Comparison of Work Patterns Between Physicians and Advanced Practice Practitioners in Primary Care and Specialty Practice Settings

Importance

Despite the increasing involvement of advanced practice practitioners (APPs; ie, nurse practitioners and physician assistants) in care delivery across specialties, the work patterns of APPs compared with physicians and how they are integrated into care teams have not been well characterized.

Objective

To characterize differences between physicians and APPs across specialty types related to days with appointments, visit types seen, and time spent using the electronic health record (EHR).

Design, Setting, and Participants

This nationwide, cross-sectional study used EHR data from physicians and APPs (ie, nurse practitioners and physician assistants) at all US institutions that used Epic Systems' EHR between January and May 2021. Data analysis was performed from March 2022 to April 2023.

Main Outcomes and Measures

Appointment scheduling patterns, percentage of new and established and level of evaluation and management (E/M) visits, and EHR use metrics per day and week.

Results

The sample consisted of 217 924 clinicians across 389 organizations, including 174 939 physicians and 42 985 APPs. Although primary care physicians were more likely than APPs to have more than 3 days per week with appointments (50 921 physicians [79.5%] vs 17 095 APPs [77.9%]), this trend was reversed for medical (38 645 physicians [64.8%] vs 8124 APPs [74.0%]) and surgical (24 155 physicians [47.1%] vs 5198 APPs [51.7%]) specialties. Medical and surgical specialty physicians saw 6.7 and 7.4 percentage points, respectively, more new patient visits than did their APP counterparts, whereas primary care physicians saw 2.8 percentage points fewer new patient visits than did APPs. Physicians saw a greater percentage of level 4 or 5 visits across all specialties. Medical and surgical physicians spent 34.3 and 45.8 fewer minutes per day, respectively, using the EHR than did APPs in their specialties, whereas primary care physicians spent 17.7 minutes per day more. These differences translated to primary care physicians spending 96.3 minutes more per week using the EHR than APPs, whereas medical and surgical physicians spent 149.9 and 140.7 fewer minutes, respectively, than did their APP counterparts.

Conclusions and Relevance

This cross-sectional, national study of clinicians found significant differences in visit and EHR patterns for physicians compared with APPs across specialty types. By underscoring the different current usage of physicians vs APPs across specialty types, this study helps place into context the work and visit patterns of physicians compared with APPs and serves as a foundation for evaluations of clinical outcomes and quality.

Quality Frameworks for Virtual Care: Expert Panel Recommendations

Given the significant advance of virtual care in the past year and half, it seems timely to focus on quality frameworks and how they have evolved collaboratively across health care organizations. Massachusetts General Hospital's (MGH) Center for TeleHealth and Mass General Brigham's (MGB) Virtual Care Program are committed to hosting annual symposia on key topics related to virtual care. Subject matter experts across the country, health care organizations, and academic medical centers are invited to participate. The inaugural MGH/MGB Virtual Care Symposium, which focused on rethinking curriculum, competency, and culture in the virtual care era, was held on September 2, 2020. The second MGH/MGB Virtual Care Symposium was held on November 2, 2021, and focused on virtual care quality frameworks. Resultant topics were (1) guiding principles necessary for the future of virtual care measurement; (2) best practices deployed to measure quality of virtual care and how they compare and align with in-person frameworks; (3) evolution of quality frameworks over time; (4) how increased adoption of virtual care has impacted patient access and experience and how it has been measured; (5) the pitfalls and barriers which have been encountered by organizations in developing virtual care quality frameworks; and (6) examples of how quality frameworks have been applied in various use cases. Common elements of a quality framework for virtual care programs among symposium participants included improving the patient and provider experience, a focus on achieving health equity, monitoring success rates and uptime of the technical elements of virtual care, financial stewardship, and clinical outcomes. Virtual care represents an evolution in the access to care paradigm that helps keep health care aligned with other modern industries in digital technology and systems adoption. With advances in health care delivery models, it is vitally important that the quality measurement systems be adapted to include virtual care encounters. New methods may be necessary for asynchronous transactions, but synchronous virtual visits and consults can likely be accommodated in traditional quality frameworks with minimal adjustments. Ultimately, quality frameworks for health care will adapt to hybrid in-person and virtual care practices.

