Factors associated with Americans' ratings of health care quality: what do they tell us about the raters and the health care system?

Association of the affordable care act with perceived health care quality of cancer survivors

BACKGROUND

The association between the Patient Protection and Affordable Care Act (ACA) and perceptions of health care quality of cancer survivors is not well established. The purpose of this study was to examine changes in perceived health care quality concurrent with the implementation of the ACA among cancer survivors relative to a non-cancer comparison group.

METHODS

We used cross-sectional data from the Health Information National Trends Survey (N = 30,542). Participants were considered cancer survivors if they had a diagnosis greater than five years before the interview. The pre-ACA period included the years 2008 through 2014. The post-ACA period included 2017 through 2020. Using difference-in-differences methods, we estimated the association of ACA implementation with perceived health care quality (measured from excellent to fair/poor) using propensity score-matched cancer survivors (n = 2298) and a non-cancer comparison group (n = 6669) with weighted logistic models.

RESULTS

There were similar distributions of perceptions of excellent, very good, good, and fair/poor health care quality regardless of cancer status or time-period. The pre-post ACA implementation difference of reporting excellent, very good and good health care quality (odds ratio [OR]: 1.0, 95% confidence interval [CI]: 0.83-1.19; OR: 0.98, 95% CI 0.83-1.19; and OR: 1.05, 95% CI: 0.87-1.28 respectively) compared to fair/poor was similar in cancer survivors relative to the non-cancer comparison group.

CONCLUSIONS

The initial implementation of the ACA appeared to have no effect on perceived overall health care quality reported by cancer survivors when compared to individuals without a history of cancer. Health care policies and domains which continue to support better patient-perceived care quality should be assessed in the cancer survivor population.

An integrative model of patients' perceived value of healthcare service quality in North Cyprus

Background

Improving healthcare quality has become an essential objective for all health institutions worldwide to address the need to improve services, manage costs and satisfy patient expectations about the quality of care. As health is one of the leading service sectors of the North Cyprus economy, analysing patients’ perceived value of healthcare service quality is crucial. In this research, a comparative analysis of existing models revealed affordability, acceptability and accessibility as the leading modern service quality indicators affecting patients’ perceived value of healthcare service quality. The quality of services is a leading factor impacting business competition and retention dictated by the current market. This study aimed to investigate the factors that influence patient perceptions of healthcare service quality in North Cyprus.

Methods

A self-administered questionnaire was carried out among 388 patients of public and private hospitals in North Cyprus, and the data were analysed using partial least squares-structural equation modelling.

Results

Empirical results highlight that the acceptability of healthcare services is a prerequisite for perceiving a high value of service quality. The affordability and accessibility of services, respectively, were less effective. Results concerning mediating effects confirm that acceptability could fully mediate the relationship between affordability and perceived value and could partially mediate the impact of accessibility on the perceived quality of healthcare services.

Conclusion

This study contributes to healthcare theory and practice by developing a conceptual framework to provide policymakers and managers with a practical understanding of factors that affect healthcare service quality.

Assessment of Discordance Between Physicians and Family Members Regarding Prognosis in Patients With Severe Acute Brain Injury

IMPORTANCE

Shared decision-making requires key stakeholders to align in perceptions of prognosis and likely treatment outcomes.

OBJECTIVE

For patients with severe acute brain injury, the objective of this study was to better understand prognosis discordance between physicians and families by determining prevalence and associated factors.

DESIGN, SETTING, AND PARTICIPANTS

This mixed-methods cross-sectional study analyzed a cohort collected from January 4, 2018, to July 22, 2020. This study was conducted in the medical and cardiac intensive care units of a single neuroscience center. Participants included families, physicians, and nurses of patients admitted with severe acute brain injury.

EXPOSURES

Severe acute brain injury was defined as stroke, traumatic brain injury, or hypoxic ischemic encephalopathy with a Glasgow Coma Scale score less than or equal to 12 points after hospital day 2.

MAIN OUTCOMES AND MEASURES

Prognosis discordance was defined as a 20% or greater difference between family and physician prognosis predictions; misunderstanding was defined as a 20% or greater difference between physician prediction and the family's estimate of physician prediction; and optimistic belief difference was defined as any difference (>0%) between family prediction and their estimate of physician prediction. Logistic regression was used to identify associations with discordance. Optimistic belief differences were analyzed as a subgroup of prognosis discordance.

