Identifying predictors of high quality care in English general practice: observational study.

OBJECTIVES: To assess variation in the quality of care in general practice and identify factors associated with high quality care. DESIGN: Observational study. SETTING: Stratified random sample of 60 general practices in six areas of England. OUTCOME MEASURES: Quality of management of chronic disease (angina, asthma in adults, and type 2 diabetes) and preventive care (rates of uptake for immunisation and cervical smear), access to care, continuity of care, and interpersonal care (general practice assessment survey). Multiple logistic regression with multilevel modelling was used to relate each of the outcome variables to practice size, routine booking interval for consultations, socioeconomic deprivation, and team climate. RESULTS: Quality of clinical care varied substantially, and access to care, continuity of care, and interpersonal care varied moderately. Scores for asthma, diabetes, and angina were 67%, 21%, and 17% higher in practices with 10 minute booking intervals for consultations compared with practices with five minute booking intervals. Diabetes care was better in larger practices and in practices where staff reported better team climate. Access to care was better in small practices. Preventive care was worse in practices located in socioeconomically deprived areas. Scores for satisfaction, continuity of care, and access to care were higher in practices where staff reported better team climate. CONCLUSIONS: Longer consultation times are essential for providing high quality clinical care. Good teamworking is a key part of providing high quality care across a range of areas and may need specific support if quality of care is to be improved. Additional support is needed to provide preventive care to deprived populations. No single type of practice has a monopoly on high quality care: different types of practice may have different strengths.

Doctor discontent. A comparison of physician satisfaction in different delivery system settings, 1986 and 1997.

OBJECTIVE: To examine the differences in physician satisfaction associated with open- versus closed-model practice settings and to evaluate changes in physician satisfaction between 1986 and 1997. Open-model practices refer to those in which physicians accept patients from multiple health plans and insurers (i.e., do not have an exclusive arrangement with any single health plan). Closed-model practices refer to those wherein physicians have an exclusive relationship with a single health plan (i.e., staff- or group-model HMO). DESIGN: Two cross-sectional surveys of physicians; one conducted in 1986 (Medical Outcomes Study) and one conducted in 1997 (Study of Primary Care Performance in Massachusetts). SETTING: Primary care practices in Massachusetts. PARTICIPANTS: General internists and family practitioners in Massachusetts. MEASUREMENTS: Seven measures of physician satisfaction, including satisfaction with quality of care, the potential to achieve professional goals, time spent with individual patients, total earnings from practice, degree of personal autonomy, leisure time, and incentives for high quality. RESULTS: Physicians in open- versus closed-model practices differed significantly in several aspects of their professional satisfaction. In 1997, open-model physicians were less satisfied than closed-model physicians with their total earnings, leisure time, and incentives for high quality. Open-model physicians reported significantly more difficulty with authorization procedures and reported more denials for care. Overall, physicians in 1997 were less satisfied in every aspect of their professional life than 1986 physicians. Differences were significant in three areas: time spent with individual patients, autonomy, and leisure time (P < or =.05). Among open-model physicians, satisfaction with autonomy and time with individual patients were significantly lower in 1997 than 1986 (P < or =.01). Among closed-model physicians, satisfaction with total earnings and with potential to achieve professional goals were significantly lower in 1997 than in 1986 (P < or =.01). CONCLUSIONS: This study finds that the state of physician satisfaction in Massachusetts is extremely low, with the majority of physicians dissatisfied with the amount of time they have with individual patients, their leisure time, and their incentives for high quality. Satisfaction with most areas of practice declined significantly between 1986 and 1997. Open-model physicians were less satisfied than closed-model physicians in most aspects of practices.

The quality of physician-patient relationships. Patients' experiences 1996-1999.

