Patient-reported experiences with hospitals: comparison of proxy and patient scores using propensity-score matching

Factors influencing patient experience in hospital wards: a systematic review

BACKGROUND

Patient experience plays an essential role in improving clinical effectiveness and patient safety. It's important to identify factors influencing patient experience and to improve quality of healthcare.

OBJECTIVE

To identify factors that influence patient experience in hospital wards.

METHODS

We conducted a systematic review including six databases; they were PubMed, CINAHL, Embase, PsycInfo, ProQuest, and Cochrane. Studies were included if they met the inclusion criteria. The JBI checklist was used to perform quality appraisal. We used 5 domains of the ecological model to organize and synthesize our findings to comprehensively understand the multi-level factors influencing the issue.

RESULT

A total of 138 studies were included, and 164 factors were identified. These factors were integrated into 6 domains. All domains but one (survey-related factors) could be mapped onto the attributes of the ecological framework: intrapersonal, interpersonal, institutional, community, and public policy level factors. All factors had mixed effect on patient experience. The intrapersonal level refers to individual characteristics of patients. The interpersonal level refers to interactions between patients and healthcare providers, such as the caring time spent by a nurse. The institutional level refers to organizational characteristics, rules and regulations for operations, such as hospital size and accreditation. The community level refers to relationships among organizations, institutions, and informational networks within defined boundaries, such as a hospital located in a larger population area. Public policy level refers to local, state, national, and global laws and policies, including health insurance policies. The sixth domain, survey-related factors, was added to the framework and included factors such as survey response rate and survey response time.

CONCLUSION

The factors influencing patient experience are comprehensive, ranging from intrapersonal to public policy. Providers should adopt a holistic and integrated perspective to assess patient experience and develop context-specific interventions to improve the quality of care. PROSPERO REGISTRATION NUMBER CRD42023401066.

Impact of Prediagnosis Risk of Major Depressive Disorder and Health-Related Quality of Life on Treatment Choice for Stage II-III Rectal Cancer

PURPOSE

We hypothesized that depressive symptoms and health-related quality of life (HRQOL) reported by patients before their cancer diagnoses would be associated with treatment choice for stage II and III rectal cancer, specifically whether patients underwent surgery.

METHODS

The Surveillance, Epidemiology, and End Results and Medicare Health Outcomes Survey linked data set was used to identify patients with stage II-III rectal adenocarcinoma diagnosed between 2004 and 2013 who had completed the health outcomes survey within 36 months before their cancer diagnoses. Risk for major depressive disorder (MDD) was determined on the basis of responses to screening questions for depressive disorders. HRQOL was assessed using the Mental Component Summary and Physical Component Summary of the 36-Item Short Form Survey and Veterans RAND 12-Item Health Survey. Using univariable and multivariable analyses, we assessed for associations between health survey responses and ultimate treatment modality.

RESULTS

We identified 142 evaluable patients, of whom 109 (76.8%) underwent surgery. Thirty patients (21.1%) met criteria for being at risk for MDD before their cancer diagnoses. Patients at risk for MDD underwent surgery less often than those not at risk (P = .0499), and this association strengthened after adjusting for patient characteristics (odds ratio, 0.17; 95% CI, 0.04 to 0.82; P = .027). There was a nonsignificant trend between higher Mental Component Summary scores (indicating higher self-reported mental HRQOL) and increased frequency of undergoing surgery (P = .081). There were no significant associations between the Physical Component Summary and treatment modality.

CONCLUSION

In Medicare beneficiaries with stage II-III rectal cancer, those at risk for MDD underwent standard-of-care treatment with surgery less frequently. Further studies are warranted to assess the effect of mental health on clinical decision making in this patient population.

The use of proxies and proxy-reported measures: a report of the international society for quality of life research (ISOQOL) proxy task force

AIMS

Proxy reports are often used when patients are unable to self-report. It is unclear how proxy measures are currently in use in adult health care and research settings. We aimed to describe how proxy reports are used in these settings, including the use of measures developed specifically for proxy reporting in adult health populations.