RESULTS

Among 222 enrolled patients, prognostic predictions were available for 193 patients (mean [SD] age, 57 [19] years; 106 men [55%]). Prognosis discordance occurred for 118 patients (61%) and was significantly more common among families who identified with minoritized racial groups compared with White families (odds ratio [OR], 3.14; CI, 1.40-7.07, P = .006); among siblings (OR, 4.93; 95% CI, 1.35-17.93, P = .02) and adult children (OR, 2.43; 95% CI, 1.10-5.37; P = .03) compared with spouses; and when nurses perceived family understanding as poor compared with good (OR, 3.73; 95% CI, 1.88-7.40; P < .001). Misunderstanding was present for 80 of 173 patients (46%) evaluated for this type of prognosis discordance, and optimistic belief difference was present for 94 of 173 patients (54%). In qualitative analysis, faith and uncertainty emerged as themes underlying belief differences. Nurse perception of poor family understanding was significantly associated with misunderstanding (OR, 2.06; 95% CI, 1.07-3.94; P = .03), and physician perception with optimistic belief differences (OR, 2.32; 95% CI, 1.10-4.88; P = .03).

CONCLUSIONS AND RELEVANCE

Results of this cross-sectional study suggest that for patients with severe acute brain injury, prognosis discordance between physicians and families was common. Efforts to improve communication and decision-making should aim to reduce this discordance and find ways to target both misunderstanding and optimistic belief differences.

Patient experience of hospital care in China: major findings from the Chinese Patient Experience Questionnaire Survey (2016-2018)

OBJECTIVES

China launched the National Healthcare Improvement Initiative (NHII) in 2015 to improve patient experiences in healthcare. This study aimed to generate evidence of hospital care quality from the patients' perspective.

DESIGN

This nationwide cross-sectional study interviewed participants from 31 provinces, municipalities and autonomous regions across China.

SETTING

A total of 117 tertiary hospitals in mainland China.

PARTICIPANTS

48 422 responses from outpatients and 35 957 responses from inpatients were included in this study.

PRIMARY OUTCOME MEASURE

The scores of six predefined domains in the Chinese Patient Experience Questionnaire, five of which were designed to reflect specific dimensions of care, and one of which indicated the overall rating.

RESULTS

More than 80% of the respondents viewed their care experiences as positive. The NHII seems to have had a positive impact, as indicated by the steady, although unremarkable, increase in the patient experience scores over the 2016-2018 period. The Chinese patients generally reported a positive experience with the clinical aspects of care, but reported a less positive experience with the environmental, interpersonal and social services aspects of care. The institutional factors, including region and type of hospital, and personal factors, such as gender, age, education and occupation, were factors affecting the patient experience in China. Humanistic care was the aspect of care with the greatest association with the overall patient experience rating in both the outpatient and inpatient settings.

CONCLUSIONS

The national survey indicated an overall positive patient perspective of care in China. Older age, higher education level and formal employment status were found to be correlated with positive care experiences, as were higher levels of economic development of the region, a more generous insurance benefits package and a higher degree of coordinated care. The interpersonal-related initiatives had substantial roles in the improvement of the patient experience. In the regions where farmers and users of traditional Chinese medicine services constitute a greater proportion of the population, improvement of patient experiences for these groups deserves special policy attention.

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.

Effect of the treatment-before-deposit policy on trust in physicians and perceived service quality among patients in 12 hospitals in China

This study examined effects of the treatment-before-deposit policy on Chinese patients' trust in physicians and perceived service quality. This study included 3313 patients recruited from 12 hospitals in China. The research team used cross-sectional survey to examine Chinese patients' experience with the treatment-before-deposit policy, perceived service quality, and trust in their physicians. Using mediation analysis, we estimated direct and indirect effects of the treatment-before-deposit policy on patients' perceived service quality and trust in their physicians. Patients who benefitted from the treatment-before-deposit policy reported greater service quality and higher trust in their physicians. The impacts of whether patients benefitted from the policy on trust in physicians were fully mediated by perceived service quality with statistically significant indirect effect. The results support the hypothesis that the treatment-before-deposit policy improves patients' perceived service quality and trust in physicians.

Patient Centered Medical Home Care Among Near-Old and Older Race/Ethnic Minorities in the US: Findings from the Medical Expenditures Panel Survey

Access to Patient Centered Medical Home (PCMH) care has not been explored among older racial/ethnic minorities. We used data on adults 55-years and older from the Medical Expenditure Panel Survey (2008-2013). We account for five features of PCMH experiences and focus on respondents self-identifying as Non-Latino White, Black, and Latino. We used regression models to examine associations between PCMH care and its domains and race/ethnicity and decomposition techniques to assess contribution to differences by predisposing, enabling and health need factors. We found low overall access and significant racial/ethnic variations in experiences of PCMH. Our results indicated strong deficiencies in access to a personal primary care physician provided healthcare. Factors contributing to differences in reported PCMH experiences relative to Whites differed by racial/ethnic grouping. Policy initiatives aimed at addressing accessibility to personal physician directed healthcare could potentially reduce racial/ethnic differences while increasing national access to PCMH care.

Access to Electronic Personal Health Records Among Patients With Multiple Chronic Conditions: A Secondary Data Analysis

BACKGROUND

In the United States, national incentives for offering access to electronic personal health records (ePHRs) through electronic means are geared toward creating a culture of patient engagement. One group of patients who stand to benefit from online access to ePHRs is the growing population with multiple chronic conditions (MCC). However, little is known about the current availability and use of ePHRs and patient portals among those managing MCC.