BACKGROUND: Our objective was to examine how patients of primary care physicians are responding to a changing health care environment. The quality of their relationship with their primary care physicians and their experience with organizational features of care were monitored over a 3-year period. METHODS: This was a longitudinal observational study (1996-1999). Participants completed a self-administered questionnaire at baseline and at follow-up. The questionnaires included measures of primary care quality from the Primary Care Assessment Survey (PCAS). We included insured adults employed by the Commonwealth of Massachusetts who remained with one primary care physician throughout the study period (n=2383). The outcomes were unadjusted mean scale score changes in each of the 8 PCAS over the 3 years and associated standardized difference scores (effect sizes). The 8 PCAS scales measured relationship quality (4 scales: communication, interpersonal treatment, physician's knowledge of the patient, patient trust) and organizational features of care (4 scales: financial access, organizational access, visit-based continuity, integration of care). RESULTS: There were significant declines in 3 of the 4 relationship scales: communication (effect size [ES] = -0.095), interpersonal treatment (ES = -0.115), and trust (ES = -0.046). Improvement was observed in physician's knowledge of the patient (ES = 0.051). There was a significant decline in organizational access (ES = -0.165) and an increase in visit-based continuity (ES = 0.060). There were no significant changes in financial access and integration of care indexes. CONCLUSIONS: The declines in access and 3 of the 4 indexes of physician-patient relationship quality are of concern, especially if they signify a trend.

Switching doctors: predictors of voluntary disenrollment from a primary physician's practice.

BACKGROUND: Our objective was to evaluate 8 interpersonal and structural features of care as predictors of patients' voluntary disenrollment from their primary care physician's practice. METHODS: We performed a longitudinal observational study in which participants completed a validated questionnaire at baseline (1996) and follow-up (1999). The questionnaire measured 4 elements of the quality of physician-patient relations (communication, interpersonal treatment, physician's knowledge of the patient, and patient trust) and 4 structural features of care (access, visit-based continuity, relationship duration, and integration of care). Study participants were insured adults who reported having a regular personal physician at baseline and who completed both baseline and follow-up questionnaires (n=4108). The outcome measured was voluntary disenrollment from the primary physician's practice between baseline and follow-up. RESULTS: One fifth of the patients voluntarily left their primary physician's practice during the study period. When tested independently, all 8 scales significantly predicted voluntary disenrollment (P <.001), with somewhat larger effects associated with the 4 relationship quality measures. In multivariable models, a composite relationship quality factor most strongly predicted voluntary disenrollment (odds ratio [OR]=1.6; P<.001), and the 2 continuity scales also significantly predicted disenrollment (OR=1.1; P<.05). Access and integration did not significantly predict disenrollment in the presence of these variables. CONCLUSIONS: These findings highlight the importance of relationship quality in determining patients' loyalty to a physician's practice. They suggest that in the race to the bottom line medical practices and health plans cannot afford to ignore that the essence of medical care involves the interaction of one human being with another.

Do patient assessments of primary care differ by patient ethnicity?

OBJECTIVE: To determine if patient assessments (reports and ratings) of primary care differ by patient ethnicity. DATA SOURCES/STUDY DESIGN: A self-administered patient survey of 6,092 Massachusetts employees measured seven defining characteristics of primary care: (1) access (financial, organizational); (2) continuity (longitudinal, visit based); (3) comprehensiveness (knowledge of patient, preventive counseling); (4) integration; (5) clinical interaction (communication, thoroughness of physical examinations); (6) interpersonal treatment; and (7) trust. The study employed a cross-sectional observational design. PRINCIPAL FINDINGS: Asians had the lowest primary care performance assessments of any ethnic group after adjustment for socioeconomic and other factors. For example, compared to whites, Asians had lower scores for communication (69 vs. 79, p = .001) and comprehensive knowledge of patient (56 vs. 48, p = .002), African Americans and Latinos had less access to care, and African Americans had less longitudinal continuity than whites. CONCLUSIONS: We do not know what accounts for the observed differences in patient assessments of primary care. The fact that patient reports as well as the more subjective ratings of care differed by ethnicity suggests that quality differences might exist that need to be addressed.

Part-time physicians. Physician workload and patient-based assessments of primary care performance.

