Anton J. Kuzel

Patient Reports of Preventable Problems and Harms in Primary Health Care

BACKGROUND Despite recent attention given to medical errors, little is known about the kinds and importance of medical errors in primary care. The principal aims of this study were to develop patient-focused typologies of medical errors and harms in primary care settings and to discern which medical errors and harms seem to be the most important. METHODS Thirty-eight in-depth anonymous interviews of adults from rural, suburban, and urban locales in Virginia and Ohio were conducted to solicit stories of preventable problems with primary health care that led to physical or psychological harm. Transcriptions were analyzed to identify, name, and organize the stories of errors and harms. RESULTS The 38 narratives described 221 problematic incidents that predominantly involved breakdowns in the clinician-patient relationship (n = 82, 37%) and access to clinicians (n = 63, 29%). There were several reports of perceived racism. The incidents were linked to 170 reported harms, 70% of which were psychological, including anger, frustration, belittlement, and loss of relationship and trust in one’s clinician. Physical harms accounted for 23% of the total and included pain, bruising, worsening medical condition, and adverse drug reactions. DISCUSSION The errors reported by interviewed patients suggest that breakdowns in access to and relationships with clinicians may be more prominent medical errors than are technical errors in diagnosis and treatment. Patients were more likely to report being harmed psychologically and emotionally, suggesting that the current preoccupation of the patient safety movement with adverse drug events and surgical mishaps could overlook other patient priorities.

A String of Mistakes: The Importance of Cascade Analysis in Describing, Counting, and Preventing Medical Errors

BACKGROUND Notions about the most common errors in medicine currently rest on conjecture and weak epidemiologic evidence. We sought to determine whether cascade analysis is of value in clarifying the epidemiology and causes of errors and whether physician reports are sensitive to the impact of errors on patients. METHODS Eighteen US family physicians participating in a 6-country international study filed 75 anonymous error reports. The narratives were examined to identify the chain of events and the predominant proximal errors. We tabulated the consequences to patients, both reported by physicians and inferred by investigators. RESULTS A chain of errors was documented in 77% of incidents. Although 83% of the errors that ultimately occurred were mistakes in treatment or diagnosis, 2 of 3 were set in motion by errors in communication. Fully 80% of the errors that initiated cascades involved informational or personal miscommunication. Examples of informational miscommunication included communication breakdowns among colleagues and with patients (44%), misinformation in the medical record (21%), mishandling of patients’ requests and messages (18%), inaccessible medical records (12%), and inadequate reminder systems (5%). When asked whether the patient was harmed, physicians answered affirmatively in 43% of cases in which their narratives described harms. Psychological and emotional effects accounted for 17% of physician-reported consequences but 69% of investigator-inferred consequences. CONCLUSIONS Cascade analysis of physicians’ error reports is helpful in understanding the precipitant chain of events, but physicians provide incomplete information about how patients are affected. Miscommunication appears to play an important role in propagating diagnostic and treatment mistakes.

Elements of the patient-centered medical home in family practices in Virginia.

PURPOSE The patient-centered medical home (PCMH) is a widely accepted theory of a practice model to improve quality of care, patient satisfaction, and access to primary care services. This study explores existing elements of the PCMH and characteristics of family practices in Virginia. METHOD We developed and administered a survey questionnaire to capture information on practice characteristics and PCMH elements. We randomly sampled 700 family medicine offices in Virginia from a population of practices derived from the Virginia Board of Medicine Practitioner Information Database. We used a mixed-mode survey, allowing practices in the sample to respond by mail or Internet or at a regional family medicine conference. RESULTS The survey resulted in a response rate of 56%, with 342 office locations participating in the study. Most practices reported continuity-of-care processes (87%) and clinical guidelines (77%). Fewer reported use of patient surveys (48%), electronic medical record for internal coordination (38%), community linkages for care (31%), and clinical performance measurement (28%). A small number reported patient registries for multiple diseases (19%). Very few practices exhibited all elements outlined in the PCMH model (1%). Practice size (number of physicians) is significantly related to PCMH model alignment. CONCLUSIONS Most family practices in Virginia exhibit some elements of the PCMH model. Full implementation of the PCMH model is low. Baseline information on practice characteristics, prevalence of PCMH, and challenges of small practices should be considered in guiding efforts, evaluating progress, and developing policies for care model reform.

