Does physician uncertainty affect patient satisfaction?

Physicians may choose one of several strategies when initially uncertain about making a specific therapeutic recommendation. The authors investigated how patients’ satisfaction is affected by disclosure of uncertainty and its attempted resolution during a clinical encounter. Three hundred and four patients awaiting appointments at a university hospital’s ambulatory medical clinic were randomized to view one of five videotapes (VTs) of a patient seeking advice about antimicrobial prophylaxis for a heart murmur. In VT-1 and VT-2, the physician disclosed no uncertainty and prescribed therapy. In VT-3, VT-4, and VT-5, the physician openly conveyed uncertainty but then: (VT-3) prescribed antibiotics without resolving his uncertainty; (VT-4) consulted a reference book with the patient present, then prescribed; or (VT-5) checked a computer with the patient present, then prescribed. Patients rated their satisfaction with the physician on a standardized questionnaire. Differences in satisfaction between the five VTs were significant (p=0.001), with the highest ratings found for VT-1 and VT-2, where no uncertainty was disclosed. The lowest ratings in satisfaction were found when the physician expressed but then ignored uncertainty (VT-3) or examined a textbook (VT-4). Global satisfaction was inversely and significantly correlated (r=−0.47) with the patients’ perception of uncertainty in the physician. The manner in which clinical uncertainty is disclosed to patients and then resolved by the physician appears to affect patients’ satisfaction. Received from the General Medicine Unit. Department of Medicine; and the Division of Behavioral and Psychosocial Medicine, Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York. Dr. Johnson is now at the North Canton Medical Foundation, North Canton, Ohio. Supported by a grant from the Charles A. Dana Foundation. Presented at the tenth annual meeting of the Society for Research and Education in Primary Care Internal Medicine, San Diego, California, April 30, 1987.     

Effect of physician and patient gender concordance on patient satisfaction and preventive care practices

OBJECTIVE: To explore the role of the gender of the patient and the gender of the physician in explaining differences in patient satisfaction and patient-reported primary care practice. DESIGN: Cross-sectional mailed survey [response rate of 71%]. SETTING: A large group-model Health Maintenance Organization (HMO) in northern California. PATIENTS/PARTICIPANTS: Random sample of HMO members aged 35 to 85 years with a primary care physician. The respondents (N=10,205) were divided into four dyads: female patients of female doctors; male patients of female doctors; female patients of male doctors; and male patients of male doctors. Patients were also stratified on the basis of whether they had chosen their physician or had been assigned. MEASUREMENTS AND MAIN RESULTS: Among patients who chose their physician, females who chose female doctors were the least satisfied of the four groups of patients for four of five measures of satisfaction. Male patients of female physicians were the most satisfied. Preventive care and health promotion practices were comparable for male and female physicians. Female patients were more likely to have chosen their physician than males, and were much more likely to have chosen female physicians. These differences were not seen among patients who had been assigned to their physicians and were not due to differences in any of the measured aspects of health values or beliefs. CONCLUSIONS: Our study revealed differences in patient satisfaction related to the gender of the patient and of the physician. While our study cannot determine the reasons for these differences, the results suggest that patients who choose their physician may have different expectations, and the difficulty of fulfilling these expectations may present particular challenges for female physicians. This research is supported by grant RO1-HS08269 from the Agency for Health Care Policy and Research. The authors wish to acknowledge the invaluable contributions of our project coordinator, Alison F. Truman, MS.     

