Association of Clinician Denial of Patient Requests With Patient Satisfaction

Factors That Influence Clinician Prescribing of Corticosteroids for Acute Idiopathic and Multiple Sclerosis-Associated Optic Neuritis: A Qualitative Study

BACKGROUND

Treatment with corticosteroids is common for patients with idiopathic and multiple sclerosis-associated optic neuritis (I/MS-ON). Yet, the Optic Neuritis Treatment Trial and meta-analyses confirm that few patients benefit and that visual benefit is of questionable clinical significance, short-lived, and comes with potential harms. The purpose of this study was to uncover the breadth of factors that underlie clinicians' treatment decisions and determine how these factors may influence corticosteroid use for I/MS-ON.

METHODS

We performed semistructured, one-on-one, qualitative interviews with neurologists, neuro-ophthalmologists, and emergency department clinicians at 15 academic and private practices across the United States. The interview guide used the Theoretical Domain Framework and a vignette to explore numerous factors that might influence decision making for definite I/MS-ON. We analyzed transcripts using inductive thematic analysis to generate themes.

RESULTS

A total of 22 clinicians were interviewed before thematic saturation was reached: 8 neuro-ophthalmologists, 8 neurologists, and 6 emergency medicine (EM) clinicians (2 physician assistants, 4 physicians). All neuro-ophthalmologists and nearly all neurologists (7 of 8) were aware of risks/benefits of corticosteroid treatment for I/MS-ON. However, neuro-ophthalmologists varied in their corticosteroid treatment recommendation (n = 3 recommended treatment, n = 2 recommended observation, n = 3 recommended shared decision making), whereas all neurologists recommended corticosteroids, indicating that knowledge of corticosteroid risk/benefit alone does not drive decision making. EM clinicians were not aware of risk/benefits of corticosteroid treatment for I/MS-ON and relied on the treatment recommendations of neurologists. Clinicians recommending corticosteroids held personal beliefs that corticosteroids benefit those with worse vision loss, relieve pain, allow earlier return to work, or have easily mitigated side effects. They also perceived that prescribing steroid was the principal method of "doing something," which fit a key provider role. Clinicians who did not recommend corticosteroids or were neutral perceived the risks as nontrivial, considered discussing treatment trade-offs as "doing something" and incorporated patient preferences.

CONCLUSIONS

Knowledge of risk/benefits of corticosteroids are necessary but not sufficient for evidence-based I/MS-ON practice. Variation in how clinicians treat patients with acute I/MS-ON is influenced largely by psychosocial factors, such as beliefs about corticosteroid risk/benefit trade-offs and the role of the clinician to provide treatment. Interventions to support evidence-based decision making for I/MS-ON treatment will need to provide risk/benefit information to support clinicians with varying levels of expertise, incorporate patient preference, and normalize the option to observe.

Denial of prescription pain medication among people who use drugs in Vancouver, Canada

BACKGROUND

People who use drugs experience pain at two to three times the rate of the general population and yet continue to face substantial barriers to accessing appropriate and adequate treatment for pain. In light of the overdose crisis and revised opioid prescribing guidelines, we sought to identify factors associated with being denied pain medication and longitudinally investigate denial rates among people who use drugs.

METHODS

We used multivariable generalized estimating equations analyses to investigate factors associated with being denied pain medication among people who use drugs reporting pain in three prospective cohort studies in Vancouver, Canada. Analyses were restricted to study periods in which participants requested a prescription for pain from a healthcare provider. Descriptive statistics detail denial rates and actions taken by participants after being denied.

RESULTS

Among 1168 participants who requested a prescription for pain between December 2012 and March 2020, the median age was 47 years and 63.0% were male. Among 4,179 six-month observation periods, 907 (21.7%) included a report of being denied requested pain medication. In multivariable analyses, age was negatively associated with prescription denial (adjusted odds ratio [AOR] = 0.98, 95% confidence interval [CI]:0.97-0.99), while self-managing pain (AOR = 2.48, 95%CI:2.04-3.00), experiencing a non-fatal overdose (AOR = 1.51, 95%CI:1.22-1.88), engagement in opioid agonist therapy (AOR = 1.32, 95%CI:1.09-1.61), and daily use of heroin or other unregulated opioids (AOR = 1.32, 95%CI:1.05-1.66) were positively associated with being denied. Common actions taken (n = 895) after denial were accessing the unregulated drug supply (53.5%), doing nothing (30.6%), and going to a different doctor/emergency room (6.1%). The period following the introduction of new prescribing guidelines was not associated with a change in denial rates.

CONCLUSIONS

A substantial proportion of people who use drugs continue to be denied prescriptions for pain, with such denial associated with important substance use-related harms, including non-fatal overdose. Guidelines specific to the pharmaceutical management of pain among people who use drugs are needed.

Patient initiated radiology requests: proof of wellness through images

BACKGROUND

Traditionally, general practitioners (GPs) have initiated the need for, and ordered, radiological tests. With the emergence of consumer-centred care, patients have started to request scans from doctors on their own initiative. Consumeristic health care has shifted the patient-doctor dyadic relationship, with GPs trending towards accommodating patients' requests.

METHODS

A mixed method analysis was conducted using a survey instrument with open ended questions and concurrent interviews to explore participants' responses from their requests for radiological studies from GPs. Themes emerging from both qualitative and quantitative methodologies were mapped onto the Andersen Newman Model (ANM).

RESULTS

Data were analysed for 'predisposing,' 'need' and 'enabling' elements of the ANM model and were correspondingly mapped to patient's requests for radiological referrals according to the elements of the ANM. Participants expressed anxiety about their health, were confident in the types of radiological scans they desired and typically indicated the need for evidence of good health. Their desire for such requested scans was often enabled through prior exposure to health information and the experience of specific symptoms. Requests came with the expectation of validation, and if these requests were denied, participants indicated that they would seek another doctor who would oblige.

CONCLUSIONS

In our modest study of Australian patients, participants were well informed about their health. Exposure to information seems to create a sense of anxiousness prior to visiting the doctor. Individuals sought visual proof of wellness through imaging, and doctors in return often accommodated patient requests for radiological studies to appease patients' needs and to maintain workflow.

Prescription Opioids and Patient-Reported Outcomes and Satisfaction After Carpal Tunnel Release Surgery

BACKGROUND

Amount of opioid use correlates poorly with procedure-related pain; however, prescription limits raise concerns about inadequate pain control and impacts on patient-reported quality indicators. There remain no consistent guidelines for postoperative pain management after carpal tunnel release (CTR). We sought to understand how postoperative opioid use impacts patient-reported outcomes after CTR.

METHODS

This is a pragmatic cohort study using prospectively collected data from all adult patients undergoing uncomplicated primary CTR over 17 months at our center. Patients were categorized as having received or not received a postoperative opioid prescription, and then as remaining on a prescription opioid at 2-week follow-up or not. Questionnaires were completed before surgery and at 2-week follow-up. We collected brief Michigan Hand questionnaire (bMHQ) score, Patient-Reported Outcomes Measurement Information System Global Health score, satisfaction, and pain score.

RESULTS

Of 505 included patients, 405 received a postoperative prescription and 67 continued use at 2-weeks. These 67 patients reported lower bMHQ, lower satisfaction, and higher postoperative pain compared to those that discontinued. Multivariable regressions showed that receiving postoperative prescriptions did not significantly influence outcomes or satisfaction. However, remaining on the prescription at 2 weeks was associated with significantly lower bMHQ scores, particularly in patients reporting less pain.

CONCLUSIONS

Patients remaining on a prescription after CTR reported worse outcomes compared to those who discontinued. Unexpectedly, the widest bMHQ score gap was seen across patients reporting lowest pain scores. Further research into this high-risk subgroup is needed to guide policy around using pain and patient-reported outcomes as quality measures.Level of Evidence: Level III.

Using Sentiment Analysis to Understand What Patients Are Saying About Hand Surgeons Online

BACKGROUND

Physician review websites have influence on a patient's selection of a provider. Written reviews are subjective and difficult to quantitatively analyze. Sentiment analysis of writing can quantitatively assess surgeon reviews to provide actionable feedback for surgeons to improve practice. The objective of this study is to quantitatively analyze large subset of written reviews of hand surgeons using sentiment analysis and report unbiased trends in words used to describe the reviewed surgeons and biases associated with surgeon demographic factors.

METHODS

Online written and star-rating reviews of hand surgeons were obtained from healthgrades.com and webmd.com. A sentiment analysis package was used to calculate compound scores of all reviews. Mann-Whitney U tests were performed to determine the relationship between demographic variables and average sentiment score of written reviews. Positive and negative word and word-pair frequency analysis was also performed.

