Hector P. Rodriguez

Evaluating Patients' Experiences with Individual Physicians A Randomized Trial of Mail, Internet, and Interactive Voice Response Telephone Administration of Surveys

Background:There is increasing interest in measuring patients’ experiences with individual physicians, and empirical evidence supports this area of measurement. However, the high cost of data collection remains a significant barrier. Survey modes with the potential to lower costs, such as Internet and interactive voice response (IVR) telephone, are attractive alternatives to mail, but their comparative response rates and data quality have not been tested. Methods:We randomly assigned adult patients from the panels of 62 primary care physicians in California to complete a brief, validated patient questionnaire by mail, Internet (web), or IVR. After 2 invitations, web and IVR nonrespondents were mailed a paper copy of the survey (“crossover” to mail). We analyzed and compared (n = 9126) the response rates, respondent characteristics, substantive responses, and costs by mode (mail, web and IVR) and evaluated the impact of “crossover” respondents. Results:Response rates were higher by mail (50.8%) than web (18.4%) or IVR (34.7%), but after crossover mailings, response rates in each arm were approximately 50%. Mail and web produced identical scores for individual physicians, but IVR scores were significantly lower even after adjusting for respondent characteristics. There were no significant physician-mode interactions, indicating that statistical adjustment for mode resolves the IVR effect. Web and IVR costs were higher than mail. Conclusions:The equivalence of individual physician results in mail and web modes is noteworthy, as is evidence that IVR results are comparable after adjustment for mode. However, the higher overall cost of web and IVR, as the result of the need for mailings to support these modes, suggests that they do not presently solve cost concerns related to obtaining physician-specific information from patients.

Use of Preventive Care Services Among Latino Subgroups

BACKGROUND Previous studies demonstrate a clear gap in access and receipt of preventive care between Latinos and non-Latino whites. Most of this work, however, pools Latinos together when they compare different racial and ethnic groups. There is currently no information about the consistency of preventive care utilization across major Latino subgroups. PURPOSE This study tests for three bundles of preventive care services to analyze the main determinants of adult preventive care receipt among the largest subgroups of U.S. Latinos and non-Latino whites. It also examines the contribution of observed and unobserved factors in explaining differences in the provision of preventive care services. METHODS The Medical Expenditure Panel Survey and the National Health Interview Survey from 2000 to 2006 were merged in 2009. The sample consisted of 28,781 Latinos and 78,979 non-Latino whites. This study compared disparities in the receipt of adult preventive care services and separately examined differences in the provision of the most cost-effective preventive services. Multivariate models adjust for confounding factors. The decomposition technique was used to parse out differences into observed and unobserved components. RESULTS Latinos of Mexican and Central/South American origin are much less likely to receive guideline-recommended preventive care services than non-Latino whites and other Latino subgroups. Larger disparities were observed for the most cost-effective preventive care services: smoking-cessation advice, colorectal cancer screening, and influenza vaccination. Observed factors accounted for a larger share of disparities across measures (33%-100%), with lack of health insurance coverage and not having a usual source of care as the largest and most consistent factors explaining disparities. CONCLUSIONS Health insurance coverage expansion and more integration of Latinos into primary care practices can substantially reduce disparities in the receipt of preventive care services. Preventive care initiatives should prioritize the availability of cost-effective services among Latinos of Mexican and Central/South American heritage.

Multidisciplinary primary care teams: effects on the quality of clinician-patient interactions and organizational features of care.

Background:Multidisciplinary teams may hold promise for improving primary care quality. This study examined the influence of multidisciplinary teams on patients’ assessments of primary care, including access, integration, and clinician–patient interaction quality. Methods:From January 2004 through March 2005, a large multispecialty practice in Massachusetts obtained data monthly from patients of 145 primary care physicians using a well-validated patient questionnaire. The analytic sample included respondents with at least 2 primary care visits over the study period (n = 14,835). For each respondent, administrative data were used to compute visit continuity over the study period and to classify each primary care visit as PCP, on-team, or off-team. Multivariate regression modeled the relationship of visit continuity to each primary care measure. Results:Approximately one-third of patients (35%) saw only their PCP; 15% had only PCP and “on-team” visits; 9% had a mix of PCP, on-, and off-team visits; and 41% had only “off-team” visits when not seeing their PCP. Greater PCP continuity was associated with more favorable scores on nearly all measures (P < 0.001). An exception was patients’ assessments of teams, which were better when on- versus off-team visits occurred (P < 0.01). For other measures, the decrements associated with discontinuity were the same irrespective of whether discontinuities involved on- or off-team visits. Conclusions:The finding that PCP visit discontinuities are associated with more negative care experiences, irrespective of whether discontinuities involve on- or off-team visits, highlights the challenges of incorporating teams into primary care in ways that patients experience as value-added rather than disruptive to primary care relationships.

