Unsolicited Patient Complaints Identify Physicians with Evidence of Neurocognitive Disorders.

OBJECTIVES: Determine whether words contained in unsolicited patient complaints differentiate physicians with and without neurocognitive disorders (NCD). METHODS: We conducted a nested case-control study using data from 144 healthcare organizations that participate in the Patient Advocacy Reporting System program. Cases (physicians with probable or possible NCD) and two comparison groups of 60 physicians each (matched for age/sex and site/number of unsolicited patient complaints) were identified from 33,814 physicians practicing at study sites. We compared the frequency of words in patient complaints related to an NCD diagnostic domain between cases and our two comparison groups. RESULTS: Individual words were all statistically more likely to appear in patient complaints for cases (73% of cases had at least one such word) compared to age/sex matched (8%, p < 0.001 using Pearson's χ2 test, χ2 = 30.21, df = 1) and site/complaint matched comparisons (18%, p < 0.001 using Pearson's χ2 test, χ2 = 17.51, df = 1). Cases were significantly more likely to have at least one complaint with any word describing NCD than the two comparison groups combined (conditional logistic model adjusted odds ratio 20.0 [95% confidence interval 4.9-81.7]). CONCLUSIONS: Analysis of words in unsolicited patient complaints found that descriptions of interactions with physicians with NCD were significantly more likely to include words from one of the diagnostic domains for NCD than were two different comparison groups. Further research is needed to understand whether patients might provide information for healthcare organizations interested in identifying professionals with evidence of cognitive impairment.

Triaging Patient Complaints: Monte Carlo Cross-Validation of Six Machine Learning Classifiers.

BACKGROUND: Unsolicited patient complaints can be a useful service recovery tool for health care organizations. Some patient complaints contain information that may necessitate further action on the part of the health care organization and/or the health care professional. Current approaches depend on the manual processing of patient complaints, which can be costly, slow, and challenging in terms of scalability. OBJECTIVE: The aim of this study was to evaluate automatic patient triage, which can potentially improve response time and provide much-needed scale, thereby enhancing opportunities to encourage physicians to self-regulate. METHODS: We implemented a comparison of several well-known machine learning classifiers to detect whether a complaint was associated with a physician or his/her medical practice. We compared these classifiers using a real-life dataset containing 14,335 patient complaints associated with 768 physicians that was extracted from patient complaints collected by the Patient Advocacy Reporting System developed at Vanderbilt University and associated institutions. We conducted a 10-splits Monte Carlo cross-validation to validate our results. RESULTS: We achieved an accuracy of 82% and F-score of 81% in correctly classifying patient complaints with sensitivity and specificity of 0.76 and 0.87, respectively. CONCLUSIONS: We demonstrate that natural language processing methods based on modeling patient complaint text can be effective in identifying those patient complaints requiring physician action.

Use of Unsolicited Patient Observations to Identify Surgeons With Increased Risk for Postoperative Complications.

Importance: Unsolicited patient observations are associated with risk of medical malpractice claims. Because lawsuits may be triggered by an unexpected adverse outcome superimposed on a strained patient-physician relationship, a question remains as to whether behaviors that generate patient dissatisfaction might also contribute to the genesis of adverse outcomes themselves. Objective: To examine whether patients of surgeons with a history of higher numbers of unsolicited patient observations are at greater risk for postoperative complications than patients whose surgeons generate fewer such unsolicited patient observations. Design, Setting, and Participants: This retrospective cohort study used data from 7 academic medical centers participating in the National Surgical Quality Improvement Program and the Vanderbilt Patient Advocacy Reporting System from January 1, 2011, to December 31, 2013. Patients older than 18 years included in the National Surgical Quality Improvement Program who underwent inpatient or outpatient operations at 1 of the participating sites during the study period were included. Patients were excluded if the attending surgeon had less than 24 months of data in the Vanderbilt Patient Advocacy Reporting System preceding the date of the operation. Data analysis was conducted from June 1, 2015, to October 20, 2016. Exposures: Unsolicited patient observations for the patient's surgeon in the 24 months preceding the date of the operation. Main Outcomes and Measures: Postoperative surgical or medical complications as defined by the National Surgical Quality Improvement Program within 30 days of the operation of interest. Results: Among the 32 125 patients in the cohort (13 230 men, 18 895 women; mean [SD] age, 55.8 [15.8] years), 3501 (10.9%) experienced a complication, including 1754 (5.5%) surgical and 2422 (7.5%) medical complications. Prior unsolicited patient observations for a surgeon were significantly associated with the risk of a patient having any complication (odds ratio, 1.0063; 95% CI, 1.0004-1.0123; P = .03), any surgical complication (odds ratio, 1.0104; 95% CI, 1.0022-1.0186; P = .01), any medical complication (odds ratio, 1.0079; 95% CI, 1.0009-1.0148; P = .03), and being readmitted (odds ratio, 1.0088, 95% CI, 1.0024-1.0151; P = .007). The adjusted rate of complications was 13.9% higher for patients whose surgeon was in the highest quartile of unsolicited patient observations compared with patients whose surgeon was in the lowest quartile. Conclusions and Relevance: Patients whose surgeons have large numbers of unsolicited patient observations in the 24 months prior to the patient's operation are at increased risk of surgical and medical complications. Efforts to promote patient safety and address risk of malpractice claims should continue to focus on surgeons' ability to communicate respectfully and effectively with patients and other medical professionals.

