Ann Louise Puopolo

Is the Professional Satisfaction of General Internists Associated with Patient Satisfaction

AbstractBACKGROUND: The growth of managed care has raised a number of concerns about patient and physician satisfaction. An association between physicians’ professional satisfaction and the satisfaction of their patients could suggest new types of organizational interventions to improve the satisfaction of both. OBJECTIVE: To examine the relation between the satisfaction of general internists and their patients. DESIGN: Cross-sectional surveys of patients and physicians. SETTING: Eleven academically affiliated general internal medicine practices in the greater-Boston area. PARTICIPANTS: A random sample of English-speaking and Spanish-speaking patients (n=2,620) with at least one visit to their physician (n=166) during the preceding year. MEASUREMENTS: Patients’ overall satisfaction with their health care, and their satisfaction with their most recent physician visit. MAIN RESULTS: After adjustment, the patients of physicians who rated themselves to be very or extremely satisfied with their work had higher scores for overall satisfaction with their health care (regression coefficient 2.10; 95% confidence interval 0.73–3.48), and for satisfaction with their most recent physician visit (regression coefficient 1.23; 95% confidence interval 0.26–2.21). In addition, younger patients, those with better overall health status, and those cared for by a physician who worked part-time were significantly more likely to report better satisfaction with both measures. Minority patients and those with managed care insurance also reported lower overal satisfaction. CONCLUSIONS: The patients of physicians who have higher professional satisfaction may themselves be more satisfied with their care. Further research will need to consider factors that may mediate the relation between patient and physician satisfaction.

Drug Complications in Outpatients

OBJECTIVE: Outpatient drug complications have not been well studied. We sought to assess the incidence and characteristics of outpatient drug complications, identify their clinical and nonclinical correlates, and evaluate their impact on patient satisfaction. DESIGN: Retrospective chart reviews and patient surveys. SETTING: Eleven Boston-area ambulatory clinics. PATIENTS: We randomly selected 2,248 outpatients, 20 to 75 years old. MEASUREMENTS AND MAIN RESULTS: Among 2,248 patients reporting prescription drug use, 394 (18%) reported a drug complication. In contrast, chart review revealed an adverse drug event in only 64 patients (3%). In univariate analyses, significant correlates of patient-reported drug complications were number of medical problems, number of medications, renal disease, failure to explain side effects before treatment, lower medication compliance, and primary language other than English or Spanish. In multivariate analysis, independent correlates were number of medical problems (odds ratio [OR] 1.17; 95% confidence interval [95% CI] 1.05 to 1.30), failure to explain side effects (OR 1.65; 95% CI, 1.16 to 2.35), and primary language other than English or Spanish (OR 1.40; 95% CI, 1.01 to 1.95). Patient satisfaction was lower among patients who reported drug complications (P < .0001). In addition, 48% of those reporting drug complications sought medical attention and 49% experienced worry or discomfort. On chart review, 3 (5%) of the patients with an adverse drug event required hospitalization and 8 (13%) had a documented previous reaction to the causative drug. CONCLUSIONS: Drug complications in the ambulatory setting were common, although most were not documented in the medical record. These complications increased use of the medical system and correlated with dissatisfaction with care. Our results indicate a need for better communication about potential side effects of medications, especially for patients with multiple medical problems.

