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Elliott MN, Lehrman WG, Goldstein EH, Giordano LA, Beckett MK, Cohea CW, Cleary PD. Hospital survey shows improvements in patient experience. Health Aff (Millwood) 2011; 29:2061-7. [PMID: 21041749 DOI: 10.1377/hlthaff.2009.0876] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Hospitals are improving the inpatient care experience. A government survey that measures patients' experiences with a range of issues from staff responsiveness to hospital cleanliness-the Hospital Consumer Assessment of Healthcare Providers and Systems survey-is showing modest but meaningful gains. Using data from the surveys reported in March 2008 and March 2009, we present the first comprehensive national assessment of changes in patients' experiences with inpatient care since public reporting of the results began. We found improvements in all measures of patient experience, except doctors' communication. These improvements were fairly uniform across hospitals. The largest increases were in measures related to staff responsiveness and the discharge information that patients received.
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Meterko M, Wright S, Lin H, Lowy E, Cleary PD. Mortality among patients with acute myocardial infarction: the influences of patient-centered care and evidence-based medicine. Health Serv Res 2010; 45:1188-204. [PMID: 20662947 DOI: 10.1111/j.1475-6773.2010.01138.x] [Citation(s) in RCA: 139] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Recent studies have suggested that there is a positive impact of patient-centered care (PCC) on both the patient-physician relationship and subsequent patient health-related behaviors. One recent prospective study reported a significant relationship between the degree of PCC experienced by patients during their hospitalization for acute myocardial infarction (AMI) and their postdischarge cardiac symptoms. A limitation of this study, however, was a lack of information regarding the technical quality of the AMI care, which might have explained at least part of the differences in outcomes. The present study was undertaken to test the influence of both PCC and technical care quality on outcomes among AMI patients. METHODS We analyzed data from a national sample of 1,858 veterans hospitalized for an initial AMI in a Department of Veterans Affairs medical center during fiscal years 2003 and 2004 for whom data had been compiled on evidence-based treatment and who had also completed a Picker questionnaire assessing perceptions of PCC. Cox proportional hazards models were used to estimate the relationship between PCC and survival 1-year postdischarge, controlling for technical quality of care, patient clinical condition and history, admission process characteristics, and patient sociodemographic characteristics. We hypothesized that better PCC would be associated with a lower probability of death 1-year postdischarge, even after controlling for patient characteristics and the technical quality of care. RESULTS Better PCC was associated with a significantly but modestly lower hazard of death over the 1-year study period (hazard ratio 0.992, 95 percent confidence interval 0.986-0.999). CONCLUSIONS Providing PCC may result in important clinical benefits, in addition to meeting patient needs and expectations.
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Anastario MP, Rodriguez HP, Gallagher PM, Cleary PD, Shaller D, Rogers WH, Bogen K, Safran DG. A randomized trial comparing mail versus in-office distribution of the CAHPS Clinician and Group Survey. Health Serv Res 2010; 45:1345-59. [PMID: 20579126 DOI: 10.1111/j.1475-6773.2010.01129.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To assess the effect of survey distribution protocol (mail versus handout) on data quality and measurement of patient care experiences. DATA SOURCES/STUDY SETTING Multisite randomized trial of survey distribution protocols. Analytic sample included 2,477 patients of 15 clinicians at three practice sites in New York State. DATA COLLECTION/EXTRACTION METHODS Mail and handout distribution modes were alternated weekly at each site for 6 weeks. PRINCIPAL FINDINGS Handout protocols yielded an incomplete distribution rate (74 percent) and lower overall response rates (40 percent versus 58 percent) compared with mail. Handout distribution rates decreased over time and resulted in more favorable survey scores compared with mailed surveys. There were significant mode-physician interaction effects, indicating that data cannot simply be pooled and adjusted for mode. CONCLUSIONS In-office survey distribution has the potential to bias measurement and comparison of physicians and sites on patient care experiences. Incomplete distribution rates observed in-office, together with between-office differences in distribution rates and declining rates over time suggest staff may be burdened by the process and selective in their choice of patients. Further testing with a larger physician and site sample is important to definitively establish the potential role for in-office distribution in obtaining reliable, valid assessment of patient care experiences.
