Elizabeth Wenghofer

Influence of Physicians' Management and Communication Ability on Patients' Persistence With Antihypertensive Medication

BACKGROUNDnLess than 75% of people prescribed antihypertensive medication are still using treatment after 6 months. Physicians determine treatment, educate patients, manage side effects, and influence patient knowledge and motivation. Although physician communication ability likely influences persistence, little is known about the importance of medical management skills, even though these abilities can be enhanced through educational and practice interventions. The purpose of this study was to determine whether a physicians medical management and communication ability influence persistence with antihypertensive treatment.nnnMETHODSnThis was a population-based study of 13,205 hypertensive patients who started antihypertensive medication prescribed by a cohort of 645 physicians entering practice in Quebec, Canada, between 1993 and 2007. Medical Council of Canada licensing examination scores were used to assess medical management and communication ability. Population-based prescription and medical services databases were used to assess starting therapy, treatment changes, comorbidity, and persistence with antihypertensive treatment in the first 6 months.nnnRESULTSnWithin 6 months after starting treatment, 2926 patients (22.2%) had discontinued all antihypertensive medication. The risk of nonpersistence was reduced for patients who were treated by physicians with better medical management (odds ratio per 2-SD increase in score, 0.74; 95% confidence interval, 0.63-0.87) and communication (0.88; 0.78-1.00) ability and with early therapy changes (odds ratio, 0.45; 95% confidence interval, 0.37-0.54), more follow-up visits, and nondiuretics as the initial choice of therapy. Medical management ability was responsible for preventing 15.8% (95% confidence interval, 7.5%-23.3%) of nonpersistence.nnnCONCLUSIONnBetter clinical decision-making and data collection skills and early modifications in therapy improve persistence with antihypertensive therapy.

Patient Satisfaction as an Indicator of Quality Care in Independent Health Facilities: Developing and Assessing a Tool to Enhance Public Accountability

The objective of this research was to examine the performance of a brief patient survey about quality of care received in community-based diagnostic and therapeutic facilities. The survey was administered to patients in 44 facilities that were also scheduled for a formal external assessment. The response rate was 53%. Patients generally rated their care positively; 18.5% of patients rated at least 1 item as fair or poor. The amount of information received about risks and complications was rated least favorably; concern and caring shown by staff was rated most favorably. The 10 items which patients rated regarding aspects of quality formed an internally consistent scale (a = .93). Patients ratings were not useful predictors of assessor ratings. Although patients ratings cannot substitute for expert on-site assessments, they are an important part of a quality management program. The patient survey provides additional, complementary information about components of quality care that are important to them.

Health services utilization after induced abortions in Ontario: a comparison between community clinics and hospitals.

The purpose of this study was to compare postabortion health services utilization of hospital abortion patients with community clinic abortion patients using administrative databases. The study was a retrospective cohort study. The study group consisted of patients with induced abortions (n = 41,039) performed in hospitals or community clinics recorded in the 1995 Ontario Health Insurance Plan claims (OHIP) database. An age-matched cohort of 39,220 women who did not undergo induced abortions was selected from the same data source to serve as controls. The main outcome measures were health services utilization indicators constructed from OHIP data within 3 months postabortion from office consultations, emergency room consultations, and hospital admissions. Hospitalization indicators were constructed from Canadian Institute for Health Information hospital discharge data with-in 3 months postabortion and included data on hospitalizations for infection, certain surgical events, or psychiatric problems. Postabortion health services utilization and hospitalization were higher in the patient population, regardless of service location, than in the age-matched cohort. Within the abortion patient population, hospital day-surgery patients had higher rates of postabortion utilization and hospitalization than did community clinic patients. Multivariate analysis revealed that hospital day surgery patients had a higher risk of subsequent post-abortion hospitalizations for infections (odds ratio [OR] 1.67, 95% confidence interval [CI] 1.23-2.28), surgical events (OR 1.70, 95% CI 1.30-3.24) and psychiatric problems (OR 2.65, 95% CI 1.77-3.98) than community clinic patients. The rates of postabortion health services utilization and risk of hospitalization were lower in community clinic abortion patients than in hospital day-surgery patients. However, it is not possible to fully control for important confounding variables when using these administrative data.

Physician-patient encounters: the structure of performance in family and general office practice.

