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Objectives To evaluate the use of a modified Consumer Assessment of Healthcare Providers and Systems (CAHPS(R)) survey to support quality improvement in a collaborative focused on patient-centred care, assess subsequent changes in patient experiences, and identify factors that promoted or impeded data use. Background Healthcare systems are increasingly using surveys to assess patients' experiences of care but little is established about how to use these data in quality improvement. Design Process evaluation of a quality improvement collaborative. Setting and participants The CAHPS team from Harvard Medical School and the Institute for Clinical Systems Improvement organized a learning collaborative including eight medical groups in Minnesota. Intervention Samples of patients recently visiting each group completed a modified CAHPS(R) survey before, after and continuously over a 12-month project. Teams were encouraged to set goals for improvement using baseline data and supported as they made interventions with bi-monthly collaborative meetings, an online tool reporting the monthly data, a resource manual called The CAHPS(R) Improvement Guide, and conference calls. Main outcome measures Changes in patient experiences. Interviews with team leaders assessed the usefulness of the collaborative resources, lessons and barriers to using data. Results Seven teams set goals and six made interventions. Small improvements in patient experience were observed in some groups, but in others changes were mixed and not consistently related to the team actions. Two successful groups appeared to have strong quality improvement structures and had focussed on relatively simple interventions. Team leaders reported that frequent survey reports were a powerful stimulus to improvement, but that they needed more time and support to engage staff and clinicians in changing their behaviour. Conclusions Small measurable improvements in patient experience may be achieved over short projects. Sustaining more substantial change is likely to require organizational strategies, engaged leadership, cultural change, regular measurement and performance feedback and experience of interpreting and using survey data. [ABSTRACT FROM AUTHOR]

Objective: Patient care experience survey data might be useful for managing individual physician malpractice risk, but available evidence is limited. This study assesses whether patients' experiences with individual physicians, as measured by a validated survey, are associated with patient complaints and malpractice lawsuits.Design: Random samples of active patients in physicians' panels, with sample sizes adequate to provide highly reliable, stable information about patients' experiences with each physician (n = 19 202, average respondents per physician = 119) were used to assess the relation of patient survey measures to malpractice risk.Setting: A large multi-specialty physician organization in eastern Massachusetts, USA.Participants: Physicians providing care for at least 5 years in adult primary care and select high-risk specialty departments between January 1996 and December 2005 (n = 161).Main Outcome Measures: Patient complaints (2001-05) and malpractice lawsuits (1996-2005).Results: Compared to primary care physicians, high-risk specialists had a lower patient complaint rate (0.34 vs. 1.36 complaints per patient care full time equivalent; P < 0.001), but a higher lawsuit rate (0.09 vs. 0.05 lawsuits per patient care full time equivalent; P = 0.02). Irrespective of physician specialty, the quality of physician-patient interactions (IRR = 0.61; P < 0.001) and care coordination (IRR = 0.65; P < 0.001) were inversely associated with patient complaints. Patient survey measures were not associated with malpractice lawsuits.Conclusions: The results underscore the challenges organizations face when attempting to use patient survey data to manage individual physician medical malpractice risk. Because lawsuits are infrequent events, calibrating these validated patient survey measures to malpractice lawsuit risk will require large physician samples from diverse practices. [ABSTRACT FROM AUTHOR]

BACKGROUND: Multidisciplinary teams may hold promise for improving primary care quality. This study examined the influence of multidisciplinary teams on patients' assessments of primary care, including access, integration, and clinician-patient interaction quality. METHODS: From January 2004 through March 2005, a large multispecialty practice in Massachusetts obtained data monthly from patients of 145 primary care physicians using a well-validated patient questionnaire. The analytic sample included respondents with at least 2 primary care visits over the study period (n=14,835). For each respondent, administrative data were used to compute visit continuity over the study period and to classify each primary care visit as PCP, on-team, or off-team. Multivariate regression modeled the relationship of visit continuity to each primary care measure. RESULTS: Approximately one-third of patients (35%) saw only their PCP; 15% had only PCP and 'on-team' visits; 9% had a mix of PCP, on-, and off-team visits; and 41% had only 'off-team' visits when not seeing their PCP. Greater PCP continuity was associated with more favorable scores on nearly all measures (P<0.001). An exception was patients' assessments of teams, which were better when on- versus off-team visits occurred (P<0.01). For other measures, the decrements associated with discontinuity were the same irrespective of whether discontinuities involved on- or off-team visits. CONCLUSIONS: The finding that PCP visit discontinuities are associated with more negative care experiences, irrespective of whether discontinuities involve on- or off-team visits, highlights the challenges of incorporating teams into primary care in ways that patients experience as value-added rather than disruptive to primary care relationships. [ABSTRACT FROM AUTHOR]

Background: There is increasing interest in measuring patients' experiences with individual physicians, and empirical evidence supports this area of measurement. However, the high cost of data collection remains a significant barrier. Survey modes with the potential to lower costs, such as Internet and interactive voice response (IVR) telephone, are attractive alternatives to mail, but their comparative response rates and data quality have not been tested.Methods: We randomly assigned adult patients from the panels of 62 primary care physicians in California to complete a brief, validated patient questionnaire by mail, Internet (web), or IVR. After 2 invitations, web and IVR nonrespondents were mailed a paper copy of the survey ("crossover" to mail). We analyzed and compared (n = 9126) the response rates, respondent characteristics, substantive responses, and costs by mode (mail, web and IVR) and evaluated the impact of "crossover" respondents.Results: Response rates were higher by mail (50.8%) than web (18.4%) or IVR (34.7%), but after crossover mailings, response rates in each arm were approximately 50%. Mail and web produced identical scores for individual physicians, but IVR scores were significantly lower even after adjusting for respondent characteristics. There were no significant physician-mode interactions, indicating that statistical adjustment for mode resolves the IVR effect. Web and IVR costs were higher than mail.Conclusions: The equivalence of individual physician results in mail and web modes is noteworthy, as is evidence that IVR results are comparable after adjustment for mode. However, the higher overall cost of web and IVR, as the result of the need for mailings to support these modes, suggests that they do not presently solve cost concerns related to obtaining physician-specific information from patients. [ABSTRACT FROM AUTHOR]

