Patient-centred care and quality of life and hope among Japanese patients receiving home medical care: a multicentre, cross-sectional study

Abstract

Objectives

Patient-reported outcomes reflecting quality of life (QOL) and hope are essential targets for in-home medical care. This study examined the association between the quality of patient-centred care and both QOL and hope.

Design

Multicentre, cross-sectional study.

Setting

Twenty-nine home care clinics in the Tokyo Metropolitan Area, Nara Prefecture and Nagasaki Prefecture in Japan.

Participants

200 patients receiving home medical care.

Exposure

Patient-centredness was measured using the Japanese version of the Primary Care Assessment Tool-Short Form (JPCAT-SF).

Outcome measures

The primary outcome measures were QOL, assessed using the QOL-Home Care (QOL-HC) scale, and hope, measured using the Health-Related Hope (HR-Hope) scale. Mixed-effects linear models were applied.

Results

A higher JPCAT-SF total score was associated with a higher QOL-HC score (adjusted mean difference per 10-point increase: 0.28, 95% CI 0.16 to 0.40). Among the JPCAT-SF domains, higher scores in first contact (0.16, 95% CI 0.08 to 0.23), longitudinality (0.20, 95% CI 0.11 to 0.29), comprehensiveness (services available) (0.12, 95% CI 0.03 to 0.20), comprehensiveness (services provided) (0.08, 95% CI 0.01 to 0.15) and community orientation (0.11, 95% CI 0.02 to 0.20) were also associated with higher QOL-HC scores. Similarly, a higher JPCAT-SF total score was associated with a higher HR-Hope score (adjusted mean difference per 10-point increase: 4.8, 95% CI 2.9 to 6.7). Additionally, higher scores in individual JPCAT-SF domains were associated with higher HR-Hope scores: first contact (2.7, 95% CI 1.3 to 4.1), longitudinality (2.5, 95% CI 0.8 to 4.2), coordination (1.2, 95% CI 0.2 to 2.3), comprehensiveness (services available: 1.8, 95% CI 0.5 to 3.2; services provided: 1.3, 95% CI 0.4 to 2.3) and community orientation (1.8, 95% CI 0.5 to 3.1).

Conclusions

Higher quality patient-centred care is positively associated with enhanced QOL and hope among home medical care patients. Patient-centredness should be strengthened in daily clinical practice.

Correspondence to Professor Noriaki Kurita; [email protected]

STRENGTHS AND LIMITATIONS OF THIS STUDY

• The multicentre, cross-sectional study design, in which data were obtained from 29 home care clinics in Japan’s urban and rural areas, increases our findings’ external validity.

• Data were collected using standardised and validated procedures and instruments, increasing internal validity.

• While patient-centredness, quality of life (QOL) and hope were obtained from the questionnaire, the provision of comorbidities, type of residence and patient life expectancy from the medical provider ensured the accuracy of the case mix.

• By controlling confounding variables, such as life expectancy and depressive symptoms, we accurately estimated the associations of patient-centred care with QOL and hope.

• Limitations of our study include the possibility of reverse causation because of the study’s cross-sectional design, and limitations with respect to potential sampling bias (given the unknown response rate) and generalisability (due to the exclusion of patients with severe dementia).

Introduction

Maintaining or improving function and well-being are central goals in caring for patients requiring home medical care when they have chronic or progressive illnesses for which no cure or treatment is feasible.¹ Thus, patient-reported outcomes (PROs), which reflect quality of life (QOL) and hope, are essential targets for in-home medical care. However, QOL among patients receiving home medical care is often underestimated owing to such patients’ limited activities of daily living (ADLs).² Empirical evidence on approaches that home medicine physicians can implement to improve their patients’ QOL was scarce compared with approaches for outpatient and nursing home settings. Specifically, while home medicine physicians claim that the implementation of patient value-based medicine (one of the key elements of patient-centred care) can preserve a patient’s QOL even in Japan,³ there is little literature directly supporting this. For example, patient-centred care for patients with type 2 diabetes is associated with physical and mental health-related QOL.⁴ In nursing home settings, patient-centred care, such as building close relationships and collaborative decision-making, is associated with better QOL.⁵

