Setting a Fair Performance Standard for Physicians’ Quality of Patient Care

Background  

Assessing physicians’ clinical performance using statistically sound, evidence-based measures is challenging. Little research has focused on methodological approaches to setting performance standards to which physicians are being held accountable.     

Quality Monitoring of Physicians: Linking Patients’ Experiences of Care to Clinical Quality and Outcomes

Background  Physicians are increasingly asked to improve the delivery of clinical services and patient experiences of care. Objective  We evaluated the association between clinical performance and patient experiences in a statewide sample of physician practice sites and a sample of physicians within a large physician group. Design, Setting, Participants  We separately identified 373 practice sites and 119 individual primary care physicians in Massachusetts. Measurements  Using Health Plan Employer Data and Information Set data, we produced two composites addressing processes of care (prevention, disease management) and one composite addressing outcomes. Using Ambulatory Care Experiences Survey data, we produced seven composite measures summarizing the quality of clinical interactions and organizational features of care. For each sample (practice site and individual physician), we calculated adjusted Spearman correlation coefficients to assess the relationship between the composites summarizing patient experiences of care and those summarizing clinical performance. Results  Among 42 possible correlations (21 correlations involving practice sites and 21 involving individual physicians), the majority were positive in site level (71%) and physician level (67%) analyses. For the 28 possible correlations involving patient experiences and clinical process composites, 8 (29%) were significant and positive, and only 2 (7%) were significant and negative. The magnitude of the significant positive correlations ranged from 0.13 to 0.19 at the site level and from 0.28 to 0.51 at the physician level. There were no significant correlations between patient experiences and the clinical outcome composite. Conclusions  The modest correlations suggest that clinical quality and patient experience are distinct, but related domains that may require separate measurement and improvement initiatives. Acknowledgements: This study was funded by the Commonwealth Fund and the William Randolph Hearst Foundation. Dr. Sequist had full access to all the data in the study and takes responsibility for the integrity and the accuracy of the data analysis. This work was presented in abstract form at the 2007 Society for General Internal Medicine Annual Conference. We would like to thank Massachusetts Health Quality Partners for allowing us use of statewide data for these analyses; Jo-Anne Foley at HVMA for helping to obtain physician-level data; and Angela Li, Angie Rodday, and Hong Chang at Tufts-New England Medical Center for analytic support. Dr. Sequist has served as a consultant on the Aetna External Advisory Committee for Racial and Ethnic Equality.     

Differences Between Primary Care Physicians’ and Oncologists’ Knowledge,Attitudes and Practices Regarding the Care of Cancer Survivors

Background  

The growing number of cancer survivors combined with a looming shortage of oncology specialists will require greater coordination of post-treatment care responsibilities between oncologists and primary care physicians (PCPs). However, data are limited regarding these physicians’ views of cancer survivors’ care.     

Primary Care Physicians’ Use of an Electronic Medical Record System: A Cognitive Task Analysis

OBJECTIVE  To describe physicians’ patterns of using an Electronic Medical Record (EMR) system; to reveal the underlying cognitive elements involved in EMR use, possible resulting errors, and influences on patient–doctor communication; to gain insight into the role of expertise in incorporating EMRs into clinical practice in general and communicative behavior in particular. DESIGN  Cognitive task analysis using semi-structured interviews and field observations. PARTICIPANTS  Twenty-five primary care physicians from the northern district of the largest health maintenance organization (HMO) in Israel. RESULTS  The comprehensiveness, organization, and readability of data in the EMR system reduced physicians’ need to recall information from memory and the difficulty of reading handwriting. Physicians perceived EMR use as reducing the cognitive load associated with clinical tasks. Automaticity of EMR use contributed to efficiency, but sometimes resulted in errors, such as the selection of incorrect medication or the input of data into the wrong patient’s chart. EMR use interfered with patient–doctor communication. The main strategy for overcoming this problem involved separating EMR use from time spent communicating with patients. Computer mastery and enhanced physicians’ communication skills also helped. CONCLUSIONS  There is a fine balance between the benefits and risks of EMR use. Automaticity, especially in combination with interruptions, emerged as the main cognitive factor contributing to errors. EMR use had a negative influence on communication, a problem that can be partially addressed by improving the spatial organization of physicians’ offices and by enhancing physicians’ computer and communication skills.     