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McInnes K, Landon BE, Malitz FE, Wilson IB, Marsden PV, Fleishman JA, Gustafson DH, Cleary PD. Differences in patient and clinic characteristics at CARE Act funded versus non-CARE Act funded HIV clinics. AIDS Care 2010; 16:851-7. [PMID: 15385240 DOI: 10.1080/09540120412331290202] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The Ryan White CARE Act supports comprehensive care to persons with HIV infection. With an annual budget of over $1 billion, it is the largest federally funded programme for HIV care in the USA. We analysed data from the HIV Costs and Services Utilization Study, a nationally representative sample of HIV patients. Patient data were collected in 1996-97 and clinic data were collected in 1998-99. We examined whether CARE Act funded clinics differed from other HIV clinics in (1) the characteristics of their patients, and (2) their organization, staffing, and services. We found that patients at CARE Act clinics were younger, less educated, poorer, and more likely to be female, non-white, unemployed, uninsured, and have heterosexual contact as an HIV risk factor, compared to patients at other HIV clinics. CARE Act clinics tended to specialize in HIV care, had more infectious disease specialists, had fewer total patients, and provided more support services (e.g. mental health, nutrition, case management, child care). These results are consistent with findings of other studies that were limited by non-probability samples or restricted geographical areas.
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Mittler JN, Landon BE, Fisher ES, Cleary PD, Zaslavsky AM. Market variations in intensity of Medicare service use and beneficiary experiences with care. Health Serv Res 2010; 45:647-69. [PMID: 20403055 PMCID: PMC2875753 DOI: 10.1111/j.1475-6773.2010.01108.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE Examine associations between patient experiences with care and service use across markets. DATA SOURCES/STUDY SETTING Medicare fee-for-service (FFS) and managed care (Medicare Advantage [MA]) beneficiaries in 306 markets from the 2003 Consumer Assessments of Healthcare Providers and Systems (CAHPS) surveys. Resource use intensity is measured by the 2003 end-of-life expenditure index. STUDY DESIGN We estimated correlations and linear regressions of eight measures of case-mix-adjusted beneficiary experiences with intensity of service use across markets. DATA COLLECTION/EXTRACTION We merged CAHPS data with service use data, excluding beneficiaries under 65 years of age or receiving Medicaid. PRINCIPAL FINDINGS Overall, higher intensity use was associated (p<.05) with worse (seven measures) or no better care experiences (two measures). In higher-intensity markets, Medicare FFS and MA beneficiaries reported more problems getting care quickly and less helpful office staff. However, Medicare FFS beneficiaries in higher-intensity markets reported higher overall ratings of their personal physician and main specialist. Medicare MA beneficiaries in higher-intensity markets also reported worse quality of communication with physicians, ability to get needed care, and overall ratings of care. CONCLUSIONS Medicare beneficiaries in markets characterized by high service use did not report better experiences with care. This trend was strongest for those in managed care.
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Isaac T, Zaslavsky AM, Cleary PD, Landon BE. The relationship between patients' perception of care and measures of hospital quality and safety. Health Serv Res 2010; 45:1024-40. [PMID: 20528990 DOI: 10.1111/j.1475-6773.2010.01122.x] [Citation(s) in RCA: 202] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
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.
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Abstract
OBJECTIVE To examine the effect of depression treatment on medical and social outcomes for individuals with chronic pain and depression. People with chronic pain and depression have worse health outcomes than those with chronic pain alone. Little is known about the effectiveness of depression treatment for this population. METHODS Propensity score-weighted analyses, using both waves (1997-1998 and 2000-2001) of the National Survey of Alcohol, Drug, and Mental Health Problems, were used to examine the effect of a) any depression treatment and b) minimally adequate depression treatment on persistence of depression symptoms, depression severity, pain severity, overall health, mental health status, physical health status, social functioning, employment status, and number of workdays missed. Analyses were limited to those who met Composite International Diagnostic Interview Short-Form criteria for major depressive disorder, reported having at least one chronic pain condition, and completed both interviews (n = 553). RESULTS Receiving any depression treatment was associated with higher scores on the mental component summary of the Medical Outcomes Study Short Form-12, indicating better mental health (difference = 2.65 points, p = .002) and less interference of pain on work (odds ratio = 0.57, p = .02). Among those receiving treatment, minimal adequacy of treatment was not significantly associated with better outcomes. CONCLUSIONS Depression treatment improves mental health and reduces the effects of pain on work among those with chronic pain and depression. Understanding the effect of depression treatment on outcomes for this population is important for employers, healthcare providers treating this population, and policymakers working in this decade of pain control and research to improve care for chronic pain sufferers.
