Understanding the Patient Experience: Analysis of 2-Word Assessment and Its Relationship to Likelihood to Recommend in Outpatient Hand Surgery.

BACKGROUND: Actionable feedback from patients after a clinic visit can help inform ways to better deliver patient-centered care. A 2-word assessment may serve as a proxy for lengthy post-visit questionnaires. We tested the use of a 2-word assessment in an outpatient hand clinic. METHODS: New patients were asked to provide a 2-word assessment of the following: (1) their physician; (2) their overall experience; and (3) recommendations for improvement and their likelihood to recommend (LTR) after their clinic visit. Sentiment analysis was used to categorize results into positive, neutral, or negative sentiment. Recommendations for improvement were classified into physician issue, system issue, or neither. We evaluated the relationship between LTR status, sentiment, actionable improvement opportunities, and classification (physician issue, system issue, or neither). Recommendations for improvement were classified into themes based on prior literature. RESULTS: Sixty-seven (97.1%) patients noted positive sentiment toward their physician; 67 (97.1%) noted positive sentiment toward their overall experience. About 31% of improvement recommendations were system-based, 5.9% were physician-based, and 62.7% were neither. Patients not LTR were more likely to leave actionable opportunities for improvement than those LTR (P = .01). Recommendations for improvement were classified into predetermined themes relating to: (1) physician interaction; (2) check-in process; (3) facilities; (4) unnecessary visit; and (5) appointment delays. CONCLUSION: Patients not likely to recommend provided actionable opportunities for improvement using a simple 2-word assessment. Implementation of a 2-word assessment in a hand clinic can be used to obtain actionable, real-time patient feedback that can inform operational change and improve the patient experience.

Clinical Care Redesign to Improve Value in Carpal Tunnel Syndrome: A Before-and-After Implementation Study.

PURPOSE: Carpal tunnel surgery is one of the most common procedures completed on the upper limb in the United States. There is currently no evidence-based high-value clinical care pathway to inform the management of carpal tunnel syndrome (CTS). We created an evidence-based care pathway and implemented a quality improvement initiative to evaluate its effect on patient time, quality, and cost in a tertiary care ambulatory surgery center. METHODS: We developed a high-value clinical care pathway for CTS and implemented the intraoperative phase of the pathway. This included (1) implementing an evidence-based protocol for wide-awake local anesthesia, (2) removing non-value-added processes of care, and (3) implementing educational sessions with surgery staff regarding the initiative. We prospectively collected data on patient time, visual analog scale pain scores (quality), and percent change in total direct costs of the intraoperative phase of care (cost). RESULTS: A total of 50 patients were included in this implementation study: 30 prior to implementation of the intervention and 20 after. There was a significant decrease in average patient wheels in to surgery time, postanesthesia care unit to discharge time, and total patient time (lead time). There was no difference in preoperative or postoperative pain before and after the intervention. There was a 31% reduction in total direct costs. CONCLUSIONS: Implementing the intraoperative phase of this clinical care pathway with wide-awake surgery can reduce patient lead time, maintain quality, and reduce total direct costs in an ambulatory surgery center. CLINICAL RELEVANCE: Quality improvement interventions, such as the implementation of an evidence-based clinical care pathway for the treatment for CTS, may improve value to health systems.

Using administrative data for mortality risk adjustment in pediatric congenital cardiac surgery.

OBJECTIVE: To evaluate the performance of risk-adjustment models from the University HealthSystem Consortium and the Agency for Healthcare Research Quality on an administrative dataset for children undergoing congenital cardiac surgery. DESIGN: Retrospective cross-sectional cohort analysis. SETTING: Multi-institutional database of administrative data provided by the University HealthSystem Consortium. PATIENTS: Children whose discharge diagnosis had an associated cardiac surgical procedure. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The performance of two risk-adjustment modeling schemata was measured in terms of discrimination and calibration, and receiver operating characteristic curves were compared. Model calibration was assessed using the Hosmer-Lemeshow goodness-of-fit test. A total of 19,436 patients were included in the analysis with 816 deaths and an unadjusted overall mortality rate of 4.2%. The University HealthSystem Consortium models applied to the entire population resulted in an area under the curve = 0.73, and by comparison, the Agency for Healthcare Research Quality risk-adjustment model revealed area under the curve = 0.86. The risk-adjustment model of the University HealthSystem Consortium subgroup of Circulatory System Major Diagnostic Category 5 showed better performance with area under the curve = 0.81. Calibration using the Hosmer-Lemeshow test failed to show good agreement between the predicted and actual outcomes across the University HealthSystem Consortium mortality risk groups with an overall standardized mortality ratio of 1.2 (95% CI, 1.1-1.3; p < 0.0001) and poor predictive ability for the highest risk group, with a nearly 1.5-fold overprediction of death. The Agency for Healthcare Research Quality model shared similar calibration results with an overall standardized mortality ratio of 1.6 (95% CI, 1.5-1.7; p < 0.0001) and a nearly two-fold underprediction of death in the highest risk group. CONCLUSIONS: Administrative data can be used to create risk-adjustment models in the congenital cardiac surgery population. Risk-adjustment models generated from administrative data may represent an attractive addition to clinically derived models in pediatric congenital cardiac surgery patients and should be considered for use either alone or in combination with clinical data in future analyses where mortality is a measure of performance and quality.

Developing ambulatory care physician performance measures.

Major US corporations and consumer groups are demanding more accountability for their health care expenditures. In response, the federal government, specialty boards, and state medical boards are evaluating ways to implement objective measures of quality. Many dermatologists already choose to participate in quality measurement and improvement activities. More will need to, as recertification and relicensure requirements change. Dermatologists need measures that are specialty-specific, as measures developed for primary care physicians are generally not appropriate for a dermatologic practice.

Disparities in health care are driven by where minority patients seek care: examination of the hospital quality alliance measures.

BACKGROUND: Racial/ethnic disparities in health care are well documented, but less is known about whether disparities occur within or between hospitals for specific inpatient processes of care. We assessed racial/ethnic disparities using the Hospital Quality Alliance Inpatient Quality of Care Indicators. METHODS: We performed an observational study using patient-level data for acute myocardial infarction (5 care measures), congestive heart failure (2 measures), community-acquired pneumonia (2 measures), and patient counseling (4 measures). Data were obtained from 123 hospitals reporting to the University HealthSystem Consortium from the third quarter of 2002 to the first quarter of 2005. A total of 320,970 patients 18 years or older were eligible for at least 1 of the 13 measures. RESULTS: There were consistent unadjusted differences between minority and nonminority patients in the quality of care across 8 of 13 quality measures (from 4.63 and 4.55 percentage points for angiotensin-converting enzyme inhibitors for acute myocardial infarction and congestive heart failure [P<.01] to 14.58 percentage points for smoking cessation counseling for pneumonia [P=.02]). Disparities were most pronounced for counseling measures. In multivariate models adjusted for individual patient characteristics and hospital effect, the magnitude of the disparities decreased substantially, yet remained significant for 3 of the 4 counseling measures; acute myocardial infarction (unadjusted, 9.00 [P<.001]; adjusted, 3.82 [P<.01]), congestive heart failure (unadjusted, 8.45 [P=.02]; adjusted, 3.54 [P=.02]), and community-acquired pneumonia (unadjusted, 14.58 [P=.02]; adjusted, 4.96 [P=.01]). CONCLUSIONS: Disparities in clinical process of care measures are largely the result of differences in where minority and nonminority patients seek care. However, disparities in services requiring counseling exist within hospitals after controlling for site of care. Policies to reduce disparities should consider the underlying reasons for the disparities.