Introduction: The College of Physicians and Surgeons of Ontario, the regulatory authority for physicians in Ontario, Canada, conducts peer assessments of physicians practices as part of a broad quality assurance program. Outcomes are summarized as a single score and there is no differentiation between performance in various aspects of care. In this study we test the hypothesis that physician performance is multidimensional and that dimensions can be defined in terms of physician‐patient encounters. Methods: Peer assessment data from 532 randomly selected family practitioners were analyzed using factor analysis to assess the dimensional structure of performance. Content validity was confirmed through consultation sessions with 130 physicians. Multiple‐item measures were constructed for each dimension and reliability calculated. Analysis of variance determined the extent to which multiple‐item measure scores would vary across peer assessment outcomes. Results: Six performance dimensions were confirmed: acute care, chronic conditions, continuity of care and referrals, well care and health maintenance, psychosocial care, and patient records. Discussion: Physician performance is multidimensional, including types of physician‐patient encounters and variation across dimensions, as demonstrated by individual practice. A conceptual framework for multidimensional performance may inform the design of meaningful evaluation and educational recommendations to meet the individual performance of practicing physicians.

Physician Peer Assessments for Compliance With Methadone Maintenance Treatment Guidelines

Introduction: Medical associations and licensing bodies face pressure to implement quality assurance programs, but evidence‐based models are lacking. To improve the quality of methadone maintenance treatment (MMT), the College of Physicians and Surgeons of Ontario, Canada, conducts an innovative quality assurance program on the basis of peer assessments. Using data from this program, we assessed physician compliance with MMT guidelines and determined whether physician factors (e.g., training, years of practice), practice type, practice location, and/or caseload is associated with MMT guideline adherence. Methods: Secondary analysis of methadone practice assessment data collected by the College of Physicians and Surgeons of Ontario, Canada. Assessment data from methadone prescribing physicians who completed their first year of methadone practice were analyzed. We calculated the mean percentage compliance per guideline per physician and global compliance across all guidelines per physician. Linear regression was used to assess factors associated with compliance. Results: Data from 149 physician practices and 1,326 patient charts were analyzed. Compliance across all charts was greater than 90% for most areas of care. Compliance was less than 90% for take‐home medication procedures; urine toxicology screening; screening for hepatitis B virus (HBV), hepatitis C virus (HCV), human immunodeficiency virus (HIV), tuberculosis, other sexually transmitted infections, and completion of a psychosocial assessment. Mean global compliance across all charts and guidelines per physician was 94.3% (standard deviation = 7.4%) with a range of 70% to 100%. Linear regression analysis revealed that only year of medical school graduation was a significant predictor of physician compliance. Discussion: This is the first report of MMT peer assessments in Canada. Compliance is high. Few countries conduct similar assessment processes; none report physician‐level results. We cannot quantify the contribution of peer assessment, training, or self‐selection to the compliance rates, but compared to other areas of practice these rates suggest that peer assessment may exert a significant effect on compliance. A similar assessment process may in other areas of clinical practice improve physician compliance.

Value of General Medical Knowledge Examinations in Performance Assessment of Practicing Physicians With Potential Competence and Performance Deficiencies.

Introduction: Problems with a physicians performance may arise at any point during their career. As such, there is a need for effective, valid tools and processes to accurately assess and identify deficiencies in competence or performance. Although scores on multiple-choice questions have been shown to be predictive of some aspects of physician performance in practicing physicians, their relationship to overall clinical competence is somewhat uncertain particularly after the first 10 years of practice. As such, the purpose of this study was to examine how a general medical knowledge multiple-choice question examination is associated with a comprehensive assessment of competence and performance in experienced practicing physicians with potential competence and performance deficiencies. Methods: The study included 233 physicians, of varying specialties, assessed by the University of California, San Diego Physician Assessment and Clinical Education Program (PACE), between 2008 and 2012, who completed the Post-Licensure Assessment System Mechanisms of Disease (MoD) examination. Logistic regression determined if the examination score significantly predicted passing assessment outcome after correcting for gender, international medical graduate status, certification status, and age. Results: Most physicians (89.7%) received an overall passing assessment outcome on the PACE assessment. The mean MoD score was 66.9% correct, with a median of 68.0%. Logistic regression (P = .038) was significant in indicating that physicians with higher MoD examination scores had an increased likelihood of achieving a passing assessment outcome (odds ratio = 1.057). Discussion: Physician MoD scores are significant predictors of overall physician competence and performance as evaluated by PACE assessment.