Effectiveness of teaching quality improvement to clinicians: a systematic review.

CONTEXT: Accreditation requirements mandate teaching quality improvement (QI) concepts to medical trainees, yet little is known about the effectiveness of teaching QI. OBJECTIVES: To perform a systematic review of the effectiveness of published QI curricula for clinicians and to determine whether teaching methods influence the effectiveness of such curricula. DATA SOURCES: The electronic literature databases of MEDLINE, EMBASE, CINAHL, and ERIC were searched for English-language articles published between January 1, 1980, and April 30, 2007. Experts in the field of QI were queried about relevant studies. STUDY SELECTION: Two independent reviewers selected studies for inclusion if the curriculum taught QI principles to clinicians and the evaluation used a comparative study design. DATA EXTRACTION: Information about the features of each curriculum, its use of 9 principles of adult learning, and the type of educational and clinical outcomes were extracted. The relationship between the outcomes and the number of educational principles used was assessed. RESULTS: Of 39 studies that met eligibility criteria, 31 described team-based projects; 37 combined didactic instruction with experiential learning. The median number of adult learning principles used was 7 (range, 2-8). Evaluations included 22 controlled trials (8 randomized and 14 nonrandomized) and 17 pre/post or time series studies. Fourteen studies described educational outcomes (attitudes, knowledge, or skills or behaviors) and 28 studies described clinical process or patient outcomes. Nine of the 10 studies that evaluated knowledge reported only positive effects but only 2 of these described a validated assessment tool. The 6 assessments of attitudes found mixed results. Four of the 6 studies on skill or behavior outcomes reported only positive effects. Eight of the 28 studies of clinical outcomes reported only beneficial effects. Controlled studies were more likely than other studies to report mixed or null effects. Only 4 studies evaluated both educational and clinical outcomes, providing limited evidence that educational outcomes influence the clinical effectiveness of the interventions. CONCLUSIONS: Most published QI curricula apply sound adult learning principles and demonstrate improvement in learners' knowledge or confidence to perform QI. Additional studies are needed to determine whether educational methods have meaningful clinical benefits.

The trial of infant response to diphenhydramine: the TIRED study--a randomized, controlled, patient-oriented trial.

OBJECTIVE: To determine if infants aged 6 to 15 months with frequent parent-reported nighttime awakenings require reduced parental aid during a week of diphenhydramine hydrochloride treatment and 2 and 4 weeks after its discontinuation. DESIGN: Double-blind, randomized, controlled clinical trial. SETTING: The study was conducted from May 1, 2004, through May 1, 2005; patients were recruited nationally. PARTICIPANTS: Forty-four participants aged 6 to 15 months. INTERVENTIONS: Placebo or diphenhydramine was administered in infants 30 minutes before anticipated bedtime. MAIN OUTCOME MEASURES: The primary outcome was dichotomous: a parental report of improvement in the number of night awakenings requiring parental assistance during the intervention week, which ended on day 14. Secondary outcomes were improved sleep during the 2 weeks before days 29 and 43, parental overall happiness with sleep, and improved sleep latency. RESULTS: On June 6, 2005, the data safety monitoring board voted unanimously to stop the trial early because of lack of effectiveness of diphenhydramine over placebo. Only 1 of 22 children receiving diphenhydramine showed improvement compared with 3 of 22 receiving placebo. To reach the a priori determined sample size and have a positive outcome (ie, rejecting the null hypothesis), the trial would have needed to enroll 16 more participants in each arm, with 15 of the 16 in the diphenhydramine group and 0 of 16 in the placebo group improving. CONCLUSION: During 1 week of therapy and at follow-up 2 and 4 weeks later, diphenhydramine was no more effective than placebo in reducing nighttime awakening or improving overall parental happiness with sleep for infants.

Complexity of program and clinical outcomes of heart failure disease management incorporating specialist nurse-led heart failure clinics. A meta-regression analysis.

