Ratings Of Health Care Quality Research Articles

Development and pilot testing of survey items to assess the culture of value and efficiency in hospitals and medical offices

BackgroundGiven rising costs and changing payment models, healthcare organisations are increasingly focused on value and efficiency. The goal of our study was to develop survey items to assess clinician and...

Surrogate decision-making: Clinical uncertainty, rational apathy, and the problem of trust

This paper briefly lays out the well-known obstacles to surrogate decision-making that comports with incapacitated patients’ wishes, but then focuses primarily on exploring an additional layer of complexity that makes surrogate decision-making even more challenging. Health care agents face particularly vexing obstacles to making decisions for their incapacitated family members. A combination of factors impact the objectivity and reliability of the process. In addition, there is another decision-making realm in which the added complexities of bounded rationality, clinical uncertainty and overall Knightian uncertainty provide insurmountable, unalterable barriers to confident rational surrogate decision-making. The combination of all of these factors often leads health care agents to consent to more care than the incapacitated patient might have chosen. Even in situations in which the medical decision itself is simple to comprehend, the broader ethical and cognitive challenges inherent in such a decision are daunting. Recognition of the role of clinical uncertainty and resultant rational apathy in health care decision-making may help physicians to more effectively guide surrogate decision-making. This in turn may help surrogate decision-makers in their quest to make good decisions on behalf of patients and may provide surrogates with some comfort that they have done well in the face of an emotionally and morally challenging dilemma. Finally, it is important to recognize that there are two worlds of end-of-life care—one for low-income, uninsured patients, and another for the well-off, educated, well-insured patients. Empirical research demonstrates that minority race and lower socioeconomic status are associated with poorer patient ratings of health care quality and provider communication at the end of life.

Participatory decision-making for cancer care in a high-risk sample of low income Mexican-American breast cancer survivors: The role of acculturation.

Despite declining cancer incidence and mortality rates, Latina patients continue to have lower 5-year survival rates compared to their non-Hispanic white counterparts. Much of this difference has been attributed to lack of healthcare access and poorer quality of care. Research, however, has not considered the unique healthcare experiences of Latina patients. Latina women with prior diagnoses of stage 0-III breast cancer were asked to complete a cross-sectional survey assessing several socio-demographic factors along with their experiences as cancer patients. Using a series of linear regression models in a sample of 68 Mexican-American breast cancer survivors, we examined the extent to which patients' ratings of provider interpersonal quality of care were associated with patients' overall healthcare quality, and how these associations varied by acculturation status. Findings for Latina women indicated that both participatory decision-making (PDM) (β = 0.62, p < .0001) and trust (β = 0.53, p = .02) were significantly associated with patients' ratings of healthcare quality. The interaction between acculturation and PDM further suggested that participating in the decision-making process mattered more for less acculturated than for more acculturated patients (β = -0.51, p ≤ .01). The variation across low and high acculturated Latinas in their decision-making process introduces a unique challenge to health care providers. Further understanding the relationship between provider-patient experiences and ratings of overall healthcare quality is critical for ultimately improving health outcomes.

Self-reported patient experience and quality of care among elderly patients with colon cancer.