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Gallagher P, Ding L, Ham HP, Schor EL, Hays RD, Cleary PD. Development of a new patient-based measure of pediatric ambulatory care. Pediatrics 2009; 124:1348-54. [PMID: 19822587 PMCID: PMC5443558 DOI: 10.1542/peds.2009-0495] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE In 1995, the Agency for Health Care Policy and Research initiated the Consumer Assessments of Healthcare Providers and Systems (CAHPS) project to develop and evaluate survey protocols for collecting reliable and valid assessments of health care from consumers. CAHPS surveys are used throughout the United States for evaluating ambulatory and hospital care experiences, including a version for assessing pediatric ambulatory care; however, pediatric experts thought that the existing pediatric instruments did not adequately assess developmental and preventive care. The objective of this study was to develop and test an Ambulatory Pediatric CAHPS survey that focuses on clinicians and groups and includes measures of developmental and preventive care. METHODS To develop the survey, we conducted 2 focus groups and conducted 9 cognitive interviews. We conducted a telephone pretest with 20 parents and coded potential problems with the interview (behavioral coding). We conducted a dual-language field test of the instrument with 670 parents who reported about their children's ambulatory care. We used data from that survey to assess the reliability and validity of the measures. RESULTS Questions about developmental monitoring and preventive care were developed and tested. Two scales that were based on those new questions had good internal consistency (coefficient alpha) and inter-physician reliability. A consortium of CAHPS investigators and federal sponsors have approved the resulting instrument as a national measure of pediatric care. CONCLUSIONS A new instrument for assessing ambulatory pediatric care by clinicians and groups that includes questions about developmental and preventive care is now available for use.
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Shortridge EF, Marsden PV, Ayanian JZ, Cleary PD. Gender differences in the relationships of cardiovascular symptoms and somatosensory amplification to mortality. RESEARCH IN HUMAN DEVELOPMENT 2009; 6:219-234. [PMID: 21218196 PMCID: PMC3017363 DOI: 10.1080/15427600903281236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Symptoms of angina and dyspnea predict coronary artery disease and death less well in women than in men. Greater somatosensory amplification - a psychosocial propensity to report symptoms of physical discomfort - may lead women to report relatively high levels of angina and dyspnea for reasons unrelated to coronary disease, reducing their associations with mortality. We assessed this hypothesis in a nationally representative survey of U.S. adults. When stratified by gender, angina and dyspnea significantly predicted mortality among men, but predicted it less well among women. After adjusting for amplification, cardiovascular symptoms did not predict mortality among women, but amplification was positively associated with mortality among older women.
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Hirschhorn LR, Landers S, Mcinnes DK, Malitz F, Ding L, Joyce R, Cleary PD. Reported care quality in federal Ryan White HIV/AIDS Program supported networks of HIV/AIDS care. AIDS Care 2009; 21:799-807. [PMID: 19484615 DOI: 10.1080/09540120802511992] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Mack JW, Wolfe J, Cook EF, Grier HE, Cleary PD, Weeks JC. Peace of Mind and Sense of Purpose as Core Existential Issues Among Parents of Children With Cancer. ACTA ACUST UNITED AC 2009; 163:519-24. [DOI: 10.1001/archpediatrics.2009.57] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Simon SR, Soran CS, Kaushal R, Jenter CA, Volk LA, Burdick E, Cleary PD, Orav EJ, Poon EG, Bates DW. Physicians' use of key functions in electronic health records from 2005 to 2007: a statewide survey. J Am Med Inform Assoc 2009; 16:465-70. [PMID: 19390104 DOI: 10.1197/jamia.m3081] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE Electronic health records (EHRs) have potential to improve quality and safety, but many physicians do not use these systems to full capacity. The objective of this study was to determine whether this usage gap is narrowing over time. DESIGN Follow-up mail survey of 1,144 physicians in Massachusetts who completed a 2005 survey. MEASUREMENTS Adoption of EHRs and availability and use of 10 EHR functions. RESULTS The response rate was 79.4%. In 2007, 35% of practices had EHRs, up from 23% in 2005. Among practices with EHRs, there was little change between 2005 and 2007 in the availability of nine of ten EHR features; the notable exception was electronic prescribing, reported as available in 44.7% of practices with EHRs in 2005 and 70.8% in 2007. Use of EHR functions changed inconsequentially, with more than one out of five physicians not using each available function regularly in both 2005 and 2007. Only electronic prescribing increased substantially: in 2005, 19.9% of physicians with this function available used it most or all the time, compared with 42.6% in 2007 (p < 0.001). CONCLUSIONS By 2007, more than one third of practices in Massachusetts reported having EHRs; the availability and use of electronic prescribing within these systems has increased. In contrast, physicians reported little change in the availability and use of other EHR functions. System refinements, certification efforts, and health policies, including standards development, should address the gaps in both EHR adoption and the use of key functions.