METHODS

We systematically searched Medline, PsycINFO, PsycTESTS, CINAHL and EMBASE from database inception to February 2018. Search terms included a combination of terms for quality of life and health outcomes, proxy-reporters, and health condition terms. The data extracted included clinical context, the name of the proxy measure(s) used and other descriptive data. We determined whether the measures were developed specifically for proxy use or were existing measures adapted for proxy use.

RESULTS

The database search identified 17,677 possible articles, from which 14,098 abstracts were reviewed. Of these, 11,763 were excluded and 2335 articles were reviewed in full, with 880 included for data extraction. The most common clinical settings were dementia (30%), geriatrics (15%) and cancer (13%). A majority of articles (51%) were paired studies with proxy and patient responses for the same person on the same measure. Most paired studies (77%) were concordance studies comparing patient and proxy responses on these measures.

DISCUSSION

Most published research using proxies has focused on proxy-patient concordance. Relatively few measures used in research with proxies were specifically developed for proxy use. Future work is needed to examine the performance of measures specifically developed for proxies.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO No. CRD42018103179.

Patient experiences with general practice in Norway: a comparison of immigrant groups and the majority population following a national survey

Background

Patient experience is an important indicator of quality of health care. In Norway, little is known about the quality of health care for immigrants. The aim of this study was to compare patient-reported experiences with general practice between the Norwegian-born population and immigrant groups.

Methods

We performed secondary analyses of data from a national survey on patient experiences with general practice, including assessments of general practitioners (GPs) and their GP offices. The survey was carried out in Norway in 2018–19. The total number of respondents was 2029, with a response rate of 42.6%. Region of birth was available for 1981 participants, and these were included in the analyses (“Norway” (N = 1756), “Asia, Africa or South America” (N = 95), “Eastern Europe” (N = 70) and “Western Europe, North America or Oceania” (N = 60)). Five indicators of patient experiences were used as dependent variables in bivariate and multivariate analyses, with region of birth as the main exposure variable and other background variables about the patient as adjustment variables: “the GP” (measures related to communication and competency), “auxiliary staff” (politeness, competency, organization), “accessibility” (waiting times), “coordination” (with other services) and `enablement` (GP facilitates coping with/understanding illness).

Results

Immigrants as a whole reported poorer experiences with general practice than the majority population, with significantly poorer scores on four of five patient experience indicators. Patients from Asia/Africa/South America reported poorer experiences than those from Norway on the indicators “GP”, “auxiliary staff”, “accessibility” and “coordination”: on a scale from 0 to 100 where 100 is the best, the difference ranged from 7.8 (GP) to 20.3 (accessibility). Patients from Eastern Europe reported lower scores on “GP” and patients from Western Europe/North America/Oceania reported lower scores on “auxiliary staff”. These associations were still significant after adjustment for sex, age, self-rated physical and mental health, number of contacts with the GP and education.

Conclusions

For countries with a substantial proportion of foreign-born patients in the health system, immigrant background is an important parameter in quality improvement work. Immigrant background is also an important parameter in health service research.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-05963-3.

Patient and proxy reports regarding the experience of treatment decision-making in cancer care

OBJECTIVE

Shared decision-making, including the elicitation of patient preferences regarding treatment decisions, is considered part of high-quality cancer care. However, patients may not be able to self-report due to illness, and therefore proxy reports may be used. We sought to determine the difference between proxy and patient reports about patient decisions and preferences among patients who received or were scheduled for chemotherapy using data from a large, population-based survey of patients with incident lung or colorectal cancer.

METHODS

Of 3573 patients who received or were scheduled for chemotherapy, 3108 self-reported and 465 had proxies reporting on their behalf about preferred and actual decision roles regarding this treatment. Preferred and actual decision roles were assessed using the Control Preferences Scale, and categorized as shared, patient-controlled, or doctor-controlled. Multivariable logistic regression models were used to assess the association between patient and proxy responses and whether preferences were met. The models adjusted for sociodemographic and clinical variables and patient/proxy-reported health status.