Elderly Deaf Patients' Health Care Experiences

Background: Approximately 10% of the US population has some degree of hearing loss, and 2 million Americans are deaf. Most medical school curricula and major textbooks characterize deafness as pathologic condition only, which is at odds with the movement to understand the Deaf population as a minority group with a unique language and cultural tradition. Physicians might therefore be unprepared to meet the needs of deaf patients effectively and sensitively. This study seeks to understand the health care experiences of elderly Deaf adults in Richmond, Va. Methods: The authors conducted focus groups of elderly Deaf persons. Real-time voice-interpretation of the sign language communication allowed for tape recording and full transcription. The authors independently analyzed the transcripts using an editing style, and incorporated feedback on their interpretation from participants. Results: Participants experienced many practical barriers to effective health care, including problems with scheduling appointments and communicating with providers. They believed that providers are ill-prepared to care for them and worried that prejudice might be a more subtle obstacle. Participants seemed resigned to these circumstances. Conclusions: The authors suggest a possible explanation for this perspective, and make specific recommendations for three levels of competency in caring for deaf patients. When the provider and the office staff provide methods to communicate with deaf patients using telephone-assisted communication, qualified interpreters, and some basic knowledge of lipreading or sign language, the care of deaf patients is greatly enhanced and the physician-patient relationship improved.

Team-Based Care: A Critical Element of Primary Care Practice Transformation

The purpose of this study was to gain an in-depth understanding of how primary care practices in the United States are transforming their practice to deliver patient-centered care. The study used qualitative research methods to conduct case studies of small primary care practices in the state of Virginia. The research team collected data from practices using in-depth interviews, structured telephone questionnaires, observation, and document review. Team-based care stood out as the most critical method used to successfully transform practices to provide patient-centered care. This article presents 3 team-based care models that were utilized by the practices in this study.

Facilitators and barriers to implementing antimicrobial stewardship strategies: Results from a qualitative study

BACKGROUND Many hospitals have implemented antimicrobial stewardship programs (ASPs) and have included in their programs strategies such as prior authorization and audit and feedback. However there are few data concerning the facilitators and barriers that ASPs face when implementing their strategies. We conducted a qualitative study to discern factors that lead to successful uptake of ASP strategies. METHODS Semistructured telephone interviews were conducted from June-July 2013 with 15 ASP member pharmacists and 6 physicians representing 21 unique academic medical centers. RESULTS Successful implementation of ASP strategies was found to be related to communication style, types of relationships formed between the ASP and non-ASP personnel, and conflict management. Success was also influenced by the availability of resources in the form of adequate personnel, health information technology personnel and infrastructure, and the ability to generate and analyze ASP-specific data. Types of effective strategies commonly cited included audit and feedback; prior authorization, especially with an educative component; and use of real-time alert technology and guidelines. CONCLUSIONS Several factors may influence ASP success in the implementation of their strategies. ASP members may use these findings to improve upon the success of their programs.

How patients want to engage with their personal health record: a qualitative study

Objective To assess factors related to use and non-use of a sophisticated interactive preventive health record (IPHR) designed to promote uptake of 18 recommended clinical preventive services; little is known about how patients want to use or be engaged by such advanced information tools. Design Descriptive and interpretive qualitative analysis of transcripts and field notes from focus groups of the IPHR users and of patients who were invited but did not use the IPHR (non-users). Grounded theory techniques were then applied via an editing approach for key emergent themes. Setting Primary care patients in eight practices of the Virginia Ambulatory Care Outcomes Research Network (ACORN). Participants Three focus groups involved a total of 14 IPHR users and two groups of non-users totalled 14 participants. Outcomes/results For themes identified (relevance, trust and functionality) participants indicated that endorsement and use of the IPHR by their personal clinician was vital. In particular, participants’ comments linked the IPHR use to: (1) integrating the IPHR into current care, (2) promoting effective patient–clinician encounters and communication and (3) their confidence in the accuracy, security and privacy of the information. Conclusions In addition to patients’ stated desires for advanced functionality and information accuracy and privacy, successful adoption of the IPHRs by primary care patients depends on such technologys relevance, and on its promotion via integration with primary care practices’ processes and the patient–clinician relationship. Accordingly, models of technological success and adoption, when applied to primary care, may need to include the patient–clinician relationship and practice workflow. These findings are important for healthcare providers, the information technology industry and policymakers who share an interest in encouraging patients to use personal health records. Trial Registration Clinicaltrials.gov identifier: NCT00589173