Hope is considered an essential coping strategy,⁶ given that it is the only thing patients can hold on to in a clinical oncology setting when they cannot do anything else.⁷ The benefits of hope are supported by empirical evidence showing that higher hope is associated with lesser pain and psychological distress among patients with lung cancer.⁸ Furthermore, hope has been identified as an essential theme of patient-centred care for chronic illnesses.⁹ Despite the importance of QOL and the potential of hope in improving patient outcomes, there is a shortage of empirical research showing that providing patient-centred care improves these outcomes among patients receiving home medical care.⁹

In the United Kingdom, in-home medical care for adults with mental health problems provides elements constituting patient-centred care, such as sufficient time to talk and resolve patients’ concerns, and was positively associated with hope as a consequence.¹⁰ However, patient-centred care comprises multiple broad domains such as first contact, which refers to access to medical care, including availability outside regular hours or on days off and longitudinality, which refers to understanding the whole person and not just the disease.¹¹ In addition, whether patient-centred care can ensure the maintenance of QOL and hope among patients with impaired physical functioning due to chronic illness rather than psychological problems has not been examined. Clarifying this issue could contribute to further empirical work regarding how attending physicians can provide patient-centred home medical care.⁹

Therefore, we conducted a multicentre cross-sectional study using data from the Zaitaku Evaluative Initiatives and Outcome Study (ZEVIOUS) to examine the association of the quality of patient-centred care with QOL and hope among patients receiving home medical care.

Methods

Design, setting and participants

This study was part of the ZEVIOUS, a multicentre, cross-sectional study involving 29 home care clinics in the Tokyo Metropolitan Area, Nara Prefecture and Nagasaki Prefecture in Japan. The inclusion criteria were patients receiving home medical care, as determined by their attending physicians, who were judged as capable of responding to the questionnaire survey. The attending physicians at the facilities were requested to perform consecutive sampling. The questionnaire was distributed to each patient between January and July 2020, and the patients were requested to complete the survey. Patients with visual impairments or physical disabilities that prevented them from writing were permitted assistance by a family member or formal caregiver in answering the survey. Exclusion criteria were patients who were considered by their physicians to be unable to complete the questionnaire due to cognitive function, mental status or physical reasons.¹² The Institutional Review Board of Fukushima Medical University approved the study protocol (approval number: ippan-30254). The participants signed the written consent form and completed the questionnaire at their residences. A sample size calculation was not required for the present study because this was a secondary analysis using the ZEVIOUS data.^{12 13}

Patient-centredness (exposure)

The Japanese version of the Primary Care Assessment Tool-Short Form (JPCAT-SF) was used to measure patient-centredness in primary care settings.¹¹ The JPCAT-SF comprises 13 items encompassing six domains representing five primary care attributes: first contact (two items), longitudinality (two items), coordination (three items), comprehensiveness (two items for ‘services available’ and two items for ‘services provided’) and community orientation (two items). Detailed information regarding the items, scoring, psychometric properties and domains of the JPCAT-SF can be found in the supplementary materials (online supplemental table S1). Participants rated each item on a five-point Likert scale ranging from strongly disagree to strongly agree. We converted the responses to item scores ranging from 0 to 4 points. Domain scores were calculated by multiplying the average item scores within the same domain by 25, resulting in a range of 0–100 points, with higher scores indicating better performance. The total score represents an overall measure of the patient-centredness of primary care and was calculated as the average of the six domain scores.

QOL and hope (outcomes)

The QOL-Home Care (QOL-HC) is a four-item questionnaire that assesses the QOL of older patients receiving home medical care.¹⁴ Kamitani et al have demonstrated the face validity of the QOL-HC through item derivation by physicians and care managers and item selection by geriatricians.¹⁴ Each item is rated on a three-point scale, ranging from ‘never agree’ (0 points) to ‘always agree’ (two points), resulting in a total score ranging from 0 to 8 points (online supplemental table S2).

The Health-Related Hope (HR-Hope) scale is an 18-item unidimensional scale designed to evaluate HR-Hope among individuals with chronic conditions.¹⁵ Through structural validation, the scale comprises three subdomains: ‘something to live for’ (five items), ‘health and illness’ (six items) and ‘role and connectedness’ (seven items) (online supplemental table S3).¹⁵ Participants rate their responses to each item on a four-point Likert scale ranging from 1 = ‘I do not feel that way at all’ to 4 = ‘I strongly feel that way’. After obtaining the average score for each subdomain and the total score, the scores are scaled from 0 to 100 points. Patients without family were exempted from answering two items in the ‘role and connectedness’ subdomain (online supplemental table S3).

