Statistical Benchmarks for Health Care Provider Performance Assessment: A Comparison of Standard Approaches to a Hierarchical Bayesian Histogram-Based Method

ObjectiveExamine how widely used statistical benchmarks of health care provider performance compare with histogram-based statistical benchmarks obtained via hierarchical Bayesian modeling.ConclusionsGiven the rewards and penalties associated with characterizing top performance, the ability of statistical benchmarks to summarize key features of the provider performance distribution should be examined.     

Can data-driven benchmarks be used to set the goals of healthy people 2010?

OBJECTIVES: Expert panels determined the public health goals of Healthy People 2000 subjectively. The present study examined whether data-driven benchmarks provide a better alternative. METHODS: We developed the "pared-mean" method to define from data the best achievable health care practices. We calculated the pared-mean benchmark for screening mammography from the 1994 National Health Interview Survey, using the metropolitan statistical area as the "provider" unit. Beginning with the best-performing provider and adding providers in descending sequence, we established the minimum provider subset that included at least 10% of all women surveyed on this question. The pared-mean benchmark is then the proportion of women in this subset who received mammography. RESULTS: The pared-mean benchmark for screening mammography was 71%, compared with the Healthy People 2000 goal of 60%. CONCLUSIONS: For Healthy People 2010, benchmarks derived from data reflecting the best available care provide viable alternatives to consensus-derived targets. We are currently pursuing additional refinements to the data-driven pared-mean benchmark approach.     

Evaluation of the feasibility of a state-based vaccine safety advice network

The vaccine safety advice network is a collaborative pilot project between Vanderbilt University Medical Center, the Tennessee Department of Health, and the Centers for Disease Control and Prevention to assess the feasibility of addressing vaccine safety questions posed by healthcare providers in near real-time. Using a two-tier response system and an electronic database for query submission, the pilot project received ten queries in three and one half months. Two of three pre-specified benchmarks for program evaluation, addressing queries within 24 h of receipt and 100% provider satisfaction, were met; one benchmark, the percentage of questions addressed by Tier 1 staff, was not met. Limitations included few submitted queries primarily involving children in the pilot period, “after-only” program evaluation, and limited geographic generalizability. The study demonstrates a successful partnership between federal, state and academic institutions and a feasible method to respond to healthcare provider inquiries about vaccine safety in near real-time.     

Measuring clinical performance to provide information for quality improvement

Measures of clinical performance summarize quality of care given to groups of patients by a practice, provider network, or plan. Clinical managers can use these measures to drive and track internal quality improvements, and purchasers and accreditors can provide benchmarks based on comparisons of performance in order to stimulate internal improvements. This article explains desired properties of such clinical performance measures and the AHCPR Typology of Clinical Performance Measures Project.     

Benchmarks of fairness for health care reform: a policy tool for developing countries

Teams of collaborators from Colombia, Mexico, Pakistan, and Thailand have adapted a policy tool originally developed for evaluating health insurance reforms in the United States into "benchmarks of fairness" for assessing health system reform in developing countries. We describe briefly the history of the benchmark approach, the tool itself, and the uses to which it may be put. Fairness is a wide term that includes exposure to risk factors, access to all forms of care, and to financing. It also includes efficiency of management and resource allocation, accountability, and patient and provider autonomy. The benchmarks standardize the criteria for fairness. Reforms are then evaluated by scoring according to the degree to which they improve the situation, i.e. on a scale of -5 to 5, with zero representing the status quo. The object is to promote discussion about fairness across the disciplinary divisions that keep policy analysts and the public from understanding how trade-offs between different effects of reforms can affect the overall fairness of the reform. The benchmarks can be used at both national and provincial or district levels, and we describe plans for such uses in the collaborating sites. A striking feature of the adaptation process is that there was wide agreement on this ethical framework among the collaborating sites despite their large historical, political and cultural differences.     

Development and initial validation of a measure of coordination of health care.

