Patients' desires and expectations for medical care in primary care clinics

A Patient-Centered PaTH to Address Diabetes: Protocol for a Study on the Impact of Obesity Counseling

BACKGROUND

Overweight and obesity are America's number one health concern. The prevalence of obesity in the United States is greater than 36%, a rate that has doubled since 1970. As the second most preventable cause of death, obesity is a risk factor for diabetes, cardiovascular disease, stroke, and cancer, all major causes of death. Primary care clinics may be an ideal setting for weight control interventions to help manage and prevent diabetes. For this reason, the Centers for Medicare and Medicaid Services (CMS) implemented a health care procedure coding system code for intensive behavioral therapy (IBT) for obesity within primary care in 2012 to facilitate payment for addressing obesity, which was followed by broader coverage by most insurers for IBT for adults in 2013. However, the impact of this coverage on patient-centered outcomes is largely unknown.

OBJECTIVE

The overarching goal of this study is to understand the comparative effectiveness of obesity counseling as covered by CMS and other insurers in improving weight loss for adults either with or at increased risk for type 2 diabetes.

METHODS

This study leverages the novel infrastructure of the Patient-Centered Outcomes Research Institute-funded PaTH Clinical Data Research Network. The PaTH network is comprised of Geisinger Health System, Johns Hopkins University, Johns Hopkins Health System, Lewis Katz School of Medicine at Temple University, Temple Health System, Penn State College of Medicine, Penn State Milton S Hershey Medical Center, University of Pittsburgh, UPMC and UPMC Health Plan, and the University of Utah. Electronic health record (EHR) data will originate from the 6 PaTH health systems. Specifically, we will (1) evaluate the impact of broader preventive service coverage for obesity screening and counseling on weight loss, diabetes incidence, and diabetes outcomes in patients with diabetes or at increased risk for diabetes (defined by body mass index [BMI] ≥25). We will determine how the annual probability of receiving obesity and/or nutritional counseling changed pre- and postpolicy across all insurers in a cohort of patients with diabetes and at high risk for diabetes. We will (2) compare patient weight loss and diabetes-related outcomes among those who receive obesity screening and counseling with those who do not, following implementation of preventive service coverage. We will examine postpolicy impact of obesity screening and counseling in a cohort of patients with diabetes and at increased risk for diabetes. Specific outcomes to be examined include weight loss, diabetes incidence, and diabetes outcomes. Exploratory outcomes will include patient-reported outcomes. Furthermore, we will determine patient characteristics, including demographics, and practice characteristics, including provider type.

RESULTS

Our PCORI-funded study is underway. To date, we have obtained our second data extraction from the PaTH CDRN and are performing data editing and cleaning. Next steps include analysis of early policy change.

CONCLUSIONS

Given patients who are overweight are at highest risk for diabetes, improved weight management services could prevent diabetes and its negative health outcomes. Comparing weight and diabetes outcomes in 3 states using EHRs and claims data before and after this policy was implemented using the PaTH Network will allow important insight into policy effectiveness.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/12054.

Determinants of Patient Satisfaction in Celiac Disease Care

BACKGROUND AND GOALS

There are little data examining patient satisfaction with celiac disease (CD) care. We sought to assess how satisfied patients are with their CD care, and to determine the influencing factors.

STUDY

We distributed an online questionnaire to adults receiving programmatic updates from a CD referral center, querying aspects of CD care and using disease-specific validated instruments to measure quality of life and dietary adherence. The univariable and multivariable analyses were performed using satisfaction as a binary outcome comparing grouped "satisfied" and "very satisfied" respondents to "neutral," "dissatisfied," and "very dissatisfied" respondents.

RESULTS

Three hundred eighty-seven (22%) individuals completed the survey, and 229 met the inclusion criteria of biopsy-proven CD. Seventy-nine individuals (34.5%) reported being "very satisfied" with their CD care, 82 (35.8%) "satisfied," 46 (20.1%) "neutral," 14 (6.1%) "dissatisfied," and 8 (3.5%) "very dissatisfied." On multivariable analysis, reporting that physicians spend ample time managing CD needs (P=0.013), and having CD-antibody levels checked yearly (P=0.003), were positive predictors of patient satisfaction. Factors that were not correlated with patient satisfaction included symptom severity (P=0.268), quality of life (P=0.13), and following with a CD specialist (P=0.139).

