Influence of patient education on profiles of physician practices

Out Of Reach: Inequities In The Use Of High-Quality Home Health Agencies

Patients receiving home health services from high-quality home health agencies often experience fewer adverse outcomes (for example, hospitalizations) than patients receiving services from low-quality agencies. Using administrative data from 2016 and regression analysis, we examined individual- and neighborhood-level racial, ethnic, and socioeconomic factors associated with the use of high-quality home health agencies. We found that Black and Hispanic home health patients had a 2.2-percentage-point and a 2.5-percentage-point lower adjusted probability of high-quality agency use, respectively, compared with their White counterparts within the same neighborhoods. Low-income patients had a 1.2-percentage-point lower adjusted probability of high-quality agency use compared with their higher-income counterparts, whereas home health patients residing in neighborhoods with higher proportions of marginalized residents had a lower adjusted probability of high-quality agency use. Some 40-77 percent of the disparities in high-quality agency use were attributable to neighborhood-level factors. Ameliorating these inequities will require policies that dismantle structural and institutional barriers related to residential segregation.

Associations Between Community Sociodemographics and Performance in HEDIS Quality Measures: A Study of 22 Medical Centers in a Primary Care Network

Evaluation and payment for health plans and providers have been increasingly tied to their performance on quality metrics, which can be influenced by patient- and community-level sociodemographic factors. The aim of this study was to examine whether performance on Healthcare Effectiveness Data and Information Set (HEDIS) measures varied as a function of community sociodemographic characteristics at the primary care clinic level. Twenty-two primary care sites of a large multispecialty group practice were studied during the period of April 2013 to June 2016. Significant associations were found between sites' performance on selected HEDIS measures and their neighborhood sociodemographic characteristics. Outcome measures had stronger associations with sociodemographic factors than did process measures, with a range of significant correlation coefficients (absolute value, regardless of sign) from 0.44 to 0.72. Sociodemographic factors accounted for as much as 25% to 50% of the observed variance in measures such as HbA1c or blood pressure control.

Ethical principles for physician rating sites

During the last 5 years, an ethical debate has emerged, often in public media, about the potential positive and negative effects of physician rating sites and whether physician rating sites created by insurance companies or government agencies are ethical in their current states. Due to the lack of direct evidence of physician rating sites' effects on physicians' performance, patient outcomes, or the public's trust in health care, most contributions refer to normative arguments, hypothetical effects, or indirect evidence. This paper aims, first, to structure the ethical debate about the basic concept of physician rating sites: allowing patients to rate, comment, and discuss physicians' performance, online and visible to everyone. Thus, it provides a more thorough and transparent starting point for further discussion and decision making on physician rating sites: what should physicians and health policy decision makers take into account when discussing the basic concept of physician rating sites and its possible implications on the physician-patient relationship? Second, it discusses where and how the preexisting evidence from the partly related field of public reporting of physician performance can serve as an indicator for specific needs of evaluative research in the field of physician rating sites. This paper defines the ethical principles of patient welfare, patient autonomy, physician welfare, and social justice in the context of physician rating sites. It also outlines basic conditions for a fair decision-making process concerning the implementation and regulation of physician rating sites, namely, transparency, justification, participation, minimization of conflicts of interest, and openness for revision. Besides other issues described in this paper, one trade-off presents a special challenge and will play an important role when deciding about more- or less-restrictive physician rating sites regulations: the potential psychological and financial harms for physicians that can result from physician rating sites need to be contained without limiting the potential benefits for patients with respect to health, health literacy, and equity.

Improving the reliability of physician performance assessment: identifying the "physician effect" on quality and creating composite measures

BACKGROUND

The proliferation of efforts to assess physician performance underscore the need to improve the reliability of physician-level quality measures.

OBJECTIVE

Using diabetes care as a model, to address 2 key issues in creating reliable physician-level quality performance scores: estimating the physician effect on quality and creating composite measures.

DESIGN

Retrospective longitudinal observational study.