Ever-increasing concern about the cost and burden of quality measurement and reporting raises the question: How much do patients benefit from provider arrangements that incentivize performance improvements? We used national performance data to estimate the benefits in terms of lives saved and harms avoided if US health plans improved performance on 2 widely used quality measures: blood pressure control and colorectal cancer screening. We modeled potential results both in California Marketplace plans, where a value-based purchasing initiative incentivizes improvement, and for the US population across 4 market segments (Medicare, Medicaid, Marketplace, commercial). The results indicate that if the lower-performing health plans improve to 66th percentile benchmark scores, it would decrease annual hypertension and colorectal cancer deaths by approximately 7% and 2%, respectively. These analyses highlight the value of assessing performance accountability initiatives for their potential lives saved and harms avoided, as well as their costs and efforts., Competing Interests: Conflicts of interest Please see ICMJE form(s) for author conflicts of interest. These have been provided as supplementary materials., (© The Author(s) 2024. Published by Oxford University Press on behalf of Project HOPE - The People-To-People Health Foundation, Inc.)

On July 14, 2015, ProPublica published its Surgeon Scorecard , which displays "Adjusted Complication Rates" for individual, named surgeons for eight surgical procedures performed in hospitals. Public reports of provider performance have the potential to improve the quality of health care that patients receive. A valid performance report can drive quality improvement and usefully inform patients' choices of providers. However, performance reports with poor validity and reliability are potentially damaging to all involved. This article critiques the methods underlying the Scorecard and identifies opportunities for improvement. Until these opportunities are addressed, the authors advise users of the Scorecard -most notably, patients who might be choosing their surgeons-not to consider the Scorecard a valid or reliable predictor of the health outcomes any individual surgeon is likely to provide. The authors hope that this methodological critique will contribute to the development of more-valid and more-reliable performance reports in the future.

In 2009, Blue Cross Blue Shield of Massachusetts implemented a global budget-based payment system, the Alternative Quality Contract (AQC), in which provider groups assumed accountability for spending. We investigate the impact of global budgets on the utilization of prescription drugs and related expenditures. Our analyses indicate no statistically significant evidence that the AQC reduced the use of drugs. Although the impact may change over time, early evidence suggests that it is premature to conclude that global budget systems may reduce access to medications., (© The Author(s) 2014.)

Objectives: The objective was to identify the effect of the Alternative Quality Contract (AQC), a global payment system implemented by Blue Cross Blue Shield (BCBS) of Massachusetts in 2009, on emergency department (ED) presentations., Methods: Blue Cross Blue Shield of Massachusetts claims from 2006 through 2009 for 332,624 enrollees whose primary care physicians (PCPs) enrolled in the AQC, and 1,296,399 whose PCPs were not enrolled in the AQC, were evaluated. A pre-post, intervention-control, propensity-scored difference-in-difference approach was used to isolate the AQC effect on ED visits. The analysis adjusted for age, sex, health status, and secular trends to compare ED use between the treatment and control groups., Results: Overall, secular trends showed that the number of ED visits decreased slightly for both treatment and control groups. The adjusted analysis of the AQC group showed decreases from 0.131 to 0.127 visits per member/quarter, and the control group decreased from 0.157 to 0.152 visits per member/quarter. The difference-in-difference analysis showed the AQC had no statistically significant effect on total ED use compared to the control group., Conclusions: In the first year of this AQC, we did not find evidence of change in aggregate ED use. Similar global budget programs may not alter ED use in the initial implementation period., (© 2013 by the Society for Academic Emergency Medicine.)

Objective: To assess the relationship between clinical care metrics and patient experiences of care among patients with chronic disease., Design: Cross-sectional survey and clinical performance data., Setting: Eighty-nine medical groups across California caring for patients with chronic disease., Participants: Using patient surveys, we identified 51 129 patients with a chronic disease., Main Outcome Measures: Using patient surveys, we produced five composite measures of patient experiences of care and self-management support (scale 0-100). Using Health Plan Employer Data and Information Set data, we analyzed care for asthma, diabetes and cardiovascular disease, producing one composite summarizing clinical processes of care and one composite summarizing outcomes of care. We calculated adjusted Spearman's correlation coefficients to assess the relationship between patient experiences of care, clinical processes and clinical outcomes., Results: Clinical performance was higher for process measures compared with outcomes measures, ranging from 91% for appropriate asthma medication use to 59% for controlling low-density lipoprotein cholesterol in the presence of diabetes. Performance on patient experiences of care measures was the highest for the quality of clinical interactions (88.5) and the lowest for delivery of self-management support (68.8). Three of the 10 patient experience-clinical performance composite correlations were statistically significant. These three correlations involved composites summarizing integration of care and quality of clinical interactions, and ranged from a low of 0.30 to a high of 0.39., Conclusions: Chronic care delivery is variable across diseases and domains of care. Improving care integration processes and communication between health-care providers and their patients may lead to improved clinical outcomes.