CONCLUSIONS

The majority of patients we surveyed were satisfied with their CD care. We found that patients report higher satisfaction when they feel physicians spend time caring for their CD needs and when they receive annual CD-antibody testing. On the basis of our study, these factors are more important than disease severity, seeing a CD specialist, and quality of life in determining patient satisfaction with CD care.

Caregiver satisfaction with paediatric HIV treatment and care in Nigeria and equity implications for children living with HIV

Caregiver satisfaction has the potential to promote equity for children living with HIV, by influencing health-seeking behaviour. We measured dimensions of caregiver satisfaction with paediatric HIV treatment in Nigeria, and discuss its implications for equity by conducting facility-based exit interviews for caregivers of children receiving antiretroviral therapy in 20 purposively selected facilities within 5 geopolitical zones. Descriptive analysis and factor analysis were performed. Due to the hierarchical nature of the data, multilevel regression modelling was performed to investigate relationships between satisfaction factors and socio-demographic variables. Of 1550 caregivers interviewed, 63% (95% CI: 60.6–65.4) reported being very satisfied overall; however, satisfaction varied in some dimensions: only 55.6% (53.1–58.1) of caregivers could talk privately with health workers, 56.9% (54.4–59.3) reported that queues to see health workers were too long, and 89.9% (88.4–91.4) said that some health workers did not treat patients living with HIV with sufficient respect. Based on factor analysis, two underlying factors, labelled Availability and Attitude, were identified. In multilevel regression, the satisfaction with availability of services correlated with formal employment status (p < .01), whereas caregivers receiving care in private facilities were less likely satisfied with both availability (p < .01) and attitude of health workers (p < .05). State and facility levels influenced attitudes of the health workers (p < .01), but not availability of services. We conclude that high levels of overall satisfaction among caregivers masked dissatisfaction with some aspects of services. The two underlying satisfaction factors are part of access typology critical for closing equity gaps in access to HIV treatment between adults and children, and across socio-economic groups.

Motives for requesting an electrocardiogram in primary health care

The management of requests for diagnostic exams presents its own inherent characteristics in primary health care and reflects the specific nature of the physician-patient relationship. The scope of the study was to identify the reasons for requesting an electrocardiogram (ECG) in primary health care. A cross-sectional study was conducted in an urban region in Portugal, establishing the motives to ask for an ECG consecutively over two years, starting on 01/03/2007 using data retrieved from structured forms filled out by the physician at the moment of requesting the exam. A total of 870 ECGs of 817 patients were included. Symptoms manifested during the patient visit justified 48.5% of the ECGs, and follow-up of cardiovascular risk factors motivated 25.2%. A global health examination accounted for 22.8% of the requests. Multivariate analysis showed that the presence of symptoms (p < 0.001), presence of any cardiovascular risk factor (p = 0.002), hypertension (p < 0.001), diabetes (p = 0.002), and urgency (p < 0.001) were the main factors associated with the requests. The requests for electrocardiograms are predominantly for clinical reasons as a result of patients symptoms. The integration of expectations and beliefs of the patients is present in the decision-making process.

Patterns of treatment expectation and the physician-patient relationship perceived by women receiving traditional Chinese medicine treatment for menstrual symptoms: a Q-methodology study

BACKGROUND

The recurrence of menstrual symptoms markedly interferes with the daily life, social functioning, work disability and quality of life of women. Patient perception of healthcare services is underexplored but crucial for understanding how to efficiently develop healthcare practices.

AIMS

To identify and describe the different patterns of treatment expectation and physician-patient relationships perceived by women receiving traditional Chinese medicine treatment for menstrual symptoms.

METHODS

A two-stage data collection design was used. In the first stage, in-depth interviews with 40 participants were conducted; the interview data were used for content analysis. Q statements were developed on the basis of the content analysis results. In the second stage, a series of Q sorts was performed by 60 other participants to subjectively rank the Q statements.

RESULTS

The results of factor analysis revealed that four factors retained in the final model accounted for 56% of total variance. Women associated with Factor 1 had experienced few negative physician-patient interactions; these women were relatively young (31.6 years) and had mild perimenstrual mood discomfort (6.4). Women who loaded on Factor 2 preferred physician guidance and encountered few barriers to adherence; these participants were older (38.6 years) and had the most severe perimenstrual mood discomfort (9.5) among the four groups. The women in agreement with Factor 3 tended to patiently wait for treatment effects; these participants had the highest scores for both cyclic pelvic pain (4.9) and perimenstrual physical discomfort (8.8). The women associated with Factor 4 demanded effective treatment and had the lowest scores for both cyclic pelvic pain (3.8) and perimenstrual physical discomfort (6.8).