The Effect of Performance-Based Financial Incentives on Improving Patient Care Experiences: A Statewide Evaluation

BACKGROUNDPatient experience measures are central to many pay-for-performance (P4P) programs nationally, but the effect of performance-based financial incentives on improving patient care experiences has not been assessed.METHODSThe study uses Clinician & Group CAHPS data from commercially insured adult patients (n = 124,021) who had visits with 1,444 primary care physicians from 25 California medical groups between 2003 and 2006. Medical directors were interviewed to assess the magnitude and nature of financial incentives directed at individual physicians and the patient experience improvement activities adopted by groups. Multilevel regression models were used to assess the relationship between performance change on patient care experience measures and medical group characteristics, financial incentives, and performance improvement activities.RESULTSOver the course of the study period, physicians improved performance on the physician-patient communication (0.62 point annual increase, p < 0.001), care coordination (0.48 point annual increase, p < 0.001), and office staff interaction (0.22 point annual increase, p = 0.02) measures. Physicians with lower baseline performance on patient experience measures experienced larger improvements (p < 0.001). Greater emphasis on clinical quality and patient experience criteria in individual physician incentive formulas was associated with larger improvements on the care coordination (p < 0.01) and office staff interaction (p < 0.01) measures. By contrast, greater emphasis on productivity and efficiency criteria was associated with declines in performance on the physician communication (p < 0.01) and office staff interaction (p < 0.001) composites.CONCLUSIONSIn the context of statewide measurement, reporting, and performance-based financial incentives, patient care experiences significantly improved. In order to promote patient-centered care in pay for performance and public reporting programs, the mechanisms by which program features influence performance improvement should be clarified.

Designing a valid randomized pragmatic primary care implementation trial: The my own health report (MOHR) project

BackgroundThere is a pressing need for greater attention to patient-centered health behavior and psychosocial issues in primary care, and for practical tools, study designs and results of clinical and policy relevance. Our goal is to design a scientifically rigorous and valid pragmatic trial to test whether primary care practices can systematically implement the collection of patient-reported information and provide patients needed advice, goal setting, and counseling in response.MethodsThis manuscript reports on the iterative design of the My Own Health Report (MOHR) study, a cluster randomized delayed intervention trial. Nine pairs of diverse primary care practices will be randomized to early or delayed intervention four months later. The intervention consists of fielding the MOHR assessment – addresses 10 domains of health behaviors and psychosocial issues – and subsequent provision of needed counseling and support for patients presenting for wellness or chronic care. As a pragmatic participatory trial, stakeholder groups including practice partners and patients have been engaged throughout the study design to account for local resources and characteristics. Participatory tasks include identifying MOHR assessment content, refining the study design, providing input on outcomes measures, and designing the implementation workflow. Study outcomes include the intervention reach (percent of patients offered and completing the MOHR assessment), effectiveness (patients reporting being asked about topics, setting change goals, and receiving assistance in early versus delayed intervention practices), contextual factors influencing outcomes, and intervention costs.DiscussionThe MOHR study shows how a participatory design can be used to promote the consistent collection and use of patient-reported health behavior and psychosocial assessments in a broad range of primary care settings. While pragmatic in nature, the study design will allow valid comparisons to answer the posed research question, and findings will be broadly generalizable to a range of primary care settings. Per the pragmatic explanatory continuum indicator summary (PRECIS) framework, the study design is substantially more pragmatic than other published trials. The methods and findings should be of interest to researchers, practitioners, and policy makers attempting to make healthcare more patient-centered and relevant.Trial registrationClinicaltrials.gov: NCT01825746

Racial and Ethnic Disparities in Pediatric Experiences of Family-Centered Care

Background:Previous studies have examined racial and ethnic disparities in the receipt of family-centered care among children with special health care needs and health plan enrollees, but the extent of disparities in the general pediatric population remains unclear. Objective:To examine racial and ethnic disparities in the receipt of family-centered care among a general population of US children. Methods:Linked data from the Medical Expenditure Panel Survey and the National Health Interview Survey (2003–2006) were used to study 4 family-centered care items and an overall composite measure of family-centered care. Adjusted models examined the extent to which child characteristics, socioeconomic, and access to care factors explained racial and ethnic disparities in the provision of family-centered care. Results:Black children have similar experiences as white children on overall family-centered care and on each of the 4 components of family-centered care in models that adjust for child characteristics and socioeconomic factors. In contrast, differences in dimensions of and overall family-centered care between white children and Latino children, irrespective of interview language, persist after multivariate adjustment. Conclusions:Future research should examine the extent to which Latino-white differences in the receipt of family-centered care can be narrowed with programs and policies geared at improving parental education, health literacy, the quality of provider communication, and quality improvement strategies for health care systems.

