Quality monitoring of physicians: linking patients' experiences of care to clinical quality and outcomes

Why health care process performance measures can have different relationships to outcomes for patients and hospitals: understanding the ecological fallacy

Relationships between health care process performance measures (PPMs) and outcomes can differ in magnitude and even direction for patients versus higher level units (e.g., health care facilities). Such discrepancies can arise because facility-level relationships ignore PPM-outcome relationships for patients within facilities, may have different confounders than patient-level PPM-outcome relationships, and may reflect facility effect modification of patient PPM-outcome relationships. If a patient-level PPM is related to better patient outcomes, that care process should be encouraged. However, the finding in a multilevel analysis that the proportion of patients receiving PPM care across facilities nevertheless is linked to poor hospital outcomes would suggest that interventions targeting the health care facility also are needed.

Quality and coordination of care for patients with multiple conditions: results from an international survey of patient experience

Previous studies using clinical performance measures suggest that quality of care for patients with multiple chronic conditions is not worse than that for others. This article presents patient-reported experiences of health care among 8,973 of chronically ill adults from eight countries, using telephone survey data. We designed a ''morbidity score'' combining the number of conditions and reported health status. Respondents with high morbidity scores reported less favorable experience with coordination of care compared to those with low morbidity scores. They also reported lower ratings of overall quality of care. There were no differences in reported experience with the individual physicians. Comparing type of comorbidity, chronic lung, and mental health problems were associated with lower ratings than hypertension, heart disease, diabetes, arthritis, and cancer. The implications and limitations of this study are discussed in the context of health care reform. Pay-for-performance programs need to account for chronic conditions to avoid penalizing physicians who care for larger shares of such patients.

Assessment of quality of cancer-related follow-up care from the cancer survivor's perspective

PURPOSE

We assessed cancer survivors' perceptions of the quality of their follow-up care.

METHODS

We surveyed a population-based cohort of leukemia, bladder, and colorectal cancer survivors diagnosed 2 to 5 years previously in northern California (N = 623; participation rate, 69.2%; overall response rate, 49.2%). Data were collected between April 2003 and November 2004. Ten scales assessed survivors' perceptions of different aspects of care in the last 12 months, and an eleventh scale measured their overall ratings of care.

RESULTS

On nine of the 11 scales, mean scores ranged from 88 to 97 on a 0 to 100 response format, indicating very positive experiences. The two areas where quality perceptions were lower were discussions about health promotion and the physician's knowledge of the whole patient. In adjusted analyses, those without private health insurance (P = .02) and Hispanic and Asian survivors compared with whites (P < .001) reported worse timeliness of care. Survivors who had multiple comorbidities reported better scores on timeliness of care (P < .01) and physicians' knowledge (P = .05) than survivors without any comorbidity. Length of the patient-physician relationship was the variable most consistently found to be significantly associated with survivors' quality assessments. Physicians' information exchange had the strongest relationship with overall ratings of care, followed by physicians' affective behavior, their knowledge of the survivor, and survivors' perceptions of coordination of care (P < .001 for all).

CONCLUSION

Delivery of quality follow-up care to cancer survivors may require efforts to improve patient-centered communication and coordination. Special emphasis may need to be placed on health promotion discussions and adoption of a whole-person orientation.

Reliability of medical group and physician performance measurement in the primary care setting

BACKGROUND

Performance reporting is increasingly focused on physician practice sites and individual physicians.

OBJECTIVE

To assess the reliability of performance measurement for practice sites and individual physicians.

RESEARCH DESIGN

We used data collected across multiple payers as part of a statewide measurement collaborative to evaluate the observed measure reliability and sample size requirements to achieve acceptable reliability of 4 Health Care Effectiveness Data and Information Set measures of preventive care and 10 Health Care Effectiveness Data and Information Set measures of chronic care across 334 practice sites. We conducted a parallel set of physician-level analyses using data across 118 primary physicians practicing within a large multispecialty group.