SUBJECTS

A national sample of physicians (n = 210) their patients with diabetes (n = 7574) participating in the National Committee on Quality Assurance-American Diabetes Association's Diabetes Provider Recognition Program.

MEASURES

Using 11 diabetes process and intermediate outcome quality measures abstracted from the medical records of participants, we tested each measure for the magnitude of physician-level variation (the physician effect or "thumbprint"). We then combined measures with a substantial physician effect into a composite, physician-level diabetes quality score and tested its reliability.

RESULTS

We identified the lowest target values for each outcome measure for which there was a recognizable "physician thumbprint" (ie, intraclass correlation coefficient > or =0.30) to create a composite performance score. The internal consistency reliability (Cronbach's alpha) of the composite score, created by combining the process and outcome measures with an intraclass correlation coefficient > or =0.30, exceeded 0.80. The standard errors of the composite case-mix adjusted score were sufficiently small to discriminate those physicians scoring in the highest from those scoring in the lowest quartiles of the quality of care distribution with no overlap.

CONCLUSIONS

We conclude that the aggregation of well-tested quality measures that maximize the "physician effect" into a composite measure yields reliable physician-level quality of care scores for patients with diabetes.

Prevalence and risk factors for a high level of postnatal depression symptomatology in Italian women: a sample drawn from ante-natal classes

BACKGROUND

Depression after childbirth is a major problem affecting 10-22% of all mothers. In Italy, postnatal depression has not yet been systematically studied.

METHODS

In this retrospective study we have sought to identify risk factors, assessed during pregnancy, and their importance for postnatal depression symptoms in a sample of 297 Italian women attending ante-natal classes organised by the local Consultorio Familiare Unit of the National Health Service, Italy. The Postpartum Depression Predictors Inventory - revised form (PDPI-Revised), was used to identify risk factors, 8-9 month of pregnancy. A double-test strategy using the Edinburgh Postnatal Depression Scale (EPDS) and 12-item General Health Questionnaire (GHQ12), was administered to screen women with a higher occurrence of symptoms of postnatal depression six-eight weeks after delivery. Women with high EPDS (<8) and high GHQ12 (<3) scores were compared with those who had scored below the EPDS and/or GHQ12 threshold scores.

RESULTS

We found that 13% of the women studied showed high postnatal depressive symptomatology, which is very similar to rates of prevalence of postnatal depression in the first year after the birth of the child reported in other Western World studies. Feeling anxious during pregnancy is a strong predictor of high symptoms of depression at 6-8 weeks after delivery. However, University education and friends' support appear to be important protective factors.

CONCLUSION

These findings could be useful both for Italian health professionals and for researchers interested in the transcultural aspects of postnatal depression.

So much to do, so little time: care for the socially disadvantaged and the 15-minute visit

There is so much to do in primary care, and so little time to do it. During 15-minute visits, physicians are expected to form partnerships with patients and their families, address complex acute and chronic biomedical and psychosocial problems, provide preventive care, coordinate care with specialists, and ensure informed decision making that respects patients' needs and preferences. This is a challenging task during straightforward visits, and it is nearly impossible when caring for socially disadvantaged patients with complex biomedical and psychosocial problems and multiple barriers to care. Consider the following scenario.

Measuring quality of care in patients with multiple clinical conditions: summary of a conference conducted by the Society of General Internal Medicine

Performance measurement has been widely advocated as a means to improve health care delivery and, ultimately, clinical outcomes. However, the evidence supporting the value of using the same quality measures designed for patients with a single clinical condition in patients with multiple conditions is weak. If clinically complex patients, defined here as patients with multiple clinical conditions, present greater challenges to achieving quality goals, providers may shun them or ignore important, but unmeasured, clinical issues. This paper summarizes the proceedings of a conference addressing the challenge of measuring quality of care in the patient with multiple clinical conditions with the goal of informing the implementation of quality measurement systems and future research programs on this topic. The conference had three main areas of discussion. First, the potential problems caused by applying current quality standards to patients with multiple conditions were examined. Second, the advantages and disadvantages of three strategies to improve quality measurement in clinically complex patients were evaluated: excluding certain clinically complex patients from a given standard, relaxing the performance target, and assigning a greater weight to some measures based on the expected clinical benefit or difficulty of reaching the performance target. Third, the strengths and weaknesses of potential novel measures such change in functional status were considered. The group concurred that, because clinically complex patients present a threat to the implementation of quality measures, high priority must be assigned to a research agenda on this topic. This research should evaluate the impact of quality measurement on these patients and expand the range of quality measures relevant to the care of clinically complex patients.