Background: Cost-related underuse of medications is common among older adults, who seldom discuss medication costs with their physicians. Some older adults may use free drug samples or industry-sponsored patient assistance programs (PAP) in hopes of lowering out-of-pocket costs, although the long-term effect of these programs on drug spending is unclear., Objective: To examine older adults' use of industry-sponsored strategies to reduce out-of-pocket drug costs and the association between doctor-patient communication and use of these programs., Design: Cross-sectional analysis of a 2006 nationally representative survey of Medicare beneficiaries., Participants: 14,322 community-dwelling Medicare beneficiaries age ≥65., Main Measures: We conducted bivariate and multivariate analyses of the association between receipt of free samples and participation in PAPs with sociodemographic characteristics, health status, access to care, drug coverage, medication cost burden, and doctor-patient communication., Key Results: 51.4% of seniors reported receiving at least one free sample over the last 12 months and 29.2% reported receiving free samples more than once. In contrast, only 1.3% of seniors reported participating in an industry-sponsored PAP. Higher income respondents were more likely to report free sample receipt than low-income respondents (50.8% vs. 43.8%, p < 0.001) and less likely to report participating in a PAP (0.42% vs. 2.2%, p < 0.001). In multivariate analyses, those who reported talking to their doctor about the cost of their medications had more than twice the odds of receiving samples as those who did not (OR 2.17, 95% CI 1.95-2.42)., Conclusions: In 2006, over half of seniors in Medicare received free samples, but only 1.3% reported receiving any medications from a patient assistance program. Doctor-patient communication is strongly associated with use of these programs, which has important implications for clinical care regardless of whether these programs are viewed as drivers of prescription costs or a remedy for them.

Objective: To investigate organizational facilitators and barriers to patient-centered care in US health care institutions renowned for improving the patient care experience., Design: A qualitative study involving interviews of senior staff and patient representatives. Semi-structured interviews focused on organizational processes, senior leadership, work environment, measurement and feedback mechanisms, patient engagement and information technology and access., Setting: Eight health care organizations across the USA with a reputation for successfully promoting patient-centered care., Participants: Forty individuals, including chief executives, quality directors, chief medical officers, administrative directors and patient committee representatives., Results: Interviewees reported that several organizational attributes and processes are key facilitators for making care more patient-centered: (i) strong, committed senior leadership, (ii) clear communication of strategic vision, (iii) active engagement of patient and families throughout the institution, (iv) sustained focus on staff satisfaction, (v) active measurement and feedback reporting of patient experiences, (vi) adequate resourcing of care delivery redesign, (vii) staff capacity building, (viii) accountability and incentives and (ix) a culture strongly supportive of change and learning. Interviewees reported that changing the organizational culture from a 'provider-focus' to a 'patient-focus' and the length of time it took to transition toward such a focus were the principal barriers against transforming delivery for patient-centered care., Conclusions: Organizations that have succeeded in fostering patient-centered care have gone beyond mainstream frameworks for quality improvement based on clinical measurement and audit and have adopted a strategic organizational approach to patient focus.

Objective: To assess the effect of survey distribution protocol (mail versus handout) on data quality and measurement of patient care experiences., Data Sources/study Setting: Multisite randomized trial of survey distribution protocols. Analytic sample included 2,477 patients of 15 clinicians at three practice sites in New York State., Data Collection/extraction Methods: Mail and handout distribution modes were alternated weekly at each site for 6 weeks., Principal Findings: Handout protocols yielded an incomplete distribution rate (74 percent) and lower overall response rates (40 percent versus 58 percent) compared with mail. Handout distribution rates decreased over time and resulted in more favorable survey scores compared with mailed surveys. There were significant mode-physician interaction effects, indicating that data cannot simply be pooled and adjusted for mode., Conclusions: In-office survey distribution has the potential to bias measurement and comparison of physicians and sites on patient care experiences. Incomplete distribution rates observed in-office, together with between-office differences in distribution rates and declining rates over time suggest staff may be burdened by the process and selective in their choice of patients. Further testing with a larger physician and site sample is important to definitively establish the potential role for in-office distribution in obtaining reliable, valid assessment of patient care experiences., (Copyright © Health Research and Educational Trust.)

Background: In January 2006, 43 million Medicare beneficiaries became eligible for subsidized prescription coverage (Part D) through Medicare. To date, no longitudinal study has afforded information on beneficiaries' prescription coverage transitions and corresponding changes in prescription use and spending., Objective: To evaluate changes in Medicare beneficiaries' prescription coverage, use and spending before and after Part D implementation, including comparison of those who enrolled in Part D with those who did not., Design, Setting and Participants: Longitudinal observational study of non-institutionalized Medicare beneficiaries aged 65 and older (n = 9,573) employing administrative data from the Centers for Medicare and Medicaid Services (CMS) and survey-based data from beneficiaries (2003, 2006). Sampling drew from a 1% national probability sample (2003), oversampling low-income beneficiaries including those dually-enrolled in Medicare and Medicaid. MEASUREMENTS & MAIN RESULTS: Number and type of prescriptions, monthly out-of-pocket prescription spending, and cost-related non-adherence to prescription regimens. Most respondents who lacked prescription coverage in 2003 had acquired it by 2006 (82.6%)-primarily through Part D (63.1%). Part D enrollees who previously lacked coverage or had Medigap coverage appear particularly advantaged by Part D, as evidenced by significantly increased prescription use, lower out-of-pocket spending and lower non-adherence. Those with employer-based coverage experienced significantly increased spending. Among those still lacking coverage in 2006, high rates of cost-related non-adherence (31.8%) were reported by the low-income, chronically ill subgroup., Conclusions: In its first year, Part D coverage appears to have moderated prescription spending and cost-related burden for those who previously had meager benefits or none. Increased spending among those with employer-based coverage may reflect a narrowing of those benefits over this period. Evidence of foregone care among low-income, chronically ill seniors who still lack prescription coverage highlights the importance of targeted outreach to this group for Part D's low-income subsidy program.