ACHIEVING A PATIENT-CENTERED MEDICAL HOME AS DETERMINED BY THE NCQA—AT WHAT COST, AND TO WHAT PURPOSE?

In 2007, multiple primary care organizations (American College of Physicians [ACP], American Academy of Family Physicians [AAFP], American Academy of Pediatrics [AAP], and American Osteopathic Association [AOA)] agreed upon the basic elements of a patient-centered medical home (PCMH). In an effort to promote the adoption of these elements, the National Center for Quality Assurance (NCQA) has, in consultation with the same primary care organizations, established a set of standards for achieving a PCMH, divided into 3 levels of achievement, organized along 9 areas, and comprising 30 discrete elements, 10 of which are mandatory “must passes.” Level I recognition requires meeting 5 of these must pass elements; level II or III recognition requires the applicant meet all 10 of the must pass elements and corresponding prescribed point levels. It occurred to us that it might be useful to contemplate these standards in light of what the Institute for Healthcare Improvement is now calling the “triple aim” for improving care—managing (reducing) overall costs, ensuring a great patient experience of care, and achieving both process and outcome measures of care quality. The recent national demonstration project of the American Academy of Family Physicians—TransforMED—has shed light on both the apparent obstacles to achieving these goals and standards, as well as the kinds of resources that will be needed to overcome the barriers. We offer, as a stimulus to discussion and perhaps as a guide to empirical investigation, the following matrix in which we portray the NCQA elements along one side and the several kinds of benefits and costs along the other side. Based on our experience as practitioners and investigators, and with some support from existing literature, we suggest that there may be real differences in the relative intensity of both benefits and costs for each of the 30 NCQA elements, and indicate that by showing 1, 2, or 3 pluses in a cell to signify the relative intensities of costs and benefits: We have chosen to simply add the numbers of pluses in the 3 benefits columns and divide them by the sum of the pluses in the costs columns to derive a crude estimate of the benefit/cost ratio for each of the NCQA elements. There are obvious shortcomings to this—different constituencies would necessarily assign different utilities to each of the elements portrayed across the top, and we have not shown the reader a systematic review that would support our personal assignment of values to each cell. Think of the table ▶ below as more of an illustration or example to communicate a way of thinking about this issue. Nonetheless, it is intriguing that our personal assessment of benefit vs cost ratio bears little relationship to the points that the current NCQA rubric assigns to each of the elements of a PCMH. Table t1 In creating this table ▶, we imagined “starting from scratch,” and we recognize that the costs, in particular, might be different for some established practices, and would certainly be different for a practice to maintain the elements. We are also cognizant that both the NCQA elements and the table do not explicitly attend to a key finding of the TransforMED project: it’s all about relationships: doctor-patient, doctor-nurse-staff, and practice-community. Practices that are mindful of all of these relationships and that are relatively good at keeping them healthy are more likely to achieve and sustain the technical elements portrayed in the first column. Perhaps the columns that portray the need for leadership and for team investment are a reasonable proxy. In any case, the point of the exercise is to suggest that it may be worth thinking about what kinds of benefits accrue when one adopts each of the standards, what kinds of resources (people, time, and money) are necessary to establish the standards, and how the relative value assigned to each resource expense or benefit would depend upon what constituency is making that judgment. It also suggests that empirical research that takes into account all of these costs, benefits, and stakeholder perspectives would be more helpful than that which only examines a portion of the costs or a portion of the benefits for a single constituency.