Covariates

Demographic information, such as age, sex, education and the presence of family members, was collected through a questionnaire. The physician-in-charge provided data on comorbidities, type of residence, disease severity and patient life expectancy. Regarding the patient’s life expectancy, the home medical care physician assigned to the patient answered the following question: ‘What diseases were the leading cause of introducing home medical care?’ The physicians were allowed to choose from the following options: cerebrovascular disease, heart disease, cancer, respiratory disease, joint disease, dementia, incurable neuromuscular disease, diabetes, visual and hearing impairment, fractures and falls, spinal cord disease, infirmity, other and unknown. Regarding type of residence, the physicians answered the question: ‘What is the type of residence?’ The following options were provided: home, care home for older adults, retirement home, group home (for patients with dementia), multifunctional long-term care in a small group home and short stay. We classified the responses into those with homes and those without homes (nursing homes). Lastly, physicians were asked, ‘How long do you expect the clinical prognosis (life expectancy) of this patient to be?’ They were allowed to choose from five options: ‘less than 1 month’, ‘more than 1 month to less than 3 months’, ‘more than 3 months to less than 6 months’, ‘more than 6 months to less than 12 months’, and ‘more than 12 months’. This question and the responses to it were developed from the question ‘Would I be surprised if the person in front of me died in the next 6 months or 1 year?’ which was proposed in a previous study to initiate a discussion about end-of-life care needs and preferences in the United Kingdom.^{12 16} Depressive symptoms were assessed using the five-question Mental Health Inventory (MHI-5).¹⁷ The MHI-5 scores were calculated according to a previous study,¹⁷ and the total score was converted to 0–100. A score of ≤52 on the MHI-5 was defined as having depression.¹⁷ The care-needs level is determined by disease severity, one of the seven categories of Japanese long-term care insurance, and defined by the amount of care needed. The validation of the care-needs level was indicated by a self-reported functional decline in the ZEVIOUS study.¹⁸

Statistical analyses

Statistical analyses were performed using Stata/SE V.18 (StataCorp, College Station, TX, USA). Patient characteristics were described using means and SD for continuous variables and frequencies and percentages for categorical variables. Histograms of the QOL-HC, HR-Hope and total JPCAT-SF scores, as well as the scores of the six JPCAT-SF domains, were generated. Scatter plots illustrating the relationships between total JPCAT-SF and QOL-HC scores, as well as between total JPCAT-SF and HR-Hope scores, were created with fitted lines. The degree of correlation between the total JPCAT-SF score and both the QOL-HC and HR-Hope scores was assessed using Spearman’s rank correlation coefficient. Mixed-effects linear models were used to estimate the association between JPCAT-SF scores and QOL-HC and HR-Hope scores, considering clustering effects by the facility. Robust variance estimation was used for the QOL-HC analysis because the scale did not meet the standard assumptions of equal variance and normality. Age, sex, educational attainment, family presence, depressive symptoms, patient life expectancy and comorbidities were included as covariates in the models.

Additionally, the models were fitted, in each of which the six domain scores of the JPCAT-SF were treated as an explanatory variable. Missing exposure and covariate data were imputed five times using multiple imputations with chained equations, assuming that the mechanism of the missing data was random.¹⁹ Statistical significance was defined as p<0.05.

Patient and public involvement

This study involved the analysis of patient data collected from 29 healthcare facilities, which was conducted at Fukushima Medical University. All individual participants were anonymized to ensure their privacy and confidentiality. Patients were not involved in the direct creation or execution of the research study. The data used in this research was obtained through collaborations with participating institutions, and appropriate measures were taken to maintain data integrity and security throughout the analysis process.

Results

Patient characteristics

Of the 202 patients who received home medical care and who consented to participate, 200 with complete data on either QOL-HC (n=195) or HR-Hope (n=200) were included in the analysis (online supplemental figure S1). Their patient characteristics are presented in table 1. The mean age of the patients was 80.1 years (SD 13.9). Sixty-nine patients (35.2%) had completed elementary or junior high school, 63 (32.1%) had a high school education and 64 (32.7%) had attended college, university or graduate school. A total of 176 patients (88.0%) had family. The expected prognosis was ≥12 months for 163 patients (81.9%), 6–<12 months for 24 patients (12.1%) and <6 months for 12 patients (6.0%).