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Teh CF, Karp JF, Kleinman A, Reynolds Iii CF, Weiner DK, Cleary PD. Older people's experiences of patient-centered treatment for chronic pain: a qualitative study. PAIN MEDICINE 2009; 10:521-30. [PMID: 19207235 DOI: 10.1111/j.1526-4637.2008.00556.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Older adults with chronic pain who seek treatment often are in a health care environment that emphasizes patient-directed care, a change from the patriarchal model of care to which many older adults are accustomed. OBJECTIVE To explore the experiences of older adults seeking treatment for chronic pain, with respect to patient-directed care and the patient-provider relationship. DESIGN In-depth interviews with 15 Caucasian older adults with chronic pain who had been evaluated at a university-based pain clinic. All interviews were audiotaped and the transcripts were analyzed using a grounded theory based approach. RESULTS Older adults with chronic pain vary in their willingness to be involved in their treatment decisions. Many frequently participate in decisions about their pain treatment by asking for or refusing specific treatments, demanding quality care, or operating outside of the patient-provider relationship to manage pain on their own. However, others prefer to let their provider make the decisions. In either case, having a mutually respectful patient-provider relationship is important to this population. Specifically, participants described the importance of "being heard" and "being understood" by providers. CONCLUSIONS As some providers switch from a patriarchal model of care toward a model of care that emphasizes patient activation and patient-centeredness, the development and cultivation of valued patient-provider relationships may change. While it is important to encourage patient involvement in treatment decisions, high-quality, patient-centered care for older adults with chronic pain should include efforts to strengthen the patient-provider relationship by attending to differences in patients' willingness to engage in patient-directed care and emphasizing shared decision-making.
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Martino SC, Elliott MN, Cleary PD, Kanouse DE, Brown JA, Spritzer KL, Heller A, Hays RD. Psychometric properties of an instrument to assess Medicare beneficiaries' prescription drug plan experiences. HEALTH CARE FINANCING REVIEW 2009; 30:41-53. [PMID: 19544934 PMCID: PMC4195071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Using data from 335,249 Medicare beneficiaries who responded to the 2007 Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey, along with data from 22 cognitive interviews, we investigated the reliability and validity of an instrument designed to assess beneficiaries' experiences with their prescription drug plans. Composite measures derived from the instrument had acceptable internal consistency and sufficient plan-level reliability to inform consumer choice, quality improvement, and payor oversight. These measures were positively associated with members' overall rating of the plan and their willingness to recommend the plan. Moreover, each was independently useful in predicting beneficiaries' global ratings of their plan. This instrument can be an important tool for helping beneficiaries to choose a plan that best meets their needs.