Improving patient satisfaction with the transfer of care

OBJECTIVE: To determine whether educational sessions with medical residents, with or without letters to their patients, improve patient satisfaction with transfer of their care from a departing to a new resident in an internal medicine clinic. DESIGN: Observational study in Year 1 to establish a historical control, with a randomized intervention in Year 2. SETTING: An internal medicine clinic in a teaching hospital. PATIENTS/PARTICIPANTS: Patients of departing residents completed questionnaires in the waiting room at their first visit with a new resident, with mail-administered questionnaires for patients not presenting to the clinic within 3 months after transfer of their care. In Year 1, 376 patients completed questionnaires without intervention. The following spring, we conducted interactive seminars with 12 senior residents to improve their transfer of care skills (first intervention). Half of their patients were then randomized to receive a letter from the new doctor informing them of the change (second intervention). We assessed the efficacy of the interventions by administering questionnaires to 437 patients in the months following the interventions. MEASUREMENTS AND MAIN RESULTS: Multivariate analysis of Year 1 results identified doctors personally informing patients prior to leaving as the single strongest predictor of patient satisfaction (partial R2=.41). In Year 2, our first intervention increased the percentage of patients informed by their doctors from 71% in 1991 to 79% in 1992 (P <.001). Mean satisfaction dramatically improved, with the fraction of fully satisfied patients increasing from 47% at baseline, to 61% with the first intervention alone, and 72% with both interventions (P <.0001). CONCLUSIONS: Simple methods such as resident education and direct mailings to patients significantly ease the difficult process of transferring patients from one physician to another. This has implications not only for residency programs, but for managed care networks competing to attract and retain patients.     

When the patient abuses the physician

Journal of General Internal Medicine -     

Effect of part-time practice on patient outcomes

BACKGROUND: Primary care physicians are spending fewer hours in direct patient care, yet it is not known whether reduced hours are associated with differences in patient outcomes. OBJECTIVE: To determine whether patient outcomes vary with physicians' clinic hours. DESIGN: Cross-sectional retrospective design assessing primary care practices in 1998. SETTING: All 25 outpatient-clinics of a single medical group in western Washington. PARTICIPANTS: One hundred ninety-four family practitioners and general internists, 80% of whom were part-time, who provided ambulatory primary care services to specified HMO patient panels. Physician appointment hours ranged from 10 to 35 per week (30% to 100% of full time). MEASUREMENTS: Twenty-three measures of individual primary care physician performance collected in an administrative database were aggregated into 4 outcome measures: cancer screening, diabetic management, patient satisfaction, and ambulatory costs. Multivariate regression on each of the 4 outcomes controlled for characteristics of physicians (administrative role, gender, seniority) and patient panels (size, case mix, age, gender). MAIN RESULTS: While the effects were small, part-time physicians had significantly higher rates for cancer screening (4% higher, P =.001), diabetic management (3% higher, P =.033), and for patient satisfaction (3% higher, P =.035). After controlling for potential confounders, there was no significant association with patient satisfaction (P =.212) or ambulatory costs (P =.323). CONCLUSIONS: Primary care physicians working fewer clinical hours were associated with higher quality performance than were physicians working longer hours, but with patient satisfaction and ambulatory costs similar to those of physicians working longer hours. The trend toward part-time clinical practice by primary care physicians may occur without harm to patient outcomes.     

Recognition of patient referral desires in an academic managed care plan

OBJECTIVE: To determine the frequency and determinants of provider nonrecognition of patients’ desires for specialist referral. DESIGN: Prospective study. SETTING: Internal medicine clinic in an academic medical center providing primary care to patients enrolled in a managed care plan. PARTICIPANTS: Twelve faculty internists serving as primary care providers (PCPs) for 856 patient visits. MEASUREMENTS AND MAIN RESULTS: Patients were given previsit and postvisit questionnaires asking about referral desire and visit satisfaction. Providers, blinded to patients’ referral desire, were asked after the visit whether a referral was discussed, who initiated the referral discussion, and whether the referral was indicated. Providers failed to discuss referral with 27% of patients who indicated a definite desire for referral and with 56% of patients, who indicated a possible desire for referral. There was significant variability in provider recognition of patient referral desire. Recognition is defined as the provider indicating that a referral was discussed when the patient marked a definite or possible desire for referral. Provider recognition improved significantly (P<.05), when the patient had more than one referral desire, if the patient or a family member was a health care worker and when the patient noted a definite desire versus a possible desire for referral. Patients were more likely (P<.05) to initiate a referral discussion when they had seen the PCP previously and had more than one referral desire. Of patient-initiated referral requests, 14% were considered “not indicated” by PCPs. Satisfaction with care did not differ in patients with a referral desire that were referred and those that were nor referred. CONCLUSIONS: These PCPs frequently failed to explicitly recognize patients’ referral desires. Patients were more likely to initiate discussions of a referral desire when they saw their usual PCP and had more than a single referral desire. This work was funded by University Hospital Board of Directors, Denver, Colo.     