OBJECTIVE: To examine the relationship between the number of hours physicians work and patients' assessment of the physician. DESIGN: Cross-sectional study with physician and patient surveys. SETTING: Primary care practices in Massachusetts. PARTICIPANTS: A random sample of 6810 Massachusetts state employees in 15 different health plans. MAIN OUTCOME MEASURES: Eleven summary scales measuring 7 essential elements of primary care. Information was derived from the Primary Care Assessment Survey, a validated patient-completed questionnaire. RESULTS: Physicians were classified into 3 groups according to their reported hours of work: "overtime" (> 65 h/wk), "full time" (40-65 h/wk), and "part time" (< 40 h/wk). There was no statistically significant difference between the 3 groups of physicians in 10 of the 11 measures of primary care performance. Physicians who worked more than 65 hours per week were found to score significantly higher in the visit-based continuity of care category than physicians working fewer hours. Physicians working more than 65 hours per week were also found to be significantly less satisfied with the amount of time they had for family and personal life than the other 2 groups. CONCLUSIONS: Part-time physicians perform as well as full-time physicians in most aspects of primary care, including all interpersonal aspects of care, as reported by patients. Patients of physicians working more than 65 hours per week experienced higher levels of visit-based continuity of care than patients of physicians working fewer hours, but this appears to carry a cost to those physicians in the area of personal and professional satisfaction. Subsequent research should examine the relationship between physician workload and technical aspects of care.

Organizational and financial characteristics of health plans: are they related to primary care performance?

BACKGROUND: Primary care performance has been shown to differ under different models of health care delivery, even among various models of managed care. Pervasive changes in our nation's health care delivery systems, including the emergence of new forms of managed care, compel more current data. OBJECTIVE: To compare the primary care received by patients in each of 5 models of managed care (managed indemnity, point of service, network-model health maintenance organization [HMO], group-model HMO, and staff-model HMO) and identify specific characteristics of health plans associated with performance differences. METHODS: Cross-sectional observational study of Massachusetts adults who reported having a regular personal physician and for whom plan-type was known (n = 6018). Participants completed a validated questionnaire measuring 7 defining characteristics of primary care. Senior health plan executives provided information about financial and nonfinancial features of the plan's contractual arrangements with physicians. RESULTS: The managed indemnity system performed most favorably, with the highest adjusted mean scores for 8 of 10 measures (P<.05). Point of service and network-model HMO performance equaled the indemnity system on many measures. Staff-model HMOs performed least favorably, with adjusted mean scores that were lowest or statistically equivalent to the lowest score on all 10 scales. Among network-model HMOs, several features of the plan's contractual arrangement with physicians (ie, capitated physician payment, extensive use of clinical practice guidelines, financial incentives concerning patient satisfaction) were significantly associated with performance (P<.05). CONCLUSIONS: With US employers and purchasers having largely rejected traditional indemnity insurance as unaffordable, the results suggest that the current momentum toward open-model managed care plans is consistent with goals for high-quality primary care, but that the effects of specific financial and nonfinancial incentives used by plans must continue to be examined.

Linking primary care performance to outcomes of care.

BACKGROUND: Substantial research links many of the defining characteristics of primary care to important outcomes; yet little is known about the relative importance of each characteristic, and several characteristics have not been examined. These analyses evaluate the relationship between seven defining elements of primary care (accessibility, continuity, comprehensiveness, integration, clinical interaction, interpersonal treatment, and trust) and three outcomes (adherence to physician's advice, patient satisfaction, and improved health status). METHODS: Data were derived from a cross-sectional observational study of adults employed by the Commonwealth of Massachusetts (N = 7204). All patients completed a validated questionnaire, the Primary Care Assessment Survey. Regression methods were used to examine the association between each primary care characteristic (11 summary scales measuring 7 elements of care) and each outcome. RESULTS: Physicians' comprehensive ("whole person") knowledge of patients and patients' trust in their physician were the variables most strongly associated with adherence, and trust was the variable most strongly associated with patients' satisfaction with their physician. With other factors equal, adherence rates were 2.6 times higher among patients with whole-person knowledge scores in the 95th percentile compared with the 5th percentile (44.0% adherence vs 16.8% adherence, P < .001). The likelihood of complete satisfaction was 87.5% for those with 95th percentile trust scores compared with 0.4% for patients with 5th percentile trust scores (P < .001). The leading correlates of self-reported health improvements were integration of care, thoroughness of physical examinations, communication, comprehensive knowledge of patients, and trust (P < .001). CONCLUSIONS: Patients' trust in their physician and physicians' knowledge of patients are leading correlates of three important outcomes of care. The results are noteworthy in the context of pervasive changes in our nation's health care system that are widely viewed as threatening to the quality of physician-patient relationships.