RESULTS

Sixty-three percent of all respondents reported actual roles in decisions that matched their preferred roles (role attainment). Proxies and patients were similarly likely to report role attainment (65% vs 63%). In adjusted analyses, proxies were more likely report role attainment (OR = 1.27, 95%CI = 1.02-1.59), but this difference was smaller if health variables were excluded from the model (OR = 1.14, 95%CI = 0.92-1.41).

CONCLUSION

Most patients' preferences for treatment participation were met. Surveys from proxies appear to yield small differences on the reports of attainment of preferred treatment decision-making roles in cancer care vs surveys from patients.

Associations between adolescent experiences, parent experiences and HbA1c: results following two surveys based on the Norwegian Childhood Diabetes Registry (NCDR)

OBJECTIVE

The aim of the current study was to determine the association between the experiences of adolescents and their parents with paediatric diabetes care at hospital outpatient departments and the association between these experiences and the Hemoglobin A1c (HbA1c) levels of adolescents.

DESIGN

Cross-sectional survey.

SETTING

Paediatric diabetes care at hospital outpatient departments in Norway.

PARTICIPANTS

Parents of all outpatients registered in the Norwegian Childhood Diabetes Registry and patients in the same registry aged 12-17 years.

INTERVENTION

1399 parents participated in a national pilot survey and 335 patients aged 12-17 years from the four largest paediatric outpatient departments in Norway responded in another pilot study. 181 paired parental and patient questionnaires were analysed.

MAIN OUTCOME MEASURES

The correlations between single items, indicator scores and overall scores were explored, as was that between indicator scores and HbA1c levels.

RESULTS

There was a moderate but significant correlation between the responses of the patients and parents. For 40 of the 42 associations the correlations were significant, ranging from 0.16 to 0.42. A weak but significant negative correlation was found between the indicator scores of parents and the HbA1c levels of the adolescents. The strongest correlations were between HbA1c level and nurse contact and organisation, both with a correlation coefficient of 0.21 (p<0.01). There was no significant correlation between HbA1c level and patient indicator scores.

CONCLUSIONS

These results highlight the need to obtain information from both parents and adolescents, and indicate that the views of adolescents are not always mirrored by their parents. Three of the seven parent experience indicators were significantly related to the HbA1c levels of adolescents, but replication in future research with larger sample sizes is warranted.

The Association of Proxy Care Engagement with Proxy Reports of Patient Experience and Quality of Life

OBJECTIVE

To assess the association of proxy-specific covariates with proxy-reported patient cancer care experience, quality rating, and quality of life.

DATA SOURCES/STUDY SETTING

Secondary analysis of data from the Cancer Care Outcomes Research and Surveillance (CanCORS) study.

STUDY DESIGN

Cross-sectional observational study. The respondents were proxies for patients with incident colorectal or lung cancer.

DATA COLLECTION/EXTRACTION METHODS

Analyses used linear regression models and adjusted for patient sociodemographic and clinical characteristics. Outcomes included patients' experiences with medical care, nursing care, and care coordination, overall quality ratings, and physical and mental health, all scored on 0-100 scales (0 = worst, 100 = best). Independent variables included the proxy's relationship with the patient and engagement in patient care.

PRINCIPAL FINDINGS

Of 1,011 proxies, most were the patient's spouse (50 percent) or child (36 percent). Although most proxies (66 percent) always attended medical visits, 3 percent reported never attending. After adjustment, on average children reported worse experiences and poorer quality care than spouses (4-9 points lower across outcomes). Proxies who never attended medical visits reported significantly worse medical care (-11 points, 95 percent CI = -18 to -3) and care coordination (-13 points, 95 percent CI = -20 to -6).

CONCLUSIONS

Collecting data on proxy engagement in care is warranted if proxy responses are used.

The PU-PROM: A patient-reported outcome measure for peptic ulcer disease

Objective

Patient‐reported outcome measure (PROM) conceived to enable description of treatment‐related effects, from the patient perspective, bring the potential to improve in clinical research, and to provide patients with accurate information. Therefore, the aim of this study was to develop a patient‐centred peptic ulcer patient‐reported outcome measure (PU‐PROM) and evaluate its reliability, validity, differential item functioning (DIF) and feasibility.