RESULTS

A total of 786 hand surgeons' reviews were analyzed. Analysis showed a significant relationship between the sentiment scores and overall average star-rated reviews (r2 = 0.604, P ≤ .01). There was no significant difference in review sentiment by provider sex; however, surgeons aged 50 years and younger had more positive reviews than older (P < .01). The most frequently used bigrams used to describe top-rated surgeons were associated with good bedside manner and efficient pain management, whereas those with the worst reviews are often characterized as rude and unable to relieve pain.

CONCLUSIONS

This study provides insight into both demographic and behavioral factors contributing to positive reviews and reinforces the importance of pain expectation management.

A sentiment analysis on online psychiatrist reviews to identify clinical attributes of psychiatrists that shape the therapeutic alliance

Background

While online reviews from physician rating websites are increasingly utilized by healthcare providers to better understand patient needs, it remains difficult to objectively identify areas for improvement in providing psychiatric care.

Objectives

To quantitatively characterize the sentiment of online written reviews of psychiatrists to determine clinical attributes that can be strengthened to improve psychiatrists' therapeutic alliance with their patients.

Materials and methods

Sentiment scores of 6,400 written reviews of 400 US-based psychiatrists on a US-based online physician rating website were obtained through a natural-language-processing-based sentiment analysis. Relationships among sentiment scores, average star ratings, and demographics were examined. Linguistic analyses determined words and bigrams that were highly associated with reviews with the most positive and negative sentiment.

Findings

Sentiment scores were significantly correlated with average star ratings of the psychiatrists (R = 0.737, p < 0.001). Psychiatrists who were younger (< 56 years old) and/or practiced in the Northeast had significantly higher average star ratings than those older and/or practicing in the Southwest. Frequency analysis showed that positive reviews most frequently contained "time" (N = 1,138) and "caring" (N = 784) while negative reviews most frequently contained "medication" (N = 495) and "time" (N = 379). Logistic regression analysis revealed that reviews were more likely to be considered positive when they included "great listener" (OR = 16.89) and "comfortable" (OR = 10.72) and more likely to be negative when they included "meds" (OR = 0.55) and "side effect" (OR = 0.59).

Conclusion

Psychiatrists who are younger and located in the Northeast receive more positive reviews; there may be potential for demographic bias among patient reviewers. Patients positively rate psychiatrists who make them feel heard and comfortable but negatively rate encounters centered around medications and their side effects. Our study lends quantitative evidence to support the importance of thorough and empathetic communication of psychiatrists in building a strong therapeutic alliance.

Deprescribing in Real Time: Hospitalized Septuagenarian With Polypharmacy

Polypharmacy is a common and potentially preventable contributor to recurring emergency room visits, hospitalization, morbidity, and mortality. Its consequences are magnified in older adults due to the age-related decrease in functional and physiologic reserves, increased blood-brain barrier permeability, and altered drug metabolism, among others. In this article, we describe a case of polypharmacy in a septuagenarian to highlight the deprescribing approach implemented by the inpatient care team and to offer patient-centered insights to clinicians (primary care providers and hospitalists) when making deprescribing decisions. The overarching aim of this article is to build on existing literature regarding polypharmacy, prescribing cascades, and deprescribing in the context of what matters most and aligns with patient health priorities. This article highlights the importance of good geriatric medication reconciliation stewardship to avoid harm.

Multisite analysis of patient experience scores and risk of hospital admission: a retrospective cohort study

BACKGROUND

Routinely collected patient experience scores may inform risk of patient outcomes. The objective of the study was to evaluate the risk of hospital admission within 30-days following third-party receipt of the patient experience survey and guide interventions.

METHODS

In this retrospective cohort study, we analyzed Hospital Consumer Assessment of Healthcare Providers and Systems surveys, January 2016-July 2019, from an institution's 20 hospitals in four U.S. states. Surveys were routinely sent to patients using census sampling. We analyzed surveys received ≤60 days following discharge from patients living ≤60 miles of any of the institution's hospitals. The exposures were 19 survey items. The outcome was hospital admission within 30 days after third-party receipt of the survey. We evaluated the association of favorable (top-box) vs unfavorable (non-top-box) score for survey items with risk of 30-day hospital admission in models including patient and hospitalization characteristics and reported adjusted odds ratios (aOR [95% confidence interval]).

RESULTS

Among 40,162 respondents (mean age ± standard deviation: 68.1 ± 14.0 years), 49.8% were women and 4.3% had 30-day hospital admission. Patients with 30-day hospital admission, compared to those not admitted, were more likely to be discharged from a medical service line (62.9% vs 42.3%; P < 0.001) and have a higher Elixhauser index. Favorable vs unfavorable score for hospital rating was associated with lower odds of 30-day hospital admission in the overall cohort (0.88 [0.77-0.99]; P = 0.04), medical service line (0.81 [0.70-0.94]; P = 0.007), and upper tertile of Elixhauser index (0.79 [0.67-0.92]; P = 0.003). Favorable score for recommend hospital was associated with lower odds of 30-day hospital admission in the medical service line (0.83 [0.71-0.97]; P = 0.02) but for others (e.g. cleanliness of hospital environment) showed no association.

CONCLUSION

In routinely collected patient experience scores, favorable hospital rating was associated with lower odds of 30-day hospital admission and may inform risk stratification and interventions. Evidence-based survey items linked to patient outcomes may also inform future surveys.

Primary care physician responses to requests by older adults for unnecessary drugs: a qualitative study

Background

Unnecessary drug use can cause avoidable harm to older adults and is particularly common in primary care, but how primary care physicians (PCPs) respond to older adult requests for unnecessary drugs has not been well studied. This study is to explore PCPs’ responses to requests for unnecessary drugs from older adults, and their influencing factors and potential solutions.

Methods

This qualitative study was conducted through semi-structured, in-depth interviews from January 4 to September 30, 2020 using a grounded theory methodology. A purposive sample of PCPs affiliated with community healthcare centers in Zhejiang Province and Guangdong Province, China were recruited. The face-to-face interviews were audio-recorded, transcribed verbatim, and independently coded by two investigators. Themes surrounding PCPs’ responses to requests for unnecessary drugs, their influencing factors and potential solutions were analysed using a constant comparative approach.

Results

Of the 23 participants involved in this study, 12 (52%) were women and the mean age was 35 years. PCPs frequently declined older adults’ requests for unnecessary drugs through dissuasion, and occasionally rebuffed patients or referred them to another practitioner. PCPs may fulfill requests due to physician acquiescence, patient pressure, or inadequate supervision and support. Participants recommended four potential solutions to improve the quality of prescribing, including developing professional communication skills, enhancing pharmacist-physician collaboration, improving electronic prescription systems, and strengthening prescription management.

Conclusions

PCPs typically deny requests by older adults for unnecessary drugs according to three main patterns, and guidance is necessary to reduce the potential for adverse consequences. Factors contributing to request fulfillment by PCPs require attention, and the potential solutions recommended by participants deserve consideration to improve the service quality of prescribing for older adults in primary care practices.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01857-x.

Physician Gender and Its Association With Patient Satisfaction and Visit Length: An Observational Study in Telemedicine

Introduction

Female physicians conduct longer visits than male physicians, with negative implications for their compensation. Yet patients often report higher satisfaction with female physicians. It is unknown whether satisfaction scores for female physicians are associated with their visit lengths. Our objective was to characterize the role of the physician and patient gender with respect to visit length and patient satisfaction.

Methods

We conducted an observational cohort study with patients and physicians of a nationwide telemedicine service between 2016 and 2018. Visit length was measured by the telemedicine system. Patients rated physicians on scales of one to five stars, with five considered “top box” satisfaction. We used logistic regression to estimate differences in patient satisfaction and linear regression to estimate differences in visit length by the physician and patient gender. We tested interactions between physician and patient gender and accounted for clustering by the physician.

Results

Among 102,664 visits with 405 physicians, the mean visit length was 5.8 minutes. Visits with male physicians were 1.11 minutes shorter than those with female physicians (95% CI:-1.58, -0.65). Controlling for visit length, male physicians were less likely than female physicians to receive top-box satisfaction scores (OR: 0.72; 95% CI: 0.61, 0.85). Visits between female physicians and male patients were the longest and visits between male physicians and female patients were the shortest. Female physicians had longer visits than male physicians but this did not explain their higher satisfaction scores.

Conclusions

To reduce inequity in compensation resulting from differences in visit length, female physicians could shorten their visits without negative consequences for their satisfaction ratings.

Patient requests for radiological services: An Australian study of patient agency and the impact of online health information

ISSUE ADDRESSED

The Internet has been instrumental in patients' knowledge about health and medicine through increasing consultation of online sources that advocate self-management. For example, those patients who request referrals from their doctors for tests and procedures in radiology. Such patient-initiated referral requests can devolutionise the traditional model of health care. This study aimed to understand individuals who sought online health information (OHI) and whether requests for radiological referrals were the result of OHI seeking.