OBJECTIVES: To determine whether a hierarchy of effectiveness exists with respect to complexity of published protocols of heart failure (HF) disease management (DM) incorporating specialist nurse-led HF clinics. DATA SOURCES AND STUDY SELECTION: We searched MEDLINE (1966-November 2004), the Cochrane Library, article bibliographies, and contacted experts. Inclusion criteria were random allocation of at least 100 patients, specialist HF nurses, HF clinics, and readmission as an outcome measure. DATA EXTRACTION: Paired reviewers conducted quality assessment, deconstructed and categorized protocols by complexity, and extracted results for readmission, mortality, the combined endpoint of mortality and hospitalization, HF readmission, and hospital days utilized. DATA SYNTHESIS: Six trials were selected (N=949, mean age 73 years [range 62-79], men 58%, LVEF 34% [27-41], and average follow-up of 8.5 months [3-12]). Compared with usual care, the overall relative risk [95% confidence interval] for readmission with this strategy was 0.91 [0.72, 1.16], mortality was 0.80 [0.57, 1.06], and the combined endpoint of mortality and hospitalization was 0.88 [0.74, 1.04]. We observed better outcomes for programs with versus programs without hospital discharge planning and immediate post-discharge follow-up; readmission 0.30 [0.04, 2.60] vs. 1.00 [0.86, 1.17], mortality 0.96 [0.63, 1.47] vs. 0.75 [0.55, 1.03], the combined endpoint of mortality and hospitalization 0.61 [0.18, 2.02] vs. 0.91 [0.80, 1.03], HF readmission 0.09 [0.10, 0.65] vs. 0.65 [0.43, 1.00], and hospitalized days utilized per patient -0.26 [-0.49,-0.02] vs. 0.09 [-1.17, 1.34]. CONCLUSIONS: HF DM with specialist nurse-led HF clinics is a promising strategy or effective alternative whose benefit may be optimized by programs with a homogeneous structure and components that are delivered with consistency.

Why do patients and families request transfers to tertiary care? a qualitative study.

Interhospital transfers comprise a significant and increasing proportion of admissions to tertiary care centers. Patient dissatisfaction with the quality of hospital care may play an important role in these trends. The objective of this study was to describe why and how patients and surrogates request transfers to tertiary care. We interviewed 32 patients transferred to the Johns Hopkins Hospital, a US tertiary care center, or their surrogate decision-makers using a semi-structured, open-ended, iterative protocol. We used ethnographic decision modeling to develop an influence diagram of the decision. We contrasted subjects' perceptions of situations where patients did and did not request transfer to describe the threshold for requesting transfer. Subjects reported three major influences on the request to transfer to tertiary care: the quality of care at the community hospital compared to the tertiary center; the severity and potential consequences of the current illness; and their relationship with community hospitals, physicians, and tertiary care. Subjects' perceptions of the quality differential between community hospitals and tertiary centers focused on communication and medical errors rather than specialized care, hospital volume, or teaching status. Thresholds for when patients requested transfers were influenced by relationships with community hospitals and physicians and previous experience with tertiary care. This model provides a framework for understanding requests to transfer to tertiary care. Further investigation into the elements we have described might provide insights into improvements in the quality of care at community hospitals that might reduce the rates of requests for transfer. Our results also highlight the importance of including patient or surrogate perspectives in evaluations of the appropriateness of care.

Use of dialysis educators beyond nurses and physicians and outcomes in patients with kidney failure.

