An ethical justification for the Chronic Care Model (CCM)

Background:  Chronic diseases are major causes of morbidity and mortality in developed countries. Their effects can be mitigated by high quality evidence-based care, but this is not the norm in most systems. The Chronic Care Model (CCM) is an evidence-based policy response to this practice gap, which uses multiple strategies to promote the quality of chronic care.
Objective:  To review CCM with an ethical lens.
Methods:  We reviewed the published empirical and non-empirical articles of CCM to analyse the ethical underpinnings of this model.
Results and conclusions:  We argue that its principal ethical value lies in the institutional cooperation it builds between the stakeholders involved in health care services. First, we briefly describe CCM and argue that the pathways through which it aims to improve patients' health outcomes are not made explicit. Second, we argue that the potential of CCM to be more beneficent, compared with traditional health care systems, depends on its capacity to promote mutual trust between health care providers and patients. There is no evidence to date that the implementation of CCM enhances mutual trust between health care professionals and patients. Third, we argue that CCM seeks to enhance human agency, allowing increased expression of individual autonomy and increased respect for individuals thereby expanding human freedom and avoiding social discrimination. However, we review the communication patterns that characterize the model of doctor–patient relationship promoted by this model and argue that these communication patterns raise ethical concerns that may prevent the model from reaching its expected outcomes.     

Relationship Between Clinical Quality and Patient Experience: Analysis of Data From the English Quality and Outcomes Framework and the National GP Patient Survey

PURPOSE

Clinical quality and patient experience are both widely used to evaluate the quality of health care, but the relationship between these 2 domains remains uncertain. The aim of this study was to examine this relationship using data from 2 established measures of quality in primary care in England.

METHODS

Practice-level analyses (N = 7,759 practices in England) were conducted on measures of patient experience from the national General Practice Patient Survey (GPPS), and measures of clinical quality from the national pay-for-performance scheme (Quality and Outcomes Framework). Spearman’s rank correlation and multiple linear regression were used on practice-level estimates.

RESULTS

Although all the correlations between clinical quality summary scores and patient survey scores are positive, and most are statistically significant, the strength of the associations was weak, with the highest correlation coefficient reaching 0.18, and more than one-half were 0.11 or less. Correlations with clinical quality were highest for patient-reported access scores (telephone access 0.16, availability of urgent appointments 0.15, ability to book ahead 0.18, ability to see preferred doctor 0.17) and overall satisfaction (0.15).

CONCLUSION

Although there are associations between clinical quality and measures of patient experience, the 2 domains of care quality remain predominantly distinct. The strongest correlations are observed between practice clinical quality and practice access, with very low correlations between clinical quality and interpersonal aspects of care. The quality of clinical care and the quality of interpersonal care should be considered separately to give an overall assessment of medical care.     

Case-Mix Adjustment and the Comparison of Community Health Center Performance on Patient Experience Measures

Objective. To assess the effect of case‐mix adjustment on community health center (CHC) performance on patient experience measures. Data Sources. A Medicaid‐managed care plan in Washington State collected patient survey data from 33 CHCs over three fiscal quarters during 2007–2008. The survey included three composite patient experience measures (6‐month reports) and two overall ratings of care. The analytic sample includes 2,247 adult patients and 2,859 adults reporting for child patients. Study Design. We compared the relative importance of patient case‐mix adjusters by calculating each adjuster's predictive power and variability across CHCs. We then evaluated the impact of case‐mix adjustment on the relative ranking of CHCs. Principal Findings. Important case‐mix adjusters included adult self‐reported health status or parent‐reported child health status, adult age, and educational attainment. The effects of case‐mix adjustment on patient reports and ratings were different in the adult and child samples. Adjusting for race/ethnicity and language had a greater impact on parent reports than adult reports, but it impacted ratings similarly across the samples. The impact of adjustment on composites and ratings was modest, but it affected the relative ranking of CHCs. Conclusions. To ensure equitable comparison of CHC performance on patient experience measures, reports and ratings should be adjusted for adult self‐reported health status or parent‐reported child health status, adult age, education, race/ethnicity, and survey language. Because of the differential impact of case‐mix adjusters for child and adult surveys, initiatives should consider measuring and reporting adult and child scores separately.     