OBJECTIVE: To describe the development and initial validation of the self-administered Client Perceptions of Coordination Questionnaire. DESIGN: The instrument was developed between 1996 and 1997 through iterative item generation; within a framework of six domains of coordination, addressed across four sectors of health care provision. SETTING: 1193 individuals with complex and chronic health care needs as judged by their general practitioners (GPs), who were participants in a 2-year randomized controlled trial of a coordinated care intervention in Australia. Other samples were collected in one general practice (98) and from attendees of a chronic pain management course (29). MAIN MEASURES: Face and content validity, completion rates, transferability, internal consistency, and construct validity of the 32-item instrument. RESULTS: Most items achieved excellent completion and comprehension rates. The instrument was transferable to another chronically unwell population. Cronbach's alpha of the entire instrument was 0.92, and for six individual scales scores ranged from 0.31 to 0.86. The six scales based on principal components analysis were acceptability, received care, GP, nominated provider, client comprehension, and client capacity. The first four scales were satisfactory, but the client scales were inadequate with poor internal consistency, and convergent and discriminant validity. People with chronic pain syndromes had significantly worse experiences for almost all items, supporting construct validity. CONCLUSION: This instrument is one of the first to attempt to measure coordination of health care. Its strengths include ease of completion, transferability, and promising psychometric properties and construct validity. Problems capturing data about the patient's contribution to coordination highlight a lack of theoretical development in this area. A valid measure of coordination should be useful in needs assessment, program evaluation, and individual provider/practice audit, and would contribute to research into the experience and measurement of patient-focused care.     

The master clinician project

This article describes an internal benchmarking process developed and used by the Marshfield Clinic targeting the interface between productivity and service quality. The benchmarking first identified "better performing" physicians using production and service quality measures as benchmarks. This was followed by detailed interviews of "better performers" to discover their "best practices." Based on an analysis of the "best practices" information, a physician curriculum was designed and implemented to improve service quality and provider productivity. Optimal strategies for successful programs are discussed and, finally, recommendations for future research are identified.     

Towards a new understanding of provider continuity

Provider continuity is in need of an expanded definition that is not exclusively clinician centered. Currently, provider continuity is defined by visits over time to the same clinician. Many patients and informal caregivers, however, are co-providers of health care, not merely consumers. As a result, provider continuity will not happen if there is a lack of consistency in who attends with or for the patient during successive visits. Such fragmentation may weaken knowledge of the patient and information exchange. Consequently, there is a need to redefine provider continuity to mean that the same attendees visit the same clinician(s), service, or facility as an uninterrupted succession of events. More than semantic quibbling, the proposed reconceptualization challenges the foundation of family medicine in terms of the values and language by which the discipline defines itself in clinician-centered ways. The change required has implications for practice and research.     

Pretrial Court Diversion of People with Mental Illness

Court diversion is a method of administering justice compassionately for persons with mental illness (PMI). Evidence-based practices of this intervention were identified by reviewing the existing literature. Findings suggest that: (a) formal case finding procedures are important for the early identification of mentally ill offenders in need of services, (b) stable housing enhances the possibility that the divertee will remain in regular contact with her or his treatment provider, and (c) active case management improves compliance and reduces the likelihood of recidivism. In summary, research has not yet yielded generalizable knowledge about diversion and thus, it is suggested that evaluations should involve well-defined indicators, benchmarks, and outcomes.     

Consistency between most important reasons for using contraception and current method used: the influence of health care providers

OBJECTIVE: To identify factors related to consistency between women's "most important" reason for using contraception and their current contraceptive method. METHODS: A sample of 433 women completed a written questionnaire on demographics, contraceptive use history and the "most important" reason for using contraception. Women were grouped by whether their current contraceptive method "agreed" or "disagreed" with their "most important" reason for contracepting. Multivariable regression was used to identify factors associated with consistency between stated "most important" reason and current method used ("agreed"). RESULTS: Current contraceptive method was inconsistent with the "most important" reason for using a method in 25% of women. Demographic characteristics and knowledge of contraceptive effectiveness did not differ between the "agreed" and "disagreed" groups. Women using a method consistent with their reason were more likely to have discussed contraception with a health care provider (RR=1.59, 95% CI 1.13-2.25) even after adjusting for source of contraceptive method or source of contraceptive information (RR=1.57, 95% CI 1.10-2.23). CONCLUSION: Contact with a health care provider was the only factor associated with consistency between birth control method and reasons for initiating contraception. This association appears to be independent of knowledge about contraceptive effectiveness.     

Adding Multimedia Cues to Medical Providers’ Online Biographies: Do Pictures,Video, and B-Roll Matter?