This study examined whether patient education by nonmedical personnel (eg, social workers, dietitians) is associated with patient outcomes in a prospective cohort study of 1,005 incident dialysis patients treated at 79 United States clinics. Logistic and Poisson regression and Cox proportional hazards models were used to assess the relationship between clinic use of nonmedical educators and patient satisfaction and self-management, hospitalization, and survival, respectively. Patients treated at clinics reporting use of nonmedical educators (84%) were more likely to be satisfied with the amount of information on dialysis modalities (odds ratio [OR]=.67, 95% confidence interval [CI] 1.08--2.58) and with the amount of information they received on dialysis (OR=1.23, 95% CI 0.90--1.67; marginally significant) than those treated at clinics without nonmedical educators (16%). These patients were also less likely to be hospitalized (incidence rate ratio [IRR]=0.91, 95% CI 0.80--1.03), but the association was of borderline statistical significance. Overall satisfaction, patient self-management, and mortality were not significantly associated with use of nonmedical educators. Use of nonmedical staff for patient education at dialysis centers has a limited but positive effect on patient satisfaction and hospitalization.

Distraction therapy with nature sights and sounds reduces pain during flexible bronchoscopy: a complementary approach to routine analgesia.

STUDY OBJECTIVES: To determine whether distraction therapy with nature sights and sounds during flexible bronchoscopy (FB) reduces pain and anxiety. DESIGN: Randomized controlled trial. SETTING: Teaching hospital in Baltimore, MD. PATIENTS: Consecutive adult patients (n = 80) undergoing FB with conscious sedation. INTERVENTION: Nature scene murals were placed at the bedside, and patients were provided a tape of nature sounds to listen to before, during, and after the procedure. Patients assigned to the control group were not offered either the nature scene or the sounds. MEASUREMENTS AND RESULTS: The primary outcomes were patient ratings of pain control (a 5-point scale ranging from poor to excellent) and anxiety. In a multivariate ordinal logistic regression model, the odds of better pain control were greater in the intervention patients than in the control patients (odds ratio [OR], 4.76; 95% confidence interval [CI], 1.35 to 16.7), after adjustment for age, gender, race, education, health status, and dose of narcotic medication. Older patients and patients with better health status reported significantly less pain. There was no difference in patient-reported anxiety between the two groups (OR, 0.87; 95% CI, 0.39 to 1.96). CONCLUSIONS: Distraction therapy with nature sights and sounds significantly reduces pain in patients undergoing FB. Although the precise mechanism of this beneficial effect requires further investigation, clinicians should consider this nonintrusive strategy in addition to standard analgesic medications in patients undergoing painful, invasive procedures.

The relationship between age and process of care and patient tolerance of bronchoscopy.

OBJECTIVES: To determine whether patient age is associated with differences in flexible bronchoscopy technique and tolerance. DESIGN: Prospective cohort study. SETTING: University hospital system. PARTICIPANTS: One thousand three hundred fifty-eight adults, including 219 (16.1%) aged 70 and older, undergoing bronchoscopy. MEASUREMENTS: Indications, sampling procedures, medication doses, patient reports of pain, willingness to return, and adverse events associated with bronchoscopy. RESULTS: Indications for bronchoscopy varied with age, with solitary pulmonary nodule (P <.001), mass (P <.001), or lymphadenopathy (P <.001) being more common in older patients. Invasive sampling methods were used more often with increasing age, but variation in disease processes between age groups accounted for the difference in sampling method performed. Mean doses of midazolam and fentanyl given for sedation decreased with increasing age (P <.001). There was no significant difference between older and younger patients in reported very good to excellent pain control (50% of patients >/=70 vs 64% of patients <40; P =.56) or in willingness to return for repeat bronchoscopy (98% vs 92%, respectively; P =.324). Overall risk for an adverse event increased with increasing patient age (P <.01), but adverse events were uncommon and generally not severe. Hypotension and pneumothorax were rare but occurred more often in older persons (1.9% and 3.4% in patients >/=70 vs 0.5% and 0.7% in patients <40, respectively). CONCLUSION: Despite more-invasive sampling methods and less sedation during bronchoscopy, elderly patients tolerate bronchoscopy as well as younger patients. There is increased risk for adverse events with increasing age, but the absolute frequency is low, suggesting that chronological age should not be a contraindication for bronchoscopy in older persons.

Using participant information to develop a tool for the evaluation of community health worker outreach services.