33 Background: Although studies have identified demographic and clinical factors associated with quality colorectal cancer care, the association between patient-reported experience of care and quality of care is unknown. Our primary aim was to assess the relationship between patient-reported experience of care and receipt of guideline-concordant colon cancer (CC) treatment. Methods: Fee-For-Service Medicare beneficiaries with resected stage I-III CC (2003-2013) were identified in the linked SEER registry and Consumer Assessment of Healthcare Providers and Systems patient experience survey (SEER-CAHPS) dataset. Patient-reported ratings were compared based on receipt of care consistent with recommended treatment guidelines [resection of ≥ 12 lymph nodes (LN) (stage I-III) and receipt of adjuvant chemotherapy (stage III)]. Linear regression was performed to compare mean patient experience scores by receipt of guideline concordant care, adjusting for patient and hospital factors. Results: 1010 patients with stage I-III CC were identified (mean age 76.7, SE 6.9). Of these, 58.4% of stage I (n = 192/329) and 73.4% of stage II (n = 298/406) patients underwent resection of ≥ 12 LN. Among stage III patients, 76.0% (n = 209/275) underwent resection of ≥ 12 LN and 52.4% (n = 144/275) received adjuvant chemotherapy. By multivariable analysis, patient-reported ratings of health care quality, personal and specialty physicians, customer service, physician communication, getting needed care, and getting care quickly were similar among patients who received guideline-concordant treatment compared to those who did not. However, mean ratings of overall health care quality [91.3 (SE 2.0) vs. 82.4 (SE 1.7), p = 0.0004] and getting needed care [92.8 (SE 2.4) vs. 86.8 (SE 2.0), p = 0.047] were higher among stage III patients who received guideline concordant care compared to those who did not. Conclusions: Patient-reported ratings of health care quality and ability to get needed care are associated with guideline concordant cancer care among elderly patients with stage III CC. Further investigation is needed to determine if patient-reported experience correlates with other clinical measures of quality of colorectal cancer care.

Effectiveness of a Comprehensive Case Management Service for Children With Medical Complexity.

To assess whether children with medical complexity (CMC) exposed to a hospital-based comprehensive case management service (CCMS) experience improved health care quality, improved functional status, reduced hospital-based utilization, and/or reduced overall health care costs. Eligible CMC at Seattle Children's Hospital were enrolled in a cluster randomized controlled trial between December 1, 2010, and September 29, 2014. Participating primary care providers (PCPs) were randomly assigned, and CMC either had access to an outpatient hospital-based CCMS or usual care directed by their PCP. The CCMS included visits to a multidisciplinary clinic ≥ every 6 months for 1.5 years, an individualized shared care plan, and access to CCMS providers. Differences between control and intervention groups in change from baseline to 12 months and baseline to 18 months (difference of differences) were tested. Two hundred PCPs caring for 331 CMC were randomly assigned. Intervention group (n = 181) parents reported more improvement in the Consumer Assessment of Healthcare Providers and Systems version 4.0 Child Health Plan Survey global health care quality ratings than control group parents (6.7 [95% confidence interval (CI): 3.5-9.8] vs 1.3 [95% CI: 1.9-4.6] at 12 months). We did not detect significant differences in child functional status and most hospital-based utilization between groups. The difference in change of overall health care costs was higher in the intervention group (+$8233 [95% CI: $1701-$16 937]) at 18 months). CCMS clinic costs averaged $3847 per child-year. Access to a CCMS generally improved health care quality, but was not associated with changes in child functional status or hospital-based utilization, and increased overall health care costs among CMC.

A network perspective on patient experiences and health status: the Medical Expenditure Panel Survey 2004 to 2011

BackgroundThere is a growing emphasis on the need to engage patients in order to improve the quality of health care and improve health outcomes. However, we are still lacking a comprehensive understanding on how different measures of patient experiences interact with one another or relate to health status. This study takes a network perspective to 1) study the associations between patient characteristics and patient experience in health care and 2) identify factors that could be prioritized to improve health status.MethodsThis study uses data from the two-year panels from the Medical Expenditure Panel Survey (MEPS) initiated between 2004 and 2011 in the United States. The 88 variables regarding patient health and experience with health care were identified through the MEPS documentation. Sex, age, race/ethnicity, and years of education were also included for analysis. The bnlearn package within R (v3.20) was used to 1) identify the structure of the network of variables, 2) assess the model fit of candidate algorithms, 3) cross-validate the network, and 4) fit conditional probabilities with the given structure.ResultsThere were 51,023 MEPS interviewees aged 18 to 85 years (mean = 44, 95% CI = 43.9 to 44.2), with years of education ranging from 1 to 19 (mean = 7.4, 95% CI = 7.40 to 7.46). Among all, 55% and 74% were female and white, respectively. There were nine networks identified and 17 variables not linked to others, including death in the second years, sex, entry years to the MEPS, and relations of proxies. The health status in the second years was directly linked to that in the first years. The health care ratings were associated with how often professionals listened to them and whether professionals’ explanation was understandable.ConclusionsIt is feasible to construct Bayesian networks with information on patient characteristics and experiences in health care. Network models help to identify significant predictors of health care quality ratings. With temporal relationships established, the structure of the variables can be meaningful for health policy researchers, who search for one or a few key priorities to initiate interventions or health care quality improvement programs.

