title: Which patients improve: characteristics increasing sensitivity to a supportive patient-practitioner relationship.
abstract: Supportive social relationships, including a positive patient-practitioner relationship, have been associated with positive health outcomes. Using the data from a randomized controlled trial (RCT) undertaken in the Boston area of the United States, this study sought to identify baseline factors predictive of patients' response to an experimentally applied supportive patient-practitioner relationship. To sort through the hundreds of potential attributes affecting the patient-practitioner relationship, we applied a false discovery rate method borrowed from the field of genomics and bioinformatics. To our knowledge such a method has not previously been applied to generate hypotheses from clinical trial data. In a previous RCT, our team investigated the effect of the patient-practitioner relationship on symptom improvement in patients with irritable Bowel syndrome (IBS). Data were collected on a sample of 289 individuals with IBS using a three-week, single blind, three arm, randomized controlled design. We found that a supportive patient-practitioner relationship significantly improved symptomatology and quality of life. A complex, multi-level measurement package was used to prospectively measure change and identify factors associated with improvement. Using a local false discovery rate procedure, we examined the association of 452 baseline subject variables with sensitivity to treatment. Out of 452 variables, only two baseline factors, reclusiveness, and previous trial experience increased sensitivity to the supportive patient-practitioner relationship. A third variable, additional opportunity during the study for subjects to discuss their illness through experiential interview, was associated with improved outcomes among subjects who did not receive the supportive patient-practitioner relationship. The few variables associated with differential benefit suggest that a patient-centered supportive patient-practitioner relationship may be beneficial for most patients. This may be especially important for reclusive individuals. Within the context of our study, additional study attention in the form of repeated experiential interviews compensated for a lack of positive patient-practitioner support. A supportive patient-practitioner relationship may also help overcome low provider expectations for subjects with previous trial experience. These results converge with the results of the parent trial, implicating the importance of the social world in healing.
authors.affiliation: Harvard Medical School, Osher Research Center, Boston, MA United States. Electronic address: lisa_conboy@hms.harvard.edu.
authors.forename: Lisa Ann
authors.initials: LA
authors.lastname: Conboy
authors.affiliation: Department of Biostatistics, Massachusetts General Hospital, Boston, MA, United States.
authors.forename: Eric
authors.initials: E
authors.lastname: Macklin
authors.affiliation: Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States.
authors.forename: John
authors.initials: J
authors.lastname: Kelley
authors.affiliation: Department of Gastroenterology, Beth Israel Hospital, Boston, MA, United States.
authors.forename: Efi
authors.initials: E
authors.lastname: Kokkotou
authors.affiliation: Department of Gastroenterology, Beth Israel Hospital, Boston, MA, United States.
authors.forename: Anthony
authors.initials: A
authors.lastname: Lembo
authors.affiliation: Harvard Medical School, Osher Research Center, Boston, MA United States.
authors.forename: Ted
authors.initials: T
authors.lastname: Kaptchuk
mesh_terms: D005189:False Positive Reactions; D005260:Female; D006801:Humans; D007407:Interviews as Topic; D043183:Irritable Bowel Syndrome / Q000628:therapy; D008297:Male; D017063:Outcome Assessment, Health Care; D018802:Patient-Centered Care; D010817:Physician-Patient Relations; D016032:Randomized Controlled Trials as Topic; D012934:Social Isolation; D012944:Social Support