Background: Patient experience measures are central to many pay-for-performance (P4P) programs nationally, but the effect of performance-based financial incentives on improving patient care experiences has not been assessed., Methods: The study uses Clinician & Group CAHPS data from commercially insured adult patients (n = 124,021) who had visits with 1,444 primary care physicians from 25 California medical groups between 2003 and 2006. Medical directors were interviewed to assess the magnitude and nature of financial incentives directed at individual physicians and the patient experience improvement activities adopted by groups. Multilevel regression models were used to assess the relationship between performance change on patient care experience measures and medical group characteristics, financial incentives, and performance improvement activities., Results: Over the course of the study period, physicians improved performance on the physician-patient communication (0.62 point annual increase, p < 0.001), care coordination (0.48 point annual increase, p < 0.001), and office staff interaction (0.22 point annual increase, p = 0.02) measures. Physicians with lower baseline performance on patient experience measures experienced larger improvements (p < 0.001). Greater emphasis on clinical quality and patient experience criteria in individual physician incentive formulas was associated with larger improvements on the care coordination (p < 0.01) and office staff interaction (p < 0.01) measures. By contrast, greater emphasis on productivity and efficiency criteria was associated with declines in performance on the physician communication (p < 0.01) and office staff interaction (p < 0.001) composites., Conclusions: In the context of statewide measurement, reporting, and performance-based financial incentives, patient care experiences significantly improved. In order to promote patient-centered care in pay for performance and public reporting programs, the mechanisms by which program features influence performance improvement should be clarified.

Background: Self-management support is an important component of improving chronic care delivery., Objective: To validate a new measure of self-management support and to characterize performance, including comparisons across chronic conditions., Design, Setting, Participants: We incorporated a new question module for self-management support within an existing annual statewide patient survey process in 2007., Measurements: The survey identified 80,597 patients with a chronic illness on whom the new measure could be evaluated and compared with patients' experiences on four existing measures (quality of clinical interactions, coordination of care, organizational access, and office staff). We calculated Spearman correlation coefficients for self-management support scores for individual chronic conditions within each medical group. We fit multivariable logistic regression models to identify predictors of more favorable performance on self-management support., Results: Composite scores of patient care experiences, including quality of clinical interactions (89.2), coordination of care (77.6), organizational access (76.3), and office staff (85.8) were higher than for the self-management support composite score (69.9). Self-management support scores were highest for patients with cancer (73.0) and lowest for patients with hypertension (67.5). The minimum sample size required for medical groups to provide a reliable estimate of self-management support was 199. There was no consistent correlation between self-management support scores for individual chronic conditions within medical groups. Increased involvement of additional members of the healthcare team was associated with higher self-management support scores across all chronic conditions., Conclusion: Measurement of self-management support is feasible and can identify gaps in care not currently included in standard measures of patient care experiences.

Background: The use of item screeners is viewed as an essential feature of quality survey design because only respondents who are 'qualified' to answer questions that apply to a subset of the sample are directed to answer. However, empirical evidence supporting this view is scant., Objective: This study compares data quality resulting from the administration of ambulatory care experience measures that use item screeners versus tailored 'not applicable' options in response scales., Methods: Patients from the practices of 367 primary care physicians in 65 medical groups were randomly assigned to receive one of two versions of a well validated ambulatory care experience survey. Respondents (n = 2240) represent random samples of active established patients from participating physicians' panels.The 'screener' survey version included item screeners for five test items and the 'no screener' version included tailored 'not applicable' options in response scales instead of using screeners.The main outcomes measures were data quality resulting from the two item versions, including the mean item scores, the level of missing values, outgoing patient sample sizes needed to achieve adequate medical group-level reliability, and the relative ranking of medical groups., Results: Mean survey item scores generally did not differ by version. There were consistently fewer respondents to the 'screener' versions than 'no screener' versions. However, because the 'screener' versions improved measurement precision, smaller outgoing patient samples were needed to achieve adequate medical group-level reliability for four of the five items than for the 'no screener' version. The relative ranking of medical groups did not differ by item version., Conclusion: Screeners appear to reduce noise by ensuring that respondents who are not 'qualified' to answer a question are screened out instead of providing unreliable responses. The increased precision resulting from 'screener' versions appears to more than offset the higher item non-response rates compared with 'no screener' versions.

Background: Concierge medical practice is a relatively new and somewhat controversial development in primary-care practice. These practices promise patients more personalized care and dedicated service, in exchange for an annual membership fee paid by patients. The experiences of patients using these practices remain largely undocumented., Objective: To assess the experiences of patients in a concierge medicine practice compared with those in a general medicine practice., Methods: Stratified random samples of patients empanelled to each of the four doctors who practice at both a general medicine and a concierge medicine practice separately situated at an academic medical center were drawn. Patients were eligible for the study if they had a visit with the physician between January and May 2006. The study questionnaire (Consumer Assessment of Healthcare Providers and Systems Clinician and Group Survey, supplemented with items from the Ambulatory Care Experiences Survey) was administered by mail to 100 general medicine patients per physician (n = 400) and all eligible concierge medicine patients (n = 201). Patients who completed the survey and affirmed the study physician as their primary-care physician formed the analytic sample (n = 344) that was used to compare the experiences of concierge medicine and general medicine patients. Models controlled for respondent characteristics and accounted for patient clustering within physicians using physician fixed effects., Results: Patients' experiences with organizational features of care, comprising care co-ordination (p < 0.01), access to care (p < 0.001) and interactions with office staff (p < 0.001), favored concierge medicine over general medicine practice. The quality of physician-patient interactions did not differ significantly between the two groups. However, the patients of the concierge medicine practice were more likely to report that their physician spends sufficient time in clinical encounters than patients of the general medicine practice (p < 0.003)., Conclusion: The results suggest patients of the concierge medicine practice experienced and reported enhanced service, greater access to care, and better care co-ordination than those of the general medicine practice. This suggests that further study to understand the etiology of these differences may be beneficial in enhancing patients' experience in traditional primary-care practices.