Evaluating the Impact of Parent-Reported Medical Home Status on Children's Health Care Utilization, Expenditures, and Quality: A Difference-in-Differences Analysis with Causal Inference Methods.

To evaluate the effects of the parent-reported medical home status on health care utilization, expenditures, and quality for children. Medical Expenditure PanelSurvey (MEPS) during 2004-2012, including a total of 9,153 children who were followed up for 2years in the survey. We took a causal difference-in-differences approach using inverse probability weighting and doubly robust estimators to study how changes in medical home status over a 2-year period affected children's health care outcomes. Our analysis adjusted for children's sociodemographic, health, and insurance statuses. We conducted sensitivity analyses using alternative statistical methods, different approaches to outliers and missing data, and accounting for possible common-method biases. Compared with children whose parents reported having medical homes in both years 1 and 2, those who had medical homes in year 1 but lost them in year 2 had significantly lower parent-reported ratings of health care quality and higher utilization of emergency care. Compared with children whose parents reported having no medical homes in both years, those who did not have medical homes in year 1 but gained them in year 2 had significantly higher ratings of health care quality, but no significant differences in health care expenditures and utilization. Having a medical home may help improve health care quality for children; losing a medical home may lead to higher utilization of emergency care.

Reducing Racial Disparities in Breast Cancer Survivors' Ratings of Quality Cancer Care: The Enduring Impact of Trust.

Patient satisfaction provides an important illumination of the quality of care that is delivered. Satisfaction with care is often lower in Black women compared with their non-Hispanic White counterparts. Data are lacking regarding quality ratings of breast cancer patients. We examined racial disparities in ratings of the quality of cancer care in newly diagnosed Black (n = 217) and White (n = 152) patients. This was a cross-sectional observational study. Patients were recruited through hospitals and community outreach. Women with primary invasive, nonmetastatic breast cancer were eligible. Trained interviewers administered a standardized survey through telephone; clinical data were abstracted from medical records. The primary outcome, healthcare quality, was assessed using the PSQ-18, which assessed patients' ratings regarding four healthcare domains: interpersonal care, financial issues, technical ratings of physicians, and access and convenience. Independent variables included healthcare factors (e.g., suspicion toward the healthcare system), psychosocial factors (e.g., physicians' solicitation behaviors), and socioeconomic factors (e.g., limited access to resources). Multiple linear regression was used to evaluate associations between each healthcare quality domain and independent variables. In univariate analysis, Black women reported lower ratings for four domains: technical (Black m = 3.99; White m = 4.26; p < .001), interpersonal (Black m = 4.15, White m = 4.35; p < .01), financial (Black m = 3.81, White m = 4.0, p < .001), and access and convenience (Black m = 3.92, White m = 4.08, p < .01). After adjusting for healthcare characteristics and psychosocial factors, trust in providers was significantly associated with three domains (β = 0.085, p < .001, technical; β = 0.066, p < .0001, interpersonal; β = 0.043, p < .0001, financial). Racial disparities in ratings of healthcare quality were diminished across several domains after controlling for psychosocial and healthcare factors. Strategies aimed at improving self-efficacy in women with higher levels of mistrust may improve patient satisfaction.

Healthcare utilization and quality among survivors of adolescent and young adult cancer.

