Samuel A. Skootsky

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.

Health care reform as perceived by first year medical students

Our study objective was to evaluate the attitudes of first year medical students toward the health care system using a self administered questionnaire to all first year medical students at the medical schools in the University of California system. Of 631 students surveyed, 94% comleted the instrument. Students were asked about their attitudes toward and familiarity with concepts in health services, access to care, and managed care. Our findings indicated that most students were unfamiliar with concepts related to health services. Students were concerned about access to care; sixty-six percent of students favor a national health insurance plan. A majority of students supported allowing patients access to the current health care system regardless of the cost or utility of a medical test or procedure. Thirty-nine percent felt that rationing health care in any form (transplants, access to the intensive care unit, etc.) is contrary to the way medicine should be practiced. 72% felt that practicing physicians had a major responsibility to help reduce health care costs. When asked about specific changes intended to control health costs, students identified reform of medical malpractice system (63%) and increased spending on preventive health (60%) as the two proposals most likely to be effective. Students generally held negative attitudes toward managed care organizations; only 10% would chose to receive their care in HMOs. We conclude that first year medical students generally have little understanding of the health care system. Despite this, they hold strong opinions about access to care, managed care organizations and strategies intended to reduce health care spending. It is up to medical educators to find creative methods of introducing these content areas into an already bulging curriculum.

Entering first-year medical students’ attitudes toward managed care

PURPOSE. To study the attitudes of entering first-year medical students toward reform of the U.S. health care system. METHOD. All 631 first-year medical students at the five medical schools in the University of California System were asked during orientation (late summer of 1992) to complete a self-administered questionnaire regarding their attitudes toward and knowledge about health care reform. Statistical methods used were chi-square tests and factor analyses. RESULTS. Of the 631 students, 594 (94%) responded. Of the respondents, 392 (66%) felt that there should be a national health insurance plan, and 428 (72%) felt that practicing physicians had a major responsibility to help reduce health care costs. When asked about specific changes intended to control health care costs, the students identified reform of the medical malpractice system (374, 63%) and increased spending on preventive health (356, 60%) as the most likely to be effective. The students generally held negative attitudes toward managed care organizations; only 59 (10%) indicated they would choose to receive care in health maintenance organizations. CONCLUSION. The students held strong opinions about access to care, managed care organizations, and strategies intended to reduce health care spending. Medical educators not only need to find creative methods of introducing these content areas into medical school curricula but should also anticipate the need for strategies to deal with negative attitudes held by students.

Differences in CAHPS Reports and Ratings of Health Care Provided to Adults and Children

Background:Consumer assessment of health care is an important metric for evaluating quality of care. These assessments can help purchasers, health plans, and providers deliver care that fits patients’ needs. Objective:To examine differences in reports and ratings of care delivered to adults and children and whether they vary by site. Research Design:This observational study compares adult and child experiences with care at a large west coast medical center and affiliated clinics and a large mid-western health plan using Consumer Assessment of Healthcare Providers and Systems Clinician & Group 1.0 Survey data. Results:Office staff helpfulness and courtesy was perceived more positively for adult than pediatric care in the west coast site. In contrast, more positive perceptions of pediatric care were observed in both sites for coordination of care, shared decision making, overall rating of the doctor, and willingness to recommend the doctor to family and friends. In addition, pediatric care was perceived more positively in the mid-west site for access to care, provider communication, and office staff helpfulness and courtesy. The differences between pediatric care and adult care were larger in the mid-western site than the west coast site. Conclusions:There are significant differences in the perception of care for children and adults with care provided to children tending to be perceived more positively. Further research is needed to identify the reasons for these differences and provide more definitive information at sites throughout the United States.

Building the Infrastructure for Value at UCLA: Engaging Clinicians and Developing Patient-Centric Measurement.

