Denise D. Quigley

Specialties Differ in Which Aspects of Doctor Communication Predict Overall Physician Ratings

ABSTRACTBACKGROUNDEffective doctor communication is critical to positive doctor–patient relationships and predicts better health outcomes. Doctor communication is the strongest predictor of patient ratings of doctors, but the most important aspects of communication may vary by specialty.OBJECTIVETo determine the importance of five aspects of doctor communication to overall physician ratings by specialty.DESIGNFor each of 28 specialties, we calculated partial correlations of five communication items with a 0–10 overall physician rating, controlling for patient demographics.PATIENTSConsumer Assessment of Healthcare Providers and Systems Clinician and Group (CG-CAHPS®) 12-month Survey data collected 2005–2009 from 58,251 adults at a 534-physician medical group.MAIN MEAsURESCG-CAHPS includes a 0 (“Worst physician possible”) to 10 (“Best physician possible”) overall physician rating. Five doctor communication items assess how often the physician: explains things; listens carefully; gives easy-to-understand instructions; shows respect; and spends enough time.KEY RESULTSPhysician showing respect was the most important aspect of communication for 23/28 specialties, with a mean partial correlation (0.27, ranging from 0.07 to 0.44 across specialties) that accounted for more than four times as much variance in the overall physician rating as any other communication item. Three of five communication items varied significantly across specialties in their associations with the overall rating (p < 0.05).CONCLUSIONSAll patients valued respectful treatment; the importance of other aspects of communication varied significantly by specialty. Quality improvement efforts by all specialties should emphasize physicians showing respect to patients, and each specialty should also target other aspects of communication that matter most to their patients. The results have implications for improving provider quality improvement and incentive programs and the reporting of CAHPS data to patients. Specialists make important contributions to coordinated patient care, and thus customized approaches to measurement, reporting, and quality improvement efforts are important.

Evaluating the Content of the Communication Items in the CAHPS ® Clinician and Group Survey and Supplemental Items with What High-Performing Physicians Say They Do

BackgroundA doctor’s ability to communicate effectively is key to establishing and maintaining positive doctor–patient relationships. The Consumer Assessment of Healthcare Providers and System (CAHPS®) Clinician and Group Survey is the standard for collecting and reporting information about patients’ experiences of care in the USA.ObjectiveTo evaluate how well CAHPS® Clinician and Group 2.0 core and supplemental survey items (CG-CAHPS) with a 12-month reference capture doctor–patient communication.Data Sources/Study SettingEleven of the 40 highest-rated physicians on the CG-CAHPS survey treating patients in a Midwest commercial health plan.Study DesignData were obtained via semi-structured interviews. Specific behaviors, practices, and opinions about doctor communication were coded and compared to the CG-CAHPS items.Principal FindingsCG-CAHPS fully captures six of the nine behaviors most commonly mentioned by high-performing physicians: employing office staff with good people skills; involving office staff in communication with patients; spending enough time with patients; listening carefully; providing clear, simple explanations; and devising an action plan with each patient. Three physician behaviors identified as key were not captured in CG-CAHPS items: use of nonverbal communication; greeting patients and introducing oneself; and tracking personal information about patients.ConclusionsCG-CAHPS survey items capture many of the most commonly mentioned doctor–patient communication behaviors and practices identified by high-performing physicians. Nonverbal communication, greeting patients, and tracking personal information about patients were identified as key aspects of doctor–patient communication, but are not captured by the current CG-CAHPS. We recommend further research to assess patients’ perceptions of specific verbal and nonverbal behaviors (such as leaning forward in a chair, casually asking about other family members), followed by the development of new items (if needed) that aim to capture what these specific behaviors represent to patients (e.g., listens attentively, seems to care about me as a person, empathy). We also recommend including items about greeting and tracking personal information about patients in future CAHPS item sets addressing doctor–patient communication. Enriching the content of the CAHPS communication measure can help health-care organizations improve doctor–patient communication and interactions.

