Megan K. Beckett

Reducing Patients’ Unmet Concerns in Primary Care: the Difference One Word Can Make

ContextIn primary, acute-care visits, patients frequently present with more than 1 concern. Various visit factors prevent additional concerns from being articulated and addressed.ObjectiveTo test an intervention to reduce patients’ unmet concerns.DesignCross-sectional comparison of 2 experimental questions, with videotaping of office visits and pre and postvisit surveys.SettingTwenty outpatient offices of community-based physicians equally divided between Los Angeles County and a midsized town in Pennsylvania.ParticipantsA volunteer sample of 20 family physicians (participation rate = 80%) and 224 patients approached consecutively within physicians (participation rate = 73%; approximately 11 participating for each enrolled physician) seeking care for an acute condition.InterventionAfter seeing 4 nonintervention patients, physicians were randomly assigned to solicit additional concerns by asking 1 of the following 2 questions after patients presented their chief concern: “Is there anything else you want to address in the visit today?” (ANY condition) and “Is there something else you want to address in the visit today?” (SOME condition).Main Outcome MeasuresPatients’ unmet concerns: concerns listed on previsit surveys but not addressed during visits, visit time, unanticipated concerns: concerns that were addressed during the visit but not listed on previsit surveys.ResultsRelative to nonintervention cases, the implemented SOME intervention eliminated 78% of unmet concerns (odds ratio (OR) = .154, p = .001). The ANY intervention could not be significantly distinguished from the control condition (p = .122). Neither intervention affected visit length, or patients’; expression of unanticipated concerns not listed in previsit surveys.ConclusionsPatients’ unmet concerns can be dramatically reduced by a simple inquiry framed in the SOME form. Both the learning and implementation of the intervention require very little time.

Effects of Survey Mode, Patient Mix, and Nonresponse on CAHPS® Hospital Survey Scores

OBJECTIVE To evaluate the need for survey mode adjustments to hospital care evaluations by discharged inpatients and develop the appropriate adjustments. DATA SOURCE A total of 7,555 respondents from a 2006 national random sample of 45 hospitals who completed the CAHPS Hospital (HCAHPS [Hospital Consumer Assessments of Healthcare Providers and Systems]) Survey. STUDY DESIGN/DATA COLLECTION/EXTRACTION METHODS We estimated mode effects in linear models that predicted each HCAHPS outcome from hospital-fixed effects and patient-mix adjustors. PRINCIPAL FINDINGS Patients randomized to the telephone and active interactive voice response (IVR) modes provided more positive evaluations than patients randomized to mail and mixed (mail with telephone follow-up) modes, with some effects equivalent to more than 30 percentile points in hospital rankings. Mode effects are consistent across hospitals and are generally larger than total patient-mix effects. Patient-mix adjustment accounts for any nonresponse bias that could have been addressed through weighting. CONCLUSIONS Valid comparisons of hospital performance require that reported hospital scores be adjusted for survey mode and patient mix.

The Quality of Retrospective Data An Examination of Long-Term Recall in a Developing Country

The literature on reporting error provides insights into the quality of retrospective reports, particularly as it pertains to short-term recall. Less is understood about the generalizability of these findings to longer-term retrospective reports. We review studies analyzing the quality of retrospective reports in the Malaysian Family Life Surveys (MFLS), fielded in Peninsular Malaysia in 1976 and 1988, and conclude that many of the data quality problems found previously are present in the MFLS. We summarize this literature, place studies based on the MFLS within the context of the reporting error literature, and discuss implications for the design of future surveys.

Characteristics of Hospitals Demonstrating Superior Performance in Patient Experience and Clinical Process Measures of Care

Prior research suggests hospital quality of care is multidimensional. In this study, the authors jointly examine patient experience of care and clinical care measures from 2,583 hospitals based on inpatients discharged in 2006 and 2007. The authors use multinomial logistic regression to identify key characteristics of hospitals that perform in the top quartile on both, either, and neither dimension of quality. Top performers on both quality measures tend to be small (<100 beds), large (>200 beds) and rural, located in the New England or West North Central Census divisions, and nonprofit. Top performers in patient experience only are most often small and rural, located in the East South Central division, and government owned. Top performers in clinical care only are most often medium to large and urban, located in the West North Central division, and non—government owned. These findings provide an overview of how these dimensions of quality vary across hospitals.

Do hospitals rank differently on HCAHPS for different patient subgroups

Prior research documents differences in patient-reported experiences by patient characteristics. Using nine measures of patient experience from 1,203,229 patients discharged in 2006-2007 from 2,684 acute and critical access hospitals, the authors find that adjusted hospital scores measure distinctions in quality for the average patient with high reliability. The authors also find that hospital “ranks” (the relative scores of hospitals for patients of a given type) vary substantially by patient health status and race/ ethnicity/language, and moderately by patient education and age (p < .05 for almost all measures). Quality improvement efforts should examine hospital performance with both sicker and healthier patients, because many hospitals that do well with one group (relative to other hospitals) may not do well with another. The experiences of American Indians/Alaska Natives should also receive particular attention. As HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) data accumulate, reports that drill down to hospital performance for patient subtypes (especially by health status) may be valuable.