MEASURES

Observed reliabilities and estimated sample size requirements to achieve reliability ≥0.70.

RESULTS

At the practice site level, sample sizes required to achieve a reliability of 0.70 were less than 200 patients per site for all 4 measures of preventive care, all 4 process measures of diabetes care, and 2 outcomes measures of diabetes care. Larger samples were required to achieve reliability for cholesterol screening in the presence of cardiovascular disease (n = 249) and use of appropriate asthma medications (n = 351). At the physician level, less than 200 patients were required for all 4 measures of preventive care, but for many chronic care measures the samples of patients available per physician were not sufficient to achieve a reliability of 0.70.

CONCLUSION

In a multipayer collaborative, sample sizes were adequate to reliably assess clinical process and outcome measures at the practice site level. For individual physicians, sample sizes proved adequate to reliably measure preventive care, but may not be feasible for chronic care assessment.

Language barriers, physician-patient language concordance, and glycemic control among insured Latinos with diabetes: the Diabetes Study of Northern California (DISTANCE)

BACKGROUND

A significant proportion of US Latinos with diabetes have limited English proficiency (LEP). Whether language barriers in health care contribute to poor glycemic control is unknown.

OBJECTIVE

To assess the association between limited English proficiency (LEP) and glycemic control and whether this association is modified by having a language-concordant physician.

DESIGN

Cross-sectional, observational study using data from the 2005-2006 Diabetes Study of Northern California (DISTANCE). Patients received care in a managed care setting with interpreter services and self-reported their English language ability and the Spanish language ability of their physician. Outcome was poor glycemic control (glycosylated hemoglobin A1c > 9%).

KEY RESULTS

The unadjusted percentage of patients with poor glycemic control was similar among Latino patients with LEP (n = 510) and Latino English-speakers (n = 2,683), and higher in both groups than in whites (n = 3,545) (21% vs 18% vs. 10%, p < 0.005). This relationship differed significantly by patient-provider language concordance (p < 0.01 for interaction). LEP patients with language-discordant physicians (n = 115) were more likely than LEP patients with language-concordant physicians (n = 137) to have poor glycemic control (27.8% vs 16.1% p = 0.02). After controlling for potential demographic and clinical confounders, LEP Latinos with language-concordant physicians had similar odds of poor glycemic control as Latino English speakers (OR 0.89; CI 0.53-1.49), whereas LEP Latinos with language-discordant physicians had greater odds of poor control than Latino English speakers (OR 1.76; CI 1.04-2.97). Among LEP Latinos, having a language discordant physician was associated with significantly poorer glycemic control (OR 1.98; CI 1.03-3.80).

CONCLUSIONS

Language barriers contribute to health disparities among Latinos with diabetes. Limited English proficiency is an independent predictor for poor glycemic control among insured US Latinos with diabetes, an association not observed when care is provided by language-concordant physicians. Future research should determine if strategies to increase language-concordant care improve glycemic control among US Latinos with LEP.

Defining and measuring the patient-centered medical home

The patient-centered medical home (PCMH) is four things: 1) the fundamental tenets of primary care: first contact access, comprehensiveness, integration/coordination, and relationships involving sustained partnership; 2) new ways of organizing practice; 3) development of practices' internal capabilities, and 4) related health care system and reimbursement changes. All of these are focused on improving the health of whole people, families, communities and populations, and on increasing the value of healthcare. The value of the fundamental tenets of primary care is well established. This value includes higher health care quality, better whole-person and population health, lower cost and reduced inequalities compared to healthcare systems not based on primary care. The needed practice organizational and health care system change aspects of the PCMH are still evolving in highly related ways. The PCMH will continue to evolve as evidence comes in from hundreds of demonstrations and experiments ongoing around the country, and as the local and larger healthcare systems change. Measuring the PCMH involves the following: Giving primacy to the core tenets of primary care. Assessing practice and system changes that are hypothesized to provide added value Assessing development of practices' core processes and adaptive reserve. Assessing integration with more functional healthcare system and community resources. Evaluating the potential for unintended negative consequences from valuing the more easily measured instrumental features of the PCMH over the fundamental relationship and whole system aspects. Recognizing that since a fundamental benefit of primary care is its adaptability to diverse people, populations and systems, functional PCMHs will look different in different settings. Efforts to transform practice to patient-centered medical homes must recognize, assess and value the fundamental features of primary care that provide personalized, equitable health care and foster individual and population health.