OBJECTIVE: Because there is no instrument that measures how clients judge community health worker (CHW) services, we sought to develop such a questionnaire. We report how we used client information to develop a brief questionnaire evaluating CHW services. DESIGN: We conducted and content-analyzed 18 in-depth semi-structured interviews of clients receiving CHW services to determine aspects of care salient to clients. Based on the results of these analyses, we developed and administered an in-person survey measuring the importance of 57 aspects of CHW services to 84 clients in 3 programs using CHWs to help control hypertension or diabetes. RESULTS: Clients perceived a broad array of aspects of CHW care including CHW attributes, services, benefits or outcomes of service and service arrangements. The 15 aspects ranking highest included: 1) CHW knows job; 2) CHW keeps client alive; 3) CHW gives information on high blood pressure; 4) CHW shows respect; 5) blood pressure is lowered; 6) CHW pays attention; 7) client gets better medical care; 8) CHW speaks understandably; and 9) client gets needed care. CONCLUSION: We used client information to generate and determine the relative importance of a pool of aspects that we and others can use to construct brief questionnaires to measure clients' judgments of CHW services. Such questionnaires are needed for ongoing evaluation as more providers and managed care organizations increase their use of CHWs for outreach programs.

Conceptual framework for a new tool for evaluating the quality of diabetes consumer-information Web sites.

BACKGROUND: Most existing tools for measuring the quality of Internet health information focus almost exclusively on structural criteria or other proxies for quality of information, rather than evaluating information accuracy and comprehensiveness. OBJECTIVE: This research sought to build a conceptual framework that could lay the groundwork for a robust performance-measurement system for evaluating the quality of Internet health information. METHODS: Application of the quality-of-care measurement paradigm to developing a conceptual framework for defining and evaluating the quality of diabetes consumer-information Web sites. RESULTS: Performance measures related to accuracy and comprehensiveness of information can be added to structural criteria to provide a more-robust approach to Web site evaluation. CONCLUSIONS: The development and implementation of a reliable and valid method for evaluating the quality of Internet health sites could provide lay people with a tool to identify useful content more easily and distinguish between beneficial and misleading information.

Design and testing of a tool for evaluating the quality of diabetes consumer-information Web sites.

BACKGROUND: Most existing tools for measuring the quality of Internet health information focus almost exclusively on structural criteria or other proxies for quality information rather than evaluating actual accuracy and comprehensiveness. OBJECTIVE: This research sought to develop a new performance-measurement tool for evaluating the quality of Internet health information, test the validity and reliability of the tool, and assess the variability in diabetes Web site quality. METHODS: An objective, systematic tool was developed to evaluate Internet diabetes information based on a quality-of-care measurement framework. The principal investigator developed an abstraction tool and trained an external reviewer on its use. The tool included 7 structural measures and 34 performance measures created by using evidence-based practice guidelines and experts' judgments of accuracy and comprehensiveness. RESULTS: Substantial variation existed in all categories, with overall scores following a normal distribution and ranging from 15% to 95% (mean was 50% and median was 51%). Lin's concordance correlation coefficient to assess agreement between raters produced a rho of 0.761 (Pearson's r of 0.769), suggesting moderate to high agreement. The average agreement between raters for the performance measures was 0.80. CONCLUSIONS: Diabetes Web site quality varies widely. Alpha testing of this new tool suggests that it could become a reliable and valid method for evaluating the quality of Internet health sites. Such an instrument could help lay people distinguish between beneficial and misleading information.

Comprehensive discharge planning with postdischarge support for older patients with congestive heart failure: a meta-analysis.