Method

To develop a conceptual framework and item pool for the PU‐PROM, we performed a literature review and consulted other measures created in China and other countries. Beyond that, we interviewed 10 patients with peptic ulcers, and consulted six key experts to ensure that all germane parameters were included. In the first item selection phase, classical test theory and item response theory were used to select and adjust items to shape the preliminary measure completed by 130 patients and 50 controls. In the next phase, the measure was evaluated used the same methods with 492 patients and 124 controls. Finally, we used the same population in the second item reselection to assess the reliability, validity, DIF and feasibility of the final measure.

Results

The final peptic ulcer PRO measure comprised four domains (physiology, psychology, society and treatment), with 11 subdomains, and 54 items. The Cronbach's α coefficient of each subdomain for the measure was >0.800. Confirmatory factory analysis indicated that the construct validity fulfilled expectations. Model fit indices, such as RMR, RMSEA, NFI, NNFI, CFI and IFI, showed acceptable fit. The measure showed a good response rate.

Conclusions

The peptic ulcer PRO measure had good reliability, validity, DIF and feasibility, and can be used as a clinical research evaluation instrument with patients with peptic ulcers to assess their condition focus on treatment. This measure may also be applied in other health areas, especially in clinical trials of new drugs, and may be helpful in clinical decision making.

Estimating the incidence and the economic burden of third and fourth-degree obstetric tears in the English NHS: an observational study using propensity score matching

OBJECTIVE

Obstetric care is a high-risk area in healthcare delivery, so it is essential to have up-to-date quantitative evidence in this area to inform policy decisions regarding these services. In light of this, the objective of this study is to investigate the incidence and economic burden of third and fourth-degree lacerations in the English National Health Service (NHS) using recent national data.

METHODS

We used coded inpatient data from Hospital Episode Statistics (HES) for the financial years from 2010/2011 to 2013/2014 for all females that gave birth during that period in the English NHS. Using HES, we used pre-existing safety indicator algorithms to calculate the incidence of third and fourth-degree obstetric tears and employed a propensity score matching method to estimate the excess length of stay and economic burden associated with these events.

RESULTS

Observed rates per 1000 inpatient episodes in 2010/2011 and 2013/2014, respectively: Patient Safety Indicator-trauma during vaginal delivery with instrument (PSI 18)=84.16 and 91.24; trauma during vaginal delivery without instrument (PSI 19)=29.78 and 33.43; trauma during caesarean delivery (PSI 20)=3.61 and 4.56. Estimated overall (all PSIs) economic burden for 2010/2011=£10.7 million and for 2013/2014=£14.5 million, expressed in 2013/2014 prices.

CONCLUSIONS

Despite many initiatives targeting the quality of maternity care in the NHS, the incidence of third and fourth-degree lacerations has increased during the observed period which signals that quality improvement efforts in obstetric care may not be reducing incidence rates. Our conservative estimates of the financial burden of these events appear low relative to total NHS expenditure for these years.

Systematic review of caregiver responses for patient health-related quality of life in adult cancer care

PURPOSE

In surveys and in research, proxies such as family members may be used to assess patient health-related quality of life. The aim of this research is to help cancer researchers select a validated health-related quality of life tool if they anticipate using proxy-reported data.

METHODS

Systematic review and methodological appraisal of studies examining the concordance of paired adult cancer patient and proxy responses for multidimensional, validated HRQOL tools. We searched PubMed, CINAHL, PsycINFO and perused bibliographies of reviewed papers. We reviewed concordance assessment methods, results, and associated factors for each validated tool.

RESULTS

A total of 32 papers reporting on 29 study populations were included. Most papers were cross-sectional (N = 20) and used disease-specific tools (N = 19), primarily the FACT and EORTC. Patient and proxy mean scores were similar on average for tools and scales, with most mean differences <10 points but large standard deviations. Average ICCs for the FACT and EORTC ranged from 0.35 to 0.62, depending on the scale. Few papers (N = 15) evaluated factors associated with concordance, and results and measurement approaches were inconsistent. The EORTC was the most commonly evaluated disease-specific tool (N = 5 papers). For generic tools, both concordance and associated factor information was most commonly available for the COOP/WONCA (N = 3 papers). The MQOL was the most frequently evaluated end-of-life tool (N = 3 papers).