Use of preventive care services among Latino subgroups

BACKGROUND

Previous studies demonstrate a clear gap in access and receipt of preventive care between Latinos and non-Latino whites. Most of this work, however, pools Latinos together when they compare different racial and ethnic groups. There is currently no information about the consistency of preventive care utilization across major Latino subgroups.

PURPOSE

This study tests for three bundles of preventive care services to analyze the main determinants of adult preventive care receipt among the largest subgroups of U.S. Latinos and non-Latino whites. It also examines the contribution of observed and unobserved factors in explaining differences in the provision of preventive care services.

METHODS

The Medical Expenditure Panel Survey and the National Health Interview Survey from 2000 to 2006 were merged in 2009. The sample consisted of 28,781 Latinos and 78,979 non-Latino whites. This study compared disparities in the receipt of adult preventive care services and separately examined differences in the provision of the most cost-effective preventive services. Multivariate models adjust for confounding factors. The decomposition technique was used to parse out differences into observed and unobserved components.

RESULTS

Latinos of Mexican and Central/South American origin are much less likely to receive guideline-recommended preventive care services than non-Latino whites and other Latino subgroups. Larger disparities were observed for the most cost-effective preventive care services: smoking-cessation advice, colorectal cancer screening, and influenza vaccination. Observed factors accounted for a larger share of disparities across measures (33%-100%), with lack of health insurance coverage and not having a usual source of care as the largest and most consistent factors explaining disparities.

CONCLUSIONS

Health insurance coverage expansion and more integration of Latinos into primary care practices can substantially reduce disparities in the receipt of preventive care services. Preventive care initiatives should prioritize the availability of cost-effective services among Latinos of Mexican and Central/South American heritage.

Statewide evaluation of measuring physician delivery of self-management support in chronic disease care

BACKGROUND

Self-management support is an important component of improving chronic care delivery.

OBJECTIVE

To validate a new measure of self-management support and to characterize performance, including comparisons across chronic conditions.

DESIGN, SETTING, PARTICIPANTS

We incorporated a new question module for self-management support within an existing annual statewide patient survey process in 2007.

MEASUREMENTS

The survey identified 80,597 patients with a chronic illness on whom the new measure could be evaluated and compared with patients' experiences on four existing measures (quality of clinical interactions, coordination of care, organizational access, and office staff). We calculated Spearman correlation coefficients for self-management support scores for individual chronic conditions within each medical group. We fit multivariable logistic regression models to identify predictors of more favorable performance on self-management support.

RESULTS

Composite scores of patient care experiences, including quality of clinical interactions (89.2), coordination of care (77.6), organizational access (76.3), and office staff (85.8) were higher than for the self-management support composite score (69.9). Self-management support scores were highest for patients with cancer (73.0) and lowest for patients with hypertension (67.5). The minimum sample size required for medical groups to provide a reliable estimate of self-management support was 199. There was no consistent correlation between self-management support scores for individual chronic conditions within medical groups. Increased involvement of additional members of the healthcare team was associated with higher self-management support scores across all chronic conditions.

CONCLUSION

Measurement of self-management support is feasible and can identify gaps in care not currently included in standard measures of patient care experiences.