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Magid DJ, Sullivan AF, Cleary PD, Rao SR, Gordon JA, Kaushal R, Guadagnoli E, Camargo CA, Blumenthal D. The safety of emergency care systems: Results of a survey of clinicians in 65 US emergency departments. Ann Emerg Med 2008; 53:715-23.e1. [PMID: 19054592 DOI: 10.1016/j.annemergmed.2008.10.007] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2008] [Revised: 09/30/2008] [Accepted: 10/06/2008] [Indexed: 11/24/2022]
Abstract
STUDY OBJECTIVE Well-functioning systems are critical to safe patient care, but little is known about the status of such systems in US health care facilities, including high-risk settings such as the emergency department (ED). The purpose of this study is to assess the degree to which EDs are designed, managed, and supported in ways that ensure patient safety. METHODS This was a validated, psychometrically tested survey of clinicians working in 65 US EDs that assessed clinician perceptions about the EDs' physical environment, staffing, equipment and supplies, nursing, teamwork, safety culture, triage and monitoring, information coordination and consultation, and inpatient coordination. RESULTS Overall 3,562 eligible respondents completed the survey (response rate=66%). Survey respondents commonly reported problems in 4 systems critical to ED safety: physical environment, staffing, inpatient coordination, and information coordination and consultation. ED clinicians reported that there was insufficient space for the delivery of care most (25%) or some (37%) of the time. Respondents indicated that the number of patients exceeded ED capacity to provide safe care most (32%) or some of the time (50%). Only 41% of clinicians indicated that most of the time specialty consultation for critically ill patients arrived within 30 minutes of being contacted. Finally, half of respondents reported that ED patients requiring admission to the ICU were rarely transferred from the ED to the ICU within 1 hour. CONCLUSION Reports by ED clinicians suggest that substantial improvements in institutional design, management, and support for emergency care are necessary to maximize patient safety in US EDs.
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Teh CF, Reynolds CF, Cleary PD. Quality of depression care for people with coincident chronic medical conditions. Gen Hosp Psychiatry 2008; 30:528-35. [PMID: 19061679 PMCID: PMC2598839 DOI: 10.1016/j.genhosppsych.2008.07.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2007] [Revised: 07/08/2008] [Accepted: 07/09/2008] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Depression is common and associated with poor outcomes for people with chronic medical conditions (CMCs). The goals of this study were (1) to determine the effect of CMCs on the use and quality of depression care and (2) to understand whether the patient-provider relationship mediates the relationship between CMCs and depression care quality. METHOD With the use of data from the 1997-1998 National Survey of Alcohol, Drug, and Mental Health Problems (Healthcare for Communities), the relationships between CMCs, depression recognition, receipt of minimally adequate depression care and the patient-provider relationship were assessed with multivariate linear and logistic regression models for 1309 adults who met criteria for major depressive disorder. RESULTS Depressed patients with a CMC were more likely to have their depression recognized by a provider (OR=2.10; 95% CI=1.32-3.35) and to take antidepressant medications (32% vs. 19%, P=.02) than those without a CMC. However, having a CMC was not associated with receiving minimally adequate depression care or patient satisfaction. Depression recognition was associated with number of medical visits (OR=1.12; 95% CI=1.09-1.15), having a usual source of care (OR=3.57; 95% CI=2.26-5.63), and provider trust (OR=1.07; 95% CI=1.04-1.11). CONCLUSION Depressed people with a comorbid CMC are more likely to have their depression recognized than those without a CMC, though were no more likely to receive minimally adequate depression care. Aspects of the patient-provider relationship, including trust and continuity of care, may help to explain the increased rate of depression recognition among patients with severe CMCs.
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McInnes DK, Cleary PD, Stein KD, Ding L, Mehta CC, Ayanian JZ. Perceptions of cancer-related information among cancer survivors: a report from the American Cancer Society's Studies of Cancer Survivors. Cancer 2008; 113:1471-9. [PMID: 18666212 DOI: 10.1002/cncr.23713] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Sources of cancer-related information are rapidly increasing, but little is known about whether the health information available to cancer survivors meets their needs. METHODS The authors surveyed 778 Massachusetts cancer survivors 3, 6, or 11 years after their diagnosis for 6 common cancers. They analyzed their views about 5 types of cancer-related information, the quality of that information, barriers to getting it, their experiences with physicians providing cancer care, and the quality of their cancer care. RESULTS Among 462 (61%) respondents who reported needing cancer information, many gave unfavorable ratings (fair or poor) of the quality of cancer information regarding cancer support groups (38%), long-term side effects (36%), experiences of other cancer patients (26%), and cancer physicians (26%). About 20% of respondents reported sometimes experiencing barriers to obtaining cancer information, although fewer than 10% usually or always experienced barriers. For both men and women, worse physical and mental functioning was associated with greater need for information, worse ratings of information quality, and more barriers to obtaining information (all P<.01). Cancer survivors who were black or had lower incomes reported more problems obtaining needed information, and younger women had greater information needs than older women (all P <.01). CONCLUSIONS Opportunities exist to improve the quality, content and delivery of cancer-related information to survivors, especially for those who are racial/ethnic minorities, have low incomes, or are in worse physical or mental health. Providing information more effectively to cancer survivors may improve their care and health outcomes.