Health Literacy and the Patient With Heart Failure—Implications for Patient Care and Research: A Consensus Statement of the Heart Failure Society of America

BackgroundLow health literacy compromises patient safety, quality health care, and desired health outcomes. Specifically, low health literacy is associated with decreased knowledge of one's medical condition, poor medication recall, nonadherence to treatment plans, poor self-care behaviors, compromised physical and mental health, greater risk of hospitalization, and increased mortality.MethodsThe health literacy literature was reviewed for: definitions, scope, risk factors, assessment, impact on health outcomes (cardiovascular disease and heart failure), and interventions. Implications for future research and for clinical practice to address health literacy in heart failure patients were summarized.ResultsGeneral health literacy principles should be applied to patients with heart failure, similar to others with chronic conditions. Clinicians treating patients with heart failure should address health literacy using five steps: recognize the consequences of low health literacy, screen patients at risk, document literacy levels and learning preferences, and integrate effective strategies to enhance patients' understanding into practice.ConclusionAlthough the literature specifically addressing low health literacy in patients with heart failure is limited, it is consistent with the larger body of health literacy evidence. Timely recognition of low health literacy combined with tailored interventions should be integrated into clinical practice.     

The Role of Patient Activation on Patient–Provider Communication and Quality of Care for US and Foreign Born Latino Patients

BACKGROUND

Previous research has shown positive effects of patient activation on healthcare outcomes, but there is practically no information on the generalization of these findings for Latino patients. Little data are available on whether patient activation is associated with healthcare outcomes for Latino patients and whether activation varies by language proficiency and nativity status.

OBJECTIVE

We examined the levels of activation by characteristics of Latino patients (e.g. nativity, language, health status). We investigated whether patient activation relates to the quality of care received and enhanced doctor–patient communication for Latino patients.

DESIGN

We conducted analyses of 1,067 US born and foreign born Latinos who participated in the second wave of the PEW/RWJF Hispanic Healthcare Survey during 2008.

PARTICIPANTS

Participants were self-identified Latinos (18+) with a doctor visit, living in the contiguous United States who could be contacted by telephone.

RESULTS

US born Latinos had significantly (P?<?0.001) greater patient activation scores than foreign born Latinos (75 versus 70). Latinos classified as bilingual and those reporting excellent health evidenced higher mean activation scores as compared to Spanish-speaking Latinos and those reporting fair or poor health. After adjusting for demographics, health status, other language and service use factors, patient activation was strongly associated with self-reported quality of care and better doctor–patient communication among both US and foreign born Latino respondents.

CONCLUSIONS

Interventions that augment patient activation could increase quality of care and improved patient–provider communication, potentially reducing health care disparities for Latinos.

     

Trends and Quality of Care in Outpatient Visits to Generalist and Specialist Physicians Delivering Primary Care in the United States, 1997–2010

BACKGROUND

Although many specialists serve as primary care physicians (PCPs), the type of patients they serve, the range of services they provide, and the quality of care they deliver is uncertain.

OBJECTIVE

To describe trends in patient, physician, and visit characteristics, and compare visit-based quality for visits to generalists and specialists self-identified as PCPs.

DESIGN

Cross-sectional study and time trend analysis.

DATA

Nationally representative sample of visits to office-based physicians from the National Ambulatory Medical Care Survey, 1997–2010.

MAIN MEASURES

Proportions of primary care visits to generalist and specialists, patient characteristics, principal diagnoses, and quality.

KEY RESULTS

Among 84,041 visits to self-identified PCPs representing an estimated 4.0 billion visits, 91.5 % were to generalists, 5.9 % were to medical specialists and 2.6 % were to obstetrician/gynecologists. The proportion of PCP visits to generalists increased from 88.4 % in 1997 to 92.4 % in 2010, but decreased for medical specialists from 8.0 % to 4.8 %, p?=?0.04). The proportion of medical specialist visits in which the physician self-identified as the patient’s PCP decreased from 30.6 % in 1997 to 9.8 % in 2010 (p?<?0.01). Medical specialist PCPs take care of older patients (mean age 61 years), and dedicate most of their visits to chronic disease management (51.0 %), while generalist PCPs see younger patients (mean age 55.4 years) most commonly for new problems (40.5 %). Obstetrician/gynecologists self-identified as PCPs see younger patients (mean age 38.3 p?<?0.01), primarily for preventive care (54.0 %, p?<?0.01). Quality of care for cardiovascular disease was better in visits to cardiologists than in visits to generalists, but was similar or better in visits to generalists compared to visits to other medical specialists.

CONCLUSIONS

Medical specialists are less frequently serving as PCPs for their patients over time. Generalist, medical specialist, and obstetrician/gynecologist PCPs serve different primary care roles for different populations. Delivery redesign efforts must account for the evolving role of generalist and specialist PCPs in the delivery of primary care.     

Attention to Inpatients�� Religious and Spiritual Concerns: Predictors and Association with Patient Satisfaction

Background

Little is known about how often patients desire and experience discussions with hospital personnel regarding R/S (religion and spirituality) or what effects such discussions have on patient satisfaction.

Objective, Design and Participants

We examined data from the University of Chicago Hospitalist Study, which gathers sociodemographic and clinical information from all consenting general internal medicine patients at the University of Chicago Medical Center.