英国改善患者体验指南解析

改善人民群众看病就医体验,是深化医药卫生体制改革的必然要求和最终目标,实施健康中国战略对增强人民群众获得感又提出了新的要求。从国际经验来看,要实现"以患者为中心"的价值医疗,改善患者体验是一个很好的切入点。英国是国际上较早重视改善患者体验的国家,除了像大多数国家那样通过改进医疗服务质量来改善患者体验之外,还发布了专门的改善患者体验指南。文章对英国改善患者体验指南的内容进行了详细介绍,并提出了相应建议,以资为我国患者体验相关研究和政策制定提供借鉴。     

Patient involvement in clinical decision making: the effect of GP attitude on patient satisfaction

OBJECTIVE: This study investigates general practitioners' (GPs) and patients' attitudes to shared decision making, and how these attitudes affect patient satisfaction. BACKGROUND: Sharing of information and decisions in the consultation is largely accepted as the ideal in general practice. Studies show that most patients prefer to be involved in decision making and shared decision making is associated with patient satisfaction, although preferences vary. Still we know little about how the interaction of GP and patients' attitudes affects patient satisfaction. One such study was conducted in the USA, but comparative studies are lacking. DESIGN: Questionnaire survey distributed through GPs. SETTING AND PARTICIPANTS: The results are based on the combined questionnaires of 41 GPs and 829 of their patients in the urban municipality of Bergen in the western part of Norway. Main variables studied The data were collected using a nine-item survey instrument constructed to measure attitudes towards patient involvement in medical consultations. The patients were also asked to rate their satisfaction with their GP. RESULTS AND CONCLUSIONS: The patients had a strong preference for shared decision making. The GPs also generally preferred shared decision making, but to a lesser degree than the patients, which is the opposite of the findings of the US study. There was a positive effect of the GP's attitude towards shared decision making on patient satisfaction, but no significant effect of congruence of attitudes between patient and GP on patient satisfaction. The suggested explanation is that GPs that are positive to sharing decisions are more responsive to patients' needs and therefore satisfy patients even when the patient's attitude differs from the GPs' attitude. Hence, although some patients do prefer a passive role, it is important to promote positive attitudes towards patient involvement in medical consultations.     

The Patient‐Centered Medical Home and Patient Experience

Objective

To examine the relationship between practices'' reported use of patient-centered medical home (PCMH) processes and patients'' perceptions of their care experience.

Data Source

Primary survey data from 393 physician practices and 1,304 patients receiving care in those practices.

Study Design

This is an observational, cross-sectional study. Using standard ordinary least-squares and a sample selection model, we estimated the association between patients'' care experience and the use of PCMH processes in the practices where they receive care.

Data Collection

We linked data from a nationally representative survey of individuals with chronic disease and two nationally representative surveys of physician practices.

Principal Findings

We found that practices'' use of PCMH processes was not associated with patient experience after controlling for sample selection as well as practice and patient characteristics.

Conclusions

In our study, which was large, but somewhat limited in its measures of the PCMH and of patient experience, we found no association between PCMH processes and patient experience. The continued accumulation of evidence related to the possibilities of the PCMH, how PCMH is measured, and how the impact of PCMH is gauged provides important information for health care decision makers.     

Patient Satisfaction and Organizational Impact: A Hierarchical Linear Modeling Approach

This article presents the rationale for using multilevel analysis to address the broad environmental contexts in patient satisfaction research. This study utilized patient satisfaction data and the American Hospital Association Hospital Guide Book (2004). This study found significant contributions of individual patient attribute reactions (nursing care, physician care, etc.), and also clearly demonstrated hospital-level effects and cross-level interactions on patient satisfaction. Thus, it is clear that patient satisfaction is not solely explained by patients' attribute reactions and their demographic variables, but is also explained by patients' hospital levels. This approach would offer additional understanding in patient satisfaction research.     

Subjective Quality Information: Effects of Patient Experience Outcomes and Display Formats on Evaluation and Choice Intentions

This study analyzes the impact of subjective quality information in the form of aggregate patient experience outcomes on respondent evaluation and intended choice of hospitals. We compared clinical performance-based quality measures (i.e., wound infection rates) with participant evaluations and choice intentions when they were additionally provided with subjective quality information (i.e., patient experience outcomes in different display formats). Results suggest that patient experience outcomes significantly affected the evaluations and choice intentions. Additionally, we found significant effects of subjective information display formats. Limitations, directions for future research, and implications for publishing subjective quality information in health care markets are discussed.     

The Relationship between Health Plan Performance Measures and Physician Network Overlap: Implications for Measuring Plan Quality

ObjectiveTo examine the extent to which health plan quality measures capture physician practice patterns rather than plan characteristics.ConclusionsStandard health plan performance measures reflect physician practice patterns rather than plans'' effort to improve quality. This implies that more provider-oriented measurement, such as would be possible with accountable care organizations or medical homes, may facilitate patient decision making and provide further incentives to improve performance.     