CONCLUSIONS

Proxy and patient scores are similar on average, but there is large, clinically important residual variability. The evidence base is strongest for the EORTC (disease-specific tools), COOP/WONCA (generic tools), and MQOL (end-of-life-specific tools).

Differences between Proxy and Patient Assessments of Cancer Care Experiences and Quality Ratings

OBJECTIVE

To assess the impact of proxy survey responses on cancer care experience reports and quality ratings.

DATA SOURCES/STUDY SETTING

Secondary analysis of data from Cancer Care Outcomes Research and Surveillance (CanCORS). Recruitment occurred from 2003 to 2005.

STUDY DESIGN

The study was a cross-sectional observational study. The respondents were patients with incident colorectal or lung cancer or their proxies.

DATA COLLECTION/EXTRACTION METHODS

Analyses used linear regression models with an independent variable for proxy versus patient responses as well as study site and clinical covariates. The outcomes were experiences with medical care, nursing care, care coordination, and care quality rating. Multiple imputation was used for missing data.

PRINCIPAL FINDINGS

Among 6,471 respondents, 1,011 (16 percent) were proxies. The proportion of proxy respondents varied from 6 percent to 28 percent across study sites. Adjusted proxy scores were modestly higher for medical care experiences (+1.28 points [95 percent CI:+ 0.05 to +2.51]), but lower for nursing care (-2.81 [95 percent CI: -4.11 to -1.50]) and care coordination experiences (-2.98 [95 percent CI: -4.15 to -1.81]). There were no significant differences between adjusted patient and proxy ratings of quality.

CONCLUSIONS

Proxy responses have small but statistically significant differences from patient responses. However, if ratings of care are used for financial incentives, such differences could be exaggerated across practices or areas if proxy use varies.

Association of functional status and treatment choice among older men with prostate cancer in the Medicare Advantage population

BACKGROUND

There are several effective treatments for prostate cancer. To what extent a patient's functional status influences the treatment decision is unknown. This study examined the association between functional status and treatment among older men with prostate cancer.

METHODS

Surveillance, Epidemiology, and End Results-Medicare Health Outcomes Survey data were used to identify men who were 65 years old or older and were diagnosed with prostate cancer between 1998 and 2009. The primary outcome was treatment choice: conservative management, surgery, or radiation within 1 year of the diagnosis. The exposure was the functional status assessed as 4 measures within 3 domains: 1) physical function (activities of daily living [ADLs] and physical component summary score), 2) cognitive function (survey completer: self vs proxy), and 3) emotional well-being (mental component summary score). A multivariate, multinomial logistic regression was fitted with adjustments for several patient, tumor, and regional characteristics.

RESULTS

This study identified 508 conservative management patients, 195 surgery patients, and 603 radiation patients. Compared with men with no ADL dependency, those with any ADL dependency had lower odds of receiving surgery (odds ratio [OR], 0.61; 95% confidence interval [CI], 0.38-0.99) or radiation (OR, 0.58; 95% CI, 0.43-0.78) versus conservative management. ADL dependency did not differ when surgery and radiation were compared. Patients with a proxy survey response were less likely to receive surgery or radiation versus conservative management.

CONCLUSIONS

Functional status is associated with treatment choice for men with prostate cancer. Future research should examine whether this is due to physician recommendations, patient preferences, or a combination. Cancer 2016;122:3199-206. © 2016 American Cancer Society.

Incidence and impact of proxy response in measuring patient experience: secondary analysis of a large postal survey using propensity score matching

OBJECTIVE

To determine whether use of proxy respondents in a patient experience survey was related to patient characteristics, and to compare patient and proxy responses.

DESIGN

Secondary analysis, using propensity score matching, of the NHS adult inpatient survey, a large cross-sectional survey.

SETTING

Hospitals (n = 161) providing inpatient services in England in 2011.

PARTICIPANTS

The survey received 70 863 responses: 10 661 (15.6%) involved proxy respondents in some way.

