Allyson Ross Davies

Does free care improve adults' health? Results from a randomized controlled trial.

Does free medical care lead to better health than insurance plans that require the patient to shoulder part of the cost? In an effort to answer this question, we studied 3958 people between the ages of 14 and 61 who were free of disability that precluded work and had been randomly assigned to a set of insurance plans for three or five years. One plan provided free care; the others required enrollees to pay a share of their medical bills. As previously reported, patients in the latter group made approximately one-third fewer visits to a physician and were hospitalized about one-third less often. For persons with poor vision and for low-income persons with high blood pressure, free care brought an improvement (vision better by 0.2 Snellen lines, diastolic blood pressure lower by 3 mm Hg); better control of blood pressure reduced the calculated risk of early death among those at high risk. For the average participant, as well as for subgroups differing in income and initial health status, no significant effects were detected on eight other measures of health status and health habits. Confidence intervals for these eight measures were sufficiently narrow to rule out all but a minimal influence, favorable or adverse, of free care for the average participant. For some measures of health in subgroups of the population, however, the broader confidence intervals make this conclusion less certain.

COMPARISON OF HEALTH OUTCOMES AT A HEALTH MAINTENANCE ORGANISATION WITH THOSE OF FEE-FOR-SERVICE CARE

To determine whether health outcomes in a health maintenance organisation (HMO) differed from those in the fee-for-service (FFS) system, 1673 individuals ages 14 to 61 were randomly assigned to one HMO or to an FFS insurance plan in Seattle, Washington for 3 or 5 years. For non-poor individuals assigned to the HMO who were initially in good health there were no adverse effects. Health outcomes in the two systems of care differed for high and low income individuals who began the experiment with health problems. For the high income initially sick group, the HMO produced significant improvements in cholesterol levels and in general health ratings by comparison with free FFS care. The low income initially sick group assigned to the HMO reported significantly more bed-days per year due to poor health and more serious symptoms than those assigned free FFS care, and a greater risk of dying by comparison with pay FFS plans.

The functional status questionnaire

A comprehensive functional assessment requires thorough and careful inquiry, which is difficult to accomplish in most busy clinical practices. This paper examines the reliability and validity of the Functional Status Questionnaire (FSQ), a brief, standardized, self-administered questionnaire designed to provide a comprehensive and feasible assessment of physical, psychological, social and role function in ambulatory patients. The FSQ can be completed and computer-scored in minutes to produce a one-page report which includes six summated-rating scale scores and six single-item scores. The clinician can use this report both to screen for and to monitor patients’ functional status. In this study, the FSQ was administered to 497 regular users of Boston’s Beth Israel Hospital’ Healthcare Associates and 656 regular users of 76 internal medicine practices in Los Angeles. The data demonstrate that the FSQ produces reliable sub-scales with construct validity. The authors believe the FSQ addresses many of the problems behind the slow diffusion into primary care of systematic functional assessment.

Patient Satisfaction and Change in Medical Care Provider: A Longitudinal Study

Longitudinal data from The Rand Corporations Health Insurance Experiment were used to test the hypothesis that provider continuity can be modeled as one behavioral consequence of patient satisfaction. Bivariate and multivariate analyses (controlling for sociodemographic characteristics, prior use of services, health status, and health insurance plan) supported our hypotheses. A multivariate linear probability function indicated that a 1-point decrease on a general satisfaction scale was associated with a 3.4 percentage-point increase in the probability of provider change. The relationship between satisfaction scores and continuity during the following year appears to be roughly linear; we observed no “threshold” satisfaction level at which the probability of provider change increased markedly. We discuss needed improvements in the measurement of provider continuity and the need for further study of other behavioral consequences of patient satisfaction.

Choosing measures of health status for individuals in general populations.

This paper offers suggestions to adi the selection of appropriate instruments and data gathering methods for studies that require measures of personal health status applicable in general populations. Before selecting measures, the reason for studying health status must be identified. Next, definitional issues arise when attempting to specify the components of health that are to be studied. Evidence supports restriction of the definition of personal health status to its physical and mental components, rather than including social circumstances as well. In evaluating the suitability of available measures, three features must be considered: 1) practicality in terms of administration, respondent burden, and analysis; 2) reliability in terms of the study design and group or individual comparisons; 3) validity, in terms of providing information about the particular health components of interest to the study. Evaluating validity will be difficult for most available measures; careful attention to item content will be helpful in choosing appropriate measures. Despite problems in development and interpretation, overall health status indicators will prove useful to many studies and should be considered, as should both subjective and objective measures of health status. Given that the reasons to measure health have been identified, the aspects of health to be measured specified, and attention paid to their suitability, appropriate measures may often be found among those now available.

Methods for assessing condition-specific and generic functional status outcomes after total knee replacement.

Many assume that, relative to generic measures, condition-specific health measures are both more sensitive to the conditions severity and more specific because they are less affected by other conditions. We analyzed the sensitivity and specificity of the generic SF-36, condition-specific scales based on the SF-36, and condition-specific measures based on the Knee Societys Clinical Rating System in a study of osteoarthritis patients following knee replacement. As hypothesized, knee-specific role function and pain measures were more specific than generic measures among patients with other comorbid conditions, and less so among patients with only knee problems. Physical function scales of both types were equally specific. Clinical indicators based on x-ray and range of motion were only weakly related to all measures of function.