The Primary Care Assessment Survey: tests of data quality and measurement performance.

OBJECTIVES: The authors examine the data quality and measurement performance of the Primary Care Assessment Survey (PCAS), a patient-completed questionnaire that operationalizes formal definitions of primary care, including the definition recently proposed by the Institute of Medicine Committee on the Future of Primary Care. METHODS: The PCAS measures seven domains of care through 11 summary scales: accessibility (organizational, financial), continuity (longitudinal, visit-based), comprehensiveness (contextual knowledge of patient, preventive counseling), integration, clinical interaction (clinician-patient communication, thoroughness of physical examinations), interpersonal treatment, and trust. Data from a study of Massachusetts state employees (n = 6094) were used to evaluate key measurement properties of the 11 PCAS scales. Analyses were performed on the combined population and for each of the 16 subgroups defined according to sociodemographic and health characteristics. RESULTS: The 11 PCAS scales demonstrated consistently strong measurement characteristics across all subgroups of this adult population. Tests of scaling assumptions for summated rating scales were well satisfied by all Likert-scaled measures. Assessment of data completeness, scale score dispersion characteristics, and inter-scale correlations provide strong evidence for the soundness of all scales, and for the value of separately measuring and interpreting these concepts. CONCLUSIONS: With public and private sector policies increasingly emphasizing the importance of primary care, the need for tools to evaluate and improve primary care performance is clear. The PCAS has excellent measurement properties, and performs consistently well across varied segments of the adult population. Widespread application of an assessment methodology, such as the PCAS, will afford an empiric basis through which to measure, monitor, and continuously improve primary care.

The relationship between patient income and physician discussion of health risk behaviors.

CONTEXT: The US Preventive Services Task Force recommends that physicians assess patients' health risk behaviors, addressing those needing modification. OBJECTIVE: To examine the relationship between patient income, health risk behaviors, the prevalence of physician discussion of these behaviors, and the receptiveness of patients to their physicians' advice. DESIGN: Employee survey. PARTICIPANTS: A random sample of 6549 Massachusetts state employees in 12 health plans. MAIN OUTCOME MEASURES: Data were obtained using a patient-completed mail survey. Trend tests were used to discern differences in the prevalence of health risk behaviors, physician discussion of these behaviors, and patient receptiveness to discussions by patient income. RESULTS: Although unhealthy behaviors were common among all income groups, physician discussion of health risk behaviors fell far short of the universal risk assessment recommended by the US Preventive Services Task Force. Low-income patients were more likely to be obese and smoke than high-income patients and were less likely to wear seat belts and exercise. In contrast, stress and alcohol consumption increased with income, while the proportion of heavy drinkers did not vary significantly. Physicians were more likely to discuss diet and exercise with high-income patients in need of these discussions than with low-income patients, but were more likely to discuss smoking with low-income patients who smoked than with high-income patients who smoked. Among patients with whom discussions occurred, low-income patients were much more likely to report attempting to change their behavior based on physician advice. CONCLUSIONS: Physician counseling of patients regarding health risk behaviors should be greatly improved if the US Preventive Services Task Force recommendations are to be fulfilled. Improvement is especially needed in regard to alcohol consumption, safe sex, and seat belt use. Physicians also need to be more vigilant in properly identifying and counseling low-income patients at risk in regard to diet and exercise and high-income patients who smoke.

Gender differences in medical treatment: the case of physician-prescribed activity restrictions.