Objective: To examine the extent to which medical group and market factors are related to individual primary care physician (PCP) performance on patient experience measures., Data Sources: This study employs Clinician and Group CAHPS survey data (n=105,663) from 2,099 adult PCPs belonging to 34 diverse medical groups across California. Medical group directors were interviewed to assess the magnitude and nature of financial incentives directed at individual physicians and the adoption of patient experience improvement strategies. Primary care services area (PCSA) data were used to characterize the market environment of physician practices., Study Design: We used multilevel models to estimate the relationship between medical group and market factors and physician performance on each Clinician and Group CAHPS measure. Models statistically controlled for respondent characteristics and accounted for the clustering of respondents within physicians, physicians within medical groups, and medical groups within PCSAs using random effects., Principal Findings: Compared with physicians belonging to independent practice associations, physicians belonging to integrated medical groups had better performance on the communication ( p=.007) and care coordination ( p=.03) measures. Physicians belonging to medical groups with greater numbers of PCPs had better performance on all measures. The use of patient experience improvement strategies was not associated with performance. Greater emphasis on productivity and efficiency criteria in individual physician financial incentive formulae was associated with worse access to care ( p=.04). Physicians located in PCSAs with higher area-level deprivation had worse performance on the access to care ( p=.04) and care coordination ( p<.001) measures., Conclusions: Physicians from integrated medical groups and groups with greater numbers of PCPs performed better on several patient experience measures, suggesting that organized care processes adopted by these groups may enhance patients' experiences. Physicians practicing in markets with high concentrations of vulnerable populations may be disadvantaged by constraints that affect performance. Future studies should clarify the extent to which performance deficits associated with area-level deprivation are modifiable.

Background: The Patient-Centered Medical Home (PCMH), a popular model for primary care reorganization, includes several structural capabilities intended to enhance quality of care. The extent to which different types of primary care practices have adopted these capabilities has not been previously studied., Objective: To measure the prevalence of recommended structural capabilities among primary care practices and to determine whether prevalence varies among practices of different size (number of physicians) and administrative affiliation with networks of practices., Design: Cross-sectional analysis., Participants: One physician chosen at random from each of 412 primary care practices in Massachusetts was surveyed about practice capabilities during 2007. Practice size and network affiliation were obtained from an existing database., Measurements: Presence of 13 structural capabilities representing 4 domains relevant to quality: patient assistance and reminders, culture of quality, enhanced access, and electronic health records (EHRs)., Main Results: Three hundred eight (75%) physicians responded, representing practices with a median size of 4 physicians (range 2-74). Among these practices, 64% were affiliated with 1 of 9 networks. The prevalence of surveyed capabilities ranged from 24% to 88%. Larger practice size was associated with higher prevalence for 9 of the 13 capabilities spanning all 4 domains (P < 0.05). Network affiliation was associated with higher prevalence of 5 capabilities (P < 0.05) in 3 domains. Associations were not substantively altered by statistical adjustment for other practice characteristics., Conclusions: Larger and network-affiliated primary care practices are more likely than smaller, non-affiliated practices to have adopted several recommended capabilities. In order to achieve PCMH designation, smaller non-affiliated practices may require the greatest investments.

Background: Physicians are increasingly asked to improve the delivery of clinical services and patient experiences of care., Objective: We evaluated the association between clinical performance and patient experiences in a statewide sample of physician practice sites and a sample of physicians within a large physician group., Design, Setting, Participants: We separately identified 373 practice sites and 119 individual primary care physicians in Massachusetts., Measurements: Using Health Plan Employer Data and Information Set data, we produced two composites addressing processes of care (prevention, disease management) and one composite addressing outcomes. Using Ambulatory Care Experiences Survey data, we produced seven composite measures summarizing the quality of clinical interactions and organizational features of care. For each sample (practice site and individual physician), we calculated adjusted Spearman correlation coefficients to assess the relationship between the composites summarizing patient experiences of care and those summarizing clinical performance., Results: Among 42 possible correlations (21 correlations involving practice sites and 21 involving individual physicians), the majority were positive in site level (71%) and physician level (67%) analyses. For the 28 possible correlations involving patient experiences and clinical process composites, 8 (29%) were significant and positive, and only 2 (7%) were significant and negative. The magnitude of the significant positive correlations ranged from 0.13 to 0.19 at the site level and from 0.28 to 0.51 at the physician level. There were no significant correlations between patient experiences and the clinical outcome composite., Conclusions: The modest correlations suggest that clinical quality and patient experience are distinct, but related domains that may require separate measurement and improvement initiatives.