CONCLUSIONS

The exploration of clustering patients according to their perspectives could influence healthcare providers to acknowledge patient expectations and enable effective communication between physicians and patients.

Measuring Quality of Care with Patient Satisfaction Scores

Quality of care is a multidimensional concept encompassing safety, efficiency, outcomes, and the patient experience. Traditional quality metrics, such as mortality rates, complication rates, and patient-reported outcomes, are time-consuming and cost-consuming to obtain and risk-stratify. The implications of reimbursement related to patient satisfaction and the ease of data collection have contributed to the perception that satisfaction is a global indicator of health-care quality; however, high satisfaction scores are not consistently correlated with traditional outcome and safety indicators. Higher patient satisfaction may be associated with increased costs of care. Costs may be further increased by the implementation of the satisfaction surveys themselves, which can increase imaging studies and prescriptions. Therefore, satisfaction surveys are not appropriate measures of overall quality of care. Accurate assessment of quality requires a multidimensional approach that includes specific measures for each domain.

Met or matched expectations: what accounts for a successful back pain consultation in primary care?

BACKGROUND

Patients' as well as doctors' expectations might be key elements for improving the quality of health care; however, previous conceptual and theoretical frameworks related to expectations often overlook such complex and complementary relationship between patients' and doctors' expectations. The concept of 'matched patient-doctor expectations' is not properly investigated, and there is lack of literature exploring such aspect of the consultation.

AIM

The paper presents a preliminary conceptual model for the relationship between patients' and doctors' expectations with specific reference to back pain management in primary care.

METHODS

The methods employed in this study are integrative literature review, examination of previous theoretical frameworks, identification of conceptual issues in existing literature, and synthesis and development of a preliminary pragmatic conceptual framework.

OUTCOME

A simple preliminary model explaining the formation of expectations in relation to specific antecedents and consequences was developed; the model incorporates several stages and filters (influencing factors, underlying reactions, judgement, formed reactions, outcome and significance) to explain the development and anticipated influence of expectations on the consultation outcome.

CONCLUSION

The newly developed model takes into account several important dynamics that might be key elements for more successful back pain consultation in primary care, mainly the importance of matching patients' and doctors' expectations as well as the importance of addressing unmet expectations.

Are GP patients' needs being met? Unfulfilled information needs among native-Dutch and Turkish-Dutch patients

OBJECTIVE

This study aims to assess unfulfilled information needs of native-Dutch and Turkish-Dutch general practitioner (GP) patients in the Netherlands. In addition, the relation between perceived and recorded information provision by GPs is studied.

METHODS

Unfulfilled information needs of native-Dutch (N=117) and Turkish-Dutch patients (N=74) were assessed through pre- and post-consultation questionnaires. Audiotapes of GP consultations were made to code GPs' information provision.

RESULTS

Turkish-Dutch patients experience more unfulfilled information needs than native-Dutch patients, in particular those who identify equally with Dutch and Turkish culture. Overall, perceived information provision is hardly related to recorded information provision.

CONCLUSION

GPs insufficiently provide Turkish-Dutch patients and, to a lesser extent, native-Dutch patients as well, the information they need.

PRACTICE IMPLICATIONS

GPs should be trained in giving adequate, tailored information to patients with various ethnic and cultural backgrounds.

Public Opinion of Pharmacists and Pharmacist Prescribing

Background:

Pharmacists generally enjoy a high ranking when members of the general public are asked to rate the most trusted professions. While it is a good thing that the pharmacy profession appears to be trustworthy, it is not clear whether the public fully appreciates what pharmacists can do.

Methods:

A telephone survey in the province of Saskatchewan was conducted between February 25 and March 2, 2010. The questionnaire consisted of 43 items.

Results:

A total of 1283 people were contacted; 403 (31.4%) agreed to participate. A majority of respondents were female (253, 62.8%). Two-thirds (262, 65%) felt they were a “customer” when visiting a pharmacy; only 14.9% (60) felt they were a “patient.” There was some limited support for an expanded role for pharmacists.