Effectiveness of a Multidisciplinary Intervention to Improve Hypertension Control in an Urban Underserved Practice

Patient-centered, multidisciplinary interventions offer one of the most promising strategies to improve blood pressure (BP) control, yet effectiveness trials in underserved real-world settings are limited. We used a multidisciplinary strategy to improve hypertension control in an underserved urban practice. We collected 1007 surveys to monitor medication adherence and used weighted generalized estimating equations to examine trends in BP control. We examined 13,404 visits from patients with hypertension between August 2010 and February 2014. Overall, BP control rates increased from 51.0% to 67.4% (adjusted odds ratio, 1.58; 95% confidence interval, 1.44-1.74) by the end of the intervention phase and were maintained during the postintervention phase (adjusted odds ratio, 1.60; 95% confidence interval, 1.41-1.82). Medication adherence scores increased across the intervention (5.9-6.6; P < .001), but were not sustained at the conclusion of the study (5.9-6.2; P = .16). A multidisciplinary team approach involving registered nurses, pharmacists, and physicians resulted in substantial improvements in hypertension control in a real-world underserved setting.

Use of CAHPS Patient Experience Surveys to Assess the Impact of Health Care Innovations

BACKGROUND The Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys are the standard for collecting information about patient experience of care in the United States. However, despite their widespread use, including in pay-for-performance and public reporting efforts and various provisions of the Affordable Care Act, knowledge about the use of CAHPS in assessing the impact of quality improvement efforts is limited. A study was conducted to examine the use of patient experience surveys in assessing the impact of innovations implemented in health care settings. METHODS Innovation profiles identified on the Agency for Healthcare Research and Quality (AHRQ) Health Care Innovations Exchange website that included patient experience (including patient satisfaction) as an outcome (N = 201), were analyzed with a variety of qualitative analysis methods. RESULTS Fewer than half of the innovations used a patient experience measure, most commonly employing global measures such as an overall rating. Most innovations assessed patient experience at a single time point, with only one third using techniques such as pre-post comparisons, time trends, or comparisons to control groups. Ten domains of measures addressed reports of patient experience, all of which could be assessed by existing CAHPS instruments. Similarly, CAHPS measures are available to assess all of the organizational processes that are addressed by innovations in the profiles and for which patients are the best source of information. While 120 of the innovations that use patient experience measures report using surveys to collect these data, only 6 reported using a CAHPS measure. CONCLUSIONS Although innovations targeting quality improvement are often evaluated using surveys, there is considerable untapped potential for using CAHPS measures or surveys to assess their effectiveness.

Bridging From the Picker Hospital Survey to the CAHPS® Hospital Survey

Objective:Illustrate an accessible method of bridging data from earlier surveys to the CAHPS® Hospital Survey to support hospitals’ internal quality improvement efforts. Data Sources/Study Setting:Survey of patients with more than 300,000 annual hospitalizations in a large urban hospital. Study Design and Data:Six pairs of parallel items from the CAHPS and Picker Hospital Surveys were administered to the same 734 patients. We assessed item comparability and applied bridging adjustments to convert old items to predicted scores on the new CAHPS items. Principle Findings:Differences in wording, response options, and cut points for “problem scores” yielded large differences in problem score rates between the Picker and CAHPS Hospital Surveys, requiring bridging formulas. Tetrachoric correlations for 5 of 6 pairs indicated high correspondence (r = 0.71–0.97, P < 0.001) in the underlying constructs assessed by the 2 surveys, validating the use of bridging. Bridged scores contain less information per observation than directly measured new scores, but with sufficient sample sizes they can be used to detect trends across the transition. Conclusions:Hospitals can use the methodology described here to trend their scores from a previous survey to the CAHPS Hospital Survey with sufficient precision to support ongoing quality improvement efforts. Hospitals should administer an instrument containing pairs of old and new items to enough patients to yield at least 625 completes to measure bridging parameters precisely. Where correspondence is high, old items can and should be replaced by CAHPS items. Important old items with weaker associations with new items may be retained.

Evaluation of CMS' FQHC APCP Demonstration: Final First Annual Report

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Use of CAHPS ® patient experience survey data as part of a patient-centered medical home quality improvement initiative