Table 1

Characteristics of patients (n=200)

Demographics	Total n=200	missing, n
Age, average years (SD)	80.1 (13.9)
Women, n (%)	118 (59%)
Education, n (%)		4
Elementary school or junior high school	69 (35.2%)
High school	63 (32.1%)
College, university or graduate school	64 (32.7%)
Presence of family, n (%)	176 (88%)
Depressive symptom, n (%)	67 (34.5%)	6
Expected prognosis, n (%)		1
≥ 12 months	163 (81.9%)
6–<12 months	24 (12.1%)
<6 months	12 (6%)
Comorbidities, n (%)
Cerebrovascular disease	34 (17%)
Heart disease	60 (30%)
Malignancy	27 (13.5%)
Respiratory disease	34 (17%)
Articular disease	27 (13.5%)
Dementia	38 (19%)
Neuromuscular disease	23 (11.5%)
Fracture/fall	20 (10%)
Weakness	38 (19%)
Spinal cord injury	7 (3.5%)
Care-needs level
Support level 1 (in need of assistance)	10 (5%)
Support level 2 (in need of assistance)	14 (7%)
Care-needs level 1 (in need of care)	38 (19%)
Care-needs level 2 (in need of care)	45 (22.5%)
Care-needs level 3 (in need of care)	27 (13.5%)
Care-needs level 4 (in need of care)	28 (14%)
Care-needs level 5 (in need of care)	19 (9.5%)
Others	19 (9.5%)

JPCAT-SF, QOL-HC and HR-Hope

The mean JPCAT-SF, mean HR-Hope and mean QOL-HC scores were 70.9 points (SD 15.6), 57.3 points (SD 23.1) and 6.4 points (SD 1.4), respectively. Figure 1 presents histograms for the QOL-HC, HR-Hope and total JPCAT-SF scores. Online supplemental figure S2 shows the six domain scores of the JPCAT-SF. Figure 2 presents scatter plots with fitted lines illustrating the relationships between the total JPCAT-SF score and both the QOL-HC and HR-Hope scores. The Spearman’s rank correlation test revealed a significant moderate correlation between the JPCAT-SF score and both the QOL-HC (ρ=0.323, p<0.001) and HR-Hope (ρ=0.346, p<0.001) scores.

Figure 1. Histograms of Quality of life-Home Care (QOL-HC), Health-Related Hope (HR-Hope) and Japanese version of the Primary Care Assessment Tool-Short Form (JPCAT-SF) total scores.

Figure 2. Scatter plots of the Japanese version of the Primary Care Assessment Tool-Short Form (JPCAT-SF) total score and the Quality of life-Home Care (QOL-HC), and Health-Related Hope (HR-Hope) with fitted lines.

Association between JPCAT-SF, QOL-HC and HR-Hope

Table 2 presents the association between the JPCAT-SF and QOL-HC total scores. Higher total JPCAT-SF scores were associated with higher QOL-HC scores (adjusted mean difference for every 10-point increase: 0.28, 95% CI 0.16 to 0.40). Age was also positively associated with QOL-HC (every 10 years increase: 0.24, 95% CI 0.11 to 0.37). Depressive symptoms were negatively associated with QOL-HC (−0.92, 95% CI −1.40 to −0.45). Sex, education level, family presence, expected prognosis and comorbidities other than respiratory disease were not significantly associated with QOL-HC.

Table 2

Associations between patient experience and Quality of life-Home Care (QOL-HC)* (n=195)