21 Background: To evaluate perceived health care quality among a national sample of survivors of adolescent and young adult (AYA) cancer relative to individuals from the general population. Methods: Using the Medical Expenditure Panel Surveys from 2008-2012, we identified 1,163 survivors diagnosed with cancer ages 15-39 who were at least five years from diagnosis and currently ages of 20-64. A comparison group with no history of cancer was created via propensity score matching on sex, age at study, race/ethnicity, census-region, and survey year. Participants with one or more health care visit in the past 12 months were asked to rate health care quality from all providers (0 = worst to 10 = best), which we categorized as low (0-4), moderate (5-7) and high (8-10). Among survivors, we identified factors such insurance and health status associated with health care quality using ordinal logistic regression. Results: Mean time since diagnosis was 18.3 years. A total of 18% of survivors of AYA cancer reported no health care visits in the previous 12 months compared to 25% of the comparison group (p &lt; 0.001). Survivors rated their health care quality lower than the comparison group (low/moderate: 30.8% vs. 22.5%, respectively, p = 0.003). Among survivors, those who were publicly insured (odds ratio (OR) = 0.62, 95% confidence interval (CI): 0.39-0.97, p = 0.04) and uninsured (OR = 0.25, 95% CI: 0.13-0.48, p &lt; 0.001) were more likely to provide lower health care quality ratings than privately insured survivors. Survivors in fair/poor health also reported poorer quality compared to those in excellent/very good/good health (OR = 0.43, 95% CI, p &lt; 0.001). Conclusions: Survivors of AYA cancer reported greater health care use and poorer health care quality compared to individuals without cancer. Our results call for targeted interventions to meet AYA cancer survivors’ health care needs and expectations.

The Relation Between Having a Usual Source of Care and Ratings of Care Quality: Does Patient-Centered Communication Play a Role?

Having a usual source of health care has been consistently associated with greater use of preventive services, decreased use of emergency services, and with patients’ ratings of quality and satisfaction with care. Ongoing patient–provider relationships may be, in part, fostered by patient-centered communication. Growing evidence demonstrates that positive patient-centered communication improves adherence to treatment recommendations, management of chronic disease, quality of life, and disease-related outcomes. We aimed to determine how patient-centered communication between patients and physicians might mediate the relation between having a source of usual care and ratings of health care quality. We analyzed data from Cycle 1 of the fourth iteration of the Health Information National Trends Survey. Data were collected through mailed questionnaire in October 2011 through February 2012 (N = 3,959). Overall, individuals with a usual source of care reported more patient-centered communication experiences and had higher ratings of quality of care. Parameter estimates for each pathway in the mediation model were estimated through regression analysis. Results confirm the importance of patient-centered communication in shaping patients’ perceptions of the quality of their care, accounting for a significant portion of the observed relation between having a usual source of care and ratings of quality.

Race, Income, and Education: Associations with Patient and Family Ratings of End-of-Life Care and Communication Provided by Physicians-in-Training

Minority race and lower socioeconomic status are associated with poorer patient ratings of health care quality and provider communication. To examine the association of race/ethnicity or socioeconomic status with patients' and families' ratings of end-of-life care and communication about end-of-life care provided by physicians-in-training. As a component of a randomized trial evaluating a program designed to improve clinician communication about end-of-life care, patients and patients' families completed preintervention survey data regarding care and communication provided by internal medicine residents and medical subspecialty fellows. We examined associations between patient and family race or socioeconomic status and ratings they gave trainees on two questionnaires: the Quality of End-of-Life Care (QEOLC) and Quality of Communication (QOC). Patients from racial/ethnic minority groups, patients with lower income, and patients with lower educational attainment gave trainees higher ratings on the end-of-life care subscale of the QOC (QOCeol). In path models, patient educational attainment and income had a direct effect on outcomes, while race/ethnicity did not. Lower family educational attainment was also associated with higher trainee ratings on the QOCeol, while family non-white race was associated with lower trainee ratings on the QEOLC and general subscale of the QOC. Patient race is associated with perceptions of the quality of communication about end-of-life care provided by physicians-in-training, but the association was opposite to our hypothesis and appears to be mediated by socioeconomic status. Family member predictors of these perceptions differ from those observed for patients. Further investigation of these associations may guide interventions to improve care delivered to patients and families.