Results of a clinical trial on care improvement for the critically ill

ObjectiveTo develop, deploy, and evaluate an intervention designed to identify and mitigate conflict in decision making in the intensive care unit. DesignNonrandomized, controlled trial. SettingSeven intensive care units at four Boston teaching hospitals. PatientsA total of 1,752 critically ill patients, including 873 study cases analyzed here. InterventionSocial workers interviewed families of patients deemed at high risk for decisional conflict and provided feedback to the clinical team, who then implemented measures to address the problems identified. Measurements and Main ResultsPatient or surrogate satisfaction with intensive care unit care and the probability of choosing a specific plan for treatment in the intensive care unit was studied. Inclusion criteria identified 873 patients at risk for decisional conflict. Thirty-nine percent of the patients in the intervention phase of the study (172 patients) received the intervention. In multivariate analyses, receiving the intervention significantly increased the likelihood of deciding to forgo resuscitation (odds ratio [OR] = 1.81, p = .017), the likelihood of choosing a treatment plan for comfort-care only (OR = 1.94, p = .018), and the likelihood of choosing an aggressive-care treatment plan (OR = 2.30, p = .002). Receiving the intervention did not significantly affect overall satisfaction with the care provided (OR = 0.68, p = .14), satisfaction with the amount of information provided (OR = 0.86, p = .44), or satisfaction with the degree of involvement in decision making (OR = 0.84, p = .54). ConclusionsAlthough there was no impact on patient or surrogate satisfaction with care provided in the intensive care unit, the intervention did facilitate deliberative decision making in cases deemed at high risk for conflict. The lessons learned from the experience with this intervention should be helpful in ongoing efforts to improve care and to achieve outcomes desired by critically ill patients, their families, and critical care clinicians.

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.

Differences in the quality of care for women with an abnormal mammogram or breast complaint.

OBJECTIVE: To examine factors associated with variation in the quality of care for women with 2 common breast problems: an abnormal mammogram or a clinical breast complaint. DESIGN: Cross-sectional patient survey and medical record review. SETTING: Ten general internal medicine practices in the Greater Boston area. PARTICIPANTS: Women who had an abnormal radiographic result from a screening mammogram or underwent mammography for a clinical breast complaint (N=579). MEASUREMENTS AND MAIN RESULTS: Three measures of the quality of care were used: (1) whether or not a woman received an evaluation in compliance with a clinical guideline; (2) the number of days until the appropriate resolution of this episode of breast care if any; and (3) a woman’s overall satisfaction with her care. Sixty-nine percent of women received care consistent with the guideline. After adjustment, women over 50 years (odds ratio [OR], 1.58; 95% [CI], 1.06 to 2.36) and those with an abnormal mammogram (compared with a clinical breast complaint: OR, 1.75; 95% CI, 1.16 to 2.64) were more likely to receive recommended care and had a shorter time to resolution of their breast problem. Women with a managed care plan were also more likely to receive care in compliance with the guideline (OR, 1.72; 95% CI, 1.12 to 2.64) and have a more timely resolution. There were no differences in satisfaction by age or type of breast problem, but women with a managed care plan were less likely to rate their care as excellent (43% vs 53%, P<.05). CONCLUSIONS: We found that a substantial proportion of women with a breast problem managed by generalists did not receive care consistent with a clinical guideline, particularly younger women with a clinical breast complaint and a normal or benign-appearing mammogram.

Inconsistent report cards: assessing the comparability of various measures of the quality of ambulatory care.

Background. Report cards based on various performance measures have become increasingly common for rating hospitals and health care plans. However, little has been done to create report cards at the ambulatory clinic level, nor has there been much comparison of the potential components of report cards. Objectives. To create a report card for ambulatory clinics based on different data collection methods and to assess the correlations of clinic scores across various domains of quality. Research Design. Cross‐sectional chart review (n = 3614), patient (n = 2180), and physician surveys (n = 169). Subjects. Sample of outpatients ages 20 to 75 and their primary care providers in 11 ambulatory clinic sites in the Boston‐area from May 1996 to June 1997. Measures. Performance on various quality indicators for each site. Results. Report card scores for five quality domains (performance on HEDIS‐like measures, clinic function, patient satisfaction, diabetes guideline compliance, asthma guideline compliance) were created for each site. None of the five domain scores were significantly correlated with any of the other domains. In addition, there was substantial intraclinic variation in domain scores when compared with the corresponding mean domain score across all clinics. Additional clinic domain scores were created by limiting measures to those found on chart review or survey alone. The chart review and survey domain scores for each clinic were also not significantly correlated. Conclusions. Report cards that emphasize only one domain of quality or use limited data collection methods may provide incomplete or inconsistent information to health care consumers about the overall quality of an outpatient clinic.

Talking with Patients about Other Clinicians' Errors

The authors discuss the challenges facing a clinician who discovers that her patient has been harmed by another health care workers medical error. They provide guidance to help clinicians and institutions disclose such errors to patients.