Summary of the 2020 AHRQ research meeting on 'advancing methods of implementing and evaluating patient experience improvement using consumer assessment of healthcare providers and systems (CAHPS®) surveys'

BACKGROUND

The Agency for Healthcare Research and Quality held a research meeting on using Consumer Assessment of Healthcare Providers and Systems (CAHPS®) data for quality improvement (QI) and evaluating such efforts.

TOPICS COVERED.

Meeting addressed: 1)What has been learned about organizational factors/environment needed to improve patient experience? 2)How have organizations used data to improve patient experience? 3)What can evaluations using CAHPS data teach us about implementing successful programs to improve patient experience?

KEY THEMES

Providers and stakeholders need to be engaged early and often, standardize QI processes, complement CAHPS data with other data, and compile dashboards of CAHPS scores to identify and track improvement. Rigorous study designs are valuable, but much can be learned and accomplished through practical organization-level studies.

Patient-centered care: achieving higher quality by designing care through the patient's eyes

Patient centered care requires that health care organizations and health care professionals actively understand what patients value. Fortunately, there are methods for gaining that understanding. But, they need to be adopted much more widely, and patients need to be treated as full partners in their care.

Correlation of Provider Burnout With Patient Experience

Initiatives to mitigate physician burnout and improve patient experience occur largely in isolation. At the level of the department/division, we found lower physician burnout was associated with a more positive patient experience. Physician Maslach Burnout Inventory data and patient Consumer Assessment of Healthcare Providers and Systems Clinician and Group experience scores were significantly correlated with 5 of 12 patient experience questions: “Got Routine Care Appointment” (−0.632, P = .001), “Recommend Provider” (−0.561, P = .005), “Provider Knew Medical History” (−0.532, P = .009), “Got Urgent Care Appointment” (−0.518, P = .014), and “Overall Rating” (−0.419, P = .047). These correlations suggest burnout and experience might be better addressed in tandem. Principles to guide an integrated approach are suggested.

The effect of administration mode on CAHPS survey response rates and results: A comparison of mail and web-based approaches

OBJECTIVE

The objective of this study was to compare response rates, respondents' characteristics, and substantive results for CAHPS surveys administered using web and mail protocols.

DATA SOURCES

Patients who had one or more primary care visits in the preceding 6 months.

STUDY DESIGN/DATA COLLECTION METHODS

Patients for whom primary care practices had email addresses were randomized to one of four survey administration protocols: web via a portal invitation; web via an email invitation; combination of web and mail; and mail only. Another sample of patients without known email addresses was surveyed by mail. Samples of nonrespondents to the Internet and mail protocols were surveyed by telephone.

PRINCIPAL FINDINGS

Response rates to surveys administered using the Internet protocols were lower than for the surveys administered by mail (20 percent vs over 40 percent). However, characteristics of respondents and survey answers were very similar across protocols. Respondents without email addresses were older, less educated, and more likely to be male than those with email addresses, and there were a few differences in their responses. There was little evidence of nonresponse bias in either the mail or web protocols.

CONCLUSION

In this well-educated patient population, web protocols had lower response rates, but substantive results very similar to those from mail protocols.

Transforming concepts in patient safety: a progress report

In 2009, the National Patient Safety Foundation’s Lucian Leape Institute (LLI) published a paper identifying five areas of healthcare that require system-level attention and action to advance patient safety. The authors argued that to truly transform the safety of healthcare, there was a need to address medical education reform; care integration; restoring joy and meaning in work and ensuring the safety of the healthcare workforce; consumer engagement in healthcare and transparency across the continuum of care. In the ensuing years, the LLI convened a series of expert roundtables to address each concept, look at obstacles to implementation, assess potential for improvement, identify potential implementation partners and issue recommendations for action. Reports of these activities were published between 2010 and 2015. While all five areas have seen encouraging developments, multiple challenges remain. In this paper, the current members of the LLI (now based at the Institute for Healthcare Improvement) assess progress made in the USA since 2009 and identify ongoing challenges.