Background: Few studies have clarified the mechanisms that contribute to racial and ethnic disparities in primary care quality among comparably-insured patients., Objective: To examine relative contribution of "between-" and "within-" physician effects on disparities in patients' experiences of primary care., Design: Regression models using physician fixed effects to account for patient clustering were specified to assess "between-" and "within-"physician effects on observed racial and ethnic disparities in patients' experiences of primary care., Participants: The Ambulatory Care Experiences Survey (ACES) was administered to patients visiting 1,588 primary care physicians (PCPs) from 27 California medical groups. The analytic sample included 49,861 patients (31.4 per PCP) who confirmed a PCP visit during the preceding 12 months., Main Results: Most racial and ethnic minority groups were significantly clustered within physician practices (p < 0.001). "Between-physician" effects were mostly negative and larger than "within-physician" effects for Latinos, Blacks, and American Indian/Alaskan Natives, indicating that disparities are mainly attributable to patient clustering within physician practices with lower performance on patient experience measures. By contrast, "within-physician" effects accounted for most disparities for Asians and Pacific Islanders, indicating these groups report worse experiences relative to Whites in the same practices. Practices with greater concentration of Blacks, Latinos and Asians had lower performance on patient experience measures (p < 0.05)., Conclusions: Targeting patient experience improvement efforts at low performing practices with high concentrations of racial and ethnic minorities might efficiently reduce disparities. Urgent study is needed to assess the contribution of "within-" and "between-" physician effects to racial and ethnic disparities in the technical quality of primary care.

Background: Studies find that primary care physician (PCP) visit continuity is positively associated with care quality. Some of the evidence base, however, relies on patient-reported continuity measures, which may be subject to response bias., Objective: To assess the concordance of patient-reported and administratively derived visit continuity measures., Design: Random samples of patients (n = 15,126) visiting 1 of 145 PCPs from a physician organization in Massachusetts were surveyed. Respondents reported their experienced visit continuity over the preceding 6 months. Usual Provider Continuity (UPC), an administratively derived measure, was calculated for each respondent. The concordance of patient reports and UPC was examined. Associations with patient-reported physician-patient interaction quality were assessed for both measures., Results: Patient-reported and administratively derived visit continuity measures were moderately correlated for overall (r = 0.30) and urgent (r = 0.30) measures and modestly correlated for the routine (r = 0.17) measure. Although patient reports and UPC were significantly associated with the physician-patient interaction quality (p < 0.001), the effect size for patient-reports was approximately five times larger than the effect size for UPC., Conclusions: Studies and quality initiatives seeking to evaluate visit continuity should rely on administratively derived measures whenever possible. Patient-reported measures appear to be subject to biases that can overestimate the relationship between visit continuity and some patient-reported outcomes.

Background: Primary-care clinicians can play an important role in reducing racial disparities in diabetes care., Objective: The objective of the study is to determine the views of primary-care clinicians regarding racial disparities in diabetes care., Design: The design of the study is through a survey of primary-care clinicians (response rate = 86%)., Participants: The participants of the study were 115 physicians and 54 nurse practitioners and physician assistants within a multisite group practice in 2007., Measurements and Main Results: We identified sociodemographic characteristics of each clinician's diabetic patient panel. We fit multivariable logistic regression models to identify predictors of supporting the collection of data on patients' race and acknowledging the existence of racial disparities among patients personally treated. Among respondents, 79% supported the collection of data on patients' race. Whereas 88% acknowledged the existence of racial disparities in diabetes care within the U.S. health system, only 40% reported their presence among patients personally treated. Clinicians caring for greater than or equal to 50% minority patients were more likely to support collection of patient race data (adjusted odds ratio [OR] 9.0; 95% confidence interval [CI] 1.2-65.0) and report the presence of racial disparities within their patient panel (adjusted OR 12.0; 95% CI 2.5-57.7). Clinicians were more likely to perceive patient factors than physician or health system factors as mediators of racial disparities; however, most supported interventions such as increasing clinician awareness (84%) and cultural competency training (88%)., Conclusions: Most primary-care clinicians support the collection of data on patients' race, but increased awareness about racial disparities at the local level is needed as part of a targeted effort to improve health care for minority patients.

Background: Although several national studies have attempted to measure medication nonadherence due to cost in cross-sectional studies of the elderly and disabled, little information exists on the psychometric properties of these measures over time., Objectives: Examine the test-retest reliability of several recently published measures of cost-related medication nonadherence, among elderly community., Methods: We developed a questionnaire and tested the reliability of measures of cost-related medication nonadherence and general cost-reduction strategies in a sample of 185 elderly in eastern Massachusetts surveyed twice (1-2 months apart). General and medicine-specific cost-related nonadherence measures included: failure to fill or delayed refilling of a prescription due to its cost, skipping doses, or taking smaller doses to make a medicine last longer. We also tested the reliability of reported drug cost-reduction strategies, such as: using generic drugs; purchasing prescriptions via mail/internet or from outside the United States; receiving prescription samples from a doctor; and spending less on food, heat, or other basic needs to afford medicines. We used the McNemar test, a matched pair chi analysis, and Kappa statistics to examine the association of responses within patients between identical items asked at 2 points in time., Results: Kappa statistics for test-retest reliability ranged from 0.6 to 0.9 for all but one measure of cost-related nonadherence, and McNemar test statistics indicated no systematic change in the measures over time., Conclusions: The estimated test-retest reliability of the measures of cost-related medication nonadherence were generally high. The measures have been integrated into the nationally representative Medicare Current Beneficiary Survey (MCBS), an ongoing national panel survey of Medicare beneficiaries, which will allow researchers and policymakers to identify changes in cost-related nonadherence among disabled and elderly Medicare beneficiaries.

