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Quality Through the
Eyes of the Patient:
State-of-the-Art
Concepts
Paul D. Cleary, Ph.D.
April 10, 2001
Perceived Problems With
Patient Surveys

All patients are very “satisfied;” why
measure that?

Satisfaction is not as important as “real”
quality.

People don’t pay attention to quality
data.
Major Advances in Patient
Surveys

We know a great deal about how
patients define quality.

We now ask about experiences
related to quality; not just
“satisfaction.
New Knowledge About
Patient Surveys

The consequences of different aspect of
quality.

Dimensions underlying multiple questions.

How to present results to consumers.

How to use results for quality improvement.
How Do Hospital Patients
Define Quality?
Picker Dimensions of Patient
Centered Care







Respect for patient preferences
Coordination of care
Information and education
Physical comfort
Emotional support
Involvement of family and friends
Continuity and transition
How Do Ambulatory
Patients Define Quality?
Consumer Assessment of Health
Plans Study (CAHPS)
Getting needed care
 Getting care when needed
 Doctor communication
 Courtesy, respect, and helpfulness of
staff
 Health plan service, information,
paperwork

Satisfaction is Not Enough

People can be satisfied with bad care

People can be dissatisfied with good
care
Ratings Versus Reports
Ratings
• Subjective
• Confounded With Attitudes Towards
Caregiver
• Non-specific
Reports
• More Objective
• Easier to Interpret
• Actionable
Ratings of Hospital Care
70%
60%
50%
40%
Excellent health
Fair/poor Health
30%
20%
10%
0%
Excellent
Good
Poor
Was There One Particular Doctor in
Charge of Your Care?
100%
% saying No
80%
60%
40%
21%
17%
13%
12%
20%
0%
less than $7,500
$7,500-$15,000
$15,001-$35,000
INCOME
more than $35,000
Construct Validity of Reports
Reports
Care
Delivery
Global Ratings
Plan Care Doctor Specialist
.46 .94
.77
.90
Customer
Service
.72
.51
.25
.46
Access
.50
.61
.33
.55
Prevention
Advice
.26
.39
.48
.20
Studies of Variability
Support Validity of Different
Dimension

Quality determined by providers (e.g.
communication) does not vary as
much between plans as quality
determined by plans (e.g. access and
customer service)
Patient Centered Care is
Related to:

Trust

Doctor and plan switching

Health outcomes
Relationship Between Number of
Problems and Low Trust
90%
Lower tertile of trust
80%
70%
60%
50%
40%
30%
20%
10%
0%
0
Source: Keating et al., 2001
1
2
3
4
Number of problems
5
6
What Predicts Lack of Trust in
Hospital Patients?









Treated with dignity and respect (OR - 3.7)
Enough say in treatment (OR - 1.7)
Regard for patients (OR - 1.3)
Coordination (OR - 1.6)
Information and Education (OR - 2.1)
Physical Comfort ( OR - 1.9)
Emotional support (OR - 2.2)
Continuity and Transition (OR - 1.3)
Courtesy and availability of staff (OR - 3.2)
Source: Joffe et al., 2001
Percent of patients who say they have
considered changing their physician
by number of problems
76%
80%
70%
61%
60%
46%
50%
40%
30%
30%
15%
20%
6%
10%
1%
2%
0%
0
1
2
3
4
5
6
7
Does Patient-Centered Care
Result in Better Outcomes?
New Hampshire AMI Study

Design: prospective cohort study

Sample: AMI patients admitted to 20 new
Hampshire hospitals in 1996

Data:

Surveys mailed 1,3, and 12 months post-mi

Hospital discharge abstracts
Angina
Better
95
90
85
80
75
70
65
60
55
50
Worse
Unadjusted Angina Score by
Problem
Group and Time
Low
Problem
High
Problem
1 mo
(P=.002)
3 mo
12 mo
(P=.02)
(P=.0002)
Adjusted Angina Level by Problem
Group and Time
Better
95
90
Angina
85
Low
Problem
80
High
Problem
75
70
65
Worse
3 mo
12 mo
(P=.0003)
Using Survey Data for
Quality Improvement
Providers, managers, and purchasers
want information that is:
Important
Interpretable
Actionable
Example of Short Term
Issue
What happened when you called for
An appointment?
Problem score = 19.3%
Correlation with evaluation = 0.30
Example of Long Term
Issue
Did You Get as Much Information
About Your Condition and
Treatment as You Wanted From
Your Provider?
Problem Score = 30.2%
Correlation With Satisfaction= 0.46
Patient Based Quality Data
Can Be Used For:
•
Internal improvement
•
Evaluation
National Variation in Problem Scores
by Hospital Type
Academic
Health
Center
13.2
Teaching
Hospital
22.9
10.2
NonTeaching
Hospital
22.1
8.6
0.0
16.7
10.0
Range
20.0
Median
30.0
Patient Safety
Patients can report about processes
that are related to safety and errors
Examples of Issues
Related to Safety
Participation in care
 Communication about medications
 Communication discharge and
treatment
 Care coordination
 Understanding tests and treatments

The Consumer Assessment of
Health Plans Study (CAHPS)
A National Model for Consumer
Choice in the U.S.
Goals of CAHPS
 Develop
standardized surveys to
assess consumer experiences
with health plans and services
 Develop
and test report formats
Examples of Specialized Surveys
Being Developed







Children with special needs
Disenrollee survey
Adult behavioral health survey (ECHO)
Pediatric behavioral health survey
Group level CAHPS
Nursing home CAHPS
Persons with mobility impairments
Current Activities

Component of national accreditation program (NCQA)

Widely used by Medicaid (low income) programs

Used nationally for Medicare (over age 65)

National CAHPS benchmarking database
Providing Quality Data to
Consumers
People will use information if it is
salient, reliable and valid, and
presented in a clear, simple format
Most Important Source of
Information
(State Employees; N = 1525)
CAHPS Report .…………………………….. 28.1 %
Other Print Material from Employer …………. 9.2 %
Benefit Fair …………………………………… 15.4 %
Internet ………………………………………... 1.4 %
Print Materials from Plans ……………………. 7.4 %
Talking with Co-Workers …………………….. 14.1 %
Newspapers or Magazines ……………………. 1.5 %
Other ….………………………………………. 15.0 %
Helpfulness of CAHPS Report
When Deciding About Health
Plans
Very helpful ……..……………. 21.8 %
 Somewhat helpful ……..……... 49.1 %
 Not very helpful ….…..……….. 14.5 %
 Not at all helpful ….…………... 14.7 %

Conclusions

Patients are the only source of
information about selected aspects of
their medical care
Patients can provide information that is:
Reliable and valid
Important
Interpretable
Actionable
Conclusions
Addressing Patient-Centered
Concerns can:
Meet patient needs
Build loyalty and reputation
Improve outcomes
Identify system problems