Ten Years, Forty Decision Aids, And Thousands Of Patient Uses: Shared Decision Making At Massachusetts General Hospital

Shared decision making is a core component of population health strategies aimed at improving patient engagement. Massachusetts General Hospital's integration of shared decision making into practice has focused on the following three elements: developing a culture receptive to, and health care providers skilled in, shared decision making conversations; using patient decision aids to help inform and engage patients; and providing infrastructure and resources to support the implementation of shared decision making in practice. In the period 2005-15, more than 900 clinicians and other staff members were trained in shared decision making, and more than 28,000 orders for one of about forty patient decision aids were placed to support informed patient-centered decisions. We profile two different implementation initiatives that increased the use of patient decision aids at the hospital's eighteen adult primary care practices, and we summarize key elements of the shared decision making program.

Patient engagement: four case studies that highlight the potential for improved health outcomes and reduced costs

The energy of patients and members of the public worldwide who care about improving health is a huge, but still largely unrecognized and untapped, resource. The aim of patient engagement is to shift the clinical paradigm from determining "what is the matter?" to discovering "what matters to you?" This article presents four case studies from around the world that highlight the proven and potential abilities of increased patient engagement to improve health outcomes and reduce costs, while extending the reach of treatment and diagnostic programs into the community. The cases are an online mental health community in the United Kingdom, a genetic screening program in the United Arab Emirates, a World Health Organization checklist for new mothers, and a hospital-based patient engagement initiative in the United States. Evidence from these and similar endeavors suggests that closer collaboration on the part of patients, families, health care providers, health care systems, and policy makers at multiple levels could help diverse nations provide more effective and population-appropriate health care with fewer resources.

National Institute of Biomedical Imaging and Bioengineering Point-of-Care Technology Research Network: Advancing Precision Medicine

To advance the development of point-of-care technology (POCT), the National Institute of Biomedical Imaging and Bioengineering established the POCT Research Network (POCTRN), comprised of Centers that emphasize multidisciplinary partnerships and close facilitation to move technologies from an early stage of development into clinical testing and patient use. This paper describes the POCTRN and the three currently funded Centers as examples of academic-based organizations that support collaborations across disciplines, institutions, and geographic regions to successfully drive innovative solutions from concept to patient care.

Improving the care of patients who have treatment-resistant depression: the promise of the PCORnet Mood Network

In this issue of JCP, Zhou and colleagues review and integrate placebo-controlled efficacy trials of medications for treatment-resistant depression (TRD) to compare efficacy in a meta-analysis. They conclude that, among 11 augmentation options for TRD, aripiprazole and quetiapine have the most robust evidence for efficacy, with the caveats that these treatments carry substantial risks of adverse events and no long-term data are available. In the absence of direct comparisons, this exercise highlights the formidable challenges that clinicians face when making decisions.

Examining the role of patient experience surveys in measuring health care quality

Patient care experience surveys evaluate the degree to which care is patient-centered. This article reviews the literature on the association between patient experiences and other measures of health care quality. Research indicates that better patient care experiences are associated with higher levels of adherence to recommended prevention and treatment processes, better clinical outcomes, better patient safety within hospitals, and less health care utilization. Patient experience measures that are collected using psychometrically sound instruments, employing recommended sample sizes and adjustment procedures, and implemented according to standard protocols are intrinsically meaningful and are appropriate complements for clinical process and outcome measures in public reporting and pay-for-performance programs.

Analysis & commentary. Measuring patient experience as a strategy for improving primary care

Patients value the interpersonal aspects of their health care experiences. However, faced with multiple resource demands, primary care practices may question the value of collecting and acting upon survey data that measure patients' experiences of care. The Consumer Assessment of Healthcare Providers and Systems (CAHPS) suite of surveys and quality improvement tools supports the systematic collection of data on patient experience. Collecting and reporting CAHPS data can improve patients' experiences, along with producing tangible benefits to primary care practices and the health care system. We also argue that the use of patient experience information can be an important strategy for transforming practices as well as to drive overall system transformation.