Academic Urological Surgeons have Greater Exposure to Risk Management Activity than Community Urological Surgeons: An Empirical Analysis of Patient Complaint Data.

INTRODUCTION: Previous research reveals associations between patient complaints and urological subspecialty, but relationships between complaints and practice environments have gone untested. In this study we explored whether associations exist between the types and rates of patient complaints filed against urological surgeons and their practice environments, defined as academic (medical school faculty) or community (independent medical group members). Complaints are a surrogate for malpractice litigation risk, so understanding the variables that drive complaints may suggest risk reduction interventions. METHODS: In this retrospective, exploratory study we examined 2,883 unsolicited patient complaints about 357 urologists affiliated with organizations partnering with the Vanderbilt Center for Patient and Professional Advocacy. Overall 222 (62%) urologists were practicing in 16 academic medical center systems and 135 (38%) in 11 community systems that recorded complaints from January 1, 2011 through December 31, 2014. Specific concerns about urologists were counted. Complaint type profiles were generated using a standardized coding system. Statistical analyses tested associations among practice environment (academic vs community), complaint counts and distribution of complaints by type. RESULTS: Academic urologists had more complaints per physician than their community colleagues (Z = 2.53, p <0.05). They also had more complaints about care/treatment, communication (p <0.05) and access issues (p <0.001). CONCLUSIONS: Academic urologists are associated with more patient complaints than community urologists, suggesting greater exposure to medical malpractice claims. Concerns regarding access, communication and the care that patients received appear to drive this discrepancy. Personal practice and clinical management solutions designed to improve these elements of patient experiences, especially access, may help reduce medical malpractice claims related activity.

Unsolicited Patient Complaints in Ophthalmology: An Empirical Analysis from a Large National Database.

PURPOSE: The number of unsolicited patient complaints about a physician has been shown to correlate with increased malpractice risk. Using a large national patient complaint database, we evaluated the number and content of unsolicited patient complaints about ophthalmologists to identify significant risk factors for receiving a complaint. DESIGN: Retrospective cohort study. PARTICIPANTS: Ophthalmologists, nonophthalmic surgeons, nonophthalmic nonsurgeons. METHODS: We analyzed 2087 unsolicited or spontaneous complaints reported about 815 ophthalmologists practicing in 24 academic and nonacademic organizations using the Patient Advocacy Reporting System (PARS). Complaints against 5273 nonophthalmic surgeons and 19487 nonophthalmic nonsurgeons during the same period were used for comparison. Complaint type profiles were assigned using a previously validated standardized coding system. We (1) described the distribution of complaints against ophthalmologists; (2) compared the distribution and rates of patient complaints about ophthalmologists with those of nonophthalmic surgeons and nonophthalmic nonsurgeons in the database; (3) analyzed differences in complaint type profiles and quantity of complaints by ophthalmic subspecialty, practice setting, physician gender, medical school type, and graduation date; and (4) identified significant risk factors for high numbers of unsolicited patient complaints after adjusting for other covariates. MAIN OUTCOME MEASURES: Unsolicited patient complaints. RESULTS: Ophthalmologists had significantly fewer complaints per physician than other nonophthalmic surgeons and nonsurgeons. Sixty-three percent of ophthalmologists had 0 complaints, whereas 10% of ophthalmologists accounted for 61% of all complaints. Ophthalmologists from academic centers, female ophthalmologists, and younger ophthalmologists had significantly more complaints (P < 0.01), and general ophthalmologists had significantly fewer complaints than subspecialists (P < 0.05). After adjusting for covariates using multivariable analysis, working at an academic center was a statistically significant risk factor (adjusted relative risk, 1.82; 95% confidence interval, 1.36-2.43; P < 0.001). CONCLUSIONS: Ophthalmologists had significantly fewer complaints than nonophthalmic surgeons and nonophthalmic nonsurgeons, and by implication may have a lower malpractice risk as a group. Nevertheless, a small number of ophthalmologists generated a disproportionate number of complaints. Working at an academic center was a significant independent risk factor for having more patient complaints. Further research is needed to clarify the underlying reasons for this association and to identify interventions that may decrease this risk.

