analysis, to have reliable
readmission rates on a sufficient number of patients.
Ordinary discharge was defined as the patient’s return to his usual
residence: deaths, voluntary discharges, transfers to another hospital,
rehabilitation transfers, Hospice transfers or discharges to Nursing
home were therefore excluded, in attempt to maximally reduce the
influence of other doctors’ contacts on the readmission event.
Two different self-administered questionnaires were used to measure
empathy in all participating physicians:
- The Jefferson Scale of Empathy (JSE) in its official Italian version,
a tool validated for use on health professionals, whose use has been
kindly granted by Jefferson University (Philadelphia, Pennsylvania,
USA) that holds all the rights.[2, 19]
- The Empathy Components Questionnaire (ECQ), a validated tool for the
measurement of empathy in the general population that is freely
available, which we have translated into Italian specifically for this
study.[20]
Both questionnaires assign higher score to higher levels of empathy. The
JSE consists of 20 questions and the ECQ consists of 27 questions. For
both questionnaires, the answers are given through a Likert scale
ranging from 1 to 7 points for the JSE and 1 to 4 points for the ECQ.
The maximum score of the JSE is 140 points and that of the ECQ is 108
points.
Empathy is a matter potentially subject to various types of response
bias: acquiescence bias and social desirability bias are the heaviest.
Therefore, it was decided to ensure anonymity to the doctors who
completed the questionnaires.[21]
The mechanism used to anonymize involved a guarantor (CT, the
statistician of the study), who was the only person able to correlate
numerical codes on the questionnaires and the names of the doctors
involved in the study.
The enrollment of the doctors took place through sealed envelopes
containing the coded questionnaires. The envelopes contained a print
that summarized the aims of the study and the anonymization mechanism,
formally asking for participation and the informing about possible
publications of the data. The return by each doctor of completed
questionnaires was considered as acceptance to participate.
Patient data was obtained from HDF digital database of IRCCS Policlinico
“San Matteo” under permission of Hospital Health Management. According
to the hospital procedures, all admitted patients sign an informed
consent allowing the use of their anonymized data for statistical and
research purposes.
We performed a data mining process to link discharge events and
subsequent ER visits in Emergency Department, using the national
identification number (codice fiscale) as a unique identifier. We
considered all Medical Ward discharges from January
1st, 2013 to May 31st, 2017 and
urgent readmission in any ward of the same hospital in the 30 days after
discharge.
Readmission events were identified through the extraction of digital
charts of the Emergency Department of the IRCCS Policlinico “San
Matteo” Foundation, which is the only Emergency Department in the city
of Pavia (approximately 75,000 inhabitants) and the referral hospital
for the entire province of Pavia (approximately 500,000 inhabitants).
We defined “index cases” all the ordinary discharges as defined above
and ”readmissions” all the index cases that, within 30 days after a
discharge, had an ER access whose outcome was ”hospitalization” or
”transferred”; even the latter, in fact, always identifies a direct
hospitalization in another hospital.
We obtained the same readmission data for the subgroup of patient
discharged with Diagnosis Related Group (DRG) 127 (Heart failure and
Shock), the most frequent DRG in General Medicine in our hospital.
Descriptive statistics were obtained for all the variables. Mean and
standard deviation for quantitative variables were used, if normally
distributed (Shapiro test), otherwise median and interquartile range
were used.
The correlations between two quantitative variables were analyzed with
the Pearson correlation coefficient.
The association between the Empathy scores (with each of the two scales)
and the readmission rate of each physician was weighted for the number
of cases (HDFs) of each doctor and was evaluated with multiple linear
regression models, in order to consider the influence of the following
factors associated with readmission:
- average Relative Weight (RW, a cost estimate of the index admission
event) of the index patients discharged by each doctors; [22]
- average age of the patients of each doctor;
- patient sex;
- age of the doctor who has discharged the patient.
The results were expressed both as ”correlation coefficients” (with
related 95% Confidence Intervals) and as BETA coefficients.
For quantitative variables, the ”correlation coefficients” express the
average change in the readmission rate for each year of age (of doctors
or patients), or for each average RW point of hospitalizations. For
qualitative variables, the ”correlation coefficients” expresses the
average change in the readmission rate for each mode of presentation of
the study variable (in this study: males vs. females). The significance
(p) of the coefficients was calculated by weighing the correlation for
the number of index cases of each physician.
The standardized BETA coefficient was obtained to compare the relative
importance of each coefficient in the regression model.[23]
For the purposes of correction, the average duration of hospitalization
for each doctor was not used, as this is always strongly correlated with
RW.