Background: Physicians and medical educators have repeatedly acknowledged the inadequacy of communication skills training in the medical school curriculum and opportunities to improve these skills in practice. This study of a controlled intervention evaluates the effect of teaching practicing physicians the skill of "agenda-setting" on patients' experiences with care. The agenda-setting intervention aimed to engage clinicians in the practice of initiating patient encounters by eliciting the full set of concerns from the patient's perspective and using that information to prioritize and negotiate which clinical issues should most appropriately be dealt with and which (if any) should be deferred to a subsequent visit., Methods: Ten physicians from a large physician organization in California with baseline patient survey scores below the statewide 25th percentile participated in the agenda-setting intervention. Eleven physicians matched on baseline scores, geography, specialty, and practice size were selected as controls. Changes in survey summary scores from pre- and post-intervention surveys were compared between the two groups. Multilevel regression models that accounted for the clustering of patients within physicians and controlled for respondent characteristics were used to examine the effect of the intervention on survey scale scores., Results: There was statistically significant improvement in intervention physicians' ability to "explain things in a way that was easy to understand" (p = 0.02) and marginally significant improvement in the overall quality of physician-patient interactions (p = 0.08) compared to control group physicians. Changes in patients' experiences with organizational access, care coordination, and office staff interactions did not differ by experimental group., Conclusion: A simple and modest behavioral training for practicing physicians has potential to positively affect physician-patient relationship interaction quality. It will be important to evaluate the effect of more extensive trainings, including those that work with physicians on a broader set of communication techniques.

Background: Nonadherence to prescription drugs results in poorer control of chronic health conditions. Because of significant racial/ethnic disparities in the control of many chronic diseases, differences in the rates of and reasons for medication nonadherence should be studied., Objectives: 1) To determine whether rates of and reasons for medication nonadherence vary by race/ethnicity among seniors; and 2) to evaluate whether any association between race/ethnicity and nonadherence is moderated by prescription coverage and income., Design/setting: Cross-sectional national survey, 2003., Patients: Medicare beneficiaries > or = 65 years of age, who reported their race/ethnicity as white, black, or Hispanic, and who reported taking at least 1 medication (n = 14,829)., Main Outcome Measures: Self-reported nonadherence (caused by cost, self-assessed need, or experiences/side effects) during the last 12 months., Results: Blacks and Hispanics were more likely than whites to report cost-related nonadherence (35.1%, 36.5%, and 26.7%, respectively, p < .001). There were no racial/ethnic differences in nonadherence caused by experiences or self-assessed need. In analyses controlling for age, gender, number of chronic conditions and medications, education, and presence and type of prescription drug coverage, blacks (odds ratio [OR] 1.38; 95% confidence interval [CI] 1.08-1.78) and Hispanics (1.35; 1.02-1.78) remained more likely to report cost-related nonadherence compared to whites. When income was added to the model, the relationship between cost-related nonadherence and race/ethnicity was no longer statistically significant (p = .12)., Conclusions: Racial/ethnic disparities in medication nonadherence exist among seniors, and are related to cost concerns, and not to differences in experiences or self-assessed need. Considering the importance of medication adherence in controlling chronic diseases, affordability of prescriptions should be explicitly addressed to reduce racial/ethnic disparities.

Background: Despite growing emphasis on public reporting of health care quality data, available data are often ignored., Objective: To evaluate the usefulness of web-based physician-level data for patients choosing a new primary care physician (PCP)., Design: Patients seeking a new PCP (n = 2225) were invited to view web-based information including PCP credentials, personal characteristics, office location and hours, and patient experience scores. Patient experience scores included validated measures of interpersonal quality, appointment access, care coordination, health promotion, and patient recommendations of the PCP. After viewing the website, participants indicated their preferred PCP and completed a study questionnaire., Results: Of the invited participants, 17% visited the website (n = 382). Patient experience scores were cited most frequently as important to physician choice (51%). Among these measures, patients' highest priorities were interpersonal quality (37%) and patient recommendations of the PCP (41%). For patients citing these priorities, the odds of choosing a highly scored physician after viewing the data was nearly 10 times that of choosing such a physician by chance (odds ratio (OR) = 9.52 and 9.71, respectively)., Conclusions: Targeting patients known to be making a health care decision appears to promote the use of performance data. Patients particularly valued data concerning other patients' experiences and, after viewing the data, made choices well-aligned with their priorities.

Background: Visit continuity is important to patients and valued by physicians. However, it is virtually impossible for primary care physicians (PCPs) to provide care during every paneled patient visit. It remains unclear whether PCP visit discontinuity can be planned in a way that is least disruptive to patients' experiences with care., Objective: This study aims to clarify whether visit continuity affects patients' experiences with primary care equally for all patients., Design: From January 2004 through March 2005, a large multispecialty practice in Massachusetts administered the Ambulatory Care Experience Survey (ACES) monthly to a random sample of patients visiting each of 145 PCPs. The analytic sample includes 14,835 patients with 2 or more primary care visits over the 6 months before being surveyed. Usual Provider Continuity (UPC), an administratively based measure of PCP visit continuity, was calculated for all respondents. Multilevel regression models that accounted for the clustering of patients within physicians modeled the relationship between UPC and each ACES measure. Interaction effects between UPC and gender, education, self-rated health, and PCP-patient relationship duration were tested., Results: Physician-patient interaction quality, including physician communication, knowledge of the patient, health promotion support, and organizational access were more strongly influenced by visit continuity among respondents in early stages of a PCP-patient relationship (P < 0.01) and with worse self-rated health (P < 0.01)., Conclusions: Improvements in physician-patient relationship quality can be achieved by targeting visit continuity improvement efforts to patients who benefit most, particularly those in early stages of a PCP-patient relationship and/or perceive their health as poor.