Variables	Mean difference in QOL-HC, points (95% CI)	P value
JPCAT-SF, total, per 10 pt higher	0.28 (0.16 to 0.40)	<0.001
Age, per 10 years higher	0.24 (0.11 to 0.37)	<0.001
Women vs men	0.22 (−0.30 to 0.74)	0.401
Educational attainment
Junior high school or lower	−0.12 (−0.56 to 0.32)	0.602
High school	−0.24 (−0.59 to 0.11)	0.176
College/university/graduate school/other	Reference
Presence of family	−0.04 (−0.66 to 0.58)	0.900
Expected prognosis
≥ 12 months	Reference
6 -<12 months	0.18 (−0.29 to 0.64)	0.459
< 6 months	0.38 (−0.26 to 1.01)	0.245
Depressive symptom	−0.92 (−1.40 to −0.45)	<0.001
Comorbidities
Cerebrovascular disease	0.14 (−0.49 to 0.77)	0.665
Heart disease	−0.08 (−0.46 to 0.30)	0.678
Malignancy	−0.35 (−0.8 to 0.09)	0.119
Respiratory disease	0.47 (−0.05 to 0.98)	0.079
Articular disease	−0.17 (−0.75 to 0.41)	0.564
Dementia	0.42 (−0.06 to 0.91)	0.088
Neuromuscular disease	−0.06 (−0.62 to 0.50)	0.834
Fracture/fall	−0.28 (−0.89 to 0.34)	0.376
Weakness	−0.31 (−0.77 to 0.15)	0.183
Spinal cord injury	0.05 (−0.74 to 0.83)	0.906
Care-needs level
Support level 1 (in need of assistance)	Reference
Support level 2 (in need of assistance)	−0.09 (−0.72 to 0.55)	0.785
Care-needs level 1 (in need of care)	0.32 (−0.24 to 0.87)	0.261
Care-needs level 2 (in need of care)	0.56 (0.09 to 1.04)	0.021
Care-needs level 3 (in need of care)	0.54 (−0.24 to 1.31)	0.176
Care-needs level 4 (in need of care)	0.18 (−0.35 to 0.71)	0.497
Care-needs level 5 (in need of care)	0.61 (−0.01 to 1.22)	0.052

Note: Analysis of 195 patients among 29 facilities.

Bold values are statistically significant.

*Mixed-effects linear regression model adjusted for covariates listed above.

JPCAT-SF, Japanese version of the Primary Care Assessment Tool-Short Form; pt, Points; QOL-HC, Quality of life-Home Care.

The associations between each JPCAT-SF domain and QOL-HC are presented in table 3. Among the JPCAT-SF domains, higher scores in first contact (0.16, 95% CI 0.08 to 0.23), longitudinality (0.20, 95% CI 0.11 to 0.29), comprehensiveness (services available: 0.12, 95% CI 0.03 to 0.20; services provided: 0.08, 95% CI 0.01 to 0.15) and community orientation (0.11, 95% CI 0.02 to 0.20) were associated with higher QOL-HC scores, whereas coordination (0.03, 95% CI −0.01 to 0.08) showed a non-significant association.

Table 3

Associations between Japanese version of the Primary Care Assessment Tool-Short Form (JPCAT-SF) domain and Quality of life-Home Care (QOL-HC)* (n=195)

The JPCAT-SF domains	Mean difference in QOL-HC, points (95% CI)	P value
First contact, per 10 pt higher	0.16 (0.08 to 0.23)	<0.001
Longitudinality, per 10 pt higher	0.20 (0.11 to 0.29)	<0.001
Coordination, per 10 pt higher	0.03 (–0.01 to 0.08)	0.159
Comprehensiveness (services available), per 10 pt higher	0.12 (0.03 to 0.20)	0.009
Comprehensiveness (services provided), per 10 pt higher	0.08 (0.01 to 0.15)	0.028
Community orientation, per 10 pt higher	0.11 (0.02 to 0.20)	0.019

Note: Analysis of 195 patients among 29 facilities.

Bold values are statistically significant.

*Mixed-effects linear regression model adjusted for covariates listed in Table 2.

JPCAT-SF, Japanese version of the Primary Care Assessment Tool-Short Form; pt, Points; QOL-HC, Quality of life-Home Care.

Table 4 shows the association between the JPCAT-SF and HR-Hope total scores. Higher total JPCAT-SF scores were associated with higher levels of HR-Hope (adjusted mean difference for every 10-point increase: 4.8, 95% CI 2.9 to 6.7). Negative associations with HR-Hope were observed for an expected prognosis of < 6 months (compared to ≥ 12 months, −13.5, 95% CI −26.3 to −0.6) and depressive symptoms (−12.6, 95% CI −18.7 to −6.5). Sex, family presence, and comorbidities were not significantly associated.