Main Measures

Primary outcomes were whether or not patients desired to have their religious or spiritual concerns addressed while hospitalized, whether or not anyone talked to them about religious and spiritual issues, and which member of the health care team spoke with them about these issues. Primary predictors were patients’ ratings of their religious attendance, their efforts to carry their religious beliefs over into other dealings in life, and their spirituality.

Key Results

Forty-one percent of inpatients desired a discussion of R/S concerns while hospitalized, but only half of those reported having such a discussion. Overall, 32% of inpatients reported having a discussion of their R/S concerns. Religious patients and those experiencing more severe pain were more likely both to desire and to have discussions of spiritual concerns. Patients who had discussions of R/S concerns were more likely to rate their care at the highest level on four different measures of patient satisfaction, regardless of whether or not they said they had desired such a discussion (odds ratios 1.4–2.2, 95% confidence intervals 1.1–3.0).

Conclusions

These data suggest that many more inpatients desire conversations about R/S than have them. Health care professionals might improve patients’ overall experience with being hospitalized and patient satisfaction by addressing this unmet patient need.KEY WORDS: patient satisfaction, physician/patient communication, quality of care, religion, spirituality     

Non-Verbal Communication Between Primary Care Physicians and Older Patients: How Does Race Matter?

BACKGROUND  

Non-verbal communication is an important aspect of the diagnostic and therapeutic process, especially with older patients. It is unknown how non-verbal communication varies with physician and patient race.     

Quality of Life and Depression in Turkish Patients with β-Thalassemia Major: A Cross-Sectional Study

Abstract

Thalassemias are the most common monogenic disorders worldwide. Thalassemia patients experience difficulties in their schooling, finding jobs and/or marriage because of functional and physical limitations caused by this disease. It is expected that the quality of life (QoL) of patients with thalassemia will be lower than those without this disease. The aim of this study was to benefit worldwide thalassemia patients in terms of QoL and mental health. This cross-sectional study was performed in Turkey. The study population consisted of of 57 β-thalassemia major (β-TM) patients and the control group. The short form-36 (SF-36) questionnaire and Beck depression inventory (BDI) were used. The mean age of the patients was 21.6?±?6.6 (age range 15-39) and the male-to-female ratio was 0.7. The mean SF-36 scores of the patient and the control groups were 59.2?±?12.4 and 75.7?±?11.8, and the mean BDI scores of the patients and controls were 13.5?±?6.4 and 6.1?±?3.7, respectively. There was a statistically significant difference between the total SF-36 and BDI scores of patients and controls. We aimed to investigate the effects of the decrease in morbidity and mortality of β-thalassemia (β-thal) due to regular transfusions and chelation therapy on the QoL and mental health of patients. The β-TM patients have a comparatively worse QoL score than the normal population. Improving QoL should be the target of clinicians who are monitoring adolescent or young adult β-TM patients.     

Differences in the Quality of the Patient–Physician Relationship Among Terminally Ill African-American and White Patients: Impact on Advance Care Planning and Treatment Preferences

BACKGROUND Little is known about the quality of the patient–physician relationship for terminally ill African Americans. OBJECTIVE To compare the quality of the patient–physician relationship between African-American and white patients and examine the extent to which relationship quality contributes to differences in advance care planning (ACP) and preferences for intensive life-sustaining treatment (LST). DESIGN Cross sectional survey of 803 terminally ill African-American and white patients. MEASUREMENTS Patient-reported quality of the patient–physician relationship (degree of trust, perceived respect, and joint decision making; skill in breaking bad news and listening; help in navigating the medical system), ACP, preferences for LST (cardiopulmonary resuscitation, major surgery, mechanical ventilation, and dialysis). RESULTS The quality of the patient–physician relationship was worse for African Americans than for white patients by all measures except trust. African Americans were less likely to have an ACP (adjusted relative risk [aRR] = 0.66, 95%CI = 0.52–0.84), and were more likely to have a preference for cardiopulmonary resuscitation and dialysis (aRR = 1.28, 95%CI = 1.03–1.58; aRR = 1.25, 95%CI = 1.07–1.47, respectively). Additional adjustment for the quality of the patient–physician relationship had no impact on the differences in ACP and treatment preferences. CONCLUSIONS Lower reported patient–physician relationship quality for African-American patients does not explain the observed differences between African Americans and whites in ACP and preferences for LST.     