CONTEXT: Comprehensive discharge planning plus postdischarge support may reduce readmission rates for older patients with congestive heart failure (CHF). OBJECTIVE: To evaluate the effect of comprehensive discharge planning plus postdischarge support on the rate of readmission in patients with CHF, all-cause mortality, length of stay (LOS), quality of life (QOL), and medical costs. DATA SOURCES: We searched MEDLINE (1966 to October 2003), the Cochrane Clinical Trials Register (all years), Social Science Citation Index (1992 to October 2003), and other databases for studies that described such an intervention and evaluated its effect in patients with CHF. Where possible we also contacted lead investigators and experts in the field. STUDY SELECTION: We selected English-language publications of randomized clinical trials that described interventions to modify hospital discharge for older patients with CHF (mean age > or =55 years), delineated clearly defined inpatient and outpatient components, compared efficacy with usual care, and reported readmission as the primary outcome. DATA EXTRACTION: Two authors independently reviewed each report, assigned quality scores, and extracted data for primary and secondary outcomes in an unblinded standardized manner. DATA SYNTHESIS: Eighteen studies representing data from 8 countries randomized 3304 older inpatients with CHF to comprehensive discharge planning plus postdischarge support or usual care. During a pooled mean observation period of 8 months (range, 3-12 months), fewer intervention patients were readmitted compared with controls (555/1590 vs 741/1714, number needed to treat = 12; relative risk [RR], 0.75; 95% confidence interval [CI], 0.64-0.88). Analysis of studies reporting secondary outcomes found a trend toward lower all-cause mortality for patients assigned to an intervention compared with usual care (RR, 0.87; 95% CI, 0.73-1.03; n = 14 studies), similar initial LOS (mean [SE]: 8.4 [2.5] vs 8.5 [2.2] days, P =.60; n = 10), greater percentage improvement in QOL scores compared with baseline scores (25.7% [95% CI, 11.0%-40.4%] vs 13.5% [95% CI, 5.1%-22.0%]; n = 6, P =.01), and similar or lower charges for medical care per patient per month for the initial hospital stay, administering the intervention, outpatient care, and readmission (-359 dollars [95% CI, -763 dollars to 45 dollars]; n = 4, P =.10 for non-US trials and -536 dollars [95% CI, -956 dollars to -115 dollars]; n = 4, P =.03, for US trials). CONCLUSION: Comprehensive discharge planning plus postdischarge support for older patients with CHF significantly reduced readmission rates and may improve health outcomes such as survival and QOL without increasing costs.

Patient ratings of dialysis care with peritoneal dialysis vs hemodialysis.

CONTEXT: In light of conflicting evidence of differential effects of dialysis modality on survival, patient experience becomes a more important consideration in choosing between hemodialysis and peritoneal dialysis. OBJECTIVE: To compare patient satisfaction with hemodialysis and peritoneal dialysis in a cohort of patients who have recently begun dialysis. DESIGN AND SETTING: Cross-sectional survey at enrollment in a prospective inception cohort study of patients who recently started dialysis at 37 dialysis centers participating in the Choices for Healthy Outcomes in Caring for End-stage Renal Disease (CHOICE) study, a national multicenter study of dialysis outcomes, from October 1995 to June 1998. PATIENTS: Of 736 enrolled incident dialysis patients, 656 (89%) returned a satisfaction questionnaire after an average of 7 weeks of dialysis. MAIN OUTCOME MEASURE: Data collected from a patient-administered questionnaire including 3 overall ratings and 20 items rating specific aspects of dialysis care. RESULTS: Patients receiving peritoneal dialysis were much more likely than those receiving hemodialysis to give excellent ratings of dialysis care overall (85% vs 56%, respectively; relative probability, 1.46 [95% confidence interval, 1.31-1.57]) and significantly more likely to give excellent ratings for each specific aspect of care rated. The 3 items with the greatest differences were in the domain of information provided (average of information items: peritoneal dialysis [69% excellent] vs hemodialysis [30% excellent]). The smallest differences were in ratings of accuracy of information from the nephrologist, response to pain, amount of fluid removed, and staff availability in an emergency. Adjustment for patient age, race, education, health status, marital status, employment status, distance from the center, and time since starting dialysis did not reduce the differences between peritoneal dialysis and hemodialysis patients. CONCLUSIONS: After several weeks of initiating dialysis, patients receiving peritoneal dialysis rated their care higher than those receiving hemodialysis. These findings indicate that clinicians should give patients more information about the option of peritoneal dialysis.