METHODS

The individuals targeted were those who have had a radiological procedure in the past 5 years. Using an online survey tool, individuals completed a 20-min anonymous survey. Included in the survey was a validated digital health literacy measurement scale, eHEALS.

RESULTS

Those who scored higher on the eHEALS measure were likely to be under 55 years of age and were more inclined to request radiological referrals. Though they were not concerned with the credibility of sourced websites, most secured the desired outcome from their requests.

CONCLUSION

Overall, this study indicates that patients are consulting online sites for health information, and individuals with higher digital literacy scores are asking doctors for referrals for radiological tests and procedures. These findings confirm our anecdotal experience in radiology departments. So what?: In conducting this study, we hope to better inform radiology and other health practitioners of the way OHI is impacting clinical practice.

Antibiotic stewardship to reduce inappropriate antibiotic prescribing in integrated academic health-system urgent care clinics

Objective:

To develop and implement antibiotic stewardship activities in urgent care targeting non–antibiotic-appropriate acute respiratory tract infections (ARIs) that also reduces overall antibiotic prescribing and maintains patient satisfaction.

Patients and setting:

Patients and clinicians at the urgent care clinics of an integrated academic health system.

Intervention and methods:

The stewardship activities started in fiscal 2020 and included measure development, comparative feedback, and clinician and patient education. We measured antibiotic prescribing in fiscal years 2019, 2020, and 2021 for the stewardship targets, potential diagnosis-shifting visits, and overall. We also collected patient satisfaction data for ARI visits.

Results:

From FY19 to FY21, 576,609 patients made 1,358,816 visits to 17 urgent care clinics, including 105,781 visits for which stewardship measures were applied and 149,691 visits for which diagnosis shifting measures were applied. The antibiotic prescribing rate decreased for stewardship-measure visits from 34% in FY19 to 12% in FY21 (absolute change, −22%; 95% confidence interval [CI], −23% to −22%). The antibiotic prescribing rate decreased for diagnosis-shifting visits from 63% to 35% (−28%; 95% CI, −28% to −27%), and the antibiotic prescribing rate decreased overall from 30% to 10% (−20%; 95% CI, −20% to −20%). The patient satisfaction rate increased from 83% in FY19 to 89% in FY20 and FY21. There was no significant association between antibiotic prescribing rates of individual clinicians and ARI visit patient satisfaction.

Conclusions:

Although it was affected by the COVID-19 pandemic, an ambulatory antimicrobial stewardship program that focused on improving non–antibiotic-appropriate ARI prescribing was associated with decreased prescribing for (1) the stewardship target, (2) a diagnosis shifting measure, and (3) overall antibiotic prescribing. Patient satisfaction at ARI visits increased over time and was not associated with clinicians’ antibiotic prescribing rates.

Moral Distress and Moral Injury Among Attending Neurosurgeons: A National Survey

BACKGROUND

"Moral distress" describes the psychological strain a provider faces when unable to uphold professional values because of external constraints. Recurrent or intense moral distress risks moral injury, burnout, and physician attrition but has not been systematically studied among neurosurgeons.

OBJECTIVE

To develop a unique instrument to test moral distress among neurosurgeons, evaluate the frequency and intensity of scenarios that may elicit moral distress and injury, and determine their impact on neurosurgical burnout and turnover.

METHODS

An online survey investigating moral distress, burnout, and practice patterns was emailed to attending neurosurgeon members of the Congress of Neurological Surgeons. Moral distress was evaluated through a novel survey designed for neurosurgical practice.

RESULTS

A total of 173 neurosurgeons completed the survey. Half of neurosurgeons (47.7%) reported significant moral distress within the past year. The most common cause was managing critical patients lacking a clear treatment plan; the most intense distress was pressure from patient families to perform futile surgery. Multivariable analysis identified burnout and performing ≥2 futile surgeries per year as predictors of distress (P < .001). Moral distress led 9.8% of neurosurgeons to leave a position and 26.6% to contemplate leaving. The novel moral distress survey demonstrated excellent internal consistency (Cronbach alpha = 0.89).

CONCLUSION

We developed a reliable survey assessing neurosurgical moral distress. Nearly, half of neurosurgeons suffered moral distress within the past year, most intensely from external pressure to perform futile surgery. Moral distress correlated with burnout risk caused 10% of neurosurgeons to leave a position and a quarter to consider leaving.

Colleague appraisal of Australian general practitioners in training: an analysis of multisource feedback data

BACKGROUND

Multisource feedback is an evidence-based and validated tool used to provide clinicians, including those in training, feedback on their professional and interpersonal skills. Multisource feedback is mandatory for participants in the Royal Australian College of General Practitioners Practice Experience Program and for some Australian General Practice Training Registrars. Given the recency of the Practice Experience Program, there are currently no benchmarks available for comparison within the program and to other comparable cohorts including doctors in the Australian General Practice Training program. The aim of this study is to evaluate and compare colleague feedback within and across General Practice trainee cohorts.

METHODS

Colleague feedback, from multisource feedback of Practice Experience Program participants and Australian General Practice Training Registrars, collected between January 2018 and April 2020, was compared to identify similarities and differences. Analyses entailed descriptive statistics, between and within groups rater consistency and agreement measures, principal component analysis, t-tests, analysis of variance, and psychometric network analysis.

RESULTS

Colleague ratings of Practice Experience Program participants (overall average 88.58%) were lower than for Registrars (89.08%), although this difference was not significant. 'Communication with patients' was rated significantly lower for Practice Experience Program participants (2.13%) while this group was rated significantly better for their 'Ability to say no' (1.78%). Psychometric network analyses showed stronger linkages between items making up the behavioural component (compared to the items of the performance and self-management components, as found by principal component analysis) for Practice Experience Program participants as compared to Registrars. Practice Experience Program participants were stronger in clinical knowledge and skills as well as confidentiality, while Registrars were stronger in communicating with patients, managing their own stress, and in their management and leadership skills.

CONCLUSIONS

The multisource feedback scores of doctors undertaking the Practice Experience Program suggests that, while all mean values are 'very good' to 'excellent', there are areas for improvement. The linkages between skills suggests that Practice Experience Program doctors' skills are somewhat isolated and have yet to fully synthesise. We now have a better understanding of how different groups of General Practitioners in training compare with respect to professional and interpersonal skills. Based on the demonstrated differences, the Practice Experience Program might benefit from the addition of educational activities to target the less developed skills.

The Impact of Diagnostic Decisions on Patient Experience in the Pediatric Emergency Department

OBJECTIVE

Patient experience serves as both a subjective measure of value-based health care delivery and a metric to inform operational decision making. The objective of this study was to determine if specific diagnostic and therapeutic interventions affect patient experience scores for children seen in the emergency department.

METHODS

We performed a retrospective observational study in the emergency department of a large quaternary care children's hospital on patients who were discharged to home and later completed a National Research Corporation Health patient experience survey. We matched the survey results to electronic health record (EHR) data and were able to extract demographics, operational metrics, and order information for each patient. We performed multiple logistic regression analyses to determine the association of image acquisition, laboratory test ordering, medication administration, and discharge prescribing with likelihood to recommend the facility as our measure of patient experience.

RESULTS

Of the 4103 patients who met inclusion criteria for the study, 75% strongly recommended the facility. Longer wait times were associated with lower patient experience scores [odds ratio (OR) per waiting room hour increase, 0.72; 95% confidence interval (CI), 0.65-0.81]. Significant diagnostic factors associated with higher patient experience included magnetic resonance imaging ordering (OR, 2.38; 95% CI, 1.00-5.67), x-ray ordering (OR, 1.19; 95% CI, 1.00-1.42), and electrocardiogram ordering (OR, 1.62; 95% CI, 1.07-2.44). Of the treatment factors studied, only antibiotic prescribing at discharge was found to have a significant positive association with patient experience (OR, 1.32; 95% CI, 1.08-1.63).

CONCLUSION

The positive association between more intensive diagnostic workups and patient experience could have implications on the utility of patient experience scores to evaluate pediatric care teams. Consideration should be taken to interpret patient experience scores in the context of compliance with approaches in evidence-based medicine.

Does de-implementation of low-value care impact the patient-clinician relationship? A mixed methods study

Background

The importance of reducing low-value care (LVC) is increasingly recognized, but the impact of de-implementation on the patient-clinician relationship is not well understood. This mixed-methods study explored the impact of LVC de-implementation on the patient-clinician relationship.