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Eselius LL, Cleary PD, Zaslavsky AM, Huskamp HA, Busch SH. Case-mix adjustment of consumer reports about managed behavioral health care and health plans. Health Serv Res 2008; 43:2014-32. [PMID: 18783456 DOI: 10.1111/j.1475-6773.2008.00894.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To develop a model for adjusting patients' reports of behavioral health care experiences on the Experience of Care and Health Outcomes (ECHO) survey to allow for fair comparisons across health plans. DATA SOURCE Survey responses from 4,068 individuals enrolled in 21 managed behavioral health plans who received behavioral health care within the previous year (response rate = 48 percent). STUDY DESIGN Potential case-mix adjustors were evaluated by combining information about their predictive power and the amount of within- and between-plan variability. Changes in plan scores and rankings due to case-mix adjustment were quantified. PRINCIPAL FINDINGS The final case-mix adjustment model included self-reported mental health status, self-reported general health status, alcohol/drug treatment, age, education, and race/ethnicity. The impact of adjustment on plan report scores was modest, but large enough to change some plan rankings. CONCLUSIONS Adjusting plan report scores on the ECHO survey for differences in patient characteristics had modest effects, but still may be important to maintain the credibility of patient reports as a quality metric. Differences between those with self-reported fair/poor health compared with those in excellent/very good health varied by plan, suggesting quality differences associated with health status and underscoring the importance of collecting quality information.
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Davies E, Shaller D, Edgman-Levitan S, Safran DG, Oftedahl G, Sakowski J, Cleary PD. Evaluating the use of a modified CAHPS survey to support improvements in patient-centred care: lessons from a quality improvement collaborative. Health Expect 2008; 11:160-76. [PMID: 18494960 PMCID: PMC5060434 DOI: 10.1111/j.1369-7625.2007.00483.x] [Citation(s) in RCA: 111] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES To evaluate the use of a modified Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey to support quality improvement in a collaborative focused on patient-centred care, assess subsequent changes in patient experiences, and identify factors that promoted or impeded data use. BACKGROUND Healthcare systems are increasingly using surveys to assess patients' experiences of care but little is established about how to use these data in quality improvement. DESIGN Process evaluation of a quality improvement collaborative. SETTING AND PARTICIPANTS The CAHPS team from Harvard Medical School and the Institute for Clinical Systems Improvement organized a learning collaborative including eight medical groups in Minnesota. INTERVENTION Samples of patients recently visiting each group completed a modified CAHPS survey before, after and continuously over a 12-month project. Teams were encouraged to set goals for improvement using baseline data and supported as they made interventions with bi-monthly collaborative meetings, an online tool reporting the monthly data, a resource manual called The CAHPS Improvement Guide, and conference calls. MAIN OUTCOME MEASURES Changes in patient experiences. Interviews with team leaders assessed the usefulness of the collaborative resources, lessons and barriers to using data. RESULTS Seven teams set goals and six made interventions. Small improvements in patient experience were observed in some groups, but in others changes were mixed and not consistently related to the team actions. Two successful groups appeared to have strong quality improvement structures and had focussed on relatively simple interventions. Team leaders reported that frequent survey reports were a powerful stimulus to improvement, but that they needed more time and support to engage staff and clinicians in changing their behaviour. CONCLUSIONS Small measurable improvements in patient experience may be achieved over short projects. Sustaining more substantial change is likely to require organizational strategies, engaged leadership, cultural change, regular measurement and performance feedback and experience of interpreting and using survey data.