Conclusions:

Gender appears to play a role in public perceptions of pharmacists; women tended to have a more favourable view of the profession than men. Lower education and income level were associated with a more positive view of pharmacists. This study adds to our understanding of the public perceptions of pharmacists and the potential for increased scope of practice. Respondents in this study, as in similar studies, generally had a positive view of the pharmacy profession, but there is still some variation, perhaps showing that an inconsistent message is being communicated to the general public about the role of pharmacists.

Expectations about and experiences with insulin therapy contribute to diabetes treatment satisfaction in insulin-naïve patients with type 2 diabetes

AIM

The aim of this study was to investigate how patients' expectations about and experiences with insulin therapy contribute to diabetes treatment satisfaction.

METHODS

The Expectations about Insulin Therapy (EAITQ) and the Experience with Insulin Therapy Questionnaires (EWITQ) were administered at baseline and end-point, respectively to insulin-naïve patients with type 2 diabetes in a randomised trial comparing treatment algorithms for inhaled insulin. Pearson correlation coefficients were calculated between EAITQ and EWITQ scores, patient characteristics and patient-reported outcomes measures. Wilcoxon Signed Rank test compared EAITQ and EWITQ item score distributions. Differences between EAITQ and EWITQ scores were calculated to categorize patients according to the extent to which their expectations were met by experiences (i.e. unmet, met, exceeded).

RESULTS

EAITQ and EWITQ data were available for 240 patients (61% male, mean age 58 years, mean diabetes duration 10 years, mean baseline HbA(1c) 8.4%). Increasingly positive expectations were significantly associated with greater self-efficacy; greater levels of positive experiences were significantly associated with greater positive expectations, shorter diabetes duration, less symptom distress, greater well-being, self-efficacy and diabetes treatment satisfaction. Overall, patients' experiences with inhaled insulin therapy were significantly more positive than their expectations: 58% patients' experiences exceeded expectations, 29% patients' experiences met expectations and 13% patients' experiences did not meet expectations. Post hoc tests indicated that treatment satisfaction scores differed among these groups (all p < 0.01).

CONCLUSION

Expectations may not independently impact treatment satisfaction, but the relationship with experiences significantly contributes to it. The EAITQ and EWITQ may be useful tools for clinicians to better understand patients' expectations about and experiences with insulin therapy.

Clinical Encounter Experiences of Patients With Nasopharyngeal Carcinoma

Nasopharyngeal carcinoma (NPC) is a commonly occurring cancer among Hong Kong Chinese, especially in the relatively young population group. Since the disease carries a favorable prognosis, sequelae following treatment have become an important concern for patients suffering from NPC, particularly because of the strong interplay of psychological, social, and biological issues during their rehabilitation. In this qualitative study, in-depth, semistructured audiotaped interviews were undertaken with 32 patients receiving rehabilitation at the physiotherapy department of a regional teaching hospital in Hong Kong. The objective of the study was to examine the rehabilitation experiences of NPC survivors to identify factors that contributed to a satisfying clinical encounter experience. During the study, data collection and analysis using a grounded theory approach were concurrently conducted. The 3 main themes that shaped the rehabilitation experiences of NPC survivors were the patient-clinician relationship, participation in therapeutic alliance, and quality rehabilitation service provision. These, together with the identified needs of the participants, contributed to the participants' perceived health-related quality of life. A constructive clinical experience was perceived when their needs were met. The findings highlight the importance of patient-centeredness in the treatment delivery and a multifaceted role of clinicians in meeting the needs of this group of cancer survivors.

The impact of a brief expectation survey on parental satisfaction in the pediatric emergency department

OBJECTIVES

To determine the effect of physician knowledge of parental expectations on satisfaction with emergency department (ED) care.

METHODS

This was a prospective, controlled, interventional trial involving parents of children presenting to a children's hospital ED. Parents completed an expectation survey on arrival, which was either immediately placed back in the enrollment envelope (control) or shown to the physician caring for the child (intervention). The physician was instructed to initial the expectation survey to acknowledge receipt of the survey. Parents then completed a satisfaction survey at discharge. The primary outcomes were differences in satisfaction with physician review of the expectation survey, as measured by 1) parental ratings of overall care and 2) their willingness to recommend the ED to others. A third (baseline) group completed only a satisfaction survey at discharge.