The Relationship between Patients' Perception of Care and Measures of Hospital Quality and Safety

Background

The extent to which patient experiences with hospital care are related to other measures of hospital quality and safety is unknown.

Methods

We examined the relationship between Hospital Consumer Assessment of Healthcare Providers and Systems scores and technical measures of quality and safety using service-line specific data in 927 hospitals. We used data from the Hospital Quality Alliance to assess technical performance in medical and surgical processes of care and calculated Patient Safety Indicators to measure medical and surgical complication rates.

Results

The overall rating of the hospital and willingness to recommend the hospital had strong relationships with technical performance in all medical conditions and surgical care (correlation coefficients ranging from 0.15 to 0.63; p<.05 for all). Better patient experiences for each measure domain were associated with lower decubitus ulcer rates (correlations −0.17 to −0.35; p<.05 for all), and for at least some domains with each of the other assessed complications, such as infections due to medical care.

Conclusions

Patient experiences of care were related to measures of technical quality of care, supporting their validity as summary measures of hospital quality. Further study may elucidate implications of these relationships for improving hospital care.     

Pairing Physician Education With Patient Activation to Improve Shared Decisions in Prostate Cancer Screening: A Cluster Randomized Controlled Trial

BACKGROUND

Most expert groups recommend shared decision making for prostate cancer screening. Most primary care physicians, however, routinely order a prostate-specific antigen (PSA) test with little or no discussion about whether they believe the potential benefits justify the risk of harm. We sought to assess whether educating primary care physicians and activating their patients to ask about prostate cancer screening had a synergistic effect on shared decision making, rates and types of discussions about prostate cancer screening, and the physician’s final recommendations.

METHODS

Our study was a cluster randomized controlled trial among primary care physicians and their patients, comparing usual education (control), with physician education alone (MD-Ed), and with physician education and patient activation (MD-Ed+A). Participants included 120 physicians in 5 group practices, and 712 male patients aged 50 to 75 years. The interventions comprised a Web-based educational program for all intervention physicians and MD-Ed+A patients compared with usual education (brochures from the Centers for Disease Control and Prevention). The primary outcome measure was patients’ reported postvisit shared decision making regarding prostate cancer screening; secondary measures included unannounced standardized patients’ reported shared decision making and the physician’s recommendation for prostate cancer screening.

RESULTS

Patients’ ratings of shared decision making were moderate and did not differ between groups. MD-Ed+A patients reported that physicians had higher prostate cancer screening discussion rates (MD-Ed+A = 65%, MD-Ed = 41%, control=38%; P <.01). Standardized patients reported that physicians seeing MD-Ed+A patients were more neutral during prostate cancer screening recommendations (MD-Ed+A=50%, MD-Ed=33%, control=15%; P <.05). Of the male patients, 80% had had previous PSA tests.

CONCLUSIONS

Although activating physicians and patients did not lead to significant changes in all aspects of physician attitudes and behaviors that we studied, interventions that involved physicians did have a large effect on their attitudes toward screening and in the discussions they had with patients, including their being more likely than control physicians to engage in prostate cancer screening discussions and more likely to be neutral in their final recommendations.     

Barriers to patient information provision in primary care: patients' and general practitioners' experiences and expectations of information for low back pain

Background As patient involvement in health‐care increases, the role of information is crucial, especially in conditions where self‐management is considered an integral part of care. However, the suitability and applicability of much patient information has not been appraised in terms of how far it meets patients' information needs. Aims To ascertain patients' and clinicians' experiences and expectations of information in low back pain in order to suggest a suitable ‘patient‐centred’ content for a patient information pack to be used in a primary care setting. Methods A qualitative study using semi‐structured interviews with General Practitioners (GPs) (n = 15) and focus groups comprising patients with low back pain (n = 37). Results Barriers to information‐giving for low back pain in primary care exist. Patients are dissatisfied with the information they receive from their GPs, especially regarding diagnosis and treatment. Patients tend to access information from a variety of other sources, which is often contradictory, conflicts with research evidence and leads to unreasonable expectations. GPs have varying views regarding the value of patient information and are equivocal about their roles as information providers. Although The Back Book is generally acceptable as a patient information leaflet for low back pain, attention to the tone of the text is required. Conclusions Barriers exist to patient information provision, both generally and for low back pain, which need to be addressed in order to close the gap between strategy and implementation. Improving clinician communication skills and involving patients in developing information materials which meet their needs are crucial to this process.     