Patient perceptions of electronic medical records use and ratings of care quality.

PurposeDespite considerable potential for improving health care quality, adoption of new technologies, such as electronic medical records (EMRs), requires prudence, to ensure that such tools are designed, implemented, and used meaningfully to facilitate patient-centered communication and care processes, and better health outcomes. The association between patients’ perceptions of health care provider use of EMRs and health care quality ratings was assessed.MethodData from two iterations of the Health Information National Trends Survey, fielded in 2011 and 2012, were pooled for these analyses. The data were collected via mailed questionnaire, using a nationally representative listing of home addresses as the sampling frame (n=7,390). All data were weighted to provide representative estimates of quality of care ratings and physician use of EMR, in the adult US population. Descriptive statistics, t-tests, and multivariable linear regression analyses were conducted.ResultsEMR use was reported significantly more frequently by females, younger age groups, non-Hispanic whites, and those with higher education, higher incomes, health insurance, and a usual source of health care. Respondents who reported physician use of EMRs had significantly higher ratings of care quality (Beta=4.83, standard error [SE]=1.7, P<0.01), controlling for sociodemographic characteristics, usual source of health care, and health insurance status.ConclusionNationally representative data suggest that patients’ perceptions of EMR use are associated with their perceptions of the quality of the health care they receive.

Factors Associated With Americans' Ratings of Health Care Quality: What Do They Tell Us About the Raters and the Health Care System?

Consumer satisfaction ratings of health care quality represent a commonly used measure of health care performance. Identifying factors associated with ratings will help us understand the relative influence of individuals' sociodemographic and health characteristics on satisfaction level, thus informing policy making and clinical practice. Existing research has yielded mixed results on key predictors of consumer ratings. Using nationally representative data, this study aims to identify factors associated with Americans' ratings of health care quality. Data from 2008 Health Information National Trends Survey (HINTS) were analyzed using weighted multinomial logistic regressions to estimate consumer ratings. Predictor variables included demographics, health status, care access, and attitude and perceptions about health. Overall ratings were positively skewed; 70% of respondents rated care as “excellent” or “very good.” Minority race, psychological distress, not having had cancer, not having a regular health care provider, not having health insurance, lacking confidence in self-care, and avoidance of doctors were significantly associated with lower ratings. The study identifies the psychosocial characteristics associated with lower consumer ratings. The results highlight the importance of using multiple approaches to assess quality of care, including considering patient characteristics, and contribute to the evidence base for evaluating overall quality of care at the dawn of health care reform.

Health Care Quality Perceptions among Foreign-Born Latinos and the Importance of Speaking the Same Language

To examine the relationship between patients' English proficiency, patient-provider language concordance, and health care quality among foreign-born Latinos in the United States. National probability sample data (from the Pew Hispanic Center/Robert Wood Johnson Foundation Latino Health Survey) were analyzed from telephone interviews with foreign-born Latino adults (n = 2921; aged 18 years and older). There were 3 main outcomes related to clinical experiences using self-reports of confusion, frustration, and perception of poor quality of care received because of English-speaking ability and accent bias, as well as an overall rating of care quality. Patients' English proficiency and patient-provider language concordance were the chief predictors. Patients' English proficiency was not significantly associated with the 3 clinical experiences measures and marginally so with overall care quality ratings. Language concordance was significantly associated with a lower likelihood of confusion, frustration, and language-related poor quality ratings, and was positively associated with patient-reported overall quality of care. In addition, providers' language concordance attenuated the statistical significance of the effects of patients' English proficiency when both were modeled simultaneously. Patient-provider language concordance plays an important role in communication barriers among foreign-born Latino patients. Our findings indicate that although patients' language proficiency is important to health care quality ratings, what may matter more is when patient and provider speak the same language.