Methods

Adult primary care patients from a large Virginia health system volunteered to participate in a survey (n = 232) or interview (n = 24). Participants completed the Patient-Doctor Relationship Questionnaire (PDRQ-9) after reading a vignette about a clinician declining to provide a low-value service: antibiotics for acute sinusitis (LVC-antibiotics); screening EKG (LVC-EKG); screening vitamin D test (LVC-vitamin D); or an alternate vignette about a high-value service, and imagining that their own primary care clinician had acted in the same manner. A different sample of participants was asked to imagine that their own primary care clinician did not order LVC-antibiotics or LVC-EKG and then respond to semi-structured interview questions. Outcomes data included participant demographics, PDRQ-9 scores (higher score = greater relationship integrity), and content analysis of transcribed interviews. Differences in PDRQ-9 scores were analyzed using one-way ANOVA. Data were integrated for analysis and interpretation.

Results

Although participants generally agreed with the vignette narrative (not providing LVC), many demonstrated difficulty comprehending the broad concept of LVC and potential harms. The topic triggered memories of negative experiences with healthcare (typically poor-quality care, not necessarily LVC). The most common recommendation for reducing LVC was for patients to take greater responsibility for their own health. Most participants believed that their relationship with their clinician would not be negatively impacted by denial of LVC because they trusted their clinician’s guidance. Participants emphasized that trusted clinicians are those who listen to them, spend time with them, and offer understandable advice. Some felt that not providing LVC would actually increase their trust in their clinician. Similar PDRQ-9 scores were observed for LVC-antibiotics (38.9), LVC-EKG (37.5), and the alternate vignette (36.4), but LVC-vitamin D was associated with a significantly lower score (31.2) (p < 0.05).

Conclusions

In this vignette-based study, we observed minimal impact of LVC de-implementation on the patient-clinician relationship, although service-specific differences surfaced. Further situation-based research is needed to confirm study findings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07345-9.

Views of healthcare consumer representatives on defensive practice: 'We are your biggest advocate and supporter… not the enemy'

Background

The patient–clinician interaction is a site at which defensive practice could occur, when clinicians provide tests, procedures and treatments mainly to reduce perceived legal risks, rather than to advance patient care. Defensive practice is a driver of low‐value care and exposes patients to the risks of unnecessary interventions. To date, patient perspectives on defensive practice and its impacts on them are largely missing from the literature. This exploratory study conducted in Australia aimed to examine the views and experiences of healthcare consumer representatives in this under‐examined area.

Methods

Semi‐structured interviews were conducted with healthcare consumer representatives involved in healthcare consumer advocacy organisations in Australia. Data were transcribed and analysed thematically.

Results

Nine healthcare consumer representatives participated. Most had over 20 years of involvement and advocacy in healthcare, including personal experiences as a patient or carer and/or formal service roles on committees or complaint bodies for healthcare organisations. Participants uniformly viewed defensive practice as having a negative impact on the clinician–patient relationship. Themes identified the importance of fostering patient–clinician partnership, effective communication and informed decision‐making. The themes support a shift from the concept of defensive practice to preventive practice in partnership, which focuses on the shared interests of patients and clinicians in achieving safe and high‐value care.

Conclusion

This Australian study offers healthcare consumers' perspectives on the impacts of defensive practice on patients. The findings highlight the features of clinician–patient partnership that will help to improve communication and decision‐making, and prevent the defensive provision of low‐value care.

Patient or Public Contribution

Healthcare consumer representatives were involved as participants in this study.

Prescription opioids are commonly unused after ambulatory head and neck surgeries: Opioids prescription presence and size has no effect on patient satisfaction with pain control

PURPOSE

To explore the opioid prescribing practices after common ambulatory head and neck surgeries in a large academic institution; and to examine the association between opioid prescription and the patient's satisfaction with pain control.

METHODS

This retrospective cohort study conducted in a tertiary academic medical center. Phone interviews of patients who underwent ambulatory head and neck surgeries one month after their procedures were conducted. The interview included, among several questions, the amount of opioid prescribed and consumed, the use of non-opioid pain medications, and the patient's satisfaction with pain control. Logistic regression models were used to investigate the significant factors affecting the patient's satisfaction with pain control.

RESULTS

Most patients were prescribed opioids at discharge (84%). Of those, 17% did not use their prescriptions. The median of leftover opioid was 76.50 morphine milligram equivalents (MMEs) with IQR (45-130.95). Patient satisfaction with pain control is not associated with opioid prescription at discharge (OR 0.195 [95% CL, 0.036-1.036], p = 0.059) or the amount of the prescribed opioid (OR 1.001 [95% CL, 0.997-1.004], p = 0.717) after controlling for other patient and procedural factors.

CONCLUSION

A significant portion of ambulatory head and neck surgery patients were discharged with opioid prescriptions they may not use. Patient satisfaction with pain control is not associated with the presence or the amount of opioid prescribed.

Behavioral Economics and Ambulatory Antibiotic Stewardship: A Narrative Review

PURPOSE

Behavioral economics recognizes that contextual, psychological, social, and emotional factors powerfully influence decision-making. Behavioral economics has the potential to provide a better understanding of, and, through subtle environmental changes, or "nudges," improve persistent quality-of-care challenges, like ambulatory antibiotic overprescribing. Despite decades of admonitions and educational initiatives, in the United States, up to 50% of ambulatory antibiotic prescriptions remain inappropriate or not associated with a diagnosis.

METHODS

We conducted a Medline search and performed a narrative review that examined the use of behavioral economics to understand the rationale for, and improvement of, ambulatory antibiotic prescribing.

FINDINGS

Clinicians prescribe antibiotics inappropriately because of perceived patient demand, to maintain patient satisfaction, diagnostic uncertainty, or time pressure, among other reasons. Behavioral economics-informed approaches offer additional improvements in antibiotic prescribing beyond clinician education and communication training. Precommitment, in which clinicians publicize their intent to prescribe antibiotics "only when they are absolutely necessary," leverages clinicians' self-conception and a desire to act in a manner consistent with public statements. Precommitment was associated with a 20% absolute reduction in the inappropriate antibiotic prescribing for acute respiratory infections. Justification alerts, in which clinicians must provide a brief written rationale for prescribing antibiotics, leverages social accountability, redefines the status quo as an active choice, and helps clinicians to shift from fast to slow, careful thinking. With justification alerts, the absolute rate of inappropriate antibiotic prescribing decreased from 23% to 5%. Peer comparison, in which clinicians receive feedback comparing their performance to their top-performing peers, provides evidence of improved performance and leverages peoples' desire to conform to social norms. Peer comparison decreased absolute inappropriate antibiotic prescribing rates from 20% to 4%, a decrease that persisted for 12 months after the end of the intervention. Also, a one-time peer-comparison letter from a high-profile messenger to primary care practices with high rates of prescribing antibiotics, there was a 6-month, 3% decrease inantibiotic prescribing. Future directions in applying behavioral economics to the inappropriate antibiotic prescribing include paying careful attention to design details; improving intervention effectiveness and durability; making harms salient; participants' involvement in the development of interventions (the "Ikea effect"); factoring in patient satisfaction; and patient-facing nudges about antibiotic use and care-seeking. In addition, the COVID pandemic could aid in ambulatory antibiotic prescribing improvements due to changing cognitive frames around respiratory symptom evaluation and antibiotic prescribing.

IMPLICATIONS

To improve ambulatory antibiotic prescribing, several behavioral economics-informed approaches-especially precommitment, justification alerts, and peer comparison-have reduced the rates of inappropriate prescribing of antibiotics to low levels.

Hidden consequences of patient satisfaction: A survey of pediatric surgeons

BACKGROUND

Patient satisfaction surveys are increasingly utilized to assess patients' perceptions of their health care. Recently, these scores have been linked to payment, potentially incentivizing practices to meet certain metrics. We hypothesize that increasing pressures to receive positive reviews have led physicians to alter the delivery of their care to accommodate patient expectations over standards of care.

METHODS

An 11-question REDCap™ survey was developed and emailed anonymously to all sixty-two surgeons across all surgical subspecialties at our children's hospital. Multiple-choice and open-ended questions were included. A modified Delphi method was used to acquire general consensus.

RESULTS

Survey response rate for analysis was 41/62 (66%). 23 (56%) stated that they have changed their clinical practice patterns due to concerns regarding patient dissatisfaction. Examples of such changes included: requesting imaging tests or laboratory studies, performing invasive procedures, referring for second opinions, and prescribing medications. Only 2% felt that these interventions led to any significant change in outcome of a patient's condition. Several respondents expressed concerns that factors outside their control (scheduling, parking, wait times) contributed to patient dissatisfaction and affected providers' ratings, while others expressed concerns about inherent biases driving survey participants.

CONCLUSIONS

As a result of patient satisfaction surveys, a significant number of surgeons reported altering their clinical practice beyond standard care to meet patient expectations. Some of these modifications included performing unnecessary interventions. Reliance on these surveys may be at odds with reducing health care costs and avoiding physician burnout. These and other unintended consequences of patient satisfaction surveys warrant further study before they are widely accepted as appropriate quality metrics.