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Ohl ME, Landon BE, Cleary PD, LeMaster J. Medical clinic characteristics and access to behavioral health services for persons with HIV. Psychiatr Serv 2008; 59:400-7. [PMID: 18378839 DOI: 10.1176/ps.2008.59.4.400] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Many persons with HIV do not receive needed behavioral health services. This study examined the impact of medical clinic characteristics on access to mental health and substance abuse care for persons with HIV. METHODS This was a longitudinal survey of patients and clinic directors participating in the HIV Cost and Services Utilization Study, a national probability sample of persons in care for HIV between 1996 and 1998 (N=2,031). Primary outcomes were receipt of outpatient mental health specialist care, outpatient substance abuse care, and abstinence from substance use in the past 30 days. RESULTS After adjustment for patient characteristics, the likelihood of care by a mental health specialist was higher for patients in HIV specialty clinics (odds ratio [OR]=2.1, 95% confidence interval [CI]=1.2-3.5) and clinics with a combination of on-site case management and affiliated mental health care (OR=2.3, CI 1.3-4.4, for off-site affiliated care; OR=2.1, CI=1.2-3.7, for on-site care). Outpatient substance abuse care also was more likely for patients in clinics with on-site case management and affiliated substance abuse care (OR=4.3, CI=1.5-12.2, for off-site affiliated care; OR=3.2, CI=1.3-8.0, for on-site care). In a subgroup of persons reporting active substance use, care in clinics with on-site case management predicted 30-day abstinence from substances at follow-up (OR=1.7, CI=1.1-2.5). CONCLUSIONS The organizational structure of medical clinics can have an important effect on use of mental health and substance abuse specialist care.
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Rodriguez HP, Marsden PV, Landon BE, Wilson IB, Cleary PD. The effect of care team composition on the quality of HIV care. Med Care Res Rev 2008; 65:88-113. [PMID: 18184871 DOI: 10.1177/1077558707310258] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Compared to single-clinician care, care provided by multiple clinicians might result in higher-quality care, especially if some of them have condition-specific expertise and complementary knowledge, skills, and roles. Individual physician continuity, which has been shown to be associated with care quality, necessarily decreases when care is provided by multiple clinicians. This study uses data from the HIV Cost and Services Utilization Study to assess the effect of care team composition on the quality of HIV care. In adjusted analyses, care teams composed of three or more clinicians were associated with more consistent prescribing of pneumocystis carinii pneumonia prophylaxis when medically indicated ( p < .01). Patients with multiple physicians generally reported worse care coordination, however, and had more inappropriate use of emergency services. These findings indicate both advantages and disadvantages to having multiple clinicians. More effort should be devoted to facilitating coordination when multiple clinicians provide care.
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Mack JW, Wolfe J, Cook EF, Grier HE, Cleary PD, Weeks JC. Hope and prognostic disclosure. J Clin Oncol 2007; 25:5636-42. [PMID: 18065734 DOI: 10.1200/jco.2007.12.6110] [Citation(s) in RCA: 241] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Physicians sometimes selectively convey prognostic information to support patients' hopes. However, the relationship between prognostic disclosure and hope is not known. PATIENTS AND METHODS We surveyed 194 parents of children with cancer (overall response rate, 70%) in their first year of treatment at the Dana-Farber Cancer Institute and Children's Hospital (Boston, MA), and we surveyed the children's physicians. We evaluated relationships between parental recall of prognostic disclosure by the physician and possible outcomes, including hope, trust, and emotional distress. Our main outcome was assessed by asking parents how often the way the child's oncologist communicated with them about the children's cancers made them feel hopeful. RESULTS Nearly half of parents reported that physician communication always made them feel hopeful. Parents who reported receiving a greater number of elements of prognostic disclosure were more likely to report communication-related hope (odds ratio [OR], 1.77 per element of disclosure; P = .001), even when the likelihood of a cure was low (OR, 5.98 per element of disclosure with likelihood of a cure < 25%; P = .03). In a multivariable model, parents were more likely to report that physician communication always made them feel hopeful when they also reported receipt of more elements of prognostic disclosure (OR, 1.60; P = .03) and high-quality communication (OR, 6.58; P < .0001). Communication-related hope was inversely associated with the child's likelihood of cure (OR, 0.65; P = .005). CONCLUSION Although physicians sometimes limit prognostic information to preserve hope, we found no evidence that prognostic disclosure makes parents less hopeful. Instead, disclosure of prognosis by the physician can support hope, even when the prognosis is poor.