Perspective: a culture of respect, part 1: the nature and causes of disrespectful behavior by physicians

A substantial barrier to progress in patient safety is a dysfunctional culture rooted in widespread disrespect. The authors identify a broad range of disrespectful conduct, suggesting six categories for classifying disrespectful behavior in the health care setting: disruptive behavior; humiliating, demeaning treatment of nurses, residents, and students; passive-aggressive behavior; passive disrespect; dismissive treatment of patients; and systemic disrespect.At one end of the spectrum, a single disruptive physician can poison the atmosphere of an entire unit. More common are everyday humiliations of nurses and physicians in training, as well as passive resistance to collaboration and change. Even more common are lesser degrees of disrespectful conduct toward patients that are taken for granted and not recognized by health workers as disrespectful.Disrespect is a threat to patient safety because it inhibits collegiality and cooperation essential to teamwork, cuts off communication, undermines morale, and inhibits compliance with and implementation of new practices. Nurses and students are particularly at risk, but disrespectful treatment is also devastating for patients. Disrespect underlies the tensions and dissatisfactions that diminish joy and fulfillment in work for all health care workers and contributes to turnover of highly qualified staff. Disrespectful behavior is rooted, in part, in characteristics of the individual, such as insecurity or aggressiveness, but it is also learned, tolerated, and reinforced in the hierarchical hospital culture. A major contributor to disrespectful behavior is the stressful health care environment, particularly the presence of "production pressure," such as the requirement to see a high volume of patients.

Perspective: a culture of respect, part 2: creating a culture of respect

Creating a culture of respect is the essential first step in a health care organization's journey to becoming a safe, high-reliability organization that provides a supportive and nurturing environment and a workplace that enables staff to engage wholeheartedly in their work. A culture of respect requires that the institution develop effective methods for responding to episodes of disrespectful behavior while also initiating the cultural changes needed to prevent such episodes from occurring. Both responding to and preventing disrespect are major challenges for the organization's leader, who must create the preconditions for change, lead in establishing and enforcing policies, enable frontline worker engagement, and facilitate the creation of a safe learning environment.When disrespectful behavior occurs, it must be addressed consistently and transparently. Central to an effective response is a code of conduct that establishes unequivocally the expectation that everyone is entitled to be treated with courtesy, honesty, respect, and dignity. The code must be enforced fairly through a clear and explicit process and applied consistently regardless of rank or station.Creating a culture of respect requires action on many fronts: modeling respectful conduct; educating students, physicians, and nonphysicians on appropriate behavior; conducting performance evaluations to identify those in need of help; providing counseling and training when needed; and supporting frontline changes that increase the sense of fairness, transparency, collaboration, and individual responsibility.

The crimson care collaborative: a student-faculty initiative to increase medical students' early exposure to primary care

The current shortage of primary care physicians (PCPs), particularly as more individuals obtain health insurance and seek primary care services, is a growing national concern. The Crimson Care Collaborative (CCC) is a joint student-faculty initiative in post-health-care-reform Massachusetts that was started with the explicit goal of attracting medical students to primary care careers. It fills a niche for student-run clinics, providing evening access to primary care services for patients without a PCP and urgent care services for patients of a Massachusetts General Hospital-affiliated internal medicine clinic, with the aim of decreasing emergency department use in both groups. Unlike other student-run clinics, CCC is integrated into the mainstream health care structure of an existing primary care clinic and, because of universal health insurance coverage in Massachusetts, can bill for its services. In addition to the clinical services offered, the student-run research team evaluates the quality of care and the patients' experiences at the clinic. This article describes the creation and development of CCC, including a brief overview of clinic operations, social services, research, laboratory services, student and patient education programs, and finance. In the wake of the Patient Protection and Affordable Care Act of 2010, CCC is an example of how students can aid the transition to universal health care in the United States and how medical schools can expose students early in their training to primary care and clinic operations.

Exploring attitudes toward advance care directives in two diverse settings

BACKGROUND

Advance care directives (ACD) are not used equally by different ethnic groups in the United States. Theories regarding this difference include lack of access to health care, mistrust of the health care system, absence of surrogate decision makers, and universal lack of knowledge on this topic. Few studies have investigated attitudes toward advance care planning for future end-of-life decision-making in the Latino and Cambodian communities.

METHODS

Six focus groups were conducted, including a total of 20 Latino and 19 Cambodian patients of two community health centers. Focus groups were audiotaped, transcribed, and qualitatively analyzed to identify major themes regarding attitudes toward advance directives and engaging in discussion about advance care planning.

RESULTS

Most patients did not have a health care proxy nor had discussed this topic with their doctor. Two broad themes were identified: integration of belief systems (including religion, suffering/destiny, and importance of quality of life) as well as process/preferences regarding decision-making (including family roles, provider roles, confusion/uncertainty regarding ACD, and openness to learning about ACD).