LEVEL OF EVIDENCE

Level IV, questionnaire.

Development and validation of a patient-reported outcome measure for patients with chronic respiratory failure: The CRF-PROM scale

Background

Various health‐related quality‐of‐life (HRQOL) tools are used to evaluate patients with chronic respiratory failure (CRF), but there is a relative lack of tools available for the evaluation of social support and treatment in these patients. The present study focused on the development of a systematic patient‐reported outcome measure (PROM) tool for use in patients with CRF.

Methods

The CRF‐PROM scale conceptual framework and item bank were generated after reviewing the corresponding literature and HRQOL scales, interviewing CRF patients and focus groups. After creation of the initial scale, the items in the scale were selected through two item selection theories, and the final scale was created. The reliability, validity and feasibility of the final scale were assessed.

Results

The CRF‐PROM scale includes four domains (i.e., physiological domain, psychological domain, social domain and therapeutic domain) and 10 dimensions. After the item selection process, the final scale included 50 items. Cronbach's α coefficients, which were all above 0.7, indicated the reliability of the scale. The results of structural validity met the relevant standards of confirmatory factor analysis. The response rates of the preinvestigation and the formal investigation were 93.3% and 97.6%, respectively.

Conclusions

The CRF‐PROM scale developed in the present study is effective and reliable. It could be used widely in the posthospital management of patients, in CRF studies and in clinical trials of new medical products and interventions.

Patient or Public Contribution

Participants from eight different hospitals and communities participated in the development or validation phase of the CRF‐PROM scale.

Association of Low-Value Care Exposure With Health Care Experience Ratings Among Patient Panels

IMPORTANCE

Patient reviews of health care experiences are increasingly used for public reporting and alternative payment models. Critics have argued that this incentivizes physicians to provide more care, including low-value care, undermining efforts to reduce wasteful practices.

OBJECTIVE

To assess associations between rates of low-value service provision to a primary care professional (PCP) patient panel and patients' ratings of their health care experiences.

DESIGN, SETTING, AND PARTICIPANTS

This quality improvement study used Medicare fee-for-service claims from January 1, 2007, to December 31, 2014, for a random 20% sample of beneficiaries to identify beneficiaries for whom each of 8 low-value services could be ordered but would be considered unnecessary. The study also used health care experience reports from independently sampled beneficiaries who responded to the 2010-2015 Consumer Assessment of Healthcare Providers and Systems (CAHPS) Medicare fee-for-service survey. Statistical analysis was performed from January 1, 2019, to December 9, 2020.

MAIN OUTCOMES AND MEASURES

The main outcomes were health care experience ratings from Medicare beneficiaries who responded to the CAHPS survey from 2 domains, namely "Your Health Care in the Last 6 Months" (overall health care, office wait time, timely access to nonurgent care, and timely access to urgent care) and "Your Personal Doctor" (overall personal physician and a composite score for interactions with personal physician). Beneficiaries in both samples were attributed to the PCP with whom they had the most spending. For each PCP, a composite score of low-value service exposure was constructed using the 20% sample; this score represented the adjusted relative propensity of the PCP patient panel to receive low-value care. The association between low-value service exposure and health care experience ratings reported by the CAHPS respondents in the PCP patient panel was estimated using regression analysis.

RESULTS

The final sample had 100 743 PCPs, with a mean of approximately 258 patients per PCP. Only 1 notable association was found; more low-value care exposure was associated with more frequent reports of having to wait more than 15 minutes after the scheduled time of an appointment (a mean of 0.448 points lower CAHPS score on a 10-point scale for PCP patient panels who received the most low-value care vs the least low-value care). Although some other associations were statistically significant, their magnitudes were substantially smaller than those typically considered meaningful in other CAHPS literature and were inconsistent in direction across levels of low-value service exposure.

CONCLUSIONS AND RELEVANCE

This quality improvement study found that more low-value care exposure for a PCP patient panel was not associated with more favorable patient ratings of their health care experiences.

Patient satisfaction scores in adults with psoriasis

Patient satisfaction is associated with improved patient retention and clinical outcomes. Previous studies investigated the impact of disease severity and mental health conditions on patient satisfaction among psoriasis patients. However, associations with healthcare utilization were not studied. Moreover, socio-demographic differences in patient satisfaction among adults with psoriasis are not well-delineated. The objectives of this study were to determine the impact of psoriasis disease on patient satisfaction among US adults and examine associations of satisfaction with healthcare utilization and socio-demographic characteristics. We analyzed the 2000-2016 Medical Expenditure Panel Surveys, representative surveys of US population health status and perceptions. Patient satisfaction was evaluated by the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. Adults with psoriasis were compared to a control group of all adults without current diagnosis of psoriasis. Multivariable linear and logistic regression models were constructed to examine associations of satisfaction among those with psoriasis. Overall, data were analyzed from 1419 adults with psoriasis who completed the entire CAHPS survey. Adults with psoriasis had similar patient satisfaction compared to healthy controls (LS-means: 86.0 vs 85.6, adjusted β [CI 95]: 0.38 [- 0.45, 1.22]). Based on sensitivity analysis, adults with vs without psoriasis had similar rates of high satisfaction in each CAHPS domain: time spent, clear explanations, listening, and respect demonstrated. Among those with psoriasis, high satisfaction was associated with ≥ 1 office visit (adjusted OR [CI 95]: 2.50 [1.63, 3.84]), and consultation with a specialist was associated with increased satisfaction (adjusted β [CI 95]: 1.36 [0.95, 1.77]). Overall satisfaction score among psoriasis adults was associated with increased age and black race, and inversely associated with lower income, public or no insurance, other race or multiracial, and multimorbidity. In conclusion, psoriasis diagnosis was not associated with difference in satisfaction. However, lower-income adults with public or no insurance and multimorbidity had lower satisfaction. Moreover, specialist consultation was associated with higher satisfaction. Multidisciplinary and increased healthcare access are needed to optimize patient satisfaction.

Evidence and politics of patient experience in Ontario: The perspective of healthcare providers and administrators

BACKGROUND

Patient experience has a direct impact on patients' engagement in healthcare, their commitment to treatment plans, and their relationship with their healthcare providers, all of which can impact their health outcomes. The complexity of the healthcare system, the increasing health needs of the population, and the priority and knowledge differences among healthcare stakeholders impact how they conceptualize and seek to achieve the ideal patient experience and the weights that they give to different elements of this experience.

AIMS

This study sought to understand the perspectives of healthcare providers and administrators in Ontario regarding the factors affecting the patient experience.

MATERIALS & METHODS

Qualitative data were collected between April 2018 and May 2019. Twenty-one semi-structured interviews were conducted. Interviewees included physicians, nurses, optometrists, dietitians, quality managers, and policymakers. Thematic analysis was used to analyse the data, utilizing and extending a previously developed patient experience framework.

RESULTS

Several themes emerged in the data, and they represent two perspectives on patient experience: the biomedical perspective, which prioritizes health outcomes and gives high weights to healthcare experience factors that can be controlled by healthcare providers, while ignoring other factors, and the sociopolitical perspective, which recognizes the impacts of healthcare politics and the social context of health on patient experience in Ontario.

CONCLUSION

The study is timely in light of the current changes in the Ontario healthcare system and the healthcare reform started by the new government, as it sheds light on the possible negative impact of healthcare policy and politics on patient experience.

Inter-specialty variation of the Press Ganey Outpatient Medical Practice Survey

ABSTRACT

Measuring patient satisfaction scores and interpreting factors that impact their variation is of importance as scores influence various aspects of health care administration. Our objective was to evaluate if Press Ganey scores differ between medical specialties.New patient visits between January 2014 and December 2016 at a single tertiary academic center were included in this study. Press Ganey scores were compared between specialties using a multivariable logistic mixed effects model. Secondary outcomes included a comparison between surgical versus non-surgical specialties, and pediatric versus adult specialties. Due to the survey's high ceiling effect, satisfaction was defined as a perfect total score.Forty four thousand four hundred ninety six patients met inclusion criteria. Compared to internal medicine, plastic surgery, general surgery, dermatology, and family medicine were more likely to achieve a perfect overall score, as, with odds ratios of 1.46 (P = .02), 1.29 (P = .002), 1.22 (P = .004), and 1.16 (P = .02) respectively. Orthopaedics, pediatric medicine, pediatric neurology, neurology, and pain management were less likely to achieve satisfaction with odds ratios of 0.85 (P = .047), 0.71 (P < .001), 0.63 (P = .005), 0.57 (P < .001), and 0.51 (P = .006), respectively. Compared to pediatric specialties, adult specialties were more likely to achieve satisfaction (OR 1.73; P < .001). There were no significant differences between surgical versus non-surgical specialties.Press Ganey scores systematically differ between specialties within the studied institution. These differences should be considered by healthcare systems that use patient satisfaction data to modify provider reimbursement.

