Quality Through the Eyes of the Patient: State-of-the-Art Concepts Paul D. Cleary, Ph.D. April 10, 2001 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.  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.  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.  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  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  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  People can be satisfied with bad care  People can be dissatisfied with good care

Ratings Versus Reports Ratings Subjective Subjective Confounded With Attitudes Towards Caregiver Confounded With Attitudes Towards Caregiver Non-specific Non-specificReports More Objective More Objective Easier to Interpret Easier to Interpret Actionable ActionableRatings Subjective Subjective Confounded With Attitudes Towards Caregiver Confounded With Attitudes Towards Caregiver Non-specific Non-specificReports More Objective More Objective Easier to Interpret Easier to Interpret Actionable Actionable

Ratings of Hospital Care

Was There One Particular Doctor in Charge of Your Care? 100% 80% 60% 40% 20% 0% INCOME $7,500-$15,000$15,001-$35,000more than $35,000 21% 17%13%12% % saying No less than $7,500

Construct Validity of Reports

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  Trust  Doctor and plan switching  Health outcomes

Relationship Between Number of Problems and Low Trust Lower tertile of trust Number of problems Source: Keating et al., 2001

What Predicts Lack of Trust in Hospital Patients? Source: Joffe et al., 2001  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)  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)

Percent of patients who say they have considered changing their physician by number of problems

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  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 (P=.002) (P=.02)(P=.0002) Worse Better Unadjusted Angina Score by Problem Group and Time

Angina (P=.0003) Better Worse Adjusted Angina Level by Problem Group and Time

Using Survey Data for Quality Improvement Providers, managers, and purchasers want information that is: ImportantInterpretableActionable Providers, managers, and purchasers want information that is: ImportantInterpretableActionable

Example of Short Term Issue What happened when you called for An appointment? Problem score = 19.3% Correlation with evaluation = 0.30 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? Did You Get as Much Information About Your Condition and Treatment as You Wanted From Your Provider? Problem Score = 30.2% Problem Score = 30.2% Correlation With Satisfaction= 0.46 Correlation With Satisfaction= 0.46 Did You Get as Much Information About Your Condition and Treatment as You Wanted From Your Provider? Did You Get as Much Information About Your Condition and Treatment as You Wanted From Your Provider? Problem Score = 30.2% Problem Score = 30.2% Correlation With Satisfaction= 0.46 Correlation With Satisfaction= 0.46

Patient Based Quality Data Can Be Used For: Internal improvement Internal improvement Evaluation Evaluation Internal improvement Internal improvement Evaluation Evaluation

National Variation in Problem Scores by Hospital Type Academic Health Center Teaching Hospital Non- Teaching Hospital Range Median

Patient Safety Patients can report about processes Patients can report about processes that are related to safety and errors that are related to safety and errors Patients can report about processes Patients can report about processes that are related to safety and errors 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  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  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  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  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 People will use information if it is salient, reliable and valid, and salient, reliable and valid, and presented in a clear, simple format presented in a clear, simple format

Most Important Source of Information (State Employees; N = 1525) CAHPS Report.…………………………… % CAHPS Report.…………………………… % Other Print Material from Employer …………. 9.2 % Other Print Material from Employer …………. 9.2 % Benefit Fair …………………………………… 15.4 % Benefit Fair …………………………………… 15.4 % Internet ……………………………………… % Internet ……………………………………… % Print Materials from Plans ……………………. 7.4 % Print Materials from Plans ……………………. 7.4 % Talking with Co-Workers …………………… % Talking with Co-Workers …………………… % Newspapers or Magazines ……………………. 1.5 % Newspapers or Magazines ……………………. 1.5 % Other ….……………………………………… % Other ….……………………………………… % CAHPS Report.…………………………… % CAHPS Report.…………………………… % Other Print Material from Employer …………. 9.2 % Other Print Material from Employer …………. 9.2 % Benefit Fair …………………………………… 15.4 % Benefit Fair …………………………………… 15.4 % Internet ……………………………………… % Internet ……………………………………… % Print Materials from Plans ……………………. 7.4 % Print Materials from Plans ……………………. 7.4 % Talking with Co-Workers …………………… % Talking with Co-Workers …………………… % Newspapers or Magazines ……………………. 1.5 % Newspapers or Magazines ……………………. 1.5 % Other ….……………………………………… % Other ….……………………………………… %

Helpfulness of CAHPS Report When Deciding About Health Plans  Very helpful ……..…………… %  Somewhat helpful ……..…… %  Not very helpful ….…..……… %  Not at all helpful ….………… %  Very helpful ……..…………… %  Somewhat helpful ……..…… %  Not very helpful ….…..……… %  Not at all helpful ….………… %

 Patients are the only source of information about selected aspects of their medical care Patients can provide information that is: Reliable and valid ImportantInterpretableActionable  Patients are the only source of information about selected aspects of their medical care Patients can provide information that is: Reliable and valid ImportantInterpretableActionable ConclusionsConclusions

ConclusionsConclusions Addressing Patient-Centered Concerns can : Meet patient needs Build loyalty and reputation Improve outcomes Identify system problems Addressing Patient-Centered Concerns can : Meet patient needs Build loyalty and reputation Improve outcomes Identify system problems