Objective To describe how practice leaders used Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Clinician and Group (CG-CAHPS) data in transitioning toward a patient-centered medical home (PCMH). Study design Interviews conducted at 14 primary care practices within a large urban Federally Qualified Health Center in California. Participants Thirty-eight interviews were conducted with lead physicians (n=13), site clinic administrators (n=13), nurse supervisors (n=10), and executive leadership (n=2). Results Seven themes were identified on how practice leaders used CG-CAHPS data for PCMH transformation. CAHPS® was used: 1) for quality improvement (QI) and focusing changes for PCMH transformation; 2) to maintain focus on patient experience; 3) alongside other data; 4) for monitoring site-level trends and changes; 5) to identify, analyze, and monitor areas for improvement; 6) for provider-level performance monitoring and individual coaching within a transparent environment of accountability; and 7) for PCMH transformation, but changes to instrument length, reading level, and the wording of specific items were suggested. Conclusion Practice leaders used CG-CAHPS data to implement QI, develop a shared vision, and coach providers and staff on performance. They described how CAHPS® helped to improve the patient experience in the PCMH model, including access to routine and urgent care, wait times, provider spending enough time and listening carefully, and courteousness of staff. Regular reporting, reviewing, and discussing of patient-experience data alongside other clinical quality and productivity measures at multilevels of the organization was critical in maximizing the use of CAHPS® data as PCMH changes were made. In sum, this study found that a system-wide accountability and data-monitoring structure relying on a standardized and actionable patient-experience survey, such as CG-CAHPS, is key to supporting the continuous QI needed for moving beyond formal PCMH recognition to maximizing primary care medical home transformation.

Patient Experience With Care and Its Association With Adherence to Hypertension Medications

BACKGROUND Medication adherence is crucial to effective chronic disease management, yet little is known about the influence of the patient-provider interaction on medication adherence to hypertensive regimens. We aimed to examine the association between the patients experience with care and medication adherence. METHODS We collected 2,128 surveys over 4 years from a convenience sample of hypertensive patients seeking care at three urban safety-net practices in upstate New York. The survey collected adherence measures using the Morisky Medication Adherence Scale (MMAS-8) and patient experience measures. We used regression models to adjust for age, gender, race/ethnicity, self-reported health status, and clustering by patients. The primary outcome was reporting of medium-to-high adherence (MMAS ≥ 6) vs. low adherence. RESULTS A total of 62.5% of respondents reported medium-to-high medication adherence. The concern the provider demonstrated for patient questions or worries (adjusted odds ratio [AOR] 1.4; 95% confidence interval [CI] 1.1-1.7), provider efforts to include the patient in decisions (AOR 1.5; 95% CI 1.8-1.9), information given (AOR 1.3; 95% CI 1.0-1.6), and the overall rating of care received (AOR 1.4; 95% CI 1.1-1.8) were associated with higher medication adherence. The amount of time the provider spent was not associated with medication adherence (AOR 1.2; 95% CI 0.9-1.4). Medium-to-high medication adherence was in turn associated with increased hypertension control rates. CONCLUSIONS Overall, better experiences with care were associated with higher adherence to hypertension regimens. However, the amount of time the provider spent with the patient was not statistically associated with medication adherence, suggesting that the quality of communication may be more important than the absolute quantity of time.

Patient Experiences with Care Differ with Chronic Care Management in a Federally Qualified Community Health Center

This study compares patient experience among practices that vary in adoption of the chronic care management (CCM) dimension of the patient-centered medical home (PCMH) model that focuses on care coordination and management of chronic diseases. Study participants were 2903 adult patients (ages 18 years or older) at 14 primary care centers in California. Seven of the sites were classified as high (more CCM) and the other 7 low on a CCM index. Hypotheses were tested using ordinary least squares regression models. After adjusting for the number of providers at the sites, high CCM scores were associated with significantly better overall ratings of providers, provider communication, follow-up on test results, and willingness to recommend the provider (differences of 5.82, 6.85, 9.81, and 4.56, respectively on the 0-100 scale scores). The results of this study provide support for the value of the PCMH for patient experiences with care.

Developing and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System for Patient Safety Events

This article describes the design, development, and testing of the Health Care Safety Hotline, a prototype consumer reporting system for patient safety events. The prototype was designed and developed with ongoing review by a technical expert panel and feedback obtained during a public comment period. Two health care delivery organizations in one metropolitan area collaborated with the researchers to demonstrate and evaluate the system. The prototype was deployed and elicited information from patients, family members, and caregivers through a website or an 800 phone number. The reports were considered useful and had little overlap with information received by the health care organizations through their usual risk management, customer service, and patient safety monitoring systems. However, the frequency of reporting was lower than anticipated, suggesting that further refinements, including efforts to raise awareness by actively soliciting reports from subjects, might be necessary to substantially increase the volume of useful reports. It is possible that a single technology platform could be built to meet a variety of different patient safety objectives, but it may not be possible to achieve several objectives simultaneously through a single consumer reporting system while also establishing trust with patients, caregivers, and providers.