Productivity, quality, and patient satisfaction

CONTEXT: Although few data are available, many believe that part-time primary care physicians (PCPs) are less productive and provide lower quality care than full-time PCPs. Some insurers exclude part-time PCPs from their provider networks. OBJECTIVE: To compare productivity, quality of preventive care, patient satisfaction, and risk-adjusted resource utilization of part-time and full-time PCPs. DESIGN: Retrospective cohort study. SETTING: Boston. PARTICIPANTS: PCPs affiliated with 2 academic outpatient primary care networks. MEASUREMENTS: PCP productivity, patient satisfaction, resource utilization, and compliance with screening guidelines. RESULTS: Part-time PCP productivity was greater than that of full-time PCPs (2.1 work relative value units (RVUs)/bookable clinical hour versus 1.3 work RVUs/bookable clinical hour, P< .01). A similar proportion of part-time PCPs (80%) and full-time PCPs (75%) met targets for mammography, Pap smears, and cholesterol screening (P = .67). After adjusting for clinical case mix, practice location, gender, board certification status, and years in practice, resource utilization of part-time PCPs (138 dollars [95% confidence interval (CI), 108 dollars to 167 dollars]) was similar to that of full-time PCPs (139 dollars [95% CI, 108 dollars to 170 dollars], P = .92). Patient satisfaction was similar for part-time and full-time PCPs. CONCLUSIONS: In these academic primary care practices, rates of patient satisfaction, compliance with screening guidelines, and resource utilization were similar for part-time PCPs compared to full-time PCPs. Productivity per clinical hour was markedly higher for part-time PCPs. Despite study limitations, these data suggest that academic part-time PCPs are at least as efficient as full-time PCPs and that the quality of their work is similar.     

The effect of primary care training on patient satisfaction ratings

This study examines the association between type of internal medicine training and satisfaction ratings among 509 patients who visited the clinic of an urban teaching hospital over a 3-month period in 1994. When controlling for patient, health-system, and other resident factors, primary care training was significantly associated with higher satisfaction ratings (cumulative odds ratio 1.53; 95% confidence interval 1.04, 2.25; p = .031) than categorical training. Using satisfaction ratings to rank the residents without adjusting for patient and health-system factors would have correctly classified only 27% of the residents in the lowest quartile. These findings have implications for both the education and potential employment of internists.     

Patient and physician satisfaction with a telephone-based anticoagulation service

OBJECTIVES: To compare the satisfaction and knowledge of patients who have their warfarin managed by their physician or by a multidisciplinary, telephone-based anticoagulation service (ACS) and to assess referring physicians' satisfaction with the ACS. DESIGN AND PARTICIPANTS: We surveyed 300 patients taking warfarin (mean age 73 years): 150 at health centers randomized to have access to an ACS, and 150 at control health centers without ACS access. We also surveyed 17 physicians who refer patients to the ACS. SETTING: Eight outpatient health centers in Missouri and Southern Illinois. MEASUREMENTS: We asked patients about the timeliness of international normalized ratio (INR) monitoring, perceived safety of warfarin, overall satisfaction with their warfarin management, and knowledge of what a high INR meant. We asked physicians at ACS-available health centers how many minutes they saved per INR by referring patients to the ACS, their satisfaction with the ACS, and their willingness to recommend the ACS to a colleague. MAIN RESULTS: As compared with patients at control health centers, patients at ACS-available health centers were more satisfied with the timeliness of getting blood test results (mean 4.31 vs 4.03, P =.02), were more likely to know what a safe INR value was (45% vs 15%, P =.001), and felt safer taking warfarin (mean 5.7 vs 5.2, P =.04). Physicians reported that using the ACS saved, on average, four minutes of their time and 13 minutes of their staff's time, per INR. All physicians recommended use of the ACS to a colleague and were highly satisfied with the ACS. CONCLUSIONS: A telephone-based ACS can be endorsed by primary-care physicians and improve patients' satisfaction with and knowledge about their antithrombotic therapy.     