Primary Care Physician Visit Continuity: A Comparison of Patient-reported and Administratively Derived Measures

BackgroundStudies find that primary care physician (PCP) visit continuity is positively associated with care quality. Some of the evidence base, however, relies on patient-reported continuity measures, which may be subject to response bias.ObjectiveTo assess the concordance of patient-reported and administratively derived visit continuity measures.DesignRandom samples of patients (n = 15,126) visiting 1 of 145 PCPs from a physician organization in Massachusetts were surveyed. Respondents reported their experienced visit continuity over the preceding 6 months. Usual Provider Continuity (UPC), an administratively derived measure, was calculated for each respondent. The concordance of patient reports and UPC was examined. Associations with patient-reported physician-patient interaction quality were assessed for both measures.ResultsPatient-reported and administratively derived visit continuity measures were moderately correlated for overall (r = 0.30) and urgent (r = 0.30) measures and modestly correlated for the routine (r = 0.17) measure. Although patient reports and UPC were significantly associated with the physician-patient interaction quality (p < 0.001), the effect size for patient-reports was approximately five times larger than the effect size for UPC.ConclusionsStudies and quality initiatives seeking to evaluate visit continuity should rely on administratively derived measures whenever possible. Patient-reported measures appear to be subject to biases that can overestimate the relationship between visit continuity and some patient-reported outcomes.

Attributing sources of variation in patients' experiences of ambulatory care.

Background:Public reporting and pay-for-performance programs increasingly rely on patient experience data to evaluate individual physicians and guide quality improvement efforts. The extent to which performance variation is attributable to physicians versus other system-level units, however, remains unclear. Methods:Using ambulatory care experience survey data from 61,839 patients of 1729 primary care physicians in California (response rate = 39.1%), this study assesses the proportion of explainable performance variation attributable to various organizational units in composite measures of physician-patient interaction, organizational features of care, and global assessments of care. For each measure, multilevel regression models that controlled for respondent characteristics and used random effects to account for the clustering of patients within physicians, physicians within care sites, care sites within medical groups, and medical groups within primary care service areas, estimated the proportion of explainable performance variation attributable to each system-level unit. Results:System-level factors explained between 27.9% to 47.7% of variation, with the highest proportion explained for the access to care composite and the lowest explained for the quality of chronic care composite. Physicians accounted for the largest proportion of explainable variance for all measures (range: 35.1%–49.0%). Care sites and primary care service areas explained substantial proportions of variance (>20% each) for the access to care and care coordination measures. Medical groups explained the largest proportions of variation (>20%) for global assessments of care. Conclusions:Individual physicians and their care sites are the most important foci for patient experience improvement efforts. Because markets contribute substantially to performance variation on organizational features of care, future research should clarify the extent to which associated performance deficits are modifiable.

Huddle up!: The adoption and use of structured team communication for VA medical home implementation

Background: Daily clinical team meetings (i.e., “huddles”) may be helpful in implementing new roles and responsibilities for patient care because they provide a regular opportunity for member learning and feedback. Purposes: We examined how huddles were implemented in the context of the VA patient-centered medical home (PCMH) transformation, including assessing barriers and facilitators to regular huddling among small teams (“teamlets”). We assessed the extent to which teamlet members that huddled had higher self-efficacy for PCMH changes, reported better teamwork experiences, and perceived more supportive practice environments. Methodology/Approach: We used a convergent mixed-methods approach to analyze 79 teamlet member interviews from six VA primary care practices and 418 clinician and staff PCMH survey responses from the six interviewed practices and 13 additional practices in the same region. Findings: Most members reported participating in teamlet huddles when asked in surveys (85%). A minority of interview participants, however, described routine huddling focused on previsit planning that included all members. When members reported routine teamlet huddling, activities included (a) previsit planning, (b) strategizing treatment plans for patients with special or complex needs, (c) addressing daily workflow and communication issues through collective problem solving, and (d) ensuring awareness of what team members do and what actions are happening on the teamlet and in the practice. Primary care providers (PCPs) were least likely to report routine huddling. PCP huddlers reported greater self-efficacy for implementing PCMH changes. All huddlers, irrespective of role, reported better teamwork and more supportive practice climates. The most common barriers to teamlet huddling were limited time and operational constraints. Practice Implications: In order to improve the impact of huddles on patient care, practice leaders should clearly communicate the goals, requirements, and benefits of huddling and provide adequate time and resources to ensure that frontline teams use huddle time to improve patient care.

The health effects of cost-related treatment delays.

The number of Americans who report delaying or forgoing necessary medical care because of cost concerns has increased markedly in recent years. Delaying or forgoing treatment may result in negative health effects, but empirical evidence is scarce. Using the merged data set of the Medical Expenditure Panel Survey and the National Health Interview Survey 2002-2006, the effect of delaying or forgoing medical care on ex post health status was estimated. Results indicate that people who delayed or forwent medical treatment were significantly less likely to report having excellent or very good ex post health status and had significantly lower quality-of-life scores compared with people who never delayed or forwent necessary medical care, controlling for socioeconomic and demographic factors, chronic medical conditions, and baseline health status. The Blinder—Oaxaca decomposition results suggest that expanding health insurance coverage can prevent 9% to 12% of the health decrements associated with delaying or forgoing medical treatment.