Developing engaging online healthcare provider biographies for prospective patients to consult is becoming a big business. Health-care systems are beginning to add more multichannel components—like videos—to these provider search tools at increasingly higher costs. Prior research finds that prospective patients desire videos offering additional footage (i.e., b-roll) displaying how a provider might interact with a patient during a consultation. Shooting and editing b-roll footage to add to providers’ videos takes additional time and resources. Using predictions and questions generated from uncertainty reduction and cue summation theories, this study sought to determine whether the addition of multichannel media (e.g., a video with added b-roll) offers any greater effects in the form of reduced uncertainty, provider likability, patient satisfaction, or trust than biographies providing fewer multichannel cues. A between-subjects online experiment randomly exposed participants (n = 523) to one of four biographies with increasing levels of multichannel components (i.e., text only biography, text with picture, video, video with b-roll). Results revealed that the two video biographies generated more significant effects than text-only biographies. However, the biography with just the video of the provider (i.e., a-roll only) and the video including added b-roll were not significantly different from one another on any of the dependent variables measured. These findings indicate that there may be a limit to the number of multichannel components needed to be an effective biography to help patients select their next healthcare provider. Both theoretical and practical implications of these results are discussed, in addition to future directions for research.     

Two approaches to measuring quality of life in the HIV/AIDS population: HAT-QoL and MOS-HIV

Objectives: Reduce the number of HIV/AIDS-Targeted Quality of Life (HAT-QoL) items, assess psychometric performance of the shortened HAT-QoL, and compare psychometric performance of HAT-QoL to that of Medical Outcomes study HIV Health Survey (MOS-HIV). Design/Subjects: Convenience sample of 215 cross-sectionally studied seropositive individuals. Methods: Subjects completed the HAT-QoL, MOS-HIV, and sociodemographic and disease-specific questions. HAT-QoL and MOS-HIV responses were entered, separately, into principal components analysis (PCA). Results from PCA, internal consistency and correlation assessments were used to aid the item removal process. Dimension characteristics (e.g., score distributions, internal consistency, scaling success rates, intercorrelations, construct validity) were evaluated. Results: PCA of subjects' (80% male; 45% white; 62% gay/bisexual) responses revealed nine previously identified HAT-QoL dimensions. The measure was shortened by removing 12 items. Two HAT-QoL dimensions (HIV mastery and provider trust) had ceiling effects. All internal consistency coefficients were >0.80, except those for sexual function (0.57) and medication concerns (0.57). HAT-QoL scaling success rates were >90% for 7 of 9 dimensions, and a majority of dimensions showed minimal to low intercorrelations. Validity assessments indicated consistent, expected relationships (p0.05) for all dimensions except the medication concerns and provider trust dimensions. PCA indicated five MOS-HIV factors. Six of the 11 previously defined MOS-HIV dimensions – physical, role, social, and cognitive function, pain, and health transition – had substantial ceiling effects. MOS-HIV scaling success rates were >90% for only 2 out of 8 evaluable dimensions; three dimensions had very low (40–73%) scaling success rates. Most MOS-HIV dimensions were moderately-to-highly intercorrelated. Validity assessments indicated consistent, expected relationships for all MOS-HIV dimensions. Conclusions: Six dimensions of the shortened HAT-QoL instrument (overall function, disclosure worries, health worries, financial worries, HIV mastery, and life satisfaction) exhibited good psychometric properties, including limited ceiling effects, low dimension intercorrelations, high internal consistency, and evidence for construct validity. All multi-item MOS-HIV dimensions had high internal consistency and all dimensions revealed consistent evidence for construct validity.     

Posing A Framework To Guide Government's Role In Payment And Delivery System Reform

Innovative payment reform initiatives occur in both the public and private sector, but the optimal role in such reforms of the public sector, specifically the Centers for Medicare and Medicaid Services, is up for debate. In this article we examine recent experiences with public-private collaboration on payment and delivery reform and present a framework for determining the role of the government in spurring reform. We argue that as a purchaser, the government should consider the scale and maturity of private-sector activity in determining how to approach designing and implementing payment and delivery system reform. The government can further spur innovation by implementing payment reform for providers less ready to participate in it-such as smaller provider groups with limited organizational and technological capacity to implement reform-through identifying best practices related to attribution models and quality benchmarks and promoting dialogue with the private sector about the testing of new reform programs.     

Negotiating and contracting in a managed care environment: considerations for practitioners.

The world of integrated service provider networks, managed care providers, and preferred provider systems requires clinical social workers to become skilled in business negotiations, with specific attention to contracting for services. This article focuses on the components of negotiating and successfully competing for contracts to gain access to and participate in provider networks for the delivery of mental health services. The authors identify critical elements involved in contracting for services from the perspective of social work practitioners who are now working with or who plan to work with managed care organizations. This pragmatic approach recognizes the controversial nature of social workers' relationship with managed care organizations and the ethical dilemmas that affect both the quality and quantity of client services.     