A prospective observational study of physician handoff for intensive-care-unit-to-ward patient transfers

Background

Poor physician handoff can be a major contributor to suboptimal care and medical errors occurring in the hospital. Physician handoffs for intensive care unit (ICU)-to-ward patient transfer may face more communication hurdles. However, few studies have focused on physician handoffs in patient transfers from the ICU to the inpatient ward.

Methods

We performed a hospitalized patient-based observational study in an urban, university-affiliated tertiary care center to assess physician handoff practices for ICU-to-ward patient transfer. One hundred twelve adult patients were enrolled. The stakeholders (sending physicians, receiving physicians, and patients/families) were interviewed to evaluate the quality of communication during these transfers. Data collected included the presence and effectiveness of communication, continuity of care, and overall satisfaction.

Results

During the initial stage of patient transfers, 15.6% of the consulted receiving physicians verbally communicated with sending physicians; 26% of receiving physicians received verbal communication from sending physicians when patient transfers occurred. Poor communication during patient transfer resulted in 13 medical errors and 2 patients being transiently “lost” to medical care. Overall, the levels of satisfaction with communication (scored on a 10-point scale) for sending physicians, receiving physicians, and patients were 7.9 ± 1.1, 8.1 ± 1.0, and 7.9 ± 1.7, respectively.

Conclusion

The overall levels of satisfaction with communication during ICU-to-ward patient transfer were reasonably high among the stakeholders. However, clear opportunities to improve the quality of physician communication exist in several areas, with potential benefits to quality of care and patient safety.     

Continuity of care and other determinants of patient satisfaction with primary care

OBJECTIVE: The patient-clinician relationship is a central feature of primary care, and recent developments in the delivery of health care have tended to limit continuity of care. The objective of this study was to evaluate the extent to which continuity of care and other factors are related to patient satisfaction. DESIGN: Cross-sectional, mailed questionnaire study. SETTING: Primary care clinics at 7 Veterans Affairs medical centers. PATIENTS/PARTICIPANTS: Patients (N=21,689) participating in the Ambulatory Care Quality Improvement Project who returned the baseline Seattle Outpatient Satisfaction Questionnaire (SOSQ). MEASUREMENTS AND MAIN RESULTS: We evaluated the association between self-reported continuity and satisfaction, after adjusting for characteristics of patients, clinics, and providers. The humanistic scale of the SOSQ measures patient satisfaction with communication skills and humanistic qualities of providers, whereas the organizational scale measures satisfaction with delivery of health care services. The mean adjusted humanistic score for patients who reported always seeing the same provider was 17.3 (95% confidence interval [CI], 15.5 to 19.1) points higher than for those who rarely saw the same provider. Similarly, the mean adjusted organizational score was 16.3 (95% CI, 14.5 to 18.1) points higher for patients who always saw the same provider compared to rarely. Demographic factors, socioeconomic status, health status, clinic site, and patient utilization of services were all associated with both the adjusted humanistic and organizational scores of the SOSQ. CONCLUSIONS: Self-reported continuity of care is strongly associated with higher patient satisfaction. This suggests that improving continuity of care may improve patient satisfaction with providers as well as with their health care organization.     

Effect of a biopsychosocial approach on patient satisfaction and patterns of care