Patient Complaints and Adverse Surgical Outcomes.

One factor that affects surgical team performance is unprofessional behavior exhibited by the surgeon, which may be observed by patients and families and reported to health care organizations in the form of spontaneous complaints. The objective of this study was to assess the relationship between patient complaints and adverse surgical outcomes. A retrospective cohort study used American College of Surgeons National Surgical Quality Improvement Program data from an academic medical center and included 10 536 patients with surgical procedures performed by 66 general and vascular surgeons. The number of complaints for a surgeon was correlated with surgical occurrences (P < .01). Surgeons with more patient complaints had a greater rate of surgical occurrences if the surgeon's aggregate preoperative risk was higher (ß = .25, P < .05), whereas there was no statistically significant relationship between patient complaints and surgical occurrences for surgeons with lower aggregate perioperative risk (ß = -.20, P = .77).

An intervention model that promotes accountability: peer messengers and patient/family complaints.

BACKGROUND: Patients and their families are well positioned to partner with health care organizations to help identify unsafe and dissatisfying behaviors and performance. A peer messenger process was designed by the Center for Professional and Patient Advocacy at Vanderbilt University Medical Center (Nashville, Tennessee) to address "high-risk" physicians identified through analysis of unsolicited patient complaints, a proxy for risk of lawsuits. METHODS: This retrospective, descriptive study used peer messenger debriefing results from data-driven interventions at 16 geographically disparate community (n = 7) and academic (n = 9) medical centers in the United States. Some 178 physicians served as peer messengers, conducting interventions from 2005, through 2009 on 373 physicians identified as high risk. RESULTS: Most (97%) of the high-risk physicians received the feedback professionally, and 64% were "Responders." Responders' risk scores improved at least 15%, where Nonresponders' scores worsened (17%) or remained unchanged (19%) (p < or = .001). Responders were more often physicians practicing in medicine and surgery than emergency medicine physicians, had longer organizational tenures, and engaged in lengthier first-time intervention meetings with messengers. Years to achieve responder status correlated positively with initial communication-related complaints (r = .32, p < .001), but all complaint categories were equally likely to change over time. CONCLUSIONS: Peer messengers, recognized by leaders and appropriately supported with ongoing training, high-quality data, and evidence of positive outcomes, are willing to intervene with colleagues over an extended period of time. The physician peer messenger process reduces patient complaints and is adaptable to addressing unnecessary variation in other quality/safety metrics.

Dual diathesis-stressor model of emotional and linguistic contributions to developmental stuttering.

This study assessed emotional and speech-language contributions to childhood stuttering. A dual diathesis-stressor framework guided this study, in which both linguistic requirements and skills, and emotion and its regulation, are hypothesized to contribute to stuttering. The language diathesis consists of expressive and receptive language skills. The emotion diathesis consists of proclivities to emotional reactivity and regulation of emotion, and the emotion stressor consists of experimentally manipulated emotional inductions prior to narrative speaking tasks. Preschool-age children who do and do not stutter were exposed to three emotion-producing overheard conversations-neutral, positive, and angry. Emotion and emotion-regulatory behaviors were coded while participants listened to each conversation and while telling a story after each overheard conversation. Instances of stuttering during each story were counted. Although there was no main effect of conversation type, results indicated that stuttering in preschool-age children is influenced by emotion and language diatheses, as well as coping strategies and situational emotional stressors. Findings support the dual diathesis-stressor model of stuttering.

Spontaneous regulation of emotions in preschool children who stutter: preliminary findings.

