Quality of Life Research

, Volume 27, Issue 12, pp 3275–3279 | Cite as

Health-related quality of life and the physician–patient alliance: a preliminary investigation of ultra-brief, real-time measures for primary care

  • Clay Graybeal
  • Brian DeSantis
  • Barry L. DuncanEmail author
  • Robert J. Reese
  • Kathryn Brandt
  • Robert T. Bohanske
Brief Communication



Many psychometrically sound measures exist but feasibility makes real-time use difficult. This study validates two ultra-brief, patient-rated instruments, the Wellness Rating Scale (WRS) and the Provider Alliance Scale (PAS).


The WRS and the EuroQol visual analogue scale (EQ VAS) were completed by patients in a primary care practice (n = 97) and a non-clinical sample of graduate students (n = 122). The WRS and the Patient-Completed Health Outcome Measures Information System-Global 10 (PROMIS) were completed by patients in a primary care setting (n = 305). The WRS and PROMIS were also administered to graduate students (n = 158). The PAS and the Patient Physician Working Alliance were administered to a primary care sample of 40 and a retrospective sample of students (n = 228).


The WRS generated reliable scores, with coefficient alphas ranging from .83 to .91. Bivariate correlations between the WRS and the EQ VAS (r = .55–.75) and PROMIS (r = .64–73) indicate moderate-to-strong concurrent validity. The larger coefficients were with patient samples. Construct validity was evidenced by higher levels of distress for chronic conditions as well as for clinical samples. The PAS achieved an alpha of .94 for the primary care sample and .87 for the retrospective sample and bivariate correlations (r = .61–.72) indicate moderate-to-strong evidence of concurrent validity.


The WRS and PAS demonstrate sufficient reliability and validity to move to the next phase of research: a randomized clinical trial comparing the use of real-time feedback from the two measures to treatment as usual targeting outcomes of chronic disease patients.


PROM Patient-centered care Patient–provider alliance Health-related quality of life EQ-5D VAS PROMIS 



The authors would like to thank Peak Vista reception staff, Carmen Rodriguez, Ruben Martinez, and Reem Muayad, and behavioral health providers Eric Attard and Sharon Glocker for their invaluable assistance in data collection, scoring, and storage.

Compliance with ethical standards

Conflict of interest

Duncan is a co-holder of the copyright of the Partners for Change Outcome Management System (PCOMS) instruments. The measures are free for individual use but Duncan receives royalties from licenses issued to organizations. The web-based application of PCOMS,, is a commercial product and he receives profits based on sales.