CONCLUSIONS

In focus groups discussing end-of-life decision making among Latino and Cambodian patients, two main themes emerged: integration of belief systems and process/preferences regarding end-of-life care. In particular, efforts to improve completion of advance care directives in diverse populations should consider patients' emphasis on quality of life and destiny in end-of-life planning as well as the role of family consensus in decision-making.

Evaluating the use of a modified CAHPS survey to support improvements in patient-centred care: lessons from a quality improvement collaborative

OBJECTIVES

To evaluate the use of a modified Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey to support quality improvement in a collaborative focused on patient-centred care, assess subsequent changes in patient experiences, and identify factors that promoted or impeded data use.

BACKGROUND

Healthcare systems are increasingly using surveys to assess patients' experiences of care but little is established about how to use these data in quality improvement.

DESIGN

Process evaluation of a quality improvement collaborative.

SETTING AND PARTICIPANTS

The CAHPS team from Harvard Medical School and the Institute for Clinical Systems Improvement organized a learning collaborative including eight medical groups in Minnesota.

INTERVENTION

Samples of patients recently visiting each group completed a modified CAHPS survey before, after and continuously over a 12-month project. Teams were encouraged to set goals for improvement using baseline data and supported as they made interventions with bi-monthly collaborative meetings, an online tool reporting the monthly data, a resource manual called The CAHPS Improvement Guide, and conference calls.

MAIN OUTCOME MEASURES

Changes in patient experiences. Interviews with team leaders assessed the usefulness of the collaborative resources, lessons and barriers to using data.

RESULTS

Seven teams set goals and six made interventions. Small improvements in patient experience were observed in some groups, but in others changes were mixed and not consistently related to the team actions. Two successful groups appeared to have strong quality improvement structures and had focussed on relatively simple interventions. Team leaders reported that frequent survey reports were a powerful stimulus to improvement, but that they needed more time and support to engage staff and clinicians in changing their behaviour.

CONCLUSIONS

Small measurable improvements in patient experience may be achieved over short projects. Sustaining more substantial change is likely to require organizational strategies, engaged leadership, cultural change, regular measurement and performance feedback and experience of interpreting and using survey data.

Validation of Toolkit After-Death Bereaved Family Member Interview

The purpose of this study was to examine the reliability and validity of the Toolkit After-Death Bereaved Family Member Interview to measure quality of care at the end of life from the unique perspective of family members. The survey included proposed problem scores (a count of the opportunity to improve the quality of care) and scales. Data were collected through a retrospective telephone survey with a family member who was interviewed between 3 and 6 months after the death of the patient. The setting was an outpatient hospice service, a consortium of nursing homes, and a hospital in New England. One hundred fifty-six family members from across these settings participated. The 8 proposed domains of care, as represented by problem scores or scales, were based on a conceptual model of patient-focused, family-centered medical care. The survey design emphasized face validity in order to provide actionable information to health care providers. A correlational and factor analysis was undertaken of the 8 proposed problem scores or scales. Cronbach's alpha scores varied from 0.58 to 0.87, with two problem scores (each of which had only 3 survey items) having a low alpha of 0.58. The mean item-to-total correlations for the other problem scores varied from 0.36 to 0.69, and the mean item-to-item correlations were between 0.32 and 0.70. The proposed problem scores or scales, with the exception of closure and advance care planning, demonstrated a moderate correlation (i.e., from 0.44 to 0.52) with the overall rating of satisfaction (as measured by a five-point, "excellent" to "poor" scale). Family members of persons who died with hospice service reported fewer problems in each of the six domains of medical care, gave a higher rating of the quality of care, and reported higher self-efficacy in caring for their loved ones. These results indicate that 7 of the 8 proposed problem scores or scales demonstrated psychometric properties that warrant further testing. The domain of closure demonstrated a poor correlation with overall satisfaction and requires further work. This survey could provide information to help guide quality improvement efforts to enhance the care of the dying.