BACKGROUND: There is a growing tendency to include in medical curricula teaching programs that promote a biopsychosocial (BPS) approach to patient care. However, we know of no attempts to assess their effect on patterns of care and health care expenditures. OBJECTIVE: To determine whether 1) a teaching intervention aiming to promote a BPS approach to care affects the duration of the doctor-patient encounter, health expenditures, and patient satisfaction with care, and 2) the teaching method employed affects these outcomes. METHODS: We compared two teaching methods. The first one (didactic) consisted of reading assignments, lectures, and group discussions. The second (interactive) consisted of reading assignments, small group discussions, Balint groups, and role-playing exercises. We videotaped patient encounters 1 month before and 6 months after the teaching interventions, and recorded the duration of the videotaped encounters and whether the doctor had prescribed medications, ordered tests, and referred the patient to consultants. Patient satisfaction was measured by a structured questionnaire. RESULTS: Both teaching interventions were followed by a reduction in medications prescribed and by improved patient satisfaction. Compared to the didactic group, the interactive group prescribed even fewer medications, ordered fewer laboratory examinations, and elicited higher scores of patient satisfaction. The average duration of the encounters after the didactic and interactive teaching interventions was longer than that before by 36 and 42 seconds, respectively. CONCLUSIONS: A BPS teaching intervention may reduce health care expenditures and enhance patients’ satisfaction, without changing markedly the duration of the encounter. An interactive method of instruction was more effective in achieving these objectives than a didactic one. Supported in part by the Chief Scientist’s Office of the Israeli Ministry of Health. This study was submitted in partial fulfillment of the requirements for the degree of PhD in medical education at Ben-Gurion University of the Negev, under the supervision of Dr. Shimon M. Glick and Dr. C.Z. Margolis, Ben-Gurion University of the Negev and Dr. Michael Katz, Haifa University.     

Collaboration in the preparation of the generalist physician

Collaborative efforts among health care professionals and institutions at all levels will be essential to the increased production of generalist physicians. There have been many successful collaborations in education and patient care among certifying boards, faculty, physicians in practice, specialists, generalists, and non-physician health professionals, as well as among the three generalist specialties. Recommended strategies to encourage collaboration in the preparation of generalist physicians include: creation of an institutional collaborative curriculum committee; design of a longitudinal curriculum on collaboration for physicians-in-training and other health professionals; implementation of collaborative patient care in ambulatory care teaching clinics; development of integrated systems of care that link inpatient, outpatient, and community-based health services; and education of physicians-in-training in these and other collaborative and co-practice models of patient care.     

Managed care, time pressure, and physician job satisfaction: Results from the physician worklife study

OBJECTIVE: To assess the association between HMO practice, time pressure, and physician job satisfaction. DESIGN: National random stratified sample of 5,704 primary care and specialty physicians in the United States. Surveys contained 150 items reflecting 10 facets (components) of satisfaction in addition to global satisfaction with current job, one’s career and one’s specialty. Linear regression-modeled satisfaction (on 1–5 scale) as a function of specialty, practice setting (solo, small group, large group, academic, or HMO), gender, ethnicity, full-time versus part-time status, and time pressure during office visits. “HMO physicians” (9% of total) were those in group or staff model HMOs with >50% of patients capitated or in managed care. RESULTS: Of the 2,326 respondents, 735 (32%) were female, 607 (26%) were minority (adjusted response rate 52%). HMO physicians reported significantly higher satisfaction with autonomy and administrative issues when compared with other practice types (moderate to large effect sizes). However, physicians in many other practice settings averaged higher satisfaction than HMO physicians with resources and relationships with staff and community (small to moderate effect sizes). Small and large group practice and academic physicians had higher global job satisfaction scores than HMO physicians (P<.05), and private practice physicians had quarter to half the odds of HMO physicians of intending to leave their current practice within 2 years (P<.05). Time pressure detracted from satisfaction in 7 of 10 satisfaction facets (P<.05) and from job, career, and specialty satisfaction (P<.01). Time allotted for new patients in HMOs (31 min) was less than that allotted in solo (39 min) and academic practices (44 min), while 83% of family physicians in HMOs felt they needed more time than allotted for new patients versus 54% of family physicians in small group practices (P<.05 after Bonferroni’s correction). CONCLUSIONS: HMO physicians are generally less satisfied with their jobs and more likely to intend to leave their practices than physicians in many other practice settings. Our data suggest that HMO physicians’ satisfaction with staff, community, resources, and the duration of new patients visits should be assessed and optimized. Whether providing more time for patient encounters would improve job satisfaction in HMOs or other practice settings remains to be determined. Presented in part at the 21st Annual Meeting of the Society of General Internal Medicine, Chicago Ill, April 1998. Other members of the CSSG include John Frey, MD, Department of Family Medicine, University of Wisconsin, Madison, Wis; Kathleen Nelson, MD, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Ala, Richard Shugerman, MD, Department of Pediatrics, University of Washington, Seattle, Wash; and David Karlson, PhD, SGIM, Washington DC. This work was supported by grant 27069 from the Robert Wood Johnson Foundation.     