Racial/Ethnic Discrimination in Health Care: Impact on Perceived Quality of Care

BackgroundRacial/ethnic minorities are more likely to report receipt of lower quality of health care; however, the mediators of such patient reports are not known.ObjectivesTo determine (1) whether racial disparities in perceptions of quality of health care are mediated by perceptions of being discriminated against while receiving medical care and (2) whether this association is further mediated by patient sociodemographic characteristics, access to care, and patient satisfaction across racial/ethnic groups.Research DesignA cross-sectional analysis of a population-based sample of California adults responding to the 2003 California Health Interview Survey. Multivariable logistic regression was used to examine the relationship between perceived discrimination and perceived quality of health care after adjusting for patient characteristics and reports of access to care.Main ResultsA total of 36,831 respondents were included. African Americans (68.7%) and Asian/Pacific Islanders (64.5%) were less likely than non-Hispanic whites (72.8%) and Hispanics (74.9%) to rate their health care quality highly. African Americans (13.1%) and Hispanics (13.4%) were the most likely to report discrimination, followed by Asian/Pacific Islanders (7.3%) and non-Hispanic whites (2.6%). Racial/ethnic discrimination in health care was negatively associated with ratings of health care quality within each racial/ethnic group, even after adjusting for sociodemographic variables and other indicators of access and satisfaction. Feeling discriminated against fully accounted for the difference in low ratings of quality care between African Americans and whites, but not for other racial/ethnic minorities.ConclusionsPatient perceptions of discrimination may play an important, yet variable role in ratings of health care quality across racial/ethnic minority groups. Health care institutions should consider how to address this patient concern as a part of routine quality improvement.

Healthcare Intensity Is Associated With Lower Ratings of Healthcare Quality by Younger Adults

Previous studies suggest a negative relationship between regional intensity of healthcare services and Medicare patients' perceptions of healthcare quality. However, no studies to date have examined the relationship across a broad age range of the population. We describe the responses of 64 088 respondents aged 19 to 69 years to an online interactive patient assessment and feedback system. We learn that in higher-intensive regions, specialty use is higher regardless of patient illness burden and that overall quality of care was lower in higher-intensity regions. The findings that "more is not better" previously associated with Medicare patients seems to apply across a much broader age segment of the population.

Women's Satisfaction with Their On‐Going Primary Health Care Services: A Consideration of Visit‐Specific and Period Assessments

To compare and contrast patient ratings of satisfaction with primary care on the day of visit versus over the last 12 months. Survey data were collected from female participants at primary care centers affiliated with the University of Michigan, University of Pittsburgh, and Wake Forest University. One thousand and twenty-one patients attending a primary care visit with at least one prior visit to the study site were consented on site, enrolled in the study, and surveyed at two time points: pre- and immediately postvisit. The previsit survey included demographics, self-rated health, visit history (site continuity), and expectations for health care; the postvisit survey focused on patient experiences during the visit, assessment of health care quality using the Primary Care Satisfaction Survey for Women instrument, and global satisfaction with visit and health care over the past 12 months. Expectation discrepancy scores were constructed from the linked expectation-experience ratings. Path analysis and indices of model fit were used to investigate the strength of theoretical links among the variables in an analytic model considering both day-of-visit and past-year ratings with global measures of patient satisfaction as the dependent variables. General health, site continuity and fulfillment of patient expectations for care were linked to global ratings of satisfaction through effects on communication, care coordination, and office staff and administration. Importantly, past-year ratings were mediated largely by care coordination and continuity; day-of-visit ratings were mediated by communication. Ratings of health care quality for a specific visit appear to be conceptually distinct from ratings of care over the past 12 months, and thus are not interchangeable.