PROBLEM Evolving payer and patient expectations have challenged academic health centers (AHCs) to improve the value of clinical care. Traditional quality approaches may be unable to meet this challenge. APPROACH One AHC, UCLA Health, has implemented a systematic approach to delivery system redesign that emphasizes clinician engagement, a patient-centric scope, and condition-specific, clinician-guided measurement. A physician champion serves as quality officer (QO) for each clinical department/division. Each QO, with support from a central measurement team, has developed customized analytics that use clinical data to define targeted populations and measure care across the full treatment episode. OUTCOMES From October 2012 through June 2015, the approach developed rapidly. Forty-three QOs are actively redesigning care delivery protocols within their specialties, and 95% of the departments/divisions have received a customized measure report for at least one patient population. As an example of how these analytics promote systematic redesign, the authors discuss how Department of Urology physicians have used these new measures, first, to better understand the relationship between clinical practice and outcomes for patients with benign prostatic hyperplasia and, then, to work toward reducing unwarranted variation. Physicians have received these efforts positively. Early outcome data are encouraging. NEXT STEPS This infrastructure of engaged physicians and targeted measurement is being used to implement systematic care redesign that reliably achieves outcomes that are meaningful to patients and clinicians-incorporating both clinical and cost considerations. QOs are using an approach, for multiple newly launched projects, to identify, test, and implement value-oriented interventions tailored to specific patient populations.

A Healthcare Provider's View of Progress on the Ground

Some of the best minds in the state participated in the Berkeley Forum for Improving California’s Healthcare Delivery System. As individuals and organizations, they have worked for decades to improve the quality, accessibility and affordability of care in California. In the Forum they worked to define initiatives that would be feasible, evidence-driven, reflective of the realities of California, and likely to substantially reduce healthcare expenditures in California. They laid out a series of recommendations that form a clear pathway to integrated care and more effective use of resources via risk-adjusted global budgets. For provider groups and health systems eager to assume more risk as a means to integrate and improve care, it was a clarion call. Of the seven initiatives called for in the Forum Report, the first two – global budgets/integrated care systems and patient centered medical homes – promise the greatest leverage in transforming health systems and represent more than three-fourths of the total projected reductions in expenditures. Since the issuance of the report, however, the momentum of the market has swung ever more decisively against these recommendations. While Medi-Cal has steadily increased the proportion of beneficiaries in managed care, commercial enrollment in risk-based products has continued to fall, in large part because commercial HMOs have lost their price advantage and employers cannot get reliable cost and utilization data from capitated networks. For providers, transforming healthcare has proven to be a slower and less certain task than they had expected. Instead of managing risk for populations,

A Multi-Level Fit-Based Quality Improvement Initiative to Improve Colorectal Cancer Screening in a Managed Care Population

Introduction: Colorectal cancer (CRC) is a common but largely preventable disease with suboptimal screening rates despite national guidelines to screen individuals age 50–75. Single‐component interventions aimed to improve screening uptake only modestly improve rates; data suggest that multi‐modal approaches may be more effective. Methods: We designed, implemented, and evaluated the impact of a multi‐modal intervention on CRC screening uptake among unscreened patients in a large managed care population. Patient‐level components included a mailed letter with education about screening options and pre‐colonoscopy telephone counseling. For providers, we facilitated communication of screening test results and work‐flow for abnormal results. System‐level modifications included establishment of a patient navigator, expedited work‐up for abnormal results, and stream‐lined colonoscopy scheduling. We measured the rate of screening uptake overall, screening uptake by modality, change in the proportion of the population screened, and positive fecal immunochemical test (FIT) follow‐up rates in the 1‐year study period. Results: There were 5093 patients in the intervention cohort. Of these, 33.2% participated in FIT or colonoscopy screening within 1 year of the mailing. A total of 1078 (21.2%) participants completed a FIT and 611 (12.0%) completed a screening colonoscopy. The screening rate in the managed care population increased from 65.1 to 76.6%. Fifty‐nine patients (5.5%) had a positive FIT, of which 30 (50.8%) completed a diagnostic colonoscopy. Conclusion: Multi‐modal interventions can result in substantial improvement in CRC screening uptake in large and diverse managed care populations. Translational Impact: Health systems should shift their focus from single‐level to multi‐level interventions when addressing barriers to CRC screening.