A growing scientific literature highlights concern about the influence of social bias in medical care. Differential treatment of male and female patients has been among the documented concerns. Yet, little is known about the extent to which differential treatment of male and female patients reflects the influence of social bias or of more acceptable factors, such as different patient preferences or different anticipated outcomes of care. This paper attempts to ascertain the underlying basis for an observed differential in physicians' tendency to advice activity restrictions for male and female patients. We explore the extent to which the gender-based treatment differential is attributable to: (1) patients' health profile, (2) patients' role responsibilities, (3) patients' illness behaviors, and (4) physician characteristics. These four categories of variables correspond to four prominent social science hypotheses concerning gender differences in health and health care utilization (i.e, biological basis hypothesis, fixed role hypothesis, socialization hypothesis, physician bias hypothesis). Data are drawn from the Medical Outcomes Study (MOS), a longitudinal observational study of 1546 patients of 349 physicians practicing in three U.S. cities. Multivariate logistic regression is used to evaluate the likelihood of physician-prescribed activity restrictions for male and female patients, and to explore the absolute and relative influence of patient and physician factors on the observed treatment differential. Results reveal that the odds of prescribed activity restrictions are 3.6 times higher for female patients than for males with equivalent characteristics. The observed differential is not explained by differences in male and female patients' health or role responsibilities. Gender differences in illness behavior and physician gender biases both appear to contribute to the observed differential. Female patients exhibit more illness behavior than males, and these behaviors increase physicians' tendency to prescribe activity restrictions. After accounting for illness behavior differences and all other factors, the odds of prescribed activity restrictions among female patients of male physicians is four times that of equivalent male patients of those physicians. Medical practice, education, and research must strive to identify and remove the likely unconscious role of social bias in medical decision making.

Asian-American patient ratings of physician primary care performance.

OBJECTIVE: To examine how Asian-American patients' ratings of primary care performance differ from those of whites. Latinos, and African-Americans. DESIGN: Retrospective analyses of data collected in a cross-sectional study using patient questionnaires. SETTING: University hospital primary care group practice. PARTICIPANTS: In phase 1, successive patients who visited the study site for appointments were asked to complete the survey. In phase 2, successive patients were selected who had most recently visited each physician, going back as far as necessary to obtain 20 patients for each physician. In total, 502 patients were surveyed, 5% of whom were Asian-American. MAIN RESULTS: After adjusting for potential confounders, Asian-Americans rated overall satisfaction and 10 of 11 scales assessing primary care significantly lower than whites did. Dimensions of primary care that were assessed include access, comprehensiveness of care, integration, continuity, clinical quality, interpersonal treatment, and trust. There were no differences for the scale of longitudinal continuity. On average, the rating scale scores of Asian-Americans were 12 points lower than those of whites (on 100-point scales). CONCLUSIONS: We conclude that Asian-American patients rate physicians primary care performance lower than do whites, African-Americans, and Latinos. Future research needs to focus on Asian-Americans to determine the generalizability of these findings and the extent to which they reflect differences in survey response tendencies or actual quality differences.

Five-hundred life-saving interventions and their cost-effectiveness.

We gathered information on the cost-effectiveness of life-saving interventions in the United States from publicly available economic analyses. "Life-saving interventions" were defined as any behavioral and/or technological strategy that reduces the probability of premature death among a specified target population. We defined cost-effectiveness as the net resource costs of an intervention per year of life saved. To improve the comparability of cost-effectiveness ratios arrived at with diverse methods, we established fixed definitional goals and revised published estimates, when necessary and feasible, to meet these goals. The 587 interventions identified ranged from those that save more resources than they cost, to those costing more than 10 billion dollars per year of life saved. Overall, the median intervention costs $42,000 per life-year saved. The median medical intervention cost $19,000/life-year; injury reduction $48,000/life-year; and toxin control $2,800,000/life-year. Cost/life-year ratios and bibliographic references for more than 500 life-saving interventions are provided.

Primary care performance in fee-for-service and prepaid health care systems. Results from the Medical Outcomes Study.

OBJECTIVE: To examine differences in the quality of primary care delivered in prepaid and fee-for-service (FFS) health care systems. STUDY DESIGN: Longitudinal study of 1208 adult patients with chronic disease whose health insurance was through a traditional indemnity (FFS) plan, an independent practice association (IPA), or a health maintenance organization (HMO). Both IPA and HMO represent prepaid care systems. Patient- and physician-provided information was obtained by self-administered questionnaires. SETTING: A total of 303 physician offices (family medicine, general internal medicine, endocrinology, or cardiology) in solo and group practices in three US cities. OUTCOMES MEASURES: Seven indicators of primary care quality--accessibility (financial and organizational), continuity, comprehensiveness, coordination, and accountability (interpersonal and technical) of care. Performance on each was evaluated in FFS, IPA, and HMO settings. Analyses controlled for patient and physician characteristics. RESULTS: Financial access was highest in prepaid systems. Organizational access, continuity, and accountability were highest in the FFS system. Coordination was highest and comprehensiveness was lowest in HMOs. CONCLUSIONS: The results mark notable differences in core dimensions of primary care quality in each of three payment systems and raise questions regarding the associated cost inefficiencies and outcomes of care. In the current health care delivery reform climate, these findings call for consideration of the relative strengths and weaknesses of each system. We suggest strategies for elevating performance in each.

