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Study Protocol



Dr. Jörg Dirmaier 

Isabelle Scholl

Universitätsklinikum Hamburg-Eppendorf

Institut und Poliklinik für Medizinische Psychologie

Martinistr. 52 (Gebäude W26)

20246 Hamburg  

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Evaluation of dimensions and measurement scales in patient-centeredness

Principal investigators: Dr. Jörg Dirmaier, Prof. Dr. Dr. Martin Härter


Project staff: Dr. Isabelle Scholl, Jördis Zill, Dipl.-Psych.


Background and aims

Patient-centeredness has gained importance over the last few decades, in particular regarding long-term conditions. However, there is a lack of theoretical and conceptual clarity regarding the term patient-centeredness. This absence of clarity results in inconsistent measurement of the construct, which leads to difficulties in the comparison of research results and in the implementation in routine practice. The aims of this project are 1) to identify the dimensions of patient-centeredness and include them in an integrative model, 2) to select and assess the most relevant dimensions, 3) to identify and assess measurement scales and find evidence for the selected dimensions, and 4) to assess the relevance and applicability of the results from in the previous phases and to develop implementation strategies.



This project is divided into four phases. In the first phase, a systematic review was carried out to identify the dimensions of patient-centeredness and an integrative model was developed. In the second phase, a group of experts (e.g., patient representatives, clinicians, researchers) assessed and prioritized the identified dimensions using an online Delphi survey. In the third phase, several systematic reviews were conducted to assess the quality of measurement scales of the selected dimensions. In the final phase, an expert workshop was held. Results of the previous phases were assessed regarding their relevance and applicability and implementation strategies were developed for research and clinical practice.



In the systematic review of definitions of patient-centeredness a total of 15 dimensions of patient-centered care were identified: essential characteristics of the clinician, clinician-patient relationship, clinician-patient communication, patient as unique person, biopsychosocial perspective, patient information, patient involvement in care, involvement of family and friends, patient empowerment, physical support, emotional support, integration of medical and non-medical care, teamwork and teambuilding, access to care, coordination and continuity of care. These dimensions were used to build an integrative model (see Figure 1), with three main elements a) principles, b) activities, and c) enablers.


FIG 1 Integrative Model

Figure 1: Integrative model of patient-centered care (Scholl et al., 2014)


In the second phase, the dimensions identified in Phase 1 were assessed and selected in a two-step online Delphi survey. In the first round N=105 and in the second round N=71 experts (researchers, patient representatives, clinicians, quality managers) participated. The results showed a tendancy to reduce the model to 14 dimensions, excluding the dimension integration of medical and non-medical care. The following five dimensions were categorized as most relevant (TOP 5 dimensions):  patient as unique person, patient involvement in care, patient information, clinician-patient-communication and patient empowerment.

In Phase 3 several systematic reviews of measures were conducted to the TOP 5 dimensions (excluding the dimension patient as a unique person, for which no search strategy could be developed due to low degree of operationalization). The conducted reviews showed that a range of measures exist for the examined dimension. However, both the quality of studies (assessed with the COSMIN checklist) and the psychometric quality showed large heterogeneity of measures. Furthermore, there are only few psychometrically sound measures available in German. As a next step, a narrative meta-review identified systematic reviews on studies reporting on associations of dimensions of patient-centered care and health related outcomes. This meta-review showed that several reviews exist for actions of patient-centered care and a few for enablers of patient-centered care. However, there is a lack of research on principles of patient-centered care. A comparison across dimensions shows that the most consistent influence of a dimension of patient-centered care was on patient satisfaction. Only few results showed an impact on health related outcomes. However, it is difficult to draw firm conclusions of these results (e.g. because of heterogeneous definitions and outcomes).

In Phase 4 the results of Phases 1-3 were presented to a group of stakeholders (including researchers, clinicians, patient representatives and other members of health care institutions. With N=22 participants this one day workshop had a good response. Recommendations for implementation at research, clinical and health policy level were derived from the workshop.



  1. Zill, J.M., Christalle, E., Müller, E., Härter, M., Dirmaier, J., Scholl, I. [shared senior authorship] (2014). Measurement of physician-patient communication - a systematic review. PLOS ONE, DOI:10.1371/journal.pone.0112637.
  2. Scholl, I., Zill, J.M., Härter, M., Dirmaier, J. (2014). An integrative model of patient-centeredness – a systematic review and concept analysis. PLOS ONE, DOI: 10.1371/journal.pone.0107828.
  3. Müller, E., Zill, J.M., Härter, M., Dirmaier, J., Scholl, I. (2014). Assessment of trust in the physician: a systematic review of measures. PLOS ONE, DOI: 10.1371/journal.pone.0106844.
  4. Scholl, I., Zill, J.M., Härter, M., Dirmaier, J. (2014) How do health services researchers understand the concept of patient-centeredness? Results from an expert survey. Patient Preference and Adherence, 8, 1153-1160.
  5. Sepucha, K., Scholl, I. (2014). Measuring shared decision making: A review of constructs, measures, and opportunities for cardiovascular care. Circulation Cardiovascular Quality and Outcomes, doi:10.1161/CIRCOUTCOMES.113.000350
  6. Scholl, I., Nicolai, J., Pahlke, S., Kriston, L., Krupat, E., Härter, M. (2014) The German version of the Four Habits Coding Scheme - association between physicians' communication and shared decision making skills in the medical encounter. Patient Education and Counseling, 94(2), 224-229.
  7. Zill, J.M., Scholl, I., Härter, M., Dirmaier, J. (2013). Evaluation of dimensions and measurement scales in patient-centeredness - Study protocol. Patient Preference and Adherence, 7, 345-351.
  8. Scholl, I., Koelewijn-van Loon, M., Sepucha, K., Elwyn, G., Härter, M., Dirmaier, J. (2011). Measurement of shared decision-making - a review of instruments. Zeitschrift für Evidenz, Fortbildung und Qualität im Gesundheitswesen, 105 (4),313-324.


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