Making the Case for a Qualitative Study of Medical Errors in Primary Care

In the interest of publicizing examples of funded qualitative health research, the authors share a proposal to the Agency for Healthcare Research and Quality in Washington, D.C., in which they sought to elicit patient stories of preventable problems in their primary health care that were associated with psychological or physical harms. These stories would allow for the construction of a tentative typology of errors and harms as experienced by patients and the contrasting of this with errors and harms reported by primary care physicians in the United States and other countries. The authors make explicit the anticipated concerns of reviewers more accustomed to quantitative research proposals and the arguments and strategies employed to address them.

Data Expressions or Expressing Data

They say you can find poetry anywhere. One of the latest trends in qualitative inquiry appears to be the transformation of data into poetry or free verse. Block quotations have always been a problem for editors and researchers. In many ways this is a new form of an old dilemma—how do we present rich data in a way that captures the richness? How should we convey the “feel” of what was said or done? Sometimes lengthy quotations extend forever in the results section, with the subjects’ voices presenting the analysis, and with minimal commentary from the researcher. Sometimes quotations are used to illustrate the analysis in various forms: raw, as delivered directly from the transcriptionist, with random punctuation; meticulously coded, with each pause measured and every utterance included; or in some cases edited, with extraneous comments culled. But there is a new form emerging: We now find cases in which the author has “converted” the transcript into some form of free verse. We are not certain why researchers are going to all of this trouble. Is it a response to the pro-art and antiscientific trend in qualitative inquiry? Is it an attempt to be more scholarly? Is it an attempt to avoid the stripping of our data of its richness, or to evoke emotions to new heights? To prove that one can be genuinely interpretive? Or a side effect of the performance side of qualitative inquiry? The editors of QHR have considered this trend carefully, and we have made the decision to resist accepting manuscripts of this genre for publication, for the reasons presented below. And rather than have our authors submit such work and then experience the disappointment of rejection, we are bringing our considerations to the fore. Now, you may agree or disagree, grumble silently, or make your feelings transparent by contributing to our Pearls, Pith, and Provocation section. So, why did we make this decision? First, a practical reason: QHR is allotted only 144 pages per issue, 12 times a year. If your article incorporating free verse increases the length of the article by 5 pages, someone else loses 5 pages. Therefore we have always adhered to the golden principle that articles must earn their space, even to the extent that a 40-page article manuscript must be twice as significant, and of greater interest to the majority of our readership, than a 20-page article. From an editorial perspective, we cannot afford the additional space unless it is justified. Next, although authors do not share their original transcripts with us, we suspect that transforming data into a “poem-like structure” of some sort changes the form of the data even if it does not change the meaning to any significant degree. If it does change the meaning, we have a validity issue; if it does not change the meaning, then why bother doing it? Perhaps there are exceptions in which the transformation of interview material into poetry, or a poetrylike structure, is useful and valid. If so, the authors must provide a convincing rationale in their text. In particular, why do the subjective aesthetic decisions they make when transforming their data add to the authenticity of their subject’s voice? In our opinion, if there is “value added” in the transformation, we need to know the guidelines and conventions that guided the authors’ decisions. This we have yet to see. Poetry, as a reflection and evocation of aspects of living, is an art form, an end in itself; its goal is to sensitize, to reveal, to cause emotive arousal. While some researchers may, in fact, also be good poets, the two practices involve very different skill sets and have different goals. Unfortunately, the conversion of text to free verse, however poignant, confuses these goals. Even if converted to poetry, the text must still be analyzed in the researcher’s voice, with theoretical concepts, with ideas and insights, because—recall— the researcher is doing research, after all. Of greater concern, the presentation of data as verse focuses on the literary device rather than the health research. What happens when good research is presented in the form of bad or mediocre poetry? We have not been convinced by a rigorous argument that such transposition enhances the depth of analysis and richness of findings. Interpretation and analysis ought to be in the realm of theoretical construction and practical import, yet much of this poetic presentation does not even attempt to explain “what this research means” for the practice world. Authors must build that in to acknowledge QHR’s typical audience and clinical roles. One final point: Rendering data into