All tests are two-tailed, and the level of significance chosen was the
usual one of 5%. The analyzes were performed with the Stata software
version 15.0.[24]
RESULTS
Twenty-tree envelopes were distributed with the JSE and ECQ
questionnaires to General Medicine doctors who had discharged patients
between 2013 and 2017. The questionnaires were distributed before
knowing how many ordinary discharge procedures had been performed by
each doctor: therefore, the envelopes were also handed to doctors who
discharged less than 100 patients in those years. This exclusion
criterion was applied subsequently, during the data processing.
To the statistician, responsible for the anonymization of the data, 22
of the 23 envelopes were returned with the completed questionnaires
(96%). All 22 returned questionnaires were fully completed.
Of the 22 participating physicians 10 were females. We measured a
greater empathy in the female gender, in accordance with previous
studies.[25] However, the difference is not statistically
significant.
Table 1 shows the mean and median scores, in both empathy scales, in
doctor’s gender subgroups:
Mean age of participant doctors was 56 ± 8 years. There was no
significant difference (p=0,418) in age between male (55 ± 8 years) and
female doctors (58 ± 9 years). Younger doctors tended to have higher
empathy scores in both JSE and ECQ scales (R2 0.639
and 0.702 respectively), but the difference was not significant
(dividing on median age p=0.217 and p=0.113 respectively).
General Medicine departments of the IRCCS Policlinico “San Matteo”
Foundation discharged 8172 patients from January 1st,
2013 to May 31st, 2017.
Of the total of patients, only the 4881 cases discharged at home were
taken into consideration of which 49.7% were males; the characteristics
of the population under analysis are presented in Table 2.
Male doctors discharged 46.6% of the patients.
Of these 4881 home discharges 4280 cases were selected as index cases,
after exclusion of the cases of the doctors excluded by design (seven
doctors who performed less than 100 ordinary discharges during the
period under analysis).
The 4280 index cases were thus discharged by 15 doctors (of which 7 were
women). The patient exclusion process is summarized in Figure 1.
In the 30 days following discharge, 716 index cases (16.7%) had at
least one access in the emergency department and 383 (8.9%) were
rehospitalized after ER evaluation.
The trend of ER access and readmission within 30 days from index
discharge is shown in Figure 2.
Several factors were related to readmission:
- Relative Weight of the index case;
- duration of the hospitalization;
- age of the patient.
Relative Weight was significantly higher in rehospitalized compared to
non-rehospitalized patients (1.211 vs 1.087, p<0.0001).
Readmitted patients had a longer average duration of index
hospitalization, compared with non-readmitted patients (13.0 vs 11.5
days, p<0.0001).
Patients who are rehospitalized are significantly older than those who
are not readmitted. (76.68 vs 74.72, p=0.0078).
There was no significant correlation between the gender of patients and
their tendency to be rehospitalized. (M 8.9% vs F 8.7%, p=0.791). The
relationship between the age of the physicians and the readmission of
the patients was as well not significant. (readmitted 57.89 y, non
readmitted 58.07, p=0.674).
Also the relationship between the gender of the doctor and the rate of
readmission had not any significance. (M 9.5% vs F 8.5%, p=0.621).
We assessed by logistic regression the correlation between the empathy
score and the 30-day readmission rate of each of the 15 physicians whose
data were evaluable. The correlation was adjusted for the following
characteristics of each doctor: mean age of his patients; sex of his
patients; average relative weight of his cases; age of the doctor
himself. Correlation was weighted by the number of ordinary discharge
procedures performed by each doctor.
We observed an inverse correlation between the empathy score and the
readmission rate both using the JSE scale and the ECQ scale with
respectively a coefficient -0.027 and ‑0.004, and an
R2 0.181 and 0.165. The correlation is highly
significant (p<0.001) for JSE scale and not significant for
the ECQ scale (p=0.904, although it was significant in univariate
analysis p=0.016); correlation data scatter and regression lines are
shown in Figure 3.
We measured the BETA value of each independent variable. BETA value
indicates how each of the factors considered in the analysis can, either
positively (patient age, patient sex, RW of cases), or negatively
(doctor’s age, empathy score) affect the occurrence of readmission.
Considering a regression model with the following independent variables
- JSE score, age and sex of patients, RW of index admission and age of
the physician - about one fifth (21%) of readmissions is attributable
to the empathy variable measured by JSE.