PURPOSE: Emotional regulation of preschool children who stutter (CWS) and children who do not stutter (CWNS) was assessed through use of a disappointing gift (DG) procedure (P. M. Cole, 1986; C. Saarni, 1984, 1992). METHOD: Participants consisted of 16 CWS and CWNS (11 boys and 5 girls in each talker group) who were 3 to 5 years of age. After assessing each child's knowledge of display rules about socially appropriate expression of emotions, the authors asked the children to participate in a DG procedure. The children received a desirable gift preceding the first free-play task and a disappointing gift preceding a second free-play task. Dependent variables consisted of participants' positive and negative expressive nonverbal behaviors exhibited during receipt of a desirable gift and disappointing gift as well as conversational speech disfluencies exhibited following receipt of each gift. RESULTS: Findings indicated that CWS and CWNS exhibited no significant differences in amount of positive emotional expressions after receiving the desired gift; however, CWS--when compared with CWNS--exhibited more negative emotional expressions after receiving the undesirable gift. Furthermore, CWS were more disfluent after receiving the desired gift than after receiving the disappointing gift. Ancillary findings also indicated that CWS and CWNS had equivalent knowledge of display rules. CONCLUSION: Findings suggest that efforts to concurrently regulate emotional behaviors and that speech disfluencies may be problematic for preschool-age CWS.

Fear and anger reactivity trajectories from 4 to 16 months: the roles of temperament, regulation, and maternal sensitivity.

Two goals guided this study: (a) describe changes in infant fear and anger reactivity from 4 to 16 months and (b) examine the degree to which infant temperament, attentional regulation, and maternal sensitivity predict reactivity trajectories. Participants included 143 mothers and infants (57% male) who visited the laboratory at 4, 8, 12, and 16 months. Infant reactivity, regulation, and maternal sensitivity were assessed from laboratory situations; infant temperament was rated by mothers on the Infant Behavior Questionnaire (Rothbart, 1981). Hierarchical linear modeling indicated that overall, fear and anger reactivity increased with age, but the rate of increase for fear slowed over time. Maternal ratings of temperamental fear and anger each predicted laboratory ratings of fear and anger reactivity, respectively. Moreover, infants who showed less regulation showed greater fear reactivity and steeper increases in anger reactivity over time. Infants whose mothers were more sensitive showed slower increases in fear reactivity. Findings from this study suggest that it is important to consider both intrinsic and extrinsic factors to gain a better understanding of the processes that may be involved in the development of emotional reactivity systems.

Influence of stuttering variation on talker group classification in preschool children: preliminary findings.

UNLABELLED: The purpose of this study was to investigate whether variations in disfluencies of young children who do (CWS) and do not stutter (CWNS) significantly change their talker group classification or diagnosis from stutterer to nonstutterer, and vice versa. Participants consisted of seventeen 3- to 5-year-old CWS and nine 3- to 5-year-old CWNS, with no statistically significant between-group difference in chronological age (CWS: M=45.53 months, S.D.=8.32; CWNS: M=47.67 months, S.D.=6.69). All participants had speech, language, and hearing development within normal limits, with the exception of stuttering for CWS. Both talker groups participated in a series of speaking samples that varied by: (a) conversational partner [parent and clinician], (b) location [home and clinic], and (c) context [conversation and narrative]. The primary dependent measures for this study were the number of stuttering-like disfluencies (SLD) per total number of spoken words [%SLD] and the ratio of SLD to total disfluencies (TD) [SLD/TD]. The results indicated that significant variability of stuttering did not exist as a result of conversational partner or location. Changes in context, however, did impact the CWS, who demonstrated higher SLD/TD in the conversation sample versus a narrative sample. Consistent with hypotheses, CWS and CWNS were accurately identified as stutterers and nonstutterers, respectively, regardless of changes to conversational partner, location or context for the overall participant sample. Present findings were taken to suggest that during assessment, variations in stuttering frequency resulting from changes in conversational partner, location or context do not significantly influence the diagnosis of stuttering, especially for children not on the talker group classification borderline between CWS and CWNS. LEARNING OUTCOMES: Readers will be able to: (1) Describe the role of variability in stuttering frequency for young children who stutter; (2) Identify three fundamental measurements of the frequency of stuttering-like and nonstuttering-like disfluencies; (3) Describe the effects of stuttering variation on talker group classification of stuttering or nonstuttering.

Do you believe in magic? Infants' social looking during violations of expectations.