  1. 1.
    de Silva, D. (2014). Helping measure person-centred care. The Health Foundation. Retrieved February 1, 2015 from,
  2. 2.
    Cherepanov, D., Palta, M., & Fryback, D. G. (2010). Underlying dimensions of the five health-related quality-of-life indexes used in utility assessment: Evidence from the National Health Measurement Study. Medicare Care, 48(8), 718–725.CrossRefGoogle Scholar
  3. 3.
    Greenhalgh, J. (2009). The applications of PROs in clinical practice: What are they, do they work, and why? Quality of Life Research, 18, 115–123.CrossRefGoogle Scholar
  4. 4.
    Valderas, J. M., Kotzeva, A., Espallargues, M., Guyatt, G., Ferrans, C. E., Halyard, et al. (2008). The impact of measuring patient-reported outcomes in clinical practice: A systematic review of the literature. Quality of Life Research, 17(2), 179–193.CrossRefGoogle Scholar
  5. 5.
    Eveleigh, R. M., Muskens, E., van Ravesteijn, H., van Dijk, I., van Rijswijk, E., & Lucassen, P. (2012). An overview of 19 instruments assessing the doctor-patient relationship: Different models or concepts used. Journal of Clinical Epidemiology, 65(1), 10–15. Scholar
  6. 6.
    Bennett, J. K., Fuertes, J. N., Keitel, M., & Phillips, R. (2011). The role of patient attachment and working alliance on patient adherence, satisfaction, and health related quality of life in lupus treatment. Patient Education and Counseling, 85, 53–59.CrossRefGoogle Scholar
  7. 7.
    Kelley, J., Kraft-Todd, G., Schapira, L., Kossowsky, J., & Riess, H. (2014). Influence of the patient-clinician relationship on healthcare outcomes: A systematic review and meta-analysis of randomized controlled trials. PLoS ONE, 9(4), e94207. Scholar
  8. 8.
    Duncan, B., & Bohanske, R. (2012). The Wellness Rating Scale. Jensen Beach: Author.Google Scholar
  9. 9.
    Duncan, B., & Bohanske, R. (2012). The Provider Alliance Scale. Jensen Beach: Author.Google Scholar
  10. 10.
    Fuertes, J. N., Mislowack, A., Bennett, J., Paul, L., Gilbert, T. C., Fontan, G., & Boylan, L. S. (2007). The physician-patient working alliance. Patient Education and Counseling, 66(1), 29–36.CrossRefGoogle Scholar
  11. 11.
    Miller, S., Duncan, B., Brown, J., Sparks, J., & Claud, D. (2003). The Outcome Rating Scale: A preliminary study of the reliability, validity, and feasibility of a brief visual analog measure. Journal of Brief Therapy, 2(2), 91–100.Google Scholar
  12. 12.
    Davis, S., & Wailoo, A. (2013). A review of the psychometric performance of the EQ-5D in people with urinary incontinence. Health and Quality of Life Outcomes, 11, 20. Scholar
  13. 13.
    Cella, D., Riley, W., Stone, A., Rothrock, N., Reeve, B., Yount, S., PROMIS Cooperative Group., et al. (2010). The patient-reported outcomes measurement information system (PROMIS) developed and tested its first wave of adult self-reported health outcome item banks: 2005–2008. Journal of Clinical Epidemiology, 63(11), 1179–1194.CrossRefGoogle Scholar
  14. 14.
    Cook K. F., Jensen, S. E., Schalet, B. D., Beaumont J. L., Amtmann D., Czajkowski S., et al. (2016). PROMIS measures of pain, fatigue, negative affect, physical function, and social function demonstrated clinical validity across a range of chronic conditions. Journal of Clinical Epidemiology, 73, 89–102.CrossRefGoogle Scholar
  15. 15.
    Duncan, B., Miller, S., Sparks, J., Claud, D., Reynolds, L., Brown, J., & Johnson, L. (2003). The Session Rating Scale: Preliminary psychometric properties of a “working” alliance measure. Journal of Brief Therapy, 3(1), 3–12.Google Scholar
  16. 16.
    Duncan, B. L., & Reese, R. J. (2015). The partners for change outcome management system (PCOMS) revisiting the client’s frame of reference. Psychotherapy, 52, 391–401. Scholar
  17. 17.
    Chronic Disease Overview. Centers for Disease Control and Prevention Web site. Retrieved February 2, 2018 from,
  18. 18.
    Brenna, P., Perola, M., van Ommen, G. J., & Riboli, E. (2017). Chronic disease research in Europe and the need for integrated population cohorts. European Journal of Epidemiology, 32(9), 741–749.CrossRefGoogle Scholar
  19. 19.
    World Health Organization, Global Health Observatory data. (2015). Top ten causes of death: Situation and tends. Retrieved February 2, 2018 from,
  20. 20.
    Ofri, D. (2017). What patients say, what doctors hear. Boston: Beacon Press.Google Scholar

Copyright information

© Springer Nature Switzerland AG 2018

Authors and Affiliations

  1. 1.University of New England College of Osteopathic MedicinePortlandUSA
  2. 2.Peak Vista Community Health CentersColorado SpringsUSA
  3. 3.Better Outcomes NowJensen BeachUSA
  4. 4.University of KentuckyLexingtonUSA
  5. 5.Southwest Behavioral & Health ServicesPhoenixUSA

Personalised recommendations