Exploratory factor analysis and psychometric evaluation of the Healthcare Provider Attitudes Toward Child Maltreatment Reporting Scale

There currently is not a well-established, psychometrically sound measure for assessing health care provider concerns about and attitudes toward reporting maltreatment. The purpose of this study is to examine the psychometric properties of the Healthcare Provider Attitudes Toward Child Maltreatment Reporting Scale. The factor structure and reliability of the scale were analyzed. Two subscales, Reporting Responsibilities and Concerns about Reporting, were identified. The total scale and the subscales were shown to have good internal consistency. Potential uses for the scale in evaluating and improving mandated reporting by health care providers are proposed.     

Mandatory presuit mediation: 5‐year results of a medical malpractice resolution program

The Florida Patient Safety and Presuit Mediation Program (FLPSMP) is a mandatory mediation program designed to provide deserving patients with fast, fair compensation while limiting the healthcare provider expenses incurred during traditional litigation. Mediation occurs before litigation begins; therefore, patients with meritorious claims receive compensation often years earlier than they would with extended litigation. This early mediation fosters confidential and candid communication between doctors and patients, which promotes early fact‐finding and candid discussion. The program went into effect across the University of Florida (UF) Health system on January 1, 2008. In an article previously published in this journal, we discussed the positive trend observed 2 years after the implementation of the FLPSMP. This article incorporates 5 years of data, which includes new benchmarks with state and national data, to demonstrate that the program can be used successfully as a medical malpractice solution.     

Decomposing the Gap in Satisfaction with Provider Communication Between English- and Spanish-Speaking Hispanic Patients

Disparities in patient-provider communication exist among racial/ethnic groups. Hispanics report the lowest satisfaction with provider communication compared to whites and blacks; these differences may be due to level of acculturation or patient-provider concordance according to their ability to speak English. Using data from the 2007–2009 Medical Expenditure Panel Survey, this study identifies and quantifies the components that constitute the gap in satisfaction with provider communication between English- and Spanish-speaking Hispanics. English-speaking Hispanics are 7.3 percentage points more likely to be satisfied with the amount of time their providers spent with them compared to Spanish-speaking Hispanics. Differences in acculturation between the two groups account for 77 % of this gap. Satisfaction with provider listening is 6.8 percentage points higher for English-speaking Hispanics. Hispanics who speak English are more satisfied with provider communication. The gap in satisfaction is largely attributable to differences in health insurance, acculturation, and education.     

An explication of treatment ideology among mental health care providers

This paper presents an exploratory analysis of the treatment ideologies of mental health care providers who work with the chronically ‘mentally ill.’ Treatment ideology is understood as the complex set of beliefs providers hold about the aetiology of mental illness, the role of the client and the provider, and the efficacy of various treatments or interventions. A case study of a large, urban mental health care organisation providing care to the chronically‘mentally ill’was conducted in 1992. The author attended a series of staff retreats, administered a questionnaire, and completed in-depth interviews with 22 providers. A typology reflecting two dimensions that juxtapose alternative treatment preferences was developed to represent the range of treatment ideologies uncovered. The first dimension reflects differing conceptions of the role of the provider (supportive or facilitative) and the second dimension reflects differing treatment goals (adjustment or autonomy). This typology was then theoretically extended to include a custodial role for the provider and a treatment goal oriented toward social control of clients. Further study of providers in differing organisation settings is needed to determine the salience of these typologies. Research must also investigate the development and consequences of treatment ideologies, with critical attention focused on the consistency (or inconsistency) of treatment ideologies within a given system, the professional and organisational sources of differing preferences for treatment, and the effect of various belief sets on health care services and outcomes.     

Provider Barriers and Facilitators to Screening for Intimate Partner Violence in Bogotá, Colombia

We conducted interviews with 27 health care personnel in Bogotá, Colombia, to examine provider barriers and facilitators to screening for intimate partner violence (IPV). We used systematic qualitative analysis to identify the range and consistency of beliefs. We found that respondents did not routinely screen for IPV. Providers listed numerous barriers to screening. Ways to improve screening included increased clinician training, installing systematic IPV screening, providing patient education, and implementing health care setting interventions. Improving the care for IPV survivors will involve translating health care personnel preferred solutions into more systematic IPV screening interventions.