RESULTS

A total of 614 (66%) of the 930 enrolled parents completed the study. Intention-to-treat analysis did not show a significant increase in parental satisfaction ratings for either overall care or recommend the ED; however, only 42% of the intervention group surveys had documented physician review. When these initialed surveys were compared with the control group in a per-protocol analysis, there was a significant improvement in parental satisfaction. There were no differences between the control and baseline groups, indicating no effect of the expectation survey completion on satisfaction.

CONCLUSIONS

Physician knowledge of written parental expectations may improve parental satisfaction during an ED visit. Further work is needed to overcome the barriers to physician review of the expectation survey to maximize parent satisfaction.

Blood tests in tired elite athletes: expectations of athletes, coaches and sport science/sports medicine staff

BACKGROUND

The issue of the expectations of elite athletes, their coaches and non-medically qualified athlete support staff of consultations with sports physicians has not been previously dealt with in the sports medicine literature. As fulfillment of expectations of the content of a consultation may influence patient's satisfaction and clinical outcome, it is important to assess the expectations of athletes and, most importantly, coaches.

OBJECTIVE

To assess the expectations and beliefs about fatigue, particularly in relation to blood tests, of athletes, their coaches and support staff in the specific context of tiredness of <7 days' duration.

SUBJECTS

28 senior sports science or non-medically qualified sports medicine staff, 22 elite coaches and 62 elite athletes from the Australian Institute of Sport were included in this study.

METHODS

A single questionnaire.

RESULTS

The expectation for a blood test at the initial consultation for short-term fatigue was particularly high among athletes (81%) and coaches (91%). This expectation increased in athletes if their performance was worsening. All groups unanimously suggested that a blood test be performed in cases of more prolonged fatigue. Increase in total training load was perceived to be the most important cause of fatigue, but issues relating to sleep were also thought to be highly relevant. All groups suggested that blood tests provide some degree of reassurance, and all groups suggested that the most important blood tests that might be performed related to exclusion of iron deficiency, anaemia and infection.

CONCLUSION

Athletes and their coaches generally expect that blood tests will be performed even when fatigue has been present for <1 week. This is at odds with currently available evidence of the diagnostic utility of these tests. Despite the current evidence base, individual factors in the athletes, coaches and doctors need to be considered when deciding on whether such testing has to be performed.

Racial and ethnic differences in patient assessments of interactions with providers: disparities or measurement biases?

Patient assessment surveys have established a primary role in health care quality measurement as evidence has shown that information from patients can affect quality improvement for practitioners and lead to positive marketwide changes. This article presents findings from the recently released National Healthcare Disparities Report revealing that although most clinical quality and access indicators show superior health care for non-Hispanic whites compared with blacks and Hispanics, blacks and Hispanics assess their interactions with providers more positively than non-Hispanic whites do. The article explores possible explanations for these racial/ethnic differences, including potential pitfalls in survey design that draw biased responses by race/ethnicity. The article then suggests strategies for refining future research on racial/ethnic disparities based on patient assessment of health care.

Do unmet expectations for specific tests, referrals, and new medications reduce patients' satisfaction?

BACKGROUND

Patient-centered care requires clinicians to recognize and act on patients' expectations. However, relatively little is known about the specific expectations patients bring to the primary care visit.

OBJECTIVE

To describe the nature and prevalence of patients' specific expectations for tests, referrals, and new medications, and to examine the relationship between fulfillment of these expectations and patient satisfaction.

DESIGN

Prospective cohort study.

SETTING

VA general medicine clinic.

PATIENTS/PARTICIPANTS

Two hundred fifty-three adult male outpatients seeing their primary care provider for a scheduled visit.

MEASUREMENTS AND MAIN RESULTS

Fifty-six percent of patients reported at least 1 expectation for a test, referral, or new medication. Thirty-one percent had 1 expectation, while 25% had 2 or more expectations. Expectations were evenly distributed among tests, referrals, and new medications (37%, 30%, and 33%, respectively). Half of the patients who expressed an expectation did not receive one or more of the desired tests, referrals, or new medications. Nevertheless, satisfaction was very high (median of 1.5 for visit-specific satisfaction on a 1 to 5 scale, with 1 representing "excellent"). Satisfaction was not related to whether expectations were met or unmet, except that patients who did not receive desired medications reported lower satisfaction.

CONCLUSIONS

Patients' expectations are varied and often vague. Clinicians trying to implement the values of patient-centered care must be prepared to elicit, identify, and address many expectations.

