Variation in Patient Experience Across the Clinic Day: a Multilevel Assessment of Four Primary Care Practices.

BACKGROUND: Patient satisfaction with healthcare is associated with clinical outcomes, provider satisfaction, and success of healthcare organizations. As the clinic day progresses, provider fatigue, deterioration with communication within the care team, and appointment spillover may decrease patient experience. OBJECTIVE: To understand the relationship between likelihood to recommend a primary care practice and scheduled appointment time across multiple practice settings. DESIGN: Retrospective cohort. PARTICIPANTS: A retrospective cohort was created of all patients seen within four primary care practices between July 1, 2016, and September 30, 2017. MAIN MEASURES: We looked at scheduled appointment time against patient likelihood to recommend a practice as a measure of overall patient experience collected routinely for clinical practice improvement by the Press Ganey Medical Practice Survey®. Adjusted mixed effects logistic regression models were created to understand the relationship between progressing appointment time on patient likelihood to recommend a practice. We constructed locally weighted smoothing (LOESS) curves to understand how reported patient experience varied over the clinic day. RESULTS: We had a response rate of 14.0% (n = 3172), 80.2% of whom indicated they would recommend our practice to others. Appointment time scheduling during the last hour (4:00-4:59 PM) had a 45% lower odds of recommending our practice when compared to the first clinic hour (adjusted OR = 0.55, 95% CI 0.35-0.86) which is similar when controlling for patient-reported wait time (aOR = 0.59, 95% CI 0.37-0.95). LOESS plots demonstrated declining satisfaction with subsequent appointment times compared with the first session hour, with no effect just after the lunch hour break. CONCLUSIONS: In primary care, appointment time of day is associated with patient-reported experience.

A Before and After Analysis of Health Care Utilization by Patients Enrolled in Opioid Controlled Substance Agreements for Chronic Noncancer Pain.

OBJECTIVE: To evaluate the impact of opioid controlled substance agreements (CSAs) enrollment on health care utilization. PATIENTS AND METHODS: We retrospectively evaluated health care utilization changes among 772 patients receiving long-term opioid therapy for chronic noncancer pain enrolled in a CSA between July 1, 2015, and December 31, 2015. We ascertained patient characteristics and utilization 12 months before and after CSA enrollment. Decreased utilization was defined as a decrease of 1 or more hospitalizations or emergency department visits and 3 or more outpatient primary and specialty care visits. Multivariate modeling assessed demographic characteristics associated with utilization changes. RESULTS: The 772 patients enrolled in an opioid CSA during the study period had a mean ± SD age of 63.5±14.9 years and were predominantly female, white, and married. The CSA enrollment was associated with decreased outpatient primary care visits (odds ratio [OR], 0.16; 95% CI, 0.14-0.19) and increased diagnostic radiology services (OR, 1.22; 95% CI, 1.02-1.47). After CSA enrollment, patients with greater comorbidity (Charlson Comorbidity Index score >3) were more likely to have reduced hospitalizations (adjusted OR, 2.8; 95% CI, 1.3-6.0; P=.008), reduced outpatient primary care visits (adjusted OR, 2.0; 95% CI, 1.2-3.2; P=.005), and reduced specialty care visits (adjusted OR, 2.0; 95% CI, 1.2-3.3; P=.006). CONCLUSION: For patients receiving long-term opioid therapy for chronic noncancer pain, CSA enrollment is associated with reductions in primary care visits and increased radiologic service utilization. Patients with greater comorbidity were more likely to have reductions in hospitalizations, outpatient primary care visits, and outpatient specialty clinic visits after CSA enrollment. The observational nature of the study does not allow the conclusion that CSA implementation is the primary reason for these observed changes.