The Impact of Electronic Health Record Implementation and Use on Performance of the Surgical Care Improvement Project Measures

Objective

To examine the impact of electronic health record (EHR) deployment on Surgical Care Improvement Project (SCIP) measures in a tertiary-care teaching hospital.

Data Sources

SCIP Core Measure dataset from the CMS Hospital Inpatient Quality Reporting Program (March 2010 to February 2012).

Study Design

One-group pre- and post-EHR logistic regression and difference-in-differences analyses.

Principal Findings

Statistically significant short-term declines in scores were observed for the composite, postoperative removal of urinary catheter and post–cardiac surgery glucose control measures. A statistically insignificant improvement in scores for these measures was noted 3 months after EHR deployment.

Conclusion

The transition to an EHR appears to be associated with a short-term decline in quality. Implementation strategies should be developed to preempt or minimize this initial decline.     

The Relationships of Physician Practice Characteristics to Quality of Care and Costs

BackgroundMedical group practices are central to many of the proposals for health care reform, but little is known about the relationship between practice-level characteristics and the quality and cost of care.MethodsPractice characteristics from a 2009 national survey of 211 group practices were linked to Medicare claims data for beneficiaries attributed to the practices. Multivariate regression was used to examine the relationship between practice characteristics and claims-computable measures of screening and monitoring, avoidable utilization, risk-adjusted per-beneficiary per-year (PBPY) costs, and the practice''s net revenue.ResultsSeveral characteristics of group practices are predictive of screening and monitoring measures. Those measures, in turn, are predictive of lower values of avoidable utilization measures that contribute to higher PBPY costs. The effects of group practice characteristics on avoidable utilization, cost, and practice net revenue appear to work primarily through improved screening and monitoring.ConclusionsPractice characteristics influence costs indirectly through a set of statistically significant relationships among screening and monitoring measures and avoidable utilization. However, these relationships are not the only pathways connecting practice characteristics to cost and those additional pathways contain substantial “noise” adding uncertainty to the estimated direct effects. Some of the attributes thought to be important characteristics of accountable care organizations and medical homes appear to be associated with lower quality and no improvement in cost.     

Assessing Patient Satisfaction and Quality of Care through Observation and Interview

The purpose of this study was to investigate patient satisfaction using an in-depth approach rather than the more common patient survey method. The authors conducted patient interviews and participant-oriented observations between patients, family members, and medical staff in a large teaching hospital to assess patients' perceptions of the quality of care provided on a medical-surgical unit. The observations were classified according to the Donabedian model of quality of care: technical care, interpersonal care, and amenities of care. Technical interactions (92.5%, or n = 123) were most common, followed by interpersonal interactions (5%, or n = 7) and interactions related to amenities of care (2%, or n = 3). Of the patients interviewed, 89% (n = 40) were satisfied with the treatment and quality of care they received. Of the 10% (n = 9) of patients who reported dissatisfaction with the hospitalization, most of the complaints were related to surgical procedures. Observations and patient interviews may provide a more informative and accurate assessment of patient satisfaction than a reliance on patient surveys as the sole measure.     

Effects of Lean Healthcare on Patient Flow: A Systematic Review

ObjectivesTo assess the effects of lean healthcare (LH) on patient flow in ambulatory care and determine whether waiting time and length of stay (LOS) decrease after LH interventions.MethodsA systematic review was performed with close adherence to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). We searched for studies of healthcare organizations applying LH interventions within ambulatory care published between 2002 and 2018. Six databases and grey literature sources were used. Two reviewers independently screened and assessed each study. When consensus was difficult to reach, a third reviewer intervened. Finally, a summary of findings was generated.ResultsOut of 5627 studies, 40 were included. Regarding LOS for all patients, 19 out of 22 studies reported a decrease. LOS for discharged patients decreased in 11 out of 13 studies, whereas LOS for admitted patients was reduced in 6 out of 7 studies. Waiting time for patients before seeing a healthcare professional decreased in 24 out of 26 studies. Waiting time to treatment and waiting time for appointments were minimized in 4 and 2 studies, respectively. Patients who left without being seen by a doctor decreased in 9 out of 12 studies. Finally, patient and staff satisfaction were measured in 8 and 2 studies, respectively, with each reporting improvements.ConclusionsAccording to our findings, LH helped to reduce waiting time and LOS in ambulatory care, mainly owing to its focus on identifying and minimizing non-value added (NVA) activities. Nevertheless, evidence of the impact of LH on patient/staff satisfaction and the translation of the obtained benefits into savings is scarce among studies.