Effect of physician-specific pay-for-performance incentives in a large group practice.

OBJECTIVE: To assess the effect of a physician-specific pay-for-performance program on quality-of-care measures in a large group practice. STUDY DESIGN: In 2007, Palo Alto Medical Clinic, a multispecialty physician group practice, changed from group-focused to physician-specific pay-for-performance incentives. Primary care physicians received incentive payments based on their quarterly assessed performance. METHODS: We examined 9 reported and incentivized clinical outcome and process measures. Five reported and nonincentivized measures were used for comparison purposes. The quality score of each physician for each measure was the main dependent variable and was calculated as follows: Quality Score = (Patients Meeting Target / Eligible Patients) x 100. Differences in scores between 2006 and 2007 were compared with differences in scores between 2005 and 2006. We also compared the performance of Palo Alto Medical Clinic with that of 2 other affiliated physician groups implementing group-level incentives. RESULTS: Eight of 9 reported and incentivized measures showed significant improvement in 2007 compared with 2006. Three measures showed an improvement trend significantly better than the previous year's trend. A similar improvement trend was observed in 1 related measure that was reported but was nonincentivized. However, the improvement trend of Palo Alto Medical Clinic was not consistently different from that of the other 2 physician groups. CONCLUSIONS: Small financial incentives (maximum, $5000/year) based on individual physicians' performance may have led to continued or enhanced improvement in well-established ambulatory care measures. Compared with other quality improvement programs having alternative foci for incentives (eg, increasing support for staff hours), the effect of physician-specific incentives was not evident.

Discharging patients earlier in the day: a concept worth evaluating.

Patient discharges from the hospital often occur late in the day and are frequently clustered after 4 PM. When inpatients leave earlier in the day, quality is improved because new admissions awaiting beds are able to leave the emergency department sooner and emergency department waiting room backlog is reduced. Nursing staff, whose work patterns traditionally result in high activity of discharge and admission between 5 PM and 8 PM, benefit by spreading out their work across a longer part of the day. Discharging patients earlier in the day also has the potential to increase patient satisfaction. Despite multiple stakeholders in the discharge planning process, physicians play the most important role. Getting physician buy-in requires an ability to teach physicians about the concept of early-in-the-day discharges and their impact on the process. We defined a new physician-centered discharge planning process and introduced it to an internal medicine team with an identical control team as a comparison. Discharge time of day was analyzed for 1 month. Mean time of day of discharge was 13:39 for the intervention group versus 15:45 for the control group (P<.001). If reproduced successfully, this process could improve quality at an important transition point in patient care.

Racial and gender disparities in receipt of highly active antiretroviral therapy persist in a multistate sample of HIV patients in 2001.

BACKGROUND: National data from the mid-1990s demonstrated that many eligible patients did not receive highly active antiretroviral therapy (HAART) and that racial and gender disparities existed in HAART receipt. We examined whether demographic disparities in the use of HAART persist in 2001 and if outpatient care is associated with HAART utilization. METHODS: Demographic, clinical, and pharmacy utilization data were collected from 10 US HIV primary care sites in the HIV Research Network (HIVRN). Using multivariate logistic regression, we examined demographic and clinical differences associated with receipt of HAART and the association of outpatient utilization with HAART. RESULTS: In our cohort in 2001, 84% of patients received HAART and 66% had 4 or more outpatient visits during calendar year (CY) 2001. Of those with 2 or more CD4 counts below 350 cells/mm in 2001, 91% received HAART; 82% of those with 1 CD4 test result below 350 cells/mm received HAART; and 77% of those with no CD4 counts below 350 cells/mm received HAART. Adjusting for care site in multivariate analyses, age >40 years (adjusted odds ratio [AOR] = 1.13), male gender (AOR = 1.23), Medicaid coverage (AOR = 1.16), Medicare coverage (AOR = 1.73), having 1 or more CD4 counts less than 350 cells/mm (AOR = 1.33), and having 4 or more outpatient visits in a year (OR = 1.34) were significantly associated with an increased likelihood of HAART. African Americans (odds ratio [OR] = 0.84) and those with an injection drug use risk factor (OR = 0.86) were less likely to receive HAART. CONCLUSIONS: Although the overall prevalence of HAART has increased since the mid-1990s, demographic disparities in HAART receipt persist. Our results support attempts to increase access to care and frequency of outpatient visits for underutilizing groups as well as increased efforts to reduce persistent disparities in women, African Americans, and injection drug users (IDUs).