Connoisseurs of care? Unannounced standardized patients' ratings of physicians

BACKGROUND

Patient satisfaction surveys can be informative, but bias and poor response rates may limit their utility as stable measures of physician performance. Using unannounced standardized patients (SPs) may overcome some of these limitations because their experience and training make them able judges of physician behavior.

OBJECTIVES

We sought to understand the reliability of unannounced SPs in rating primary care physicians when covertly presenting as real patients.

STUDY DESIGN

Data from 2 studies (Patient Centered Communication [PCC]; Social Influences in Practice [SIP]) were included. For the PCC study, 5 SPs made 192 visits to 96 physicians; for the SIP study, 18 SPs made 292 visits to 146 physicians. SPs visits to physicians were randomized, thus avoiding mutual selection bias. Each SP rated 16 to 38 physicians on interpersonal skills (autonomy support: PCC, SIP), technical skills (information gathering: SIP-only), and overall satisfaction (SIP-only). We evaluated SP evaluation consistency (physician vs. total variance rho), and SPs' overall satisfaction with specific dimensions of physician performance.

RESULTS

Scale reliability varied from 0.71 to 0.92. Physician rhos (95% confidence intervals) for autonomy support were 0.40 (0.22-0.58; PCC) and 0.30 (0.14-0.45; SIP); information gathering rho was 0.46 (0.33-0.59; SIP). Overall SP satisfaction rho was 0.47 (0.34-0.60; SIP). SPs varied significantly in adjusted overall satisfaction levels, but not other dimensions.

CONCLUSIONS

These analyses provide some evidence that medical connoisseurship can be learned. When adequately sampled by trained SPs, some physician skills can be reliably measured in community practice settings.

Customer satisfaction

PURPOSE

This paper seeks to present an analysis of the literature examining objective information concerning the subject of customer service, as it applies to the current medical practice. Hopefully, this information will be synthesized to generate a cogent approach to correlate customer service with quality.

DESIGN/METHODOLOGY/APPROACH

Articles were obtained by an English language search of MEDLINE from January 1976 to July 2005. This computerized search was supplemented with literature from the author's personal collection of peer-reviewed articles on customer service in a medical setting. This information was presented in a qualitative fashion.

FINDINGS

There is a significant lack of objective data correlating customer service objectives, patient satisfaction and quality of care. Patients present predominantly for the convenience of emergency department care. Specifics of satisfaction are directed to the timing, and amount of "caring". Demographic correlates including symptom presentation, practice style, location and physician issues directly impact on satisfaction. It is most helpful to develop a productive plan for the "difficult patient", emphasizing communication and empathy. Profiling of the customer satisfaction experience is best accomplished by examining the specifics of satisfaction, nature of the ED patient, demographic profile, symptom presentation and physician interventions emphasizing communication--especially with the difficult patient.

ORIGINALITY/VALUE

The current emergency medicine customer service dilemmas are a complex interaction of both patient and physician factors specifically targeting both efficiency and patient satisfaction. Awareness of these issues particular to the emergency patient can help to maximize efficiency, minimize subsequent medicolegal risk and improve patient care if a tailored management plan is formulated.

Is risk-adjustor selection more important than statistical approach for provider profiling? Asthma as an example

OBJECTIVES

To examine how the selections of different risk adjustors and statistical approaches affect the profiles of physician groups on patient satisfaction.

DATA SOURCES

Mailed patient surveys. Patients with asthma were selected randomly from each of 20 California physician groups between July 1998 and February 1999. A total of 2515 patients responded.