Table 4

Associations between Japanese version of the Primary Care Assessment Tool-Short Form (JPCAT-SF) and Health-Related Hope (HR-Hope)* (n=200)

Variables	Mean difference in HR-Hope, points (95% CI)	P value
JPCAT-SF, total, per 10 pt higher	4.8 (2.9 to 6.7)	<0.001
Age, per 10 years higher	−1.9 (−4.6 to 0.7)	0.143
Women vs men	0.4 (−5.8 to 6.6)	0.898
Educational attainment
Junior high school or lower	−2.7 (−10.1 to 4.8)	0.482
High school	−8.9 (−16.2 to −1.6)	0.017
College/university/graduate school/other	Reference
Presence of family	−4.5 (−13.3 to 4.2)	0.310
Expected prognosis
≥ 12 month	Reference
6–<12 month	−2.2 (−11.6 to 7.3)	0.653
< 6 month	−13.5 (−26.3 to −0.6)	0.040
Depressive symptom	−12.6 (−18.7 to −6.5)	<0.001
Comorbidities
Cerebrovascular disease	−4.9 (−12.6 to 2.9)	0.218
Heart disease	3.8 (−2.7 to 10.3)	0.250
Malignancy	2.9 (−6.9 to 12.8)	0.558
Respiratory disease	−3.6 (−11.2 to 4.0)	0.355
Articular disease	−3.5 (−11.9 to 4.9)	0.416
Dementia	3.3 (−4.6 to 11.3)	0.408
Neuromuscular disease	0.5 (−9.8 to 10.8)	0.929
Fracture/fall	6.3 (−3.3 to 15.9)	0.199
Weakness	−1.6 (−10.1 to 6.8)	0.706
Spinal cord injury	−0.5 (−17.1 to 16.0)	0.948
Care-needs level
Support level 1 (in need of assistance)	Reference
Support level 2 (in need of assistance)	0.9 (−15.1 to 17.0)	0.785
Care-needs level 1 (in need of care)	−3.2 (−17.2 to 10.9)	0.261
Care-needs level 2 (in need of care)	−3.9 (−17.6 to 9.8)	0.021
Care-needs level 3 (in need of care)	−6.8 (−21.6 to 8.0)	0.176
Care-needs level 4 (in need of care)	−1.0 (−15.7 to 13.7)	0.497
Care-needs level 5 (in need of care)	−16.1 (−31.9 to −0.3)	0.052
Others	−12.3 (−28.7 to 4.1)	0.024

Note: Analysis of 200 patients among 29 facilities.

Bold values are statistically significant.

*Mixed-effects linear regression models adjusted for covariates listed above.

HR-Hope, Health-Related Hope; pt, Points.

The associations between each JPCAT-SF domain and HR-Hope are presented in table 5. Higher scores in first contact (2.7, 95% CI 1.3 to 4.1), longitudinality (2.5, 95% CI 0.8 to 4.2), coordination (1.2, 95% CI 0.2 to 2.3), comprehensiveness (services available: 1.8, 95% CI 0.5 to 3.2; services provided: 1.3, 95% CI 0.4 to 2.3) and community orientation (1.8, 95% CI 0.5 to 3.1) were associated with higher HR-Hope scores.

Table 5

Associations between Japanese version of the Primary Care Assessment Tool-Short Form (JPCAT-SF) domain and Health-Related Hope (HR-Hope)* (n=200)

The JPCAT-SF domains	Mean difference in HR-Hope, points (95% CI)	P value
First contact, per 10 pt higher	2.7 (1.3 to 4.1)	<0.001
Longitudinality, per 10 pt higher	2.5 (0.8 to 4.2)	0.003
Coordination, per 10 pt higher	1.2 (0.2 to 2.3)	0.023
Comprehensiveness (services available), per 10 pt higher	1.8 (0.5 to 3.2)	0.009
Comprehensiveness (services provided), per 10 pt higher	1.3 (0.4 to 2.3)	0.007
Community orientation, per 10 pt higher	1.8 (0.5 to 3.1)	0.005

Note: Analysis of 200 patients among 29 facilities.

Bold values are statistically significant.

*Mixed-effects linear regression model adjusted for covariates listed in Table 4.

HR-Hope, Health-Related Hope; JPCAT-SF, Japanese version of the Primary Care Assessment Tool-Short Form; pt, Points.

Discussion

This study examined the association of patient-centred care quality with QOL-HC and HR-Hope among patients receiving home medical care. Higher levels of patient-centredness were associated with better QOL and higher hope. In particular, the ‘first contact’ and ‘longitudinality’ domains of the JPCAT-SF were strongly associated with QOL and hope.