Hospitalists and an innovative emergency department admission process.

After treatment in an emergency department (ED), patients often wait several hours for hospital admission, resulting in dissatisfaction and increased wait times for both admitted and other ED patients. We implemented a new direct admission system based on telephone consultation between ED physicians and in-house hospitalists. We studied this system, measuring admission times, length of stay, and mortality. Postintervention, admission times averaged 18 minutes for transfer to the ward compared to 2.5 hours preintervention, while pre- and postintervention length of stay and mortality rates remained similar.

Patient satisfaction with bronchoscopy.

We conducted a cohort study to characterize patient satisfaction with flexible bronchoscopy (FB) and to determine patient characteristics, care factors, and patient evaluations of bronchoscopy that are associated with a patient's willingness to return for repeat FB. Physicians and patients completed surveys between February 1997 and June 1998. Data from 481 patients were analyzed. Over 80% of the patients rated physicians as very good or excellent, but they were least satisfied with the information that they were provided about FB, waiting time before and after FB, and the FB environment. Seventy-one percent of the patients would definitely return, and 22% would probably return for a repeat FB. Better health status (odds ratio [OR] 1.4; 95% confidence interval [CI], 1.1-1.7), not being bothered by scope insertion (OR 2.0; 95% CI, 1.2-3.3), better rating of information quality (OR 1.2; 95% CI, 1.0-1.3), and better rating of physician quality (OR 1.1; 95% CI, 1.0-1.2) were associated with patients reporting that they would definitely return for a repeat FB. Although patient satisfaction with providers is high, there are specific patient and process of care factors that should be improved. Sicker patients may be at a risk of dissatisfaction with FB. Process of care measures that could improve satisfaction with FB include providing better information to patients and optimizing the experience of bronchoscope insertion.

The value of patient-reported health status in predicting short-term outcomes after coronary artery bypass graft surgery.

BACKGROUND: Risk stratification for comparison of outcomes after coronary artery bypass grafting (CABG) typically includes only clinical measures of risk. Patient-reported health status may be an important independent predictor of short-term health outcomes. OBJECTIVE: To determine whether patient-reported health status, as measured by the Physical and Mental Component Summary scores of the SF-36, predicts in-hospital mortality and prolonged length of stay after CABG, after controlling for other clinical predictors of those outcomes. RESEARCH DESIGN: Prospective cohort study conducted from September 1993 to November 1995. SUBJECTS: One thousand seven hundred seventy-eight adults who underwent isolated CABG for myocardial ischemia. MEASURES: In-hospital mortality and prolonged length of stay (> 14 days). RESULTS: There were 27 deaths and 223 patients with prolonged length of stay in the study sample. A 10-point decrease in the Physical Component Summary (PCS) score increased the odds of in-hospital mortality by 61% (OR, 1.61; 95% CI, 1.04-2.49), independent of established clinical risk factors. Similarly, a 10-point decrease in the PCS score increased the odds of prolonged length of stay by 33% (OR, 1.33; 95% CI, 1.13-1.57). A 10-point decrease in the Mental Component Summary score (MCS) decreased the odds of mortality by 36% (OR, 0.64; 95% CI, 0.43-0.95). CONCLUSIONS: The PCS score is independently and significantly associated with in-hospital mortality and prolonged length of stay, after controlling for clinical risk factors. The MCS score is independently and significantly associated only with mortality, though the direction of the effect is unexpected. The result likely reflects a property of the scoring of the MCS and not a finding of clinical substance. Although caution must be taken when interpreting the summary scores, the SF-36 yields information not otherwise captured by clinical data and may be useful in risk stratification for in-hospital mortality and prolonged length of stay after CABG.