We performed the same type of regression analysis as described above,
considering only the 590 index cases of DRG 127 (Heart failure and
Shock), i.e. the one with the highest number of readmission (62 or
10,5%) andat the same time the most frequent DRG in Internal Medicine.
In the context of DRG 127, an inverse correlation emerged between the
physician’s empathy, and the readmission rate both on the JSE scale and
on the ECQ scale with respectively coefficient -0.032 and -0.098,
R2 0.303 and 0.326, p=0.050 and p<0.001; the
correlation data scatter of DRG 127 is shown in Figure 4.
DISCUSSION AND CONCLUSIONS
This study demonstrates a significant correlation between the levels of
empathy of Internists operating in hospital wards and the readmission
rate of their patients within 30 days of discharge. This correlation
remains significant after adjustment (for age and sex of the patients,
for the average RW of the cases and for the age of the doctor) only
using JSE measurements of empathy a tool validated specifically for the
health sector); the correlation appears not significant using ECQ (a
tool validated for use in the general population), whose italian
translation has not been previously used. For each correlation we found
rather low R-square scores, as one could expect in a study with low
numbers of participants and variables with wide range of values.
The same results appear stronger considering only index cases with Heart
failure (DRG 127, the most frequent in Internal Medicine), a disease
where the importance of the interaction between patient and healthcare
professionals appears to play a substantial role.[26] In this
subgroup of patients also ECQ scores appear strongly related to the
outcome, also after adjustment.
Between the Internist and the hospitalized patient there is a care
relationship that can be as intense as the one between the Family Doctor
and his patients. A relationship based on repeated clinical contacts,
interviews and visits to establish diagnosis, to adjust therapy, to
educate and make the patient aware of his illness and to plan discharge
and follow up. Sometimes this process occurs directly with the patient,
sometimes it happens largely with his caregivers, but it is intuitive
that the Internist’s empathy could have a strong influence on the
patient’s understanding and awareness,[27] on determining a strong
therapeutic alliance,[28] in empowering the patient[29–31] and
improving the management of the emotions of both the patient and his
family.[32, 33] This study is therefore the first objective
demonstration of the clinical relevance that empathy can have in an
Internal Medicine ward, similarly to what has already been demonstrated
in Family Medicine.[3, 4] It is true that other intermediates such
as nurses, resident physicians and colleagues can affect the patient
emotions and his understanding of disease and treatment, but the
hypothesis that the doctor-patient relation during an average of twelve
days of hospitalization has a therapeutic role, seems to us reasonable.
The yield of empathy on the outcome of the patients appears to be as big
as medical interventions: for example, in patients with Heart failure
(DRG 127) a difference in JSE score of 30 points appears to have the
potential to reduce the readmission rate absolute value by approximately
1-2%: an absolute risk reduction considered worth a pharmacological
intervention.[18] The debate on the possibility of modulating
trainees and doctors Empathy through training and education is still
open.[34–36] We speculate that interventions aimed to increase
hospital doctors’ empathy could have a big impact on important outcomes
for the patients.
Elements supporting the validity of these results include the fact that
the study was conducted on a large population of patients, using
complete data from accurate databases. In addition, the response rate of
the Internists to whom the study was proposed was almost complete and an
effective anonymization process likely reduced the occurrence of
response bias. Furthermore, the results are built on readmission rate, a
robust outcome measure widely used in clinical trials.
O the other hand the observational and retrospective nature of the study
cannot demonstrate causality, but only correlations deserving further
investigation. Furthermore, our data on readmission doesn’t include
those of other hospitals, though we estimate that access to other minor
emergency departments, after an index discharge from our teaching
hospital is a rare event: our emergency rescue service favors patient’s
return to the same hospital that recently discharged him/her.[37]
Moreover, our data does not consider deaths outside the hospital but we
estimate this kind of events now very rare in the highly urbanized area
of Pavia province.
A further limitation of the study concerns the empathy evaluation method
which, by its nature, in addition to being self-assessed, does not
consider possible variations of empathy over the long period considered.
Lastly, our Italian translation of ECQ has not been validated. This fact
is a limitation of the study, because without a proper psychometric
assessment, these tests may lose their validity if translated into
another language; a good correlation between the results obtained with
the two scales reassures on the validity of the results.
The small number of doctors involved reduces the validity of the study
and probably causes low correlation values; further studies, on larger
populations, are necessary to confirm these findings, that could have a
great relevance for the training of
physicians, both in medical school and in continuing medical education.
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TABLES