RESEARCH DESIGN

A cross-sectional study. Patient satisfaction with asthma care was the performance indicator for physician group profiling. Candidate variables for risk-adjustment model development included sociodemographic, clinical characteristics, and self-reported health status. Statistical strategies were the ratio of observed-to-expected rate (OE), fixed effects (FE), and the random effects (RE) approaches. Model performance was evaluated using indicators of discrimination (C-statistic) and calibration (Hosmer-Lemeshow chi2). Ranking impact of using different risk adjustors and statistical approaches was based on the changes in absolute ranking (AR) and quintile ranking (QR) of physician group performance and the weighted kappa for quintile ranking.

RESULTS

Variables that added significantly to the discriminative power of risk-adjustment models included sociodemographic (age, sex, prescription drug coverage), clinical (asthma severity), and health status (SF-36 PCS and MCS). Based on an acceptable goodness-of-fit (P > 0.1)and higher C-statistics, models adjusting for sociodemographic, clinical, and health status variables (Model S-C-H) using either the FE or RE approach were more favorable. However, the C-statistic (=0.68) was only fair for both models. The influence of risk-adjustor selection on change of performance ranking was more salient than choice of statistical strategy (AR: 50%-80% v. 20%-55%; QR: 10%-30% v. 0%-10%). Compared to the model adjusting for sociodemographic and clinical variables only and using OE approach, the Model S-C-H using RE approach resulted in 70% of groups changing in AR and 25% changing in QR (weighted kappa: 0.88). Compared to the Consumer Assessment of Health Plans model, the Model S-C-H using RE approach resulted in 65% of groups changing in AR and 20% changing in QR (weighted kappa: 0.88).

CONCLUSIONS

In comparing the performance of physician groups on patient satisfaction with asthma care, the use of sociodemographic, clinical, and health status variables maximized risk-adjustment model performance. Selection of risk adjustors had more influence on ranking profiles than choice of statistical strategies. Stakeholders employing provider profiling should pay careful attention to the selection of both variables and statistical approach used in risk-adjustment.

Patient satisfaction profiling of individual physicians: impact of panel status

RATIONALE, AIMS AND OBJECTIVES

Evaluation of physician performance is increasingly based on patient satisfaction. However, few data are available regarding the extent to which individual physician profiles might be influenced by factors such as whether a physician's practice is open or closed. We evaluated whether panel status (whether or not a physician is accepting new patients) is associated with patient satisfaction with their primary care physician (PCP).

METHODS

Cross-sectional analysis of patient satisfaction surveys. Surveys were available for 1,750 patients cared for by 69 PCPs. Patient satisfaction with their PCP was determined based on a composite of six questions derived from the Medical Outcomes Study. We used Generalized Estimating Equations to adjust for physician level variation.

RESULTS

Patients of closed-panel physicians were more likely to rate their satisfaction with the provider as 'Excellent' or 'Very Good' compared to patients of open-panel physicians (78% vs. 69%, P <0.0001). After adjusting for satisfaction with the practice site, provider years in practice, managed care coverage, provider productivity, and patient race, the association between a closed panel and satisfaction remained significant (odds ratio 1.60, 95% confidence interval 1.10-2.31).

CONCLUSIONS

Individual physicians' patient satisfaction data are confounded by factors not likely to be adjusted for in available profiles. After adjusting for other variables, physicians with closed panels still had better patient satisfaction compared to physicians with open panels. Further research is necessary to determine if panel status might also confound patient satisfaction.

Survey response rates and overall patient satisfaction scores: what do they mean?

Within the health care community, more and more emphasis is being placed on patient satisfaction. This study was undertaken in a midwestern, nonprofit, 300-bed acute care hospital to gain a better understanding of how nonresponse rates and patient characteristics affect patient satisfaction scores. With a response rate of 34.2%, it appears that nonresponse bias may have an impact. When looking at variables that may affect the overall score, the multiple regression model used in this analysis was able to explain only 7.5% of the variability in the overall satisfaction score seeming to indicate the unpredictability of the score. This study supports the need to analyze groups of patients rather than patients as a whole to determine what affects their response, both within and between healthcare organizations.