Physician and Patient Satisfaction as Factors Related to the Organization of Internal Medicine Group Practices

The present study compares patient satisfaction scores with job satisfaction scores of the physicians providing their care in 16 general internal medicine teaching hospital group practices. Practice sites with more satisfied patients were also more likely to have more satisfied housestaff and faculty physicians. Additionally, higher satisfaction scores for both physician groups and patients were consistently associated with a greater percentage of patients experiencing continuity of care, lower patient no-show rates, more efficient use of ancillary staff in providing direct patient care, and more reasonable charges for a routine follow-up visit. These findings suggest that improving physician and patient satisfaction may have economic as well as psychological and social benefits.

Understanding patient willingness to recommend and return: a strategy for prioritizing improvement opportunities.

BACKGROUND Beginning in April 1995, an ongoing, comprehensive measurement system has been developed and refined at BJC Health System, a regional integrated delivery and financing system serving the St Louis metropolitan area, mid-Missouri, and Southern Illinois, to assess patient satisfaction with inpatient treatment, outpatient treatment, outpatient surgery, and emergency care. This system has provided the mechanism for identifying opportunities, setting priorities, and monitoring the impact of improvement initiatives. METHODS Satisfaction with key components of the care process among 23,361 patients (7,083 inpatients, 8,885 patients undergoing outpatient tests/procedures, 5,356 patients undergoing outpatient surgery, and 2,037 patients receiving emergency care) at 15 BJC Health System facilities was assessed through weekly surveys administered in April 1995 through December 1996. RESULTS Structural equation models were developed to identify the key predictors of patient advocation-willingness to return for or recommend care. Across all venues of care the compassion provided to patients had the strongest relationship to patient advocation. Within each venue of care, however, a slightly different set of secondary factors emerged. The resulting models provided important information to help prioritize competing improvement opportunities in BJC Health System. In one hospital, a general medicine unit working for several years with little success to improve its patient satisfaction decided to focus on two primary factors predicting patient advocation: nursing care delivery and compassionate care. Root cause analysis was used to determine why two items-staff willingness to help with questions/concerns and clear explanation about tests and procedures-were rated low. On the basis of feedback from phone interviews with discharged patients, the care delivery process was changed to encourage patients to ask questions. Across the next two quarters, this unit experienced significant improvements in both targeted items. DISCUSSION The significance of compassionate care and care delivery again speaks not only to the importance of the technical quality of clinical care but also to the customer-focused way in which this care was provided. After the primary predictors of patient advocation were identified, management was able to strategically focus improvement initiatives to maximize their impact. Across the organization, improvement teams scanned their data to find key factors where performance was lacking. Once these key opportunities were identified, the teams developed potential solutions and launched initiatives to improve their performance. SUMMARY AND CONCLUSIONS Results suggest that some core issues are of extreme importance to patients regardless of whether they are receiving care in an inpatient, outpatient, or emergency setting. The compassion with which care is provided appears to be the most important factor in influencing patient intentions to recommend/return, regardless of the setting in which care is provided.

Functional disability screening of ambulatory patients

The authors conducted a randomized controlled trial of functional disability screening in a hospital-based internal medicine group practice. They assigned 60 physicians and 497 of their patients to either an experimental or a control group. Every four months the patients in both groups completed a self-administered questionnaire measuring physical, psychological, and social function. The experimental group physicians received reports summarizing their patients’ responses; the control group physicians received no report. At the end of one year the authors found no significant difference between the patients of the experimental and control group physicians on any measure of functional status. Functional disability screening alone does not improve patient function.

Using root cause analysis to address patient satisfaction and other improvement opportunities.

BACKGROUND Despite the considerable attention that health care organizations are devoting to the measurement of patient satisfaction, there is often confusion about how to systematically use these data to improve an organizations performance. A model to use in applying traditional quality improvement methods and tools to patient satisfaction problems includes five primary steps: (1) identifying opportunities, (2) prioritizing opportunities, (3) conducting root cause analysis, (4) designing and testing potential solutions, and (5) implementing the proposed solution. PATIENT SATISFACTION SURVEYS A satisfaction survey serves best as a high-level screening device, not as a tool to provide highly detailed information about the root causes of patient dissatisfaction. The primary purpose of the survey in the model is to identify improvement opportunities and areas of significant improvement or deterioration. Secondary tools such as brief patient interviews or focus groups may better serve to probe intensively into the problem areas identified by the survey. These tools allow for a direct dialog with the patient to uncover root causes of dissatisfaction and establish potential solutions. DISCUSSION Although the primary focus of this model has been patient satisfaction issues, the basic steps could easily be applied to virtually any improvement opportunity. Improvement teams should commit to a schedule of 90-minute weekly meetings for 7 weeks. The model, a simple translation of traditional improvement methods and tools to address the unique issues facing patient satisfaction improvement teams, can save improvement teams considerable time, resources, and frustration as they design and launch initiatives to improve patient satisfaction.