Atopic Dermatitis Is Associated With Lower Patient Satisfaction in US Adults

BACKGROUND

Atopic dermatitis (AD) is complex with unmet needs and management challenges in clinical practice. Little is known about patient satisfaction among adults with AD.

OBJECTIVE

The aim of the study was to determine patterns and predictors of patient satisfaction among adults with AD.

METHODS

Data were analyzed from the 2000-2015 Medical Expenditure Panel Survey. Patient satisfaction was assessed by the Consumer Assessment of Healthcare Providers and Systems survey.

RESULTS

Atopic dermatitis (linear regression; adjusted β [95% confidence interval {95% CI}] = -0.75 [-1.25 to -0.25]) was associated with lower patient satisfaction compared with no AD. Adults with 1 or more office-based visits had increased odds of high satisfaction (>75th percentile; logistic regression; adjusted odds ratio [95% CI] = 1.81 [1.30-2.52]). Adults who saw an outpatient dermatologist or allergist had lower satisfaction (adjusted β [95% CI] = -0.65 [-1.27 to -0.03]). Patient satisfaction among adults with AD was associated with older age (adjusted β [95% CI] = 40-59 years, 1.85 [0.90-2.80]; ≥60 years, 6.13 [5.18-7.09]) and inversely associated with lower income (-1.82 [-2.68 to -0.96]) or middle income (-0.85 [-1.59 to -0.12]), race/ethnicity (Hispanic, -1.40 [-2.42 to -0.38]; other/multiracial, -2.34 [-3.53 to -1.15]), public (-4.50 [-6.43 to -2.58]) or no insurance (-4.53 [-6.47 to -2.59]), and multimorbidity (-0.48 [-0.61 to -0.35]).

CONCLUSIONS

Adults with AD in the United States had decreased patient satisfaction, particularly those with lower income, fewer outpatient visits, and multimorbidity. There are substantial unmet needs in patient satisfaction for AD.

Narrative Review: The Process of Expanding the Manual of Antimicrobial Stewardship by the Government of Japan

The Ministry of Health, Labour and Welfare has published the Manual of Antimicrobial Stewardship (1st edition) in June 2017 to improve the prescribing practice of antimicrobials for immunocompetent adult and pediatric (both school-aged and older children) patients. Due to the increasing demand for further promoting outpatient antimicrobial stewardship, we conducted a literature and national guideline review to identify the area of need. The results of our review revealed a high antimicrobial prescription rate in the Japanese pediatric population. Furthermore, although the Japanese clinical guidelines/guidance covered the fields of almost all infectious diseases, no system exists to estimate the incidence and treatment patterns of important infectious diseases such as asymptomatic bacteriuria, skin and soft tissue infections, and dental practices in Japan. Therefore, addressing the issues of both establishing surveillance systems and the implementation of guidelines/guidance can be the next step to promote further outpatient antimicrobial stewardship.

Patient Satisfaction in Academic Pain Management Centers: How Do We Compare?

PURPOSE OF REVIEW

The aim of the study was to investigate patient satisfaction amongst academic pain management centers and associated factors.

RECENT FINDINGS

Approximately 25% of pain management centers perform better than other practices on Press Ganey surveys. The majority of respondents (96%) indicated that pain management practices were uniquely positioned to receive poorer scores on patient satisfaction surveys. The majority of respondents (20/26), who reported a reason, indicated that limiting opioid prescribing led to poor patient satisfaction scores. Eighty-three percent of respondents indicated that they received pressure from administrators to improve patient satisfaction scores. The opioid epidemic in the USA must be addressed in order to diminish the senseless loss of life that is occurring in staggering numbers. The quality of care physicians provide has increasingly been assessed via patient satisfaction surveys. The results of these surveys often are utilized to provide financial incentives to physicians to obtain higher satisfaction scores. In the field of pain management, physicians may experience pressure to prescribe opioids in order to obtain higher patient satisfaction scores.

Nurse Decision-making for Suspected Urinary Tract Infections in Nursing Homes: Potential Targets to Reduce Antibiotic Overuse

OBJECTIVES

To determine what information is most important to registered nurses' (RNs) decisions to call clinicians about suspected urinary tract infections (UTIs) in nursing home residents.

DESIGN

Web-based discrete choice experiment with 19 clinical scenarios.

SETTING AND PARTICIPANTS

Online survey with a convenience sample of RNs (N = 881) recruited from a health care research panel.

METHODS

Clinical scenarios used information from 10 categories of resident characteristics: UTI risk, resident type, functional status, mental status, lower urinary tract status, body temperature, physical examination, urinalysis, antibiotic request, and goals of care. Participants were randomized into 2 deliberation conditions (self-paced, n = 437 and forced deliberation, n = 444). The degree to which evidence- and non-evidence-based information was important to decision-making was estimated using unconditional multinomial logistic regression.

RESULTS

For all nurses (22.8%) and the self-paced group (24.1%), lower urinary tract status had the highest importance scores for the decision to call a clinician about a suspected UTI. For the forced-deliberation group, body temperature was most important (23.7%), and lower urinary tract status was less important (21%, P = .001). The information associated with the highest odds of an RN calling about a suspected UTI was painful or difficult urination [odds ratio (OR) 4.85, 95% confidence interval (CI) 4.16-5.65], obvious blood in urine (OR 4.66, 95% CI 3.99-5.44), and temperature at 101.5° (OR 3.80, 95% CI 3.28-4.42). For the self-paced group, painful or difficult urination (OR 5.65, 95% CI 4.53-7.04) had the highest odds, whereas obvious blood in urine (OR 4.39, 95% CI 3.53-5.47) had highest odds for the forced-deliberation group.

CONCLUSIONS AND IMPLICATIONS

This study highlighted the importance of specific resident characteristics in nurse decision-making about suspected UTIs. Future antimicrobial stewardship efforts should aim to not only improve the previously studied overprescribing practices of clinicians, but to improve nurses' assessment of signs and symptoms of potential infections and how they weigh resident information.

Corticosteroid Use for Acute Respiratory Tract Infections in Direct-to-Consumer Telemedicine

BACKGROUND

Systemic corticosteroids are not indicated for acute respiratory tract infections yet are nonetheless prescribed in outpatient care. Acute respiratory tract infections are the most common diagnosis in direct-to-consumer telemedicine. The objective of this study was to characterize use of corticosteroids for acute respiratory tract infections in this setting and to assess the association between corticosteroid receipt and patient satisfaction.

METHODS

Encounters with acute respiratory tract infection patients 18 years and older on a nationwide direct-to-consumer telemedicine platform were conducted by physicians between July 2016 and July 2018. Mixed-effects logistic regression was used to assess differences in the odds of corticosteroid prescription. A second mixed-effects model assessed differences in patient satisfaction by corticosteroid or antibiotic receipt. Adjusted prescribing rates for individual physicians were estimated. Models included diagnoses, patient age and geographic region, physician specialty and geographic region, and antibiotic prescription.

RESULTS

Of the 85,972 encounters with 465 physicians, 11% resulted in the physician prescribing corticosteroids. The median physician prescribing rate was 4.0% (range: <1%-81%). Corticosteroid receipt was associated with higher satisfaction versus receiving nothing (odds ratio: 2.54; 95% confidence interval: 2.25-2.87). Patients who received both an antibiotic and a corticosteroid reported the highest satisfaction (odd ratio: 3.91; 95% confidence interval: 3.27-4.68). There was no correlation between individual physicians' corticosteroid and antibiotic prescribing rates.

CONCLUSIONS

Corticosteroid receipt was associated with patient satisfaction. Most physicians rarely prescribed corticosteroids, yet a small number prescribed them frequently. Identification of high-prescribing physicians for educational interventions could reduce use of corticosteroids for acute respiratory tract infections.

False Claims Act Liability for Overtreatment

CONTEXT

Overtreatment is costly, but is it fraud? In a growing number of False Claims Act cases, the Department of Justice has sought and received multimillion dollar settlements from providers accused of billing Medicare for unnecessary care. This article evaluates the use of the False Claims Act as a tool for reducing overuse.

METHODS

The author reviewed (1) recent cases where litigants sparred over the applicability of the False Claims Act to overtreatment, and (2) criticisms of the expanding use of the False Claims Act in health care.

FINDINGS

Some judges have dismissed suits on the grounds that expert testimony regarding the necessity of treatment is insufficient for concluding Medicare claims were false or fraudulent. Other judges have let cases proceed, especially in instances where clinicians appear to have overstated the severity of patients' illnesses to justify treatment. Cases that lead to changes in medical practice may result in substantial savings to the Medicare program.