Characteristics of hospitals demonstrating superior performance in patient experience and clinical process measures of care

Prior research suggests hospital quality of care is multidimensional. In this study, the authors jointly examine patient experience of care and clinical care measures from 2,583 hospitals based on inpatients discharged in 2006 and 2007. The authors use multinomial logistic regression to identify key characteristics of hospitals that perform in the top quartile on both, either, and neither dimension of quality. Top performers on both quality measures tend to be small (<100 beds), large (>200 beds) and rural, located in the New England or West North Central Census divisions, and nonprofit. Top performers in patient experience only are most often small and rural, located in the East South Central division, and government owned. Top performers in clinical care only are most often medium to large and urban, located in the West North Central division, and non-government owned. These findings provide an overview of how these dimensions of quality vary across hospitals.

Rapidity and modality of imaging for acute low back pain in elderly patients

BACKGROUND

Most quality metrics focus on underuse of services, leaving unclear what factors are associated with potential overuse.

METHODS

We analyzed Medicare claims from 2000-2002 and 2004-2006 for 35 039 fee-for-service Medicare beneficiaries with acute low back pain (LBP) who were treated by 1 of 4567 primary care physicians responding to the 2000-2001 or 2004-2005 Community Tracking Study Physician Surveys. We modified a measure of inappropriate imaging developed by the National Committee on Quality Assurance. We characterized the rapidity (<28 days, 29-180 days, none within 180 days) and modality of imaging (computed tomography or magnetic resonance imaging [CT/MRI], only radiograph, or no imaging). We used ordered logit models to assess relationships between imaging and patient demographics and physician/practice characteristics including exposure to financial incentives based on patient satisfaction, clinical quality, cost profiling, or productivity.

RESULTS

Of 35 039 beneficiaries with LBP, 28.8% underwent imaging within 28 days and an additional 4.6% between 28 and 180 days. Among patients who received imaging, 88.2% received radiography, while 11.8% received CT/MRI as their initial study. White patients received higher levels of imaging than black patients or those of other races. Medicaid patients received less rapid or advanced imaging than other patients. Patients had higher levels of imaging if their primary care physician worked in large practices. Compared with no incentives, clinical quality-based incentives were associated with less advanced imaging (10.5% vs 1.4% for within 28 days; P < .001), whereas incentive combinations including satisfaction measures were associated with more rapid and advanced imaging. Results persisted in multivariate analyses and when the outcome was redefined as the number of imaging studies performed.

CONCLUSIONS

Rapidity and modality of imaging for LBP is associated with patient and physician characteristics but the directionality of associations with desirable care processes is opposite of associations for measures targeting underuse. Metrics that encompass overuse may suggest new areas of focus for quality improvement.

Experiencia del paciente: una nueva forma de entender la atención al paciente oncológico

En el presente trabajo se analiza el concepto de Experiencia del Paciente (PX) así como las variables que contribuyen a la mejora del mismo. El objetivo es explicar su utilidad clínica en el ámbito de la salud, en concreto sobre la población oncológica, además de demostrar el papel activo que la Psicooncología puede tener en la implementación de esta estrategia, en relación directa con la humanización de la asistencia sanitaria. Para ello, se ha revisado la literatura con evidencia empírica existente hasta el momento y que sitúa la experiencia del paciente como un pilar indispensable a la hora de mejorar la calidad de la atención clínica, junto con la efectividad del tratamiento y la seguridad del paciente. Estos elementos presentan una interacción positiva entre ellos y están moderados por la comunicación médico-paciente, lo que evidencia la necesidad de desarrollar habilidades de comunicación por los profesionales en la práctica clínica, la coordinación de la atención sanitaria, el acceso a los servicios y la percepción del paciente respecto a la atención recibida. La experiencia del paciente resulta clínicamente relevante e influyente en la recuperación del estado de salud del paciente, así como constituye un cambio en la cultura sanitaria, cuyo protagonista es el paciente y en torno a él debe girar dicho cambio de manera multidisciplinar e integral por parte de los profesionales sanitarios implicados en su cuidado. Se concluye con una nueva línea de actuación del psicooncólogo en la experiencia del paciente para promover un servicio oncológico de calidad.