Effect of patient socioeconomic status on physician profiles for prevention, disease management, and diagnostic testing costs

BACKGROUND

Previous research shows patient socioeconomic status (SES) affects physician profiles for health status and satisfaction, but effects on other aspects of care are not known.

OBJECTIVE

To examine the effect of patient SES on physician profiles for preventive care, disease management, and diagnostic testing costs.

RESEARCH DESIGN

Cross-sectional analysis of a managed care claims data.

SUBJECTS

Five hundred sixty-eight physicians and 600,618 patients.

MEASURES

Patient age, gender, case-mix, and SES based on zip code, likelihood of having a Papanicolaou smear, mammogram, for diabetics having had a glycosylated hemoglobin, diabetic eye exam, and diagnostic testing costs.

RESULTS

For each performance indicator, except glycosylated hemoglobin, there was a statistically significant effect of adjusting for patient SES. For diabetic eye checks, mammograms and Papanicolaou tests respectively, 5%, 16%, and 21% of physicians who were outliers (in the top or bottom 5% of rankings) were no longer outliers after socioeconomic adjustment. For all performance measures the change in physician ranking was strongly correlated with the mean practice SES.

CONCLUSIONS

Patient SES, as measured by zip code, appreciably affects physician profiles for preventive care and diabetes management. Monitoring patient SES using patient zip codes could be used to target resources to improve outcomes for higher risk patients.

The effect of patient selection on comorbidity-adjusted operative mortality risk. Implications for outcomes studies of surgical procedures

Consumers of outcomes research may assume that risk-adjustment procedures based on patients' comorbid conditions will control for baseline prognostic differences between comparison groups, so that differences in risk-adjusted outcomes represent effects other than those due to differences in comorbidity severity. However, surgeons may differ in their threshold to operate on patients with different intensities of the same comorbidity, which may not be accounted for using commonly employed risk-adjustment methods. We developed a model to explore the effect that selection based on comorbidity severity could have on estimates of the risk-adjusted relative risk (RR) of operative death. Larger effects on the apparent RR of operative death were observed when both the proportion of patients in the high-risk ("selected") stratum and the relative increase in the risk of death due to being in the high-risk stratum were large. Biased estimates of the risk-adjusted RR of operative death will be observed if surgeons differentially select patients based on comorbidity severity and if differences in comorbidity severity are not captured by the risk-adjustment methodology.

Impact of patient socioeconomic status on physician profiles: a comparison of census-derived and individual measures

BACKGROUND

Patient education has been shown to affect physician performance profiles. It is not known whether census-derived measures of patient socioeconomic status (SES) show comparable effects.

OBJECTIVE

The objective of this study was to compare the effects on physician profiles for patient satisfaction and physical and mental health of adjustment for patient SES derived from patient addresses geocoded to the census block group level, zip codes, and patient education.

DESIGN

This was a cross-sectional survey of patients in physician practices.

SETTING

Subjects came from adult primary care practices in western New York.

PARTICIPANTS

A random sample of 100 primary care physicians and 50 consecutive patients seen by each physician participated in the study.

MEASUREMENTS

Independent variables were census-derived (block group and zip code) patient SES and patient-reported education. The outcomes were physician ranks for patient satisfaction (Patient Satisfaction Questionnaire) and physical and mental health status (SF-12). RESULTS. In empirical Bayes models that adjusted for patient age, age squared, gender, insurance, and case mix, both the census-derived measures (block group and zip code) of SES and education had similar effects on each of the physician profiles. CONCLUSIONS. The results suggest that SES derived from either patient addresses geocoded to the census block group level or zip codes may offer a convenient alternative to individually collected SES when adjusting physician profiles for the socioeconomic characteristics of physicians' practices. The relative ease of using zip codes compared with geocoded addresses and loss of information associated with incomplete matching during geocoding suggest that zip code-derived SES may be preferable.