Research in home-care telemedicine: challenges in patient recruitment

This study reports challenges in recruiting patients for a randomized controlled trial of homecare telemedicine. Descriptive statistics on patient eligibility for home-care telemedicine services and patient refusals for participation are provided. Frequency counts of reasons for study exclusion and participant refusal and Chi-square tests to compare race and age-related differences are given. Of 302 home-care patients reviewed, 197 (65.2%) did not meet inclusion criteria. The most common reasons for study exclusion were patients either needing <2 visits per month (n = 59, 30%) or >3 skilled nurse visits per week (n = 46, 23.4%). Of the eligible patients (n = 105), 79 persons (75.2%) refused participation. The most common reasons for refusals were lack of perceived addition benefit of telemedicine (n = 27, 34.2%), and that routine health care was sufficient (n = 23, 29.1%). Higher than expected proportions of patients did not meet chosen eligibility criteria or refused to participate. These results should be helpful in designing home-care telemedicine programs and clinical trials.

Parents’ expectations regarding their children’s eye care: interview results

PURPOSE

To determine a relevant set of concerns that parents express as expectations regarding their children's eye care.

DESIGN

Qualitative, cross-sectional, pilot study.

METHODS

A total of 48 interviews were conducted with parents of pediatric ophthalmology patients at Duke University Eye Center and the McGovern Davidson Children's Health Center at Duke University to elicit parents' expectations regarding their children's eye care. Interviews were audiotaped, transcribed, and coded for parent expectations.

RESULTS

Content analysis of transcripts from the 48 interviews yielded 35 different expectation areas for eye care, which were further classified into six groups: (1) Communication, (2) Interpersonal Manner, (3) Doctor's Skill, (4) Examination and Testing, (5) Logistics, and (6) Other. The six expectation areas most frequently identified by parents as the single "most important" expectation were the following: (1) Clinical Competence, (2) Interaction with Child, (3) Education/Training, (4) Explanation in Clear Language, (5) Information about Diagnosis, and (6) Personal Connection.

CONCLUSIONS

Parents of pediatric ophthalmology patients expressed expectation areas in the Communication group more frequently than any other group. However, when asked to identify their single most important expectation area, more than half of parents identified Clinical Competence.

Chinese fishermen's expectations on medications

This study aimed to explore the expectations on medications of Chinese fishermen, a group of culturally distinct people, when they consult their family doctors. A qualitative method of semistructured focus group interviews was used for data collection. Twenty-nine participants took part in eight focus group interviews. They were all from the southern district of Hong Kong Island where many of the residents have a fishing background. Their expectations of doctors' willingness to give them medicines might originate from their previous experiences with traditional therapies. Although some would prefer the medicines to be potent while others like them not to be too strong, they all wanted the medicines to lead them to fast recovery. It is therefore important for their western-trained family doctors to be culturally sensitive to their expectations and, hence, make more effort in explaining the use and misuse of medicines.

The problem with measuring patient perceptions of outcome with existing outcome measures in foot and ankle surgery

Quality outcome measures are the cornerstone of clinical research. A review of outcome measures used in foot and ankle surgery research reveals that the issues of validity, reliability and responsiveness of outcome measures have not been addressed. Most reports in the literature have attempted to evaluate patient perceptions of outcome following foot surgery. Underlying the many difficulties with these outcome measures is a lack of understanding of what patients perceive to be important in terms of outcome. Consequently none of the existing outcome measures can claim to be valid measures of patient perceptions of outcome, as there has been no research uncovering these perceptions. In addition, measures of general health status and quality of life in relation to outcome of foot and ankle surgery have been largely ignored to date.

Unmet expectations for care and the patient-physician relationship

OBJECTIVE

To profile patients likely to have unmet expectations for care, examine the effects of such expectations, and investigate how physicians' responses to patients' requests affect the development of unfulfilled expectations.

DESIGN

Patient and physician questionnaires were administered before and after outpatient visits. A follow-up telephone survey was administered 2 weeks post visit.

SETTING

The offices of 45 family practice, internal medicine, and cardiology physicians.

PATIENTS

Nine hundred nine adults reporting a health problem or concern.