INTERVENTION

None.

MAIN OUTCOME MEASURES

Prevalence of proxy response was explored by patient demographic characteristics. Responses were compared using seven composite domains and one overall rating. Cases involving proxy responses were matched to similar independent responses via propensity score matching and mean scores compared using t-tests.

RESULTS

Use of proxy respondents was common, with 15.7% of responses involving a proxy in some way: higher than in other similar collections internationally. Proxy response was more common for some patient groups, such as older people and those from black and minority ethnic groups. Reports made by or with the assistance of proxy respondents were markedly less positive than those from patients completing the survey unaided. This pattern was consistent across all tested variables, although the biggest differences were observed for a subjective 'overall rating' question.

CONCLUSIONS

The prevalence of proxy response varied according to patient characteristics, but proxies were consistently less positive than patients responding unaided. Possible explanations include genuine differences in care, differential health outcomes or differences in perceptions. Patient experience surveys should collect information on use of proxy respondents to enable more refined analysis.

PIPEQ-OS--an instrument for on-site measurements of the experiences of inpatients at psychiatric institutions

BACKGROUND

The Psychiatric Inpatient Patient Experience Questionnaire (PIPEQ) was developed for post-discharge measurements of experiences, but the low response rates associated with post-discharge surveys restrict their usefulness. A new questionnaire was developed based on the PIPEQ for on-site measurements of patient experiences: the PIPEQ-OS. The aim of this study was to psychometrically test the PIPEQ-OS using data from a nationally representative survey conducted in Norway in 2014.

METHODS

Data were collected using a nationally representative patient-experience survey; 25% of the institutions in each of the 4 health regions in Norway were randomly selected, yielding a total of 26 institutions. The PIPEQ-OS questionnaire was completed by patients on-site on an agreed day in week 37 of 2014. Item missing and ceiling effects were assessed, and factor analysis was used to assess the structure of the items included in the PIPEQ-OS. The scales were tested for internal consistency reliability, test-retest reliability and construct validity.

RESULTS

The initial sample comprised 857 patients. Of these, 60 were excluded for ethical reasons and 57 were excluded because they were absent on the day of the survey. Of the remaining 740 patients, 552 (74.6% of the included population) returned the questionnaire. Low levels of missing or "not applicable" responses were found for 18 of the 21 items (<20%), and 20 of 21 items were below the ceiling-effect criterion. Psychometric testing identified three scales: structure and facilities (six items), patient-centred interaction (six items) and outcomes (five items). All scales met the criterion of 0.7 for Cronbach's alpha (range: 0.79-0.91) and test-retest reliability (range: 0.83-0.84). The construct validity of the scales was supported by 14 of 15 significant associations with variables known to be related to psychiatric inpatient experiences.

CONCLUSIONS

The PIPEQ-OS comprises three scales with satisfactory internal consistency reliability and construct validity. This instrument can be used for on-site assessments of psychiatric inpatient patient experiences, but further research is needed to evaluate its usefulness as basis for external quality indicators.

It takes patience and persistence to get negative feedback about patients' experiences: a secondary analysis of national inpatient survey data

Background

Patient experience surveys are increasingly used to gain information about the quality of healthcare. This paper investigates whether patients who respond before and after reminders to a large national survey of inpatient experience differ in systematic ways in how they evaluate the care they received.

Methods

The English national inpatient survey of 2009 obtained data from just under 70,000 patients. We used ordinal logistic regression to analyse their evaluations of the quality of their care in relation to whether or not they had received a reminder before they responded.

Results

33% of patients responded after the first questionnaire, a further 9% after the first reminder, and a further 10% after the second reminder. Evaluations were less positive among people who responded only after a reminder and lower still among those who needed a second reminder.

Conclusions

Quality improvement efforts depend on having accurate data and negative evaluations of care received in healthcare settings are particularly valuable. This study shows that there is a relationship between the time taken to respond and patients’ evaluations of the care they received, with early responders being more likely to give positive evaluations. This suggests that bias towards positive evaluations could be introduced if the time allowed for patients to respond is truncated or if reminders are omitted.