Previous studies have also highlighted the importance of first contact and longitudinality in fostering hope through effective communication. For example, research involving psychologically ill patients receiving home medical care found that hope was associated with patients having sufficient time to communicate with their doctors and address their concerns.¹⁰ Additionally, studies involving terminally ill patients with malignancies have emphasised the role of communication in maintaining hope.⁶ However, the concepts and measurements of hope in these studies were not structured or validated. Furthermore, the limitations of these studies include their specific focus on psychology and end-of-life patients with malignancies, which restrict the generalisability of their findings. Previous studies have shown that patient-centred care improves QOL in different populations, including outpatients with type 2 diabetes and nursing home residents.^{4 5}

The results of the present study have several clinical implications. First, within the JPCAT domains, first contact and longitudinality were found to have stronger associations with the QOL-HC and HR-Hope than with other domains. These domains closely align with the communication pathways, particularly ‘access to care’ and ‘enhancing therapeutic alliance’. Improving first contact by providing better access to care based on patient requests and understanding patients as individuals within the context of their life histories can significantly impact QOL and hope. Second, while previous studies have focused on developing additional programmes, such as psychosocial supportive interventions,^{20 21} to improve patients’ hope, this study highlights the importance of enhancing patient-centredness in daily clinical practice. So far, additional programmes such as dignity therapy, which involves recording the things that matter most to a patient and generating a narrative,²⁰ and a programme that involves viewing a film about hope and engaging in hope activities,²¹ are mostly intended for terminally ill cancer patients. These programmes are not feasible to implement in regular medical care because of time constraints and the extra materials and special training required. Improving daily clinical practice by prioritising patient-centred conversations is more crucial than developing new programmes. From this perspective, for example, medical home care should apply a patient-centred conversation programme developed for patients with chronic kidney disease to promote advanced care planning that promotes sharing patients’ values and preferences about treatment, their families and everyday life among medical providers, patients and their families.²²

This study had several strengths. First, using validated scales, we quantified the associations between patient-centredness, QOL, and hope for the first time. Second, our findings are generalisable because of the multicentre nature of the study; that is, it was conducted in both rural and urban areas of Japan. Third, by controlling for confounding variables, such as life expectancy and depressive symptoms, we accurately estimated the associations of patient-centred care with QOL and hope.

However, this study has several limitations. First, the possibility of reverse causation remains because of the study’s cross-sectional design. For example, because patients were highly hopeful about their health, their home physicians may have responded to this and provided them with good patient-centred care. Second, the total number of patients served by the participating facilities and the number of all patients who were invited and declined to participate in the study were not collected (thus, a response rate cannot be calculated). Therefore, the sample may be subject to selection bias and may not be representative of the target population. Additionally, because this study excluded patients with severe dementia and those who were unable to respond, the findings may not be generalisable to these populations.

Conclusions

In conclusion, our study revealed that better patient-centred care was associated with a higher QOL and hope among patients receiving home medical care. Further empirical research is warranted to determine whether efforts to holistically understand patients and provide timely home medical care tailored to patient’s individual needs can improve patients’ overall well-being and hope.

The authors express their sincere gratitude to the research assistants, Ms Miyuki Sato and Ms Lisa Shimokawa (Fukushima Medical University Hospital, Fukushima City, Fukushima), for their assistance in collecting the questionnaire-based information used in this study.

Data availability statement

Data are available upon reasonable request.

Ethics statements

Patient consent for publication

Consent obtained directly from patient(s).

Ethics approval

This study involves human participants and was approved by The Institutional Review Board of Fukushima Medical University approved the study protocol (approval number: ippan-30254). Participants gave informed consent to participate in the study before taking part.

Footnote

Contributors Conceptualisation: HI, NK. Funding acquisition: HI, NK. Data curation: NK. Investigation: HI, SH, MY, YT, MH, YS, NK. Methodology: NK. Project administration: HI, SH, MY, YT, YS, NK. Resources: NK. Software: NK. Supervision: NK. Writing—original draft: HI, NK. Writing—review and editing: SH, MY, YT, MH, YS. NK is the guarantor.

Funding This work was supported by JSPS KAKENHI (Grant Number 16H05216 and 23K14706).

Competing interests None declared.

Patient and public involvement This study involved the analysis of patient data collected from 29 healthcare facilities, which was conducted at Fukushima Medical University. All individual participants were anonymized to ensure their privacy and confidentiality. Patients were not involved in the direct creation or execution of the research study. The data used in this research was obtained through collaborations with participating institutions, and appropriate measures were taken to maintain data integrity and security throughout the analysis process.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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