Influence of financial productivity incentives on the use of preventive care.

PURPOSE We examined whether physician factors, particularly financial productivity incentives, affect the provision of preventive care. SUBJECTS AND METHODS We surveyed and reviewed the charts of 4,473 patients who saw 1 of 169 internists from 11 academically affiliated primary care practices in Boston. We abstracted cancer risk factors, comorbid conditions, and the dates of the last Papanicolaou (Pap) smear, mammogram, cholesterol screening, and influenza vaccination. We obtained physician information including the method of financial compensation through a mailed physician survey. We used multivariable logistic regression to examine the association between physician factors and four outcomes based on Health Plan Employer Data and Information Set (HEDIS) measures: (1) Pap smear within the prior 3 years among women 20 to 75 years old; (2) mammogram in the prior 2 years among women 52 to 69 years old; (3) cholesterol screening within the prior 5 years among patients 40 to 64 years old; and (4) influenza vaccination among patients 65 years old and older. All analyses accounted for clus-tering by provider and site and were converted into adjusted rates. RESULTS After adjustment for practice site, clinical, and physician factors, patients cared for by physicians with financial productivity incentives were significantly less likely than those cared for by physicians without this incentive to receive Pap smears (rate difference, 12%; 95% confidence interval [CI]: 5% to 18%) and cholesterol screening (rate difference, 4%; 95% CI: 0% to 8%). Financial incentives were not significantly associated with rates of mammography (rate difference, -3%; 95% CI: -15% to 10%) or influenza vaccination (rate difference, -13%; 95% CI: -28% to 2%). CONCLUSIONS Our findings suggest that some financial productivity incentives may discourage the performance of certain forms of preventive care, specifically Pap smears and cholesterol screening. More studies are needed to examine the effects of financial incentives on the quality of care, and to examine whether quality improvement interventions or incentives based on quality improve the performance of preventive care.

Differences in the Professional Satisfaction of General Internists in Academically Affiliated Practices in the Greater-Boston Area

Managed care has created more professional constraints for general internists. We surveyed 198 general internists at 12 academically affiliated practices in the greater-Boston area to examine professional satisfaction. Overall, these physicians were moderately satisfied (mean of 59.1 on a 100-point scale). Before adjustment, women had lower overall satisfaction than men, as well as poorer satisfaction with the domains of career concerns and patient access. Gender had no independent effect on satisfaction after adjustment for age, income, percentage of time providing direct patient care, work status, and site. Younger physicians also had lower overall satisfaction, and these differences remained after adjustment. Improvements in professional satisfaction may be required to ensure the continued recruitment of young physicians, particularly women, into general internal medicine.

Race and Family History Assessment for Breast Cancer

OBJECTIVE: Studies have demonstrated disparities in breast cancer screening between racial and ethnic groups. Knowledge of a woman’s family history of breast cancer is important for initiating early screening interventions. The purpose of this study was to determine whether differences exist in the collection of family history information based on patient race. DESIGN: Cross-sectional patient telephone interview and medical record review. SETTING: Eleven primary care practices in the Greater Boston area, all associated with Harvard Medical School teaching hospitals. PARTICIPANTS: One thousand seven hundred fifty-nine women without a prior history of breast cancer who had been seen at least once by their primary care provider during the prior year. MEASUREMENTS AND MAIN RESULTS: Data were collected on patients regarding self-reported race, family breast cancer history information, and breast cancer screening interventions. Twenty-six percent (462/1,759) of the sample had documentation within their medical record of a family history for breast cancer. On multivariate analysis. after adjusting for patient age, education, number of continuous years in the provider’s practice, language, and presentation with a breast complaint, white women were more likely to be asked about a breast cancer family history when compared to nonwhite women (odds ratio, 1.68; 95% confidence interval, 1.21 to 2.35). CONCLUSIONS: The majority of women seen by primary care providers do not have documentation of a family breast cancer history assessment within their medical record. White women were more likely to have family breast cancer information documented than nonwhites.