CONCLUSIONS

Courts have struggled with how to apply the False Claims Act to overtreatment. False Claims Act cases that address unnecessary care are potentially less problematic than other types of cases that address technical violations with few implications for costs or quality.

Antibiotic Prescribing Variability in a Large Urgent Care Network: A New Target for Outpatient Stewardship

Improving antibiotic prescribing in outpatient settings is a public health priority. In the United States, urgent care (UC) encounters are increasing and have high rates of inappropriate antibiotic prescribing. Our objective was to characterize antibiotic prescribing practices during UC encounters, with a focus on respiratory tract conditions. This was a retrospective cohort study of UC encounters in the Intermountain Healthcare network. Among 1.16 million UC encounters, antibiotics were prescribed during 34% of UC encounters and respiratory conditions accounted for 61% of all antibiotics prescribed. Of respiratory encounters, 50% resulted in antibiotic prescriptions, yet the variability at the level of the provider ranged from 3% to 94%. Similar variability between providers was observed for respiratory conditions where antibiotics were not indicated and in first-line antibiotic selection for sinusitis, otitis media, and pharyngitis. These findings support the importance of developing antibiotic stewardship interventions specifically targeting UC settings.

Factors Influencing Primary Care Providers' Unneeded Lumbar Spine MRI Orders for Acute, Uncomplicated Low-Back Pain: a Qualitative Study

BACKGROUND

Clinical practice guidelines suggest that magnetic resonance imaging of the lumbar spine (LS-MRI) is unneeded during the first 6 weeks of acute, uncomplicated low-back pain. Unneeded LS-MRIs do not improve patient outcomes, lead to unnecessary surgeries and procedures, and cost the US healthcare system about $300 million dollars per year. However, why primary care providers (PCPs) order unneeded LS-MRI for acute, uncomplicated low-back pain is poorly understood.

OBJECTIVE

To characterize and explain the factors contributing to PCPs ordering unneeded LS-MRI for acute, uncomplicated low-back pain.

DESIGN

Qualitative study using semi-structured interviews.

PARTICIPANTS

Veterans Affairs PCPs identified from administrative data as having high or low rates of guideline-concordant LS-MRI ordering in 2016.

APPROACH

Providers were interviewed about their use of LS-MRI for acute, uncomplicated low-back pain and factors contributing to their decision-making. Directed content analysis of transcripts was conducted to identify and compare environmental-, patient-, and provider-level factors contributing to unneeded LS-MRI.

KEY RESULTS

Fifty-five PCPs participated (8.6% response rate). Both low (n = 33) and high (n = 22) guideline-concordant providers reported that LS-MRIs were required for specialty care referrals, but they differed in how other environmental factors (stringency of radiology utilization review, management of patient travel burden, and time constraints) contributed to LS-MRI ordering patterns. Low- and high-guideline-concordant providers reported similar patient factors (beliefs in value of imaging and pressure on providers). However, provider groups differed in how provider-level factors (guideline familiarity and agreement, the extent to which they acquiesced to patients, and belief in the value of LS-MRI) contributed to LS-MRI ordering patterns.

CONCLUSIONS

Results describe how diverse environmental, patient, and provider factors contribute to unneeded LS-MRI for acute, uncomplicated low-back pain. Prior research using a single intervention to reduce unneeded LS-MRI has been ineffective. Results suggest that multifaceted de-implementation strategies may be required to reduce unneeded LS-MRI.

Attitudes of High Versus Low Antibiotic Prescribers in the Management of Upper Respiratory Tract Infections: a Mixed Methods Study

IMPORTANCE

Inappropriate antibiotic use for upper respiratory tract infections (URTIs) is an ongoing problem in primary care. There is extreme variation in the prescribing practices of individual physicians, which cannot be explained by clinical factors.

OBJECTIVE

To identify factors associated with high and low prescriber status for management of URTIs in primary care practice.

DESIGN AND PARTICIPANTS

Exploratory sequential mixed-methods design including interviews with primary care physicians in a large health system followed by a survey. Twenty-nine physicians participated in the qualitative interviews. Interviews were followed by a survey in which 109 physicians participated.

MAIN MEASURES

Qualitative interviews were used to obtain perspectives of high and low prescribers on factors that influenced their decision making in the management of URTIs. A quantitative survey was created based on qualitative interviews and responses compared to actual prescribing rates. An assessment of self-prescribing pattern relative to their peers was also conducted.

RESULTS

Qualitative interviews identified themes such as clinical factors (patient characteristics, symptom duration, and severity), nonclinical factors (physician-patient relationship, concern for patient satisfaction, preference and expectation, time pressure), desire to follow evidence-based medicine, and concern for adverse effects to influence prescribing. In the survey, reported concern regarding antibiotic side effects and the desire to practice evidence-based medicine were associated with lower prescribing rates whereas reported concern for patient satisfaction and patient demand were associated with high prescribing rates. High prescribers were generally unaware of their high prescribing status.

CONCLUSIONS AND RELEVANCE

Physicians report that nonclinical factors frequently influence their decision to prescribe antibiotics for URTI. Physician concerns regarding antibiotic side effects and patient satisfaction are important factors in the decision-making process. Changes in the health system addressing both physicians and patients may be necessary to attain desired prescribing levels.

The inconvincible patient: how clinicians perceive demand for antibiotics in the outpatient setting

BACKGROUND

Perceived patient demand for antibiotics drives unnecessary antibiotic prescribing in outpatient settings, but little is known about how clinicians experience this demand or how this perceived demand shapes their decision-making.

OBJECTIVE

To identify how clinicians perceive patient demand for antibiotics and the way these perceptions stimulate unnecessary prescribing.

METHODS

Qualitative study using semi-structured interviews with clinicians in outpatient settings who prescribe antibiotics. Interviews were analyzed using conventional and directed content analysis.

RESULTS

Interviews were conducted with 25 clinicians from nine practices across three states. Patient demand was the most common reason respondents provided for why they prescribed non-indicated antibiotics. Three related factors motivated clinically unnecessary antibiotic use in the face of perceived patient demand: (i) clinicians want their patients to regard clinical visits as valuable and believe that an antibiotic prescription demonstrates value; (ii) clinicians want to avoid negative repercussions of denying antibiotics, including reduced income, damage to their reputation, emotional exhaustion, and degraded relationships with patients; (iii) clinicians believed that certain patients are impossible to satisfy without an antibiotic prescription and felt that efforts to refuse antibiotics to such patients wastes time and invites the aforementioned negative repercussions. Clinicians in urgent care settings were especially likely to describe being motivated by these factors.

CONCLUSION

Interventions to improve antibiotic use in the outpatient setting must address clinicians' concerns about providing value for their patients, fear of negative repercussions from denying antibiotics, and the approach to inconvincible patients.

Patient Requests for Tests and Treatments Impact Physician Management of Hypothyroidism

Background: Levothyroxine is one of the most commonly prescribed medications in the United States. Although prior research focused on over- and undertreatment and patient dissatisfaction with thyroid hormone, little is known about physician-reported barriers to managing thyroid hormone therapy. In addition, the impact of patient requests for tests and treatments on hypothyroidism management remains unexplored. Methods: We randomly surveyed physician members of the Endocrine Society, American Academy of Family Practice and American Geriatrics Society. Respondents were asked to rate barriers to management of thyroid hormone therapy. We conducted multivariable logistic regression analyses to determine correlates with physician report of the most commonly reported barriers, including patient requests. Results: Response rate was 63% (359/566). Almost half of the physicians reported that patient requests for tests and treatments were somewhat to very likely to being a barrier to appropriate management of thyroid hormone therapy (46%). Endocrinologists (odds ratio [OR] = 2.29 [95% confidence interval, CI 1.03-5.23], compared with primary care physicians) and physicians with more than 25% of patients on thyroid hormone therapy per year (OR = 1.90 [CI 1.05-3.46], compared with those with <25% patients per year) were more likely to report patient requests as a barrier. Physicians with more years in practice were less likely to do so (11-20 years: OR = 0.44 [CI 0.21-0.89]; >20 years: OR = 0.24 [CI 0.12-0.46], compared with ≤10 years). Physician-reported patient requests included requests for preparations other than synthetic thyroxine (52%), adjusting thyroid hormone dose based on symptoms when biochemically euthyroid (52%), maintaining thyrotropin level below the reference range (32%), and adjusting dose according to serum T3 level (21%). Physicians who reported receiving patient requests for the former three unconventional practices were more likely to execute them (p < 0.001, p = 0.014, p < 0.001, respectively). Conclusions: Physicians reported patient requests for tests and treatments as a common barrier to appropriate thyroid hormone management. In some scenarios, physician adherence to patient requests may be a driver for inappropriate care and lead to harm. Understanding physician-reported barriers to thyroid hormone management and factors associated with physician perception that patient requests are a barrier is key to improving patient care.