MEASUREMENTS AND MAIN RESULTS

Before their visits, patients rated their general health and trust in the index physician. After the visit, patients reported upon 8 types of unmet expectations and any request they made. Two weeks thereafter, patients rated their visit satisfaction, improvement, and intention to adhere to the physician's advice. They also reported any postvisit health system contacts. Overall, 11.6% of patients reported >/=1 unmet expectation. Visits in which a patient held an unmet expectation were rated by physicians as less satisfying and more effortful. At follow-up, patients who perceived an unmet expectation for care also reported less satisfaction with their visits, less improvement, and weaker intentions to adhere. Patients with an unmet expectation related to clinical resource allocation had more postvisit health system contacts. Unmet expectations were typically reported by a patient whose request for a resource was not fulfilled.

CONCLUSIONS

Unmet expectations adversely affect patients and physicians alike. Physicians' nonfulfillment of patients' requests plays a significant role in patients' beliefs that their physicians did not meet their expectations for care.

The mismatch between urban women's preferences for and experiences with primary care

Socioeconomic disparities in women's primary care experiences have been described previously. To better understand whether these disparities reflect personal preferences for primary care, rather than insurance or other access barriers, we conducted a telephone survey of a community-based sample of 1,205 women in Washington, DC. The study found that women of lower socioeconomic status had poorer primary care experiences compared with higher income counterparts, despite similarly high preferences for primary care. The poorer primary care experiences of lower socioeconomic status women were attenuated by better access to primary care. Differences in primary care attainment are not solely a matter of personal preferences; rather, they appear to be more strongly related to barriers to obtaining care.

Measuring patient expectations: does the instrument affect satisfaction or expectations?

BACKGROUND

Fulfillment of patients' expectations may influence health care utilization, affect patient satisfaction, and be used to indicate quality of care. Several different instruments have been used to measure expectations, yet little is known about how different assessment methods affect outcomes.

OBJECTIVE

The object of the study was to determine whether different measurement instruments elicit different numbers and types of expectations and different levels of patient satisfaction.

DESIGN

Patients waiting to see their physician were randomly assigned to receive 1 of 2 commonly used instruments assessing expectations or were assigned to a third (control) group that was not asked about expectations. After the visit, patients in all 3 groups were asked about their satisfaction and services they received.

SUBJECTS

The study subjects were 290 male, primary care outpatients in a VA general medicine clinic.

MEASURES

A "short" instrument asked about 3 general expectations for tests, referrals, and new medications, while a "long" instrument nested similar questions within a more detailed list. Wording also differed between the 2 instruments. The short instrument asked patients what they wanted; the long instrument asked patients what they thought was necessary for the physician to do. Satisfaction was measured with a visit-specific questionnaire and a more general assessment of physician interpersonal skills.

RESULTS

Patients receiving the long instrument were more likely to express expectations for tests (83% vs. 28%, P <0.001), referrals (40% vs. 18%, P <0.001), and new medications (45% vs. 28%, P <0.001). The groups differed in the number of unmet expectations: 40% of the long instrument group reported at least 1 unmet expectation compared with 19% of the short instrument group (P <0.001). Satisfaction was similar among the 3 groups.

CONCLUSIONS

These different instruments elicit different numbers of expectations but do not affect patient satisfaction.

Enhancing prevention in primary care: are interventions targeted towards consumers' and providers' perceived needs?

OBJECTIVE: To explore perceived barriers to the implementation of prevention guidelines, with a particular interest to perceived information needs from the point of view of health professionals and consumers. STUDY DESIGN: Focus group. SETTING AND PARTICIPANTS: Eight focus groups were held in three Canadian cities: three with consumer, three with family physician, and two with primary care nurses. ANALYSIS: Inductive analysis based on transcribed interviews. The material was analysed by two of the investigators. Agreement on interpretation was checked independently by three other researchers on 10% of the material. RESULTS: Lack of motivation, discontinuity of care and lack of adequate remuneration were perceived as the strongest barriers to prevention implementation. Computerized information management systems were not perceived by physicians and nurses as strong facilitating factors. Consumers expressed strongly a need for information on non-traditional preventive interventions. Physicians and nurses expressed a need for patient education material more than for practice guidelines. Research evidence was not considered as the first criteria to judge the value of preventive information. CONCLUSIONS: Evidence-based medicine has triggered a massive effort to develop technologies to support the dissemination of evidence-based information on the assumption that poor access to such information is an important barrier to implementation of effective practices. Our results suggest that such an assumption may not be correct. Providing only evidence-based information from the realm of traditional medicine will appear restrictive to most users, particularly to consumers, and may not be as valued as anticipated considering the expressed scepticism toward research evidence.