Gender differences in patients' perceptions of inpatient care.

OBJECTIVE To examine gender differences in inpatient experiences and how they vary by dimensions of care and other patient characteristics. DATA SOURCE A total of 1,971,632 patients (medical and surgical service lines) discharged from 3,830 hospitals, July 2007-June 2008, and completing the HCAHPS survey. STUDY DESIGN We compare the experiences of male and female inpatients on 10 HCAHPS dimensions using multiple linear regression, adjusting for survey mode and patient mix. Additional models add additional patient characteristics and their interactions with patient gender. PRINCIPAL FINDINGS We find generally less positive experiences for women than men, especially for Communication about Medicines, Discharge Information, and Cleanliness. Gender differences are similar in magnitude to previously reported HCAHPS differences by race/ethnicity. The gender gap is generally larger for older patients and for patients with worse self-reported health status. Gender disparities are largest in for-profit hospitals. CONCLUSIONS Targeting the experiences of women may be a promising means of improving overall patient experience scores (because women comprise a majority of all inpatients); the experiences of older and sicker women, and those in for-profit hospitals, may merit additional examination.

Substance use and high-risk sex among people with HIV: a comparison across exposure groups.

Substance use is associated with increased risk for HIV transmission by HIV-positive people to uninfected partners through sexual contact. The largest risk groups for infection, men who have sex with men (MSM) and injecting drug users (IDUs), have high rates of substance use, but little is known about their substance use post-HIV diagnosis. We compared the prevalence of substance use between these two groups and a third group, heterosexual men and women, and tested for differential association between substance use and sexual behaviors across exposure groups in a national sample of patients in treatment for HIV. Substance use was most prevalent among MSM. Substance use and current dependence were associated with being sexually active among MSM but not IDUs; marijuana, alcohol, and hard drug use were most strongly associated with being sexually active among MSM. Whereas substance use predicted high-risk sex, there were few differences among exposure groups in these associations.

Social environment, life challenge, and health among the elderly in Taiwan.

We use an ongoing longitudinal survey of elderly Taiwanese to examine the linkages among health, the social environment, and exposure to life challenge. Data from three waves of the survey provide measures of social hierarchy, social connection, life challenge, and health outcomes. On the basis of multinomial and binomial logistic models, we explore the effects of social factors and challenge on being unhealthy or deceased at follow-up. The estimates indicate that poor health status at follow-up is associated with (1) low socioeconomic status, not having any living children, limited networks of friends, and low participation in social activities; and (2) three life challenges-chronic financial problems, excessive demands placed by close relatives and friends, and having a spouse in poor health. Respondents facing several challenges or having multiple negative attributes in their social environment are especially likely to be unhealthy at follow-up, although negative attributes appear to be counteracted by positive ones. Many findings from Western societies extend to this Taiwanese population. However, some aspects of social connection and challenge hypothesized to affect health fail to reveal a significant association. The analysis identifies differences between men and women in the effects of specific challenges on health, but sex differences in the effects of socioeconomic status and social connection on health are not significant.

Outpatient Satisfaction: The Role of Nominal versus Perceived Communication

OBJECTIVE To examine the simultaneous associations of parent and coder assessments of communication events with parent satisfaction. STUDY SETTING Five hundred twenty-two pediatrician-patient encounters. STUDY DESIGN Parents reported on post-visit satisfaction with care and whether four communication events occurred. Raters also coded communication events from videotapes. Multivariate analyses predicted parent satisfaction. PRINCIPAL FINDINGS Satisfaction was greater when parents perceived at least three communication events. Parent and coder reports were nearly uncorrelated. Coder-assessed communication events not perceived by parents were unrelated to parent satisfaction. CONCLUSIONS Parents are more satisfied when most or all of the expected parent-physician communications occur. A successful pediatrician-parent communication event is one that a parent recognizes as having occurred; it is not merely one that a trained observer says occurred.

Bridging the gap between basic science and clinical practice: a role for community clinicians

BackgroundTranslating the extraordinary scientific and technological advances occurring in medical research laboratories into care for patients in communities throughout the country has been a major challenge. One contributing factor has been the relative absence of community practitioners from the US biomedical research enterprise. Identifying and addressing the barriers that prevent their participation in research should help bridge the gap between basic research and practice to improve quality of care for all Americans.MethodsWe interviewed over 200 clinicians and other healthcare stakeholders from 2004 through 2005 to develop a conceptual framework and set of strategies for engaging a stable cadre of community clinicians in a clinical research program.ResultsLack of engagement of community practitioners, lack of necessary infrastructure, and the current misalignment of financial incentives and research participation emerged as the three primary barriers to community clinician research participation. Although every effort was made to learn key motivators for engagement in clinical research from interviewees, we did not observe their behavior and self-report by clinicians does not always track with their behavior.ConclusionsA paradigm shift involving acknowledgement of the value of clinicians in the context of community research, establishment of a stable infrastructure to support a cohort of clinicians across time and research studies, and realignment of incentives to encourage participation in clinical research is required.