OBJECTIVE

The aim was to determine the associations between number of chronic conditions and sociodemographic characteristics and usage of ePHRs, and to assess how the public's use of ePHRs varies across subpopulations, including those with MCC.

METHODS

This study used data collected from the 2014 Health Information National Trends Survey (HINTS), and assessed differences in use of ePHRs between those with and without MCC (N=3497) using multiple logistic regression techniques. Variables associated with health care systems (insurance status, having a regular provider) and patient-reported self-efficacy were included in the statistical models.

RESULTS

Those with MCC (n=1555) had significantly higher odds of accessing their records three or more times in the past year compared to those reporting no chronic conditions (n=1050; OR 2.46, 95% CI 1.37-4.45), but the overall percentage of those with MCC using ePHRs remained low (371 of 1529 item respondents, 25.63% weighted). No difference in odds of accessing their records was found between those reporting one chronic condition (n=892) and those reporting none (n=1050; OR 1.02, 95% CI 0.66-1.58). Significant differences in odds of accessing ePHRs were seen between income and age groups (P<.001 and P=.05, respectively), and by whether respondents had a regular provider (P=.03).

CONCLUSIONS

We conclude that ePHRs provide a unique opportunity to enhance MCC patient self-management, but additional effort is needed to ensure that these patients are able to access their ePHRs. An increase in availability of patient access to their ePHRs may provide an opportunity to increase patient engagement and support self-management for all patients and especially those with MCC.

Race, income, and education: associations with patient and family ratings of end-of-life care and communication provided by physicians-in-training

BACKGROUND

Minority race and lower socioeconomic status are associated with poorer patient ratings of health care quality and provider communication.

OBJECTIVE

To examine the association of race/ethnicity or socioeconomic status with patients' and families' ratings of end-of-life care and communication about end-of-life care provided by physicians-in-training.

METHODS

As a component of a randomized trial evaluating a program designed to improve clinician communication about end-of-life care, patients and patients' families completed preintervention survey data regarding care and communication provided by internal medicine residents and medical subspecialty fellows. We examined associations between patient and family race or socioeconomic status and ratings they gave trainees on two questionnaires: the Quality of End-of-Life Care (QEOLC) and Quality of Communication (QOC).

RESULTS

Patients from racial/ethnic minority groups, patients with lower income, and patients with lower educational attainment gave trainees higher ratings on the end-of-life care subscale of the QOC (QOCeol). In path models, patient educational attainment and income had a direct effect on outcomes, while race/ethnicity did not. Lower family educational attainment was also associated with higher trainee ratings on the QOCeol, while family non-white race was associated with lower trainee ratings on the QEOLC and general subscale of the QOC.

CONCLUSIONS

Patient race is associated with perceptions of the quality of communication about end-of-life care provided by physicians-in-training, but the association was opposite to our hypothesis and appears to be mediated by socioeconomic status. Family member predictors of these perceptions differ from those observed for patients. Further investigation of these associations may guide interventions to improve care delivered to patients and families.

Picking up the pace: changes in method and frame for the health information national trends survey (2011-2014)

Health communication and health information technology influence the ways in which health care professionals and the public seek, use, and comprehend health information. The Health Information National Trends Survey (HINTS) program was developed to assess the effect of health communication and health information technology on health-related attitudes, knowledge, and behavior. HINTS has fielded 3 national data collections with the fourth (HINTS 4) currently underway. Throughout this time, the Journal of Health Communication has been a dedicated partner in disseminating research based on HINTS data. Thus, the authors thought it the perfect venue to provide an historical overview of the HINTS program and to introduce the most recent HINTS data collection effort. This commentary describes the rationale for and structure of HINTS 4, summarizes the methodological approach applied in Cycle 1 of HINTS 4, describes the timeline for the HINTS 4 data collection, and identifies priorities for research using HINTS 4 data.

Who gets a teach-back? Patient-reported incidence of experiencing a teach-back

To ensure comprehension, clinicians have been urged to use "teach-backs"-explicitly asking patients to repeat back key points of instruction-with every patient receiving new care management instructions. Yet, it is not known whether certain patient groups are more likely to receive teach-backs than others. This study used results from the patient survey of the Communication Climate Assessment Toolkit to examine patient-reported incidence of teach-back by patient education level, age, language preference, race/ethnicity, and perception of sufficient time with doctors. In a multivariable model, patients had significantly greater odds of reporting a teach-back if they were of African American race/ethnicity, had non-English language preference, less education, increased age, or perceived that they had sufficient time with their doctor. This study concludes that some physicians seem to be directing teach-back efforts at certain patients, including those from demographic groups where lower literacy is more common, potentially leading patients who could benefit from teach-back to be overlooked. In addition, the strong correlation between reporting receiving a teach-back and reporting having enough time with a doctor merits further study.