Using a new method of gathering patient satisfaction data to assess the effects of organizational factors on primary care quality

BACKGROUND

As health care in the United States evolves increasingly toward managed care, there are continuing concerns about maintaining the quality of the physician-patient interaction, of which patient satisfaction is one measure. A quality assessment tool that measures both patient satisfaction with care and the ways organizational factors affect satisfaction will enable clinicians and administrators to redesign the care process accordingly. SURVEY METHODOLOGY: The measure of the quality of a physician office visit includes both the administration of a standardized satisfaction instrument and direct observation of the patient throughout the care process. This methodology was tested in 1997-1998 on an initial sample of 291 patients at a large multispecialty medical group in northern California. The surveyor recorded objective characteristics of the visit, surveyed patients about their impression of certain aspects of the visit related to satisfaction, and administered a standardized visit satisfaction survey. A second set of control patients who visited the same physician on the same day was contacted by phone and given the satisfaction survey two to four weeks later.

PRINCIPAL FINDINGS

Patients readily accepted the presence of a surveyor during their visit, with an overall response rate of 78%. While patients contacted retrospectively gave lower satisfaction ratings, the presence of a surveyor did not affect patients' satisfaction responses. Data obtained by using the concurrent methodology provides significant information about organizational factors influencing patient satisfaction.

CONCLUSIONS

Measuring patient satisfaction concurrently during a physician office visit offers an attractive alternative to other methods of measuring this key aspect of quality.

Practice guidelines for clinical prevention: do patients, physicians and experts share common ground?

BACKGROUND

Clinical practice guidelines, such as those of the Canadian Task Force on Preventive Health Care, although based on sound evidence, may conflict with the perceived needs and expectations of patients and physicians. This may jeopardize the implementation of such guidelines. This study was undertaken to explore patients' and family physicians' acceptance of the task force's recommendations and the values and criteria upon which the opinions of these 2 groups are based.

METHODS

Focus groups were used to collect study data. In total, 35 physicians (in 7 groups) and 75 patient representatives (in 9 groups) participated in the focus groups. An inductive approach was used to develop coding grids and to generate themes from the transcripts of the interviews.

RESULTS

Physicians expressed resistance to discontinuing the annual check-up, which they viewed as an organizational strategy to counteract the many barriers to preventive care that they encounter. They reported difficulties in explaining to their patients the recommendations of the Canadian Task Force on Preventive Health Care, which they found complex and inconsistent with popular wisdom. Both patients and physicians attributed high value to the detection of insidious diseases, even in the absence of proof of the effectiveness of such activity.

INTERPRETATION

The patients and family physicians who participated in this study shared many opinions on the value of preventive activities that depart from the values used by "prevention experts" such as the Canadian Task Force on Preventive Health Care in establishing their recommendations. A better understanding of the values of patients and physicians would help guideline developers to create better targeted communication strategies to take these discrepancies into account.

Patients' desires and expectations for medical care: a challenge to improving patient satisfaction

Patients' desires and expectations for medical care warrant scrutiny because of their potential influence on health care use and patient satisfaction and their effects on patients' perceptions of quality of care. To determine if desires and expectations for selected elements of medical care and specialty referral differ between VA outpatients and non-VA outpatients, we conducted a cross-sectional survey of patients at a VA medical center site and 2 primary care sites of its university affiliate. Of 390 eligible patients at the VA medical center site, 270 (69%) consented to participate and returned completed self-administered questionnaires. At its university affiliate sites, 119 (73%) of the 162 eligible patients completed questionnaires. Overall, patient desire and expectation for elements of medical care and specialty referral were similar and high at all study sites. Desire ranged from 33% for a blood test to check for anemia to 80% for heart auscultation. Desire for specialty referral for hypothetical scenarios averaged 71% and 61% among VA Medical Center patients and university affiliate patients, respectively. Patient demographics and socioeconomic status were poor predictors of desire for care. These results suggest (a) that VA medical center outpatients' desires and expectations for preventive medical care are not significantly different from those of non-VA outpatients, (b) that desire is often high for both highly recommended care and care that is not generally recommended or is controversial, and (c) that high levels of desire are not limited to patients of higher levels of socioeconomic status. In an effort to improve satisfaction, it is important to examine ways in which to address patients' desires and expectations for medical care, even while faced with competing health care spending priorities.