Young infants tend to look longer at physical events that have unexpected outcomes than those that have expected outcomes, suggesting that they have knowledge of physical principles such as numerosity and occlusion (Baillargeon & Graber, 1987; Wynn, 1992). Although infants are typically tested in the presence of a caregiver, the social component of violations of expectations has received little attention. The present study investigated social looking during presumably expected and unexpected cognitive/perceptual events. Two experiments replicated the results of well-known physical knowledge experiments on addition/subtraction and occlusion in 6- (Experiments 1 and 2) and 9-month-old infants (Experiment 1), in that infants at both ages looked longer at unexpected than at expected events. Furthermore, infants at both ages initiated more looks at their caregivers' faces during unexpected than expected events. These findings are interpreted as suggesting that infants as young as 6 months of age actively seek to embed their experiences of unexpected physical/cognitive events in a social context.

Positive emotion, negative emotion, and emotion control in the externalizing problems of school-aged children.

The present study examined the role of emotion and emotion control in children's externalizing problems. Third- to sixth-grade children were administered a self-report measure of positive emotion, negative emotion, and emotion control. Peer- and teacher-reported adjustment problems were assessed. Structural equations modeling revealed that negative emotion, especially anger, was important in externalizing problems. Less positive emotion was associated with more externalizing problems. However, when negative emotion was examined in a more differentiated manner (anger, sadness and fear), the effect of positive emotion was diminished. Anger consistently emerged as a significant predictor of behavior problems. No interaction between either positive emotion and emotion control or negative emotion and emotion control was significant. Results showed main effects of each emotion component, with small interaction effects. Methodological and conceptual implications of the findings from the present study are discussed.

Relation of emotional reactivity and regulation to childhood stuttering.

UNLABELLED: The purpose of the present study was to examine relations between children's emotional reactivity, emotion regulation and stuttering. Participants were 65 preschool children who stutter (CWS) and 56 preschool children who do not stutter (CWNS). Parents completed the Behavior Style Questionnaire (BSQ) [McDevitt S. C., & Carey, W. B. (1978). A measure of temperament in 3-7 year old children. Journal of Child Psychology and Psychiatry and Allied Disciplines, 19, 245-253]. Three groups of BSQ items measuring emotional reactivity, emotion regulation, and attention regulation were identified by experts in children's emotions. Findings indicated that when compared to their normally fluent peers, CWS were significantly more reactive, significantly less able to regulate their emotions, and had significantly poorer attention regulation, even after controlling for gender, age, and language abilities. Findings suggest that the relatively greater emotional reactivity experienced by preschool children who stutter, together with their relative inability to flexibly control their attention and regulate the emotions they experience, may contribute to the difficulties these children have establishing reasonably fluent speech and language. LEARNING OUTCOMES: The reader should be able to (1) define emotional reactivity and emotion regulation, (2) explain how emotional reactivity and emotion regulation relate to preschool stuttering, and (3) understand recent empirical evidence linking reactivity and regulation to preschool stuttering.

Predicting shared parent--child book reading in infancy.

This study examined the degree to which parental contextual factors and infant characteristics predicted whether parents read aloud to their 8-month-old infants. Discriminant function analysis revealed that mothers with higher family incomes and those who reported less parenting stress and fewer general hassles were more likely to read to their infants. Gender and temperament of the infant did not significantly predict whether mothers would engage in shared reading. Furthermore, there was no evidence that mothers who reported reading aloud to their infants display more enriching parenting practices in the laboratory. Paternal contextual factors did not discriminate readers from nonreaders, but infant temperament did. Fathers who read aloud had infants who were less soothable and who displayed longer durations of orienting. The possibility that book reading could serve as 1 mediator of the temperament-cognition relationship is discussed.

Processes in language acquisition: the roles of gender, attention, and maternal encouragement of attention over time.

This longitudinal study including 87 infant-mother dyads examined the relation between infant temperamental attention, maternal encouragement of attention, language, and the effects of gender. At ages 0;4, 0;8, and 1;0, global attention was assessed from Rothbart's (1981) IBQ; manipulative exploration was assessed with the Bayley (1969) IBR; and maternal verbal, visual and physical encouragement of attention were coded from 5 minutes of mother-infant free-play. At 1;0, language was measured using language items from the Bayley Mental Scale and parent-report items from Hendrick, Prather & Tobin's (1984) SICD-Revised. Multiple regressions indicated that gender, infants' manipulative exploration and maternal physical encouragement of attention at 0;4, and maternal verbal encouragement of attention at 1;0, were all positively related to language at 1;0. Interactions indicated that girls high in 0;8 or 1;0 manipulative exploration had more advanced language skills than girls low in manipulative exploration or than boys, regardless of their attention level. Additionally, maternal verbal encouragement of attention appears to be particularly salient in the development of language for boys.