Patient Satisfaction with Clinicians and Short-Term Mortality in a US National Sample: the Roles of Morbidity and Gender

BACKGROUND

In a prior study, we found patient satisfaction was associated with mortality. However, that study included few deaths, yielding wide confidence intervals, was criticized for possible morbidity under-adjustment, and lacked power to explore sociodemographic moderation.

OBJECTIVE

To revisit the satisfaction-mortality association in a larger national sample, allowing more precise risk estimates, sequential morbidity adjustment, and exploration of sociodemographic moderation.

DESIGN

Prospective cohort study.

PARTICIPANTS

2000-2015 Adult Medical Expenditures Panel Surveys (MEPS) respondents (N = 92,952), each enrolled for 2 consecutive years.

MAIN MEASURES

We used five Consumer Assessment of Health Plans Survey (CAHPS) items to assess patients' year 1 satisfaction with their clinicians. Death during the 2 years of MEPS participation was determined by proxy report. We modeled the satisfaction-mortality association in sequential regressions: model 1 included sociodemographics, model 2 added health status (approximating recommended CAHPS adjustment), and model 3 added smoking status, disease burden, and healthcare utilization.

KEY RESULTS

Satisfaction was not associated with mortality in model 1. In model 2, higher satisfaction was associated with higher mortality (hazard ratios [95% CIs] for 2nd, 3rd, and 4th (top) quartiles vs. 1st quartile: 1.28 (1.01, 1.62), P = 0.04; 1.43 (1.12, 1.82), P = 0.004; and 1.57 (1.25, 1.98), P < 0.001, respectively). The associations were not attenuated in model 3. There was a significant interaction between gender and satisfaction (F[3, 443] = 3.62, P = 0.01). The association between satisfaction and mortality was significant in women only, such that their mortality advantage over men was eliminated in the highest satisfaction quartile.

CONCLUSIONS

The association of higher patient satisfaction with clinicians with higher short-term mortality was evident only after CAHPS-recommended adjustment, was not attenuated by further morbidity adjustment, and was evident in women but not men. The findings suggest that characteristics among women who are more satisfied with their clinicians may be associated with increased mortality risk.

The Effect of Workers' Compensation Status on the Patient Experience

Background:

Rating the patient experience is an increasingly important component of value-based health care. Generation of lower ratings on validated functional assessments by patients with Workers’ Compensation is well known; however, the relationship between Workers’ Compensation status and patient satisfaction is poorly described in orthopaedic patient populations.

Methods:

All orthopaedic outpatient patient satisfaction surveys (Press Ganey) generated over an 18-month period at a U.S. academic tertiary care center were included in this study. Data with regard to the primary payer, demographic characteristics, orthopaedic subspecialty, and planned surgical interventions with the provider for whom the survey was completed were analyzed in conjunction with patient satisfaction data.

Results:

During the study period, 3,720 consecutive patient satisfaction surveys were generated, and 244 surveys were generated by 215 patients with Workers’ Compensation. Satisfied patients with Workers’ Compensation were more likely to be male (p = 0.0007), to have higher mental health self-assessments (p = 0.004), and to be scheduled for surgical intervention (p = 0.03). Scheduling a surgical procedure was independently associated with improved patient satisfaction, whereas Workers’ Compensation status was independently associated with dissatisfaction when adjusting for sex, language, race, and marital status. Across all patient satisfaction domains, patients with Workers’ Compensation gave significantly lower scores (p < 0.05) compared with all other patients. Patients with Workers’ Compensation were more likely to rate their overall health as lower compared with other patients (p < 0.0001). Patients with Workers’ Compensation were more likely to give lower ratings to providers on a 1-to-10 scale (p < 0.0001) and were less likely to recommend the practice to others (p < 0.0001).

Conclusions:

Workers’ Compensation status is a non-modifiable independent predictor of dissatisfaction with health care compared with other primary payer groups. Further research is warranted to understand the factors influencing patient satisfaction ratings.

Patient experience: determinants and manifestations

Purpose

Patient experience is a complex multidimensional phenomenon that has been linked to constructs that are also complex to conceptualize, such as patient-centeredness, patient expectations and patient satisfaction. The purpose of this paper is to shed light on the different dimensions of patient experience, including those that receive inadequate attention from policymakers such as the patient’s lived experience of illness and the impact of healthcare politics. The paper proposes a simple classification for these dimensions, which differentiates between two types of dimensions: the determinants and the manifestations of patient experience.

Design/methodology/approach

This paper uses a narrative review of the literature to explore select constructs and initiatives developed for theorizing or operationalizing patient experience. Literature topics reviewed include healthcare quality, medical anthropology, health policy, healthcare system and public health.

Findings

The paper identifies five determinants for patient experience: the experience of illness, patient’s subjective influences, quality of healthcare services, health system responsiveness and the politics of healthcare. The paper identifies two manifestations of patient experience: patient satisfaction and patient engagement.

Originality/value

The paper proposes a classification scheme of the dimensions of patient experience and a concept map that links together heterogeneous constructs related to patient experience. The proposed classification and the concept map provide a holistic view of patient experience and help healthcare providers, quality managers and policymakers organize and focus their healthcare quality improvement endeavors on specific dimensions of patient experience while taking into consideration the other dimensions.

Are Caregivers Who Respond to the Child HCAHPS Survey Reflective of All Hospitalized Pediatric Patients?

OBJECTIVES

The Child Hospital Consumer Assessment of Healthcare Providers and Systems (C-HCAHPS) survey was developed to measure satisfaction levels of pediatric inpatients' caregivers. Studies in adults have revealed that certain demographic groups (people of color or who are multiracial and people with public insurance) respond to surveys at decreased rates, contributing to nonresponse bias. Our primary goal was to determine if results from the C-HCAHPS survey accurately reflect the intended population or reveal evidence of nonresponse bias. Our secondary goal was to examine whether demographic or clinical factors were associated with increased satisfaction levels.

METHODS

This was a retrospective cohort study of responses (n = 421) to the C-HCAHPS survey of patients admitted to a tertiary-care pediatric hospital between March 2016 and March 2017. Respondent demographic information was compared with that of all hospital admissions over the same time frame. Satisfaction was defined as "top-box" scores for questions on overall rating and willingness to recommend the hospital.

RESULTS

Caregivers returning surveys were more likely to be white, non-Hispanic, and privately insured (P < .001). Caregivers with the shortest emergency department wait times were more likely to assign top-box scores for global rating (P = .025). We found no differences in satisfaction between race and/or ethnicity, length of stay, insurance payer, or total cost.

CONCLUSIONS

Caregivers who identified with underrepresented minority groups and those without private insurance were less likely to return surveys. Among the surveys received, short emergency department wait time and older age were the only factors measured that were associated with higher satisfaction. Efforts to increase patient satisfaction on the basis of satisfaction scores may exacerbate existing disparities in health care.

Patient Characteristics Associated with Making Requests during Primary Care Visits

BACKGROUND

Patient requests for tests, treatments, or referrals occur frequently during primary care visits and pose challenges for clinicians to address, but little is known about patient characteristics that may predict requests.

OBJECTIVE

To identify patient characteristics associated with a higher rate of patient requests during primary care visits.

DESIGN, SETTING, AND SAMPLE

Cross-sectional analyses of data from 1141 adult patients attending 1319 visits with 56 primary care physicians (including 45 resident and 11 faculty physicians) in an academic family medicine practice.

MEASUREMENTS

Postvisit patient surveys including measures of patient requests for tests, prescriptions, and referrals; sociodemographics; mental and physical health status; symptom bother or worry (3-item scale; range, 3 to 15; Cronbach's α = 0.83); global life satisfaction; medical skepticism; and Five Factor Model personality traits.

RESULTS

Patients made 1 or more requests in 867 visits (65.7%). In multivariate analyses of the within-visit request count, the following patient variables were statistically significantly associated with a higher rate of requests: age in years (incidence rate ratio [IRR], 1.01 [95% CI, 1.00 to 1.01]), increased symptom bother or worry (IRR, 1.06 [95% CI, 1.03 to 1.08]), a more extroverted personality (IRR, 1.12 [95% CI, 1.03 to 1.08]), greater life satisfaction (IRR, 1.01 [95% CI, 1.00 to 1.02]), and any prior encounter with the visit physician (IRR, 1.17 [95% CI, 1.04 to 1.32]).

CONCLUSIONS

Primary care physicians should expect a greater frequency of requests from older patients, patients with greater symptoms bother or worry, more extroverted patients, patients with greater global life satisfaction, and patients with whom they have had prior visits.