Patient-focused, family-centered end-of-life medical care: views of the guidelines and bereaved family members

A fundamental barrier to improving the quality of medical care at the end of life is the lack of measurement tools. The Toolkit of Instruments to Measure End of Life Care (TIME) aims to fill that void by creating measurement tools that capture the patient and family perspective. To develop a conceptual model for a retrospective survey of bereaved family members that incorporates both professional and family perspectives on what constitutes good care at the end of life, a qualitative literature review of existing professional guidelines and six focus groups with bereaved family members from acute care hospitals (n = 2), nursing homes (n = 2), and hospice/VNA home health services (n = 2) was performed. The focus groups were held in Arizona, New York, and Massachusetts and included 42 bereaved family members/friends contacted 3-12 months from the time of patient's death. Domains of care that define quality end-of-life care were defined. Focus group participants defined high quality medical care as: 1) providing dying persons with desired physical comfort; 2) helping dying persons control decisions about medical care and daily routines; 3) relieving family members of the burden of being present at all times to advocate for their loved one; 4) educating family members so they felt confident to care for their loved ones at home; and 5) providing family members with emotional support both before and after the patient's death. The qualitative literature review yielded similar results, except that the professional guidelines did not mention the advocacy burden felt by families. These two sources provided the foundation for a conceptual model of patient-focused, family-centered medical care and a new tool for surveying bereaved family members. Views of bereaved family members' stories and professional guidelines help to identify key domains of quality of end-of-life care. A new survey instrument provides a way to incorporate the perspectives of bereaved family members in measuring the quality of end-of-life care.

The effects of disseminating performance data to health plans: results of qualitative research with the Medicare Managed Care plans

OBJECTIVE

To assess the information needs and responses of managed care plans to the Medicare Managed Care Consumer Assessment of Health Plans Study (MMC-CAHPS).

DATA SOURCES/STUDY SETTING

One hundred sixty-five representatives of Medicare managed care plans participated in focus groups or interviews in the spring of 1998, 1999, and 2000.

STUDY DESIGN

In 1998 focus groups were conducted with representatives of managed care plans to develop and test a print report of MMC-CAHPS results. After the reports were disseminated focus groups and interviews were conducted in 1999 and 2000 to identify perceptions, uses, and potential enhancements of the report.

DATA COLLECTION/EXTRACTION METHODS

The study team conducted a total of 23 focus groups and 12 telephone interviews and analyzed the transcripts to identify major themes.

PRINCIPAL FINDINGS

In 1998 participants identified the report content and format that best enabled them to assess their performance relative to other Medicare managed care plans. In 1999 and 2000 participants described their responses to and uses of the report. They reported comparing the MMC-CAHPS results to internal surveys and presenting the results to senior managers, market analysts, and quality-improvement teams. They also indicated that the report's usefulness would be enhanced if it were received within six months of survey completion and if additional data analysis was presented.

CONCLUSIONS

Focus group results suggest that the MMC-CAHPS report enhances awareness and knowledge of the comparative performance of Medicare managed care plans. However, participants reported needing additional analysis of survey results to target quality-improvement activities on the populations with the most reported problems.

The built environment as a component of quality care: understanding and including the patient's perspective

BACKGROUND

Although there has been little systematic assessment of how the built environment of health care facilities affects the quality of care, the built environment is a major element of structure of care--one of three facets of quality. Yet in contrast to the growing trend of using consumer perceptions of both processes and outcomes of care in QI activities, quality assessments of the structure of care do not currently rely on patient feedback. PURPOSE OF PROJECT: During the initial phase of a multiphase project, nine focus groups were conducted in 1997 to identify the salient dimensions of experience from the patient's perspective. The content of these focus groups guided the development of assessment tools in the second phase of the project, which began in February 1998.

FINDINGS

Participants in three focus groups that were held in each of three settings--ambulatory care, acute care, and long term care--described in detail a variety of reactions to the built environment. Analysis revealed eight consistent themes in what patients and family member consumers look for in the built environment of health care. In all three settings, they want an environment, for example, that facilitates a connection to staff and caregivers, is conducive to a sense of well-being, and facilitates a connection to the outside world.

DISCUSSION

Data derived from the focus group research has guided the development of quantitative survey and assessment tools. For each setting, patient-centered checklists and questionnaires are designed to help institutions set priorities for the improvement of facility design from the patient's perspective.

Carepartner experiences with hospital care

OBJECTIVES

Family members and other "carepartners" often play an important role in the care and support of patients during and after hospitalization, yet little is known about how they assess their hospital experience or the factors that may influence their perceptions.