Social supports as a determinant of community-based care utilization among rehabilitation patients.

OBJECTIVE: We determine the extent to which noninstitutionalized long-term care patients receive assistance from family members and friends, and evaluate the effect of this assistance on use of outpatient rehabilitative and personal care services. DATA SOURCES AND STUDY SETTING: Over 12 months, primary data were collected from 289 patients in noninstitutional settings after inpatient rehabilitation at three Boston-area rehabilitation hospitals. Data on patients' acute and rehabilitative stays were obtained from medical record reviews. Patients provided primary data on sociodemographics, living arrangements, social supports, functional status, health behaviors, life events, and use of outpatient services during the study period. The latter was verified and service charge data obtained from the care providers. STUDY DESIGN: The study was longitudinal and observational. Patient-provided information was obtained at one, six, and twelve months postdischarge. ANALYTIC METHODS: Multivariate Tobit regression was used to evaluate the effect of social supports on patients' use of rehabilitative and personal care services, controlling for sociodemographics and functional status. Service use was measured as charges incurred during the 12-month study period. PRINCIPAL FINDINGS: Results confirm the primary role of family and friends in providing daily personal care and identify the availability of that support as a key determinant of expenditures on community-based personal care services. Social supports do not predict outpatient rehabilitative service use. CONCLUSIONS: Differing eligibility criteria seem appropriate for outpatient rehabilitative and personal care services. The current emphasis on functional status in determining rehabilitative service eligibility appears appropriate; but we find that considering patients' social supports would be both meaningful and appropriate in determining personal care service eligibility. This approach would avert the expense of making personal care services universally available, while facilitating assistance for patients whose functional and social status put them at increased risk of institutional placement.

An assessment of the positive predictive value and cost-effectiveness of dipyridamole myocardial scintigraphy in patients undergoing vascular surgery.

PURPOSE: The approach to cardiac risk stratification of patients undergoing vascular surgery continues to be controversial. The success of algorithms that use clinical risk factors to determine cardiac risk have been inconsistent. Dipyridamole myocardial scintigraphy (DMS) has been accepted as a sensitive, noninvasive approach to risk stratification with excellent negative predictive value. Low positive predictive value (PPV) of abnormal DMS scans is a shortcoming that contributes to extensive preoperative cardiac evaluation and intervention with associated morbidity, mortality, and cost in most patients who undergo uncomplicated vascular procedures, regardless of DMS results. METHODS: Over 6 years, 237 patients underwent DMS before surgical management of infrarenal aortic aneurysm, aortoiliac, or infrainguinal occlusive disease. The value of multiple clinical factors and DMS were assessed retrospectively for the prediction of perioperative myocardial infarction (MI), heart-related death, or preoperative selection for myocardial revascularization. Only congestive heart failure and two or more reversible defects on DMS were statistically significant on logistic regression analysis. RESULTS: The PPV of DMS was 19% for all patients with reversible defects, 12% for patients with one reversible defect, and 36.7% for patients with two or more reversible defects. The rates of cardiac death and MI were 1.3% and 5.9%, respectively. Perioperative echocardiography revealed unchanged postinfarction ejection fraction in most patients who experienced MI. Cost-effectiveness of DMS screening was evaluated. CONCLUSIONS: The costs per MI and cardiac death averted suggest a decline in cost-effectiveness of screening with DMS over time, assuming improving cardioprotective strategies of patient care. Clinical risk factors were minimally useful in the prediction of perioperative MI, heart-related death, or need for myocardial revascularization. The PPV of DMS is low, and the majority of MIs may be clinically insignificant. The cost-effectiveness of cardiac screening with DMS may not be justifiable given current trends of health care reform.