Effect of student involvement on patient perceptions of ambulatory care visits: a randomized controlled trial.

OBJECTIVE: To determine if patient satisfaction with ambulatory care visits differs when medical students participate in the visit. DESIGN: Randomized controlled trial. SETTING: Academic general internal medicine practice. PARTICIPANTS: Outpatients randomly assigned to see an attending physician only (N = 66) or an attending physician plus medical student (N = 68). MEASUREMENTS AND MAIN RESULTS: Patient perceptions of the office visit were determined by telephone survey. Overall office visit satisfaction was higher for the "attending physician only" group (61% vs 48% excellent), although this was not statistically significant (P =.16). There was no difference between the study groups for patient ratings of their physician overall (80% vs 85% excellent; P =.44). In subsidiary analyses, patients who rated their attending physician as "excellent" rated the overall office visit significantly higher in the "attending physician only" group (74% vs 55%; P =.04). Among patients in the "attending physician plus medical student" group, 40% indicated that medical student involvement "probably" or "definitely" did not improve their care, and 30% responded that they "probably" or "definitely" did not want to see a student at subsequent office visits. CONCLUSIONS: Although our sample size was small, we found no significant decrement in patient ratings of office visit satisfaction from medical student involvement in a global satisfaction survey. However, a significant number of patients expressed discontent with student involvement in the visit when asked directly. Global assessment of patient satisfaction may lack sensitivity for detection of dissatisfaction. Future research in this area should employ more sensitive measures of patient satisfaction.

Is health plan employer data and information set performance associated with withdrawal from medicare managed care?

BACKGROUND: Withdrawals of health plans from Medicare have affected more than 1.6 million beneficiaries. Some plans claim that providing higher quality care raises costs, lowers profits, and spurs withdrawal because plans cannot sustain high quality care under current payment levels. OBJECTIVE: To assess whether higher performance by Medicare health plans on quality indicators was associated with withdrawal. DESIGN: Retrospective cohort study. SUBJECTS: Taking each county where a contract was active as a unit of analysis, Medicare managed care plans active in 2310 contract-county combinations in 1997 were studied and followed for 3 years. MEASURES: Independent variables were scores on six indicators from the Health Plan Employer Data and Information Set (HEDIS) for each contract, collapsed into two summary measures: clinical and ambulatory care access. Separate Cox proportional hazards regressions were used for each indicator, and each summary measure, to assess the association of HEDIS performance with our outcome measure, time-to-withdrawal from Medicare. Multiple potential confounders were adjusted for. RESULTS: Of 2310 managed care contract-county combinations, 877 (38%) withdrew. The proportion of contract-counties with high scores on the summary clinical quality measure that withdrew was one-fifth that for low scorers (4.2% vs. 20.5%). For summary ambulatory care access performance, the corresponding ratio was two-fifths (12.8% vs. 32.0%). Lower payments were associated with higher withdrawal risk, but also higher clinical and ambulatory care access quality performance. In separate multivariable analyses controlling for confounders, both high clinical performance (HR, 0.18; 95% CI, 0.08-0.42) and high ambulatory care access performance (HR, 0.53; 95% CI, 0.27-1.07) were independently associated with lower withdrawal risk. CONCLUSIONS: Health plans continuing to provide care to Medicare beneficiaries have higher average performance on HEDIS clinical and ambulatory care access measures than plans that withdrew.