METHODS

A nationwide telephone survey of 1,800 recently discharged patients and their carepartners about their hospital experience was conducted. Carepartner responses in six domains of care were summarized, and multivariable regression analysis was used to detect independent predictors of more frequent problem reports by carepartners.

RESULTS

Carepartners reported problems most frequently in the domains of emotional support (23.9%), discharge planning (20.3%), and family participation (17.6%). Independent predictors of more frequent carepartner problem reports included poor subjective patient health status, emergency hospitalization, nonsurgical admission, carepartner income less than $7,500/year, younger carepartner age, noninvolvement of the patient's regular doctor, less frequent carepartner visits during the hospitalization, and less time spent with the patient after discharge.

CONCLUSIONS

Better awareness of the problems carepartners experience and attention to improving quality in these areas may facilitate family involvement in patient care and enhance carepartner and patient satisfaction.

Health care quality. Incorporating consumer perspectives

The goal of this article is to address, from the perspective of users of the health care system (consumers), the following questions: What are the most important health care quality gaps and/or challenges; what major changes should we anticipate in this area in the near future; and what should be the role of federal and state agencies, accreditation organizations, and philanthropic foundations in addressing these challenges? We discuss the needs, challenges, and potential action steps for increasing the prominence of the user's perspective in 3 areas: (1) the conceptualization and definition of quality; (2) the measurement of quality; and (3) routine quality assessment and improvement. The article concludes by making recommendations about the role that different agencies and organizations can and should play in meeting these challenges.

What information do consumers want and need?

This paper reviews information from surveys and focus group studies about how consumers define high-quality care and the types of information they want when making decisions about which health plan to join. The authors also interviewed consumer advocacy groups and persons responsible for disseminating health plan information to Medicare enrollees in various types of managed care plans to learn about the types of plan information that Medicare enrollees most often request. They describe the types of information that should be made available to consumers and the challenges involved in making this information understandable and useful.

Medical patients' assessments of their care during hospitalization: insights for internists

OBJECTIVE

To assess, from the patient's perspective, selected aspects of the quality of inpatient hospital care in the United States.

DESIGN

A cross-sectional survey, using telephone interviews of patients discharged from the medical services of a probability sample of 62 public and private, nonprofit, nonfederal acute care hospitals in the United States. The participating patients reported; discrete, clinically important elements of hospital care; preferences for involvement in care; health status; sociodemographic characteristics; and overall satisfaction with their hospitalization.

PATIENTS/PARTICIPANTS

2,839 patients drawn as a probability sample.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

For 32 of the 50 questions about potential problems encountered during hospitalization, at least 10% of the patients gave a response indicating a problem. One-third of the patients having a physician (31.8%) reported that that physician did not care for them during hospitalization. Other frequently reported problems included not receiving information about the hospital routine (45.1%), not being told whom to ask for help (33.9%), having pain that could have been relieved by more prompt attention (19.9%), and not being given adequate information and guidance about activities and care after discharge from the hospital (21.4-36.1%). Most patients preferred to be informed about important aspects of their care (94.7%), but their preferences for involvement in care varied widely.

CONCLUSIONS

Information from hospitalized medical patients identified several areas of concern that should be the focus of attention and could lead to systematic restructuring of hospital-based care.

Using patient reports to improve medical care: a preliminary report from 10 hospitals

This article describes the early activities of the Picker/Commonwealth Program for Patient-Centered Care and reports results from a study of 10 hospitals trying to develop better ways of providing patient-centered care. Reported problems were relatively infrequent, but several problems occurred as often as in an earlier national study of acute care hospitals. Academic medical centers and other teaching hospitals tended to have more problems than nonteaching hospitals, but there was great variability within hospital types. The article discusses ways patient reports can be used to improve the quality of hospital care.

The relationship between reported problems and patient summary evaluations of hospital care

A nationwide telephone survey of 6,455 adult medical and surgical patients discharged from 62 general hospitals focused on aspects of hospitalization that affected patients' overall evaluation of their care. Eighty percent reported the care they received was excellent or very good. The strongest predictors of patients' evaluations were reported health status and the number of problems reported. Most of the associations between patient characteristics and summary evaluations were explained by differences in the number of problems reported. However, controlling for number of reported problems, the associations between evaluations and age, health status, and preferences were still statistically significant.