Patient–Provider and Patient–Staff Racial Concordance and Perceptions of Mistreatment in the Health Care Setting

Objectives To determine what roles patient–provider and patient–staff racial concordance play on patients’ perceptions within the health care setting. Design, Setting, Participants Data from the Commonwealth Fund 2001 Quality of Care telephone survey. Analysis focused on the subsample of 6,066 adults who live in the continental United States and who reported having a regular provider or a usual source of care (n = 4,762). Measurements and Results We analyzed patients’ responses about perceptions of disrespect, unfair treatment because of race and language, and the belief that he/she would have received better treatment if he/she belonged to a different race. We compared these perceptions of mistreatment with provider and staff racial concordance, controlling for sociodemographic variables. Contrary to our hypothesis, Hispanics were more likely to report being treated with disrespect if in a concordant relationship with their provider than if in a nonconcordant one (odds ratio [OR] 2.42, P < .01). Asians were less likely to report being treated unfairly because of race if in racially concordant relationships with providers than if in nonconcordant ones (P < .05). Hispanics were also less likely to perceive unfair treatment because of language when in concordant relationships with staff as compared to nonconcordant relationships with staff (P < .05). Conclusions Patients’ perceptions of health care relationships may partially depend on racial concordance with providers and staff. The nature of the association between racial concordance and perceived disrespect varies by racial group, indicating that other race-specific factors may also need to be examined. The topics discussed in this paper were presented as an abstract at a conference for the Society of Academic Emergency Medicine, May 2006.     

Truth Telling and Treatment Strategies in End-of-Life Care in Physician-Led Accountable Care Organizations: Discrepancies Between Patients’ Preferences and Physicians’ Perceptions

Providing patient-centered care from preventive medicine to end-of-life care in order to improve care quality and reduce medical cost is important for accountable care. Physicians in the accountable care organizations (ACOs) are suitable for participating in supportive end-of-life care especially when facing issues in truth telling and treatment strategy. This study aimed to investigate patients’ attitudes toward truth telling and treatment preferences in end-of-life care and compare patients’ attitudes with their ACOs physicians’ perceptions.This nationwide study applied snowball sampling to survey physicians in physician-led ACOs and their contracted patients by questionnaire from August 2010 to July 2011 in Taiwan. The main outcome measures were beliefs about palliative care, attitudes toward truth telling, and treatment preferences.The data of 314 patients (effective response rate = 88.7%) and 177 physicians (88.5%) were analyzed. Regarding truth telling about disease prognosis, 94.3% of patients preferred to be fully informed, whereas only 80% of their physicians had that perception (P < 0.001). Significant differences were also found in attitudes toward truth telling even when encountering terminal disease status (98.1% vs 85.3%). Regarding treatment preferences in terminal illness, nearly 90% of patients preferred supportive care, but only 15.8% of physicians reported that their patients had this preference (P < 0.001).Significant discrepancies exist between patients’ preferences and physicians’ perceptions toward truth telling and treatment strategies in end-of-life care. It is important to enhance physician–patient communication about end-of-life care preferences in order to achieve the goal of ACOs. Continuing education on communication about end-of-life care during physicians’ professional development would be helpful in the reform strategies of establishing accountable care around the world.     

Why Does Patient Activation Matter? An Examination of the Relationships Between Patient Activation and Health-Related Outcomes

Background  

There is a growing awareness that patients should be more active and effective managers of their health and health care. Recent studies have found patient activation—or having the knowledge, skills, and confidence to manage one’s health, to be related to health-related outcomes. These studies have often relied on self-reported outcomes and often have used small samples.     

Comparison of Health-Related Quality of Life Preferences Between Physicians and Cirrhotic Patients: Implications for Cost–Utility Analyses in Chronic Liver Disease

Accurate assessment of utilities to calculate quality-adjusted life expectancy for medical interventions is needed in cirrhosis. To date, limited data exist in cirrhotics and are generally physician-assigned. Therefore, our aim was to determine utilities for six clinical scenarios in cirrhosis and to define if differences exist in utilities assigned by physicians versus patients. We administered a questionnaire to 83 physicians and 114 cirrhotics to obtain utilities using the time trade-off method for (1) compensated cirrhosis, (2) decompensated cirrhosis, (3) encephalopathy, (4) spontaneous bacterial peritonitis, (5) variceal bleeding, and (5) hepatocellular carcinoma. On a scale from 0 (death) to 1 (perfect health), mean utilities of physicians and patients were compared using the Student t test. One-way analysis of variance was used to compare the utilities between patients according to Child-Pugh class. Statistical significance was defined as a P value <0.05. The mean age of the physicians was 42 +/- 11, with 52% being male. The mean age of the patients was 52 +/- 9; with 59% male. The mean Child-Pugh score was 8 +/- 2 and HCV was the most common etiology (54%). The mean utilities for physicians and patients were as follows: CC, 0.78 vs. 0.88; DC, 0.55 vs. 0.74; E, 0.38 vs. 0.55; SBP, 0.33 vs. 0.45; VB, 0.27 vs. 0.40; and HCC, 0.19 vs. 0.30. All comparisons were statistically significant. Although physicians and patients assigned similar relative rankings to each health state, physicians assigned utilities were significantly different from those assigned by patients. These results suggest that studies that have used physician-assigned utilities do not accurately reflect patient preferences.