Perceptions of quality of care and the decision to leave a practice

Voluntary physician switching by human immunodeficiency virus-infected individuals: a national study of patient, physician, and organizational factors

OBJECTIVE

We sought to assess which patient, physician, and organizational factors are related to voluntary physician switching among human immunodeficiency virus (HIV)-infected patients.

DESIGN

We analyzed the results from a 3-wave survey of patients conducted by the HIV Cost and Services Utilization Study (HCSUS), a longitudinal study of a nationally representative sample of noninstitutionalized HIV-infected individuals receiving care in the contiguous United States. Physicians providing care and care site directors were surveyed once. Relationships of interpersonal aspects of care, access and continuity, technical quality of care, and physician and site characteristics to voluntary switching were analyzed using multilevel logistic regression models that nested repeated observations within patients, patients within clinicians, and clinicians within region.

RESULTS

Approximately 15% of patients voluntarily changed their usual clinicians during the 2-year study period. In a multivariate model, lower voluntary switching was predicted by patient trust (odds ratio [OR]=0.74; 95% confidence interval [95% CI]=0.61-0.90), physician antiretroviral knowledge (OR=0.26; 95% CI 0.13-0.53), moderate (rather than low or high) HIV patient volume at a care site (OR=0.09; 95% CI=0.03-0.31), and Ryan White Care Act funding (OR=0.27, 95% CI=0.14-0.52).

CONCLUSIONS

Patients with chronic illnesses may use several markers of specialization and technical quality to make decisions about their care. These results challenge the notion that patients cannot assess the quality of care they receive.

Utilization of delivery services at the primary health care level in rural Vietnam

The objective of this study is to investigate factors that influence the utilization of delivery services at the primary health care level in rural Vietnam. A quantitative survey was conducted amongst 200 women who had given birth within the past 3 months. Focus group discussions and in-depth-interviews were then undertaken using the attitudes--social influence--self-efficacy model to obtain complementary information on the delivery decision. The results show that client-perceived quality of services and socio-cultural and economic factors, rather than geographical access, can affect the utilization of delivery services. It is therefore important to improve the cost-efficiency of the health care network, and delivery services should be provided in a client-oriented manner taking into account economic, social and cultural factors.

Medical practices' sensitivity to patients' needs. Opportunities and practices for improvement

This article presents the results of a national study of medical practices' patient satisfaction using data collected from January to December 2001 with Press Ganey Associates' Medical Practice Survey (n = 503,407). The question, "Our sensitivity to your needs" (r = 0.85), most highly correlated with overall patient satisfaction. Patients' age, sex, or first visit were not predictors of sensitivity to patients' needs. Responses highly correlated with sensitivity to patients' needs: (1) concern for patients' privacy, (2) cheerfulness of practice, (3) care received during visit, and (4) likelihood to recommend practice. Patient perception and satisfaction with medical practices' sensitivity to patient needs and recommended practices for improvement are discussed.

Intention to discontinue care among primary care patients: influence of physician behavior and process of care

BACKGROUND

Specific elements of health care process and physician behavior have been shown to influence disenrollment decisions in HMOs, but not in outpatient settings caring for patients with diverse types of insurance coverage.

OBJECTIVE

To examine whether physician behavior and process of care affect patients' intention to return to their usual health care practice.

DESIGN

Cross-sectional patient survey and medical record review.

SETTING

Eleven academically affiliated primary care medicine practices in the Boston area.

PATIENTS

2,782 patients with at least one visit in the preceding year.

MEASUREMENT

Unwillingness to return to the usual health care practice.

RESULTS

Of the 2,782 patients interviewed, 160 (5.8%) indicated they would not be willing to return. Two variables correlated significantly with unwillingness to return after adjustment for demographics, health status, health care utilization, satisfaction with physician's technical skill, site of care, and clustering of patients by provider: dissatisfaction with visit duration (odds ratio [OR], 3.2; 95% confidence interval [CI], 1.4 to 7.4) and patient reports that the physician did not listen to what the patient had to say (OR, 8.8; 95% CI, 2.5 to 30.7). In subgroup analysis, patients who were prescribed medications at their last visit but who did not receive an explanation of the purpose of the medication were more likely to be unwilling to return (OR, 4.9; 95% CI, 1.8 to 13.3).

CONCLUSION

Failure of physicians to acknowledge patient concerns, provide explanations of care, and spend sufficient time with patients may contribute to patients' decisions to discontinue care at their usual site of care.