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Campbell EG, Regan S, Gruen RL, Ferris TG, Rao SR, Cleary PD, Blumenthal D. Professionalism in medicine: results of a national survey of physicians. Ann Intern Med 2007; 147:795-802. [PMID: 18056665 DOI: 10.7326/0003-4819-147-11-200712040-00012] [Citation(s) in RCA: 161] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The prospect of improving care through increasing professionalism has been gaining momentum among physician organizations. Although there have been efforts to define and promote professionalism, few data are available on physician attitudes toward and conformance with professional norms. OBJECTIVE To ascertain the extent to which practicing physicians agree with and act consistently with norms of professionalism. DESIGN National survey using a stratified random sample. SETTING Medical care in the United States. PARTICIPANTS 3504 practicing physicians in internal medicine, family practice, pediatrics, surgery, anesthesiology, and cardiology. MEASUREMENTS Attitudes and behaviors were assessed by using indicators for each domain of professionalism developed by the American College of Physicians and the American Board of Internal Medicine. Of the eligible sampled physicians, 1662 responded, yielding a 58% weighted response rate (adjusting for noneligible physicians). RESULTS Ninety percent or more of the respondents agreed with specific statements about principles of fair distribution of finite resources, improving access to and quality of care, managing conflicts of interest, and professional self-regulation. Twenty-four percent disagreed that periodic recertification was desirable. Physician behavior did not always reflect the standards they endorsed. For example, although 96% of respondents agreed that physicians should report impaired or incompetent colleagues to relevant authorities, 45% of respondents who encountered such colleagues had not reported them. LIMITATIONS Our measures of behavior did not capture all activities that may reflect on the norms in question. Furthermore, behaviors were self-reported, and the results may not be generalizable to physicians in specialties not included in the study. CONCLUSION Physicians agreed with standards of professional behavior promulgated by professional societies. Reported behavior, however, did not always conform to those norms.
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Sullivan AF, Camargo CA, Cleary PD, Gordon JA, Guadagnoli E, Kaushal R, Magid DJ, Rao SR, Blumenthal D. The National Emergency Department Safety Study: study rationale and design. Acad Emerg Med 2007; 14:1182-9. [PMID: 18045895 DOI: 10.1197/j.aem.2007.07.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The significance of medical errors is widely appreciated. Given the frequency and significance of errors in medicine, it is important to learn how to reduce their frequency; however, the identification of factors that increase the likelihood of errors poses a considerable challenge. The National Emergency Department Safety Study (NEDSS) sought to characterize organizational- and clinician-associated factors related to the likelihood of errors occurring in emergency departments (EDs). NEDSS was a large multicenter study coordinated by the Emergency Medicine Network (EMNet; www.emnet-usa.org). It was designed to determine if reports by ED personnel about safety processes are significantly correlated with the actual occurrence of errors in EDs. If so, staff reports can be used to accurately identify processes for safety improvements. Staff perceptions were assessed with a survey, while errors were assessed through chart review of three conditions: acute myocardial infarction, acute asthma, and reductions of dislocations under procedural sedation. NEDSS also examined the characteristics of EDs associated with the occurrence of errors. NEDSS is the first comprehensive national study of the frequency and types of medical errors in EDs. This article describes the methods used to develop and implement the study.
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Wilson IB, Landon BE, Marsden PV, Hirschhorn LR, McInnes K, Ding L, Cleary PD. Correlations among measures of quality in HIV care in the United States: cross sectional study. BMJ 2007; 335:1085. [PMID: 17967826 PMCID: PMC2094195 DOI: 10.1136/bmj.39364.520278.55] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To determine whether a selected set of indicators can represent a single overall quality construct. DESIGN Cross sectional study of data abstracted during an evaluation of an initiative to improve quality of care for people with HIV. SETTING 69 sites in 30 states. DATA SOURCES Medical records of 9020 patients. MAIN OUTCOME MEASURES Adjusted performance rates at site level for eight measures of quality of care specific to HIV and a site level summary performance score (the number of measures for which the site was in the top quarter of the distribution). RESULTS Of 28 site level correlations between measures, two were greater than 0.40, two were between 0.30 and 0.39, four were between 0.20 and 0.29, and the 20 remaining were all less than 0.20. One site was in the top quarter for seven measures, but no sites were in the top quarter for six or eight of the measures. Across the eight quality measures, sites were in the top quarter no more often than predicted by a chance (binomial) distribution. CONCLUSIONS The quality suggested by one measured indicator cannot necessarily be generalised to unmeasured indicators, even if this might be expected for clinical or other reasons.
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