The influence of gatekeeping and utilization review on patient satisfaction

OBJECTIVE: To examine the influence of utilization review and denial of specialty referrals on patient satisfaction with overall medical care, willingness to recommend one's physician group to a friend, and desire to disenroll from the health plan. DESIGN: Two cross-sectional questionnaires: one of physician groups and one of patient satisfaction. SETTING: Eighty-eight capitated physician groups in California. PARTICIPANTS: Participants were 11,710 patients enrolled in a large California network-model HMO in 1993 who received care in one of the 88 physician groups. MEASUREMENTS AND MAIN RESULTS: Our main measures were how groups conducted utilization review for specialty referrals and tests, patient-reported denial of specialty referrals, and patient satisfaction with overall medical care. Patients in groups that required preauthorization for access to many types of specialists were significantly (p 相似文献   

Faculty ratings of resident humanism predict patient satisfaction ratings in ambulatory medical clinics

Objective: To determine whether patient satisfaction ratings can be predicted by faculty ratings or self-ratings of resident humanism. Design: A prospective three-month collection of patient satisfaction ratings in two ambulatory care clinics and simultaneous acquisition of faculty ratings and self-ratings of resident humanism using ABIM questionnaires. Setting: Two teaching hospital ambulatory care internal medicine clinics. Participants: Forty-seven internal medicine residents and 17 faculty internists were sent questionnaires for evaluation of humanism of individual residents. One thousand one hundred ninety-four consecutive outpatients cared for by the residents were eligible for patient satisfaction questionnaires. Measurements and main results: Thirty-three residents and 13 faculty completed evaluations of resident humanism while 792 patients completed satisfaction questionnaires, which were used for analysis. The faculty ratings of resident humanism correlated strongly with patient satisfaction ratings, while the resident self-ratings did not. Conclusions: Faculty ratings of resident humanism were highly predictive of patient satisfaction with the care rendered by internal medicine residents in two ambulatory care clinics. This suggests that ambulatory care settings are useful for evaluation of noncognitive behavioral features of resident performance. Received from McGill University, Departments of Medicine and Epidemiology and Biostatistics, Montreal General and Royal Victoria Hospitals, Montreal, Quebec, Canada. Supported by the Fonds de la recherche en santé du Quebec and the Royal Victoria Hospital Department of Medicine research and education fund.     

The reform of the Israeli health care system: a comparison between older and younger consumers, one year and three years after its implementation

OBJECTIVE: One of the main objectives of the National Health Insurance Law, which was implemented in Israel in January 1995, was to increase equity among different population groups and improve services for weaker populations, such as older people. It is not clear, however, whether the law's goals are being achieved. This study aimed to examine changes in the satisfaction and perceived quality of healthcare services among older people one year and three years after enactment of the law, and to compare the satisfaction and perceptions of older people with those of young adults. DESIGN: Two cross-sectional telephone surveys conducted by the JDC-Brookdale Institute. SETTING: Israel. PARTICIPANTS: Two random samples of the adult residents of Israel at the end of 1995 and at the end of 1997. Two hundred and eighteen older people (of 1,116 respondents) were included in the first survey, and 198 older people (of 1,205 respondents) were included in the second survey. Sixty-seven percent of older respondents in both surveys were 65 to 74 years old and the remaining 33% were 75 years old and over. Forty-three percent were men. Sixty-four percent reported having had at least one chronic illness. There were no differences between the two samples, with the exception of a higher percentage of new immigrants in the second survey. MEASUREMENTS: Perception of changes in the level of services, satisfaction with services, and perceived quality of care (availability, accessibility, early detection procedures). RESULTS: Older people felt there had been an improvement in the level of sick fund (who operate as health maintenance organizations [HMOs] in the United States) services since implementation of the law. The proportion reporting improvement increased from 13% in 1995 to 28% in 1997. At the same time, the proportion of older people who sensed a decline in the level of services also increased, albeit at a much lower rate (4% in 1995 and 8% in 1997). The percentage of younger adults reporting an improvement in services and the percentage reporting a decline were greater than the percentages of older people, in both surveys. Regarding access to services, 69% waited up to 15 minutes to see their physician and 56% received an appointment to see a specialist within one week; this was an improvement. While a higher proportion of younger adults received an appointment within a shorter time span in 1995, the gap had diminished by 1997. Most of the older people felt that the office hours of their family physicians, specialists, administrative services, and laboratories were convenient. The proportion of elderly reporting so increased between 1995 and 1997, and in both surveys was higher than among younger adults. CONCLUSION: The study's findings show that older people perceived an improvement in a number of areas during the first three years of the law's implementation. Their experience was similar to that of younger adults and was even better in some areas. It is necessary to continue monitoring the impact of the law on the need for health services of vulnerable groups such as the chronically ill and disabled older people.     

Listening to older adults: elderly patients' experience of care in residency and practicing physician outpatient clinics

The population of people aged 65 and older is rapidly growing. Research has demonstrated significant quality gaps in the clinical care of older patients in the United States, especially in training programs. Little is known about how older patients' experience with care delivered in residency clinics compares with that delivered by practicing physicians. Using patient surveys from the American Board of Internal Medicine Care of the Vulnerable Elderly Practice Improvement Module, the quality of care provided to adults aged 65 and older by 52 internal medicine and family medicine residency clinics and by a group of 144 practicing physicians was studied. The residency clinics received 2,213 patient surveys, and the practicing physicians received 4,204. Controlling for age and overall health status, patients from the residency clinic sample were less likely to report receiving guidance and interventions for important aspects of care for older adults than patients from the practicing physician sample. The largest difference was observed in providing ways to help patients prevent falls or treat problems with balance or walking (42.1% vs 61.8%, P<.001). Patients from the residency clinic sample were less likely to rate their overall care as high (77.5% vs 88.8%, P<.001). Patient surveys reveal important deficiencies in processes of care that are more pronounced for patients cared for in residency clinics. Quality of patient experience and communication are vital aspects of overall quality of care, especially for older adults. Physician education at all levels, faculty development, and practice system redesign are needed to ensure that the care needs of older adults are met.     

Functional status and patient satisfaction a comparison of ischemic heart disease,obstructive lung disease,and diabetes mellitus

OBJECTIVE: To determine the extent to which chronic illness and disease severity affect patient satisfaction with their primary care provider in general internal medicine clinics. DESIGN: Cross-sectional mailed questionnaire study. SETTING: Primary care clinics at 7 Veterans Affairs medical centers. PATIENTS/PARTICIPANTS: Of 62,487 patients participating in the Ambulatory Care Quality Improvement Project, 35,383 (57%) returned an initial screening questionnaire and were subsequently sent a satisfaction questionnaire. Patients (N=21,689; 61%) who returned the Seattle Outpatient Satisfaction Survey (SOSQ) were included in the final analysis, representing 34% of the original sample. MEASUREMENTS AND MAIN RESULTS: The organizational score of the SOSQ measures satisfaction with health care services in the internal medicine clinic, and the humanistic scale measures patient satisfaction with the communication skills and humanistic qualities of the primary care physician. For ischemic heart disease (IHD), chronic obstructive pulmonary disease (COPD), and diabetes, patient ability to cope with their disease was more strongly associated with patient satisfaction than disease severity. Among IHD patients, improvement in ability to cope emotionally with their angina was associated with higher SOSQ organizational scores (standardized beta=0.18; P<.001) but self-reported physical limitation due to angina was not (beta=0.01; P=.65). Similarly, in COPD, improved ability to cope with dyspnea was associated with greater organizational scores (beta=0.11; P<.001) but physical function was not (beta=-0.03; P=.27). For diabetes, increased education was associated with improved organizational scores (beta=0.31; P<.001) but improvement in symptom burden was not (beta=0.03; P=.14). Similar results were seen with prediction of SOSQ humanistic scores. CONCLUSIONS: Patient education and ability to cope with chronic conditions are more strongly associated with satisfaction with their primary care provider than disease severity. Further improvements in patient education and self-management may lead to improved satisfaction and quality of care.