Background: Increasing numbers of medicines increase nonadherence. Little is known about how older adults manage multiple medicines for multiple illnesses., Objectives: To explore how older adults with multiple illnesses make choices about medicines., Design: Semistructured interviews with older adults taking several medications. Accounts of respondents' medicine-taking behavior were collected., Participants: Twenty community-dwelling seniors with health insurance, in Eastern Massachusetts, aged 67-90, (4-12 medicines, 3-9 comorbidities)., Approach: Qualitative analysis using constant comparison to explain real choices made about medicines in the past ("historical") and hypothetical ("future") choices., Results: Respondents reported both past ("historical") choices and hypothetical ("future") choices between medicines. Although people discussed effectiveness and future risk of the disease when prompted to prioritize their medicines (future choices), key factors leading to nonadherence (historical choices) were costs and side effects. Specific choices were generally dominated by 1 factor, and respondents rarely reported making explicit trade-offs between different factors. Factors affecting 1 choice were not necessarily the same as those affecting another choice in the same person. There was no evidence of "adherent" personalities., Conclusion: Prescribing a new medicine, a change in provider or copayment can provoke new choices about both new and existing medications in older adults with multiple morbidities.

Background: Alcohol and drug use disorders are chronic diseases that require ongoing management of physical, psychiatric, and social consequences. While specific addiction-focused interventions in primary care are efficacious, the influence of overall primary care quality (PCQ) on addiction outcomes has not been studied. The aim of this study was to prospectively examine if higher PCQ is associated with lower addiction severity among patients with substance use disorders., Study Population: Subjects with alcohol, cocaine, and/or heroin use disorders who initiated primary care after being discharged from an urban residential detoxification program., Measurements: We used the Primary Care Assessment Survey (PCAS), a well-validated, patient-completed survey that measures defining attributes of primary care named by the Institute of Medicine. Nine summary scales cover two broad areas of PCQ: the patient-physician relationship (communication, interpersonal treatment, thoroughness of the physical exam, whole-person knowledge, preventive counseling, and trust) and structural/organizational features of care (organizational access, financial access, and visit-based continuity). Each of the three addiction outcomes (alcohol addiction severity (ASI-alc), drug addiction severity (ASI-drug), and any drug or heavy alcohol use) were derived from the Addiction Severity Index and assessed 6-18 months after PCAS administration. Separate longitudinal regression models included a single PCAS scale as the main predictor variable as well as variables known to be associated with addiction outcomes., Main Results: Eight of the nine PCAS scales were associated with lower alcohol addiction severity at follow-up (p

Context: Understanding and improving the quality of medication management is particularly important in the context of the Medicare prescription drug benefit that took effect last January 2006., Objective: To determine the prevalence of physician-patient dialogue about medication cost and medication adherence among elderly adults nationwide., Design: Cross-sectional survey., Participants: National stratified random sample of community-dwelling Medicare beneficiaries aged 65 and older., Main Outcome Measures: Rates of physician-patient dialogue about nonadherence and cost-related medication switching., Results: Forty-one percent of seniors reported taking five or more prescription medications, and more than half has 2 or more prescribing physicians. Thirty-two percent overall and 24% of those with 3 or more chronic conditions reported not having talked with their doctor about all their different medicines in the last 12 months. Of seniors reporting skipping doses or stopping a medication because of side effects or perceived nonefficacy, 27% had not talked with a physician about it. Of those reporting cost-related nonadherence, 39% had not talked with a physician about it. Thirty-eight percent of those with cost-related nonadherence reported switching to a lower priced drug, and in a multivariable model, having had a discussion about drug cost was significantly associated with this switch (odds ratio [OR] 5.04, 95% confidence interval [CI] 4.28-5.93, P < .001)., Conclusions: We show that there is a communication gap between seniors and their physicians around prescription medications. This communication problem is an important quality and safety issue, and takes on added salience as physicians and patients confront new challenges associated with coverage under new Medicare prescription drug plans. Meeting these challenges will require that more attention be devoted to medication management during all clinical encounters.

Four domains of relationship have been highlighted as the cornerstones of relationship-centered health care. Of these, clinician-patient relationships have been most thoroughly studied, with a rich empirical literature illuminating significant linkages between clinician-patient relationship quality and a wide range of outcomes. This paper explores the realm of clinician-colleague relationships, which we define to include the full array of relationships among clinicians, staff, and administrators in health care organizations. Building on a stream of relevant theories and empirical literature that have emerged over the past decade, we synthesize available evidence on the role of organizational culture and relationships in shaping outcomes, and posit a model of relationship-centered organizations. We conclude that turning attention to relationship-centered theory and practice in health care holds promise for advancing care to a new level, with breakthroughs in quality of care, quality of life for those who provide it, and organizational performance.

Background: Measuring and reporting patients' experiences with health plans has been routine for several years. There is now substantial interest in measuring patients' experiences with individual physicians, but numerous concerns remain., Objective: The Massachusetts Ambulatory Care Experiences Survey Project was a statewide demonstration project designed to test the feasibility and value of measuring patients' experiences with individual primary care physicians and their practices., Design: Cross-sectional survey administered to a statewide sample by mail and telephone (May-August 2002)., Patients: Adult patients from 5 commerical health plans and Medicaid sampled from the panels of 215 generalist physicians at 67 practice sites (n=9,625)., Measurements: Ambulatory Care Experiences Survey produces 11 summary measures of patients' experiences across 2 domains: quality of physician-patient interactions and organizational features of care. Physician-level reliability was computed for all measures, and variance components analysis was used to determine the influence of each level of the system (physician, site, network organization, plan) on each measure. Risk of misclassifying individual physicians was evaluated under varying reporting frameworks., Results: All measures except 2 achieved physician-level reliability of at least 0.70 with samples of 45 patients per physician, and several exceeded 0.80. Physicians and sites accounted for the majority of system-related variance on all measures, with physicians accounting for the majority on all "interaction quality" measures (range: 61.7% to 83.9%) and sites accounting for the largest share on "organizational" measures (range: 44.8% to 81.1%). Health plans accounted for neglible variance (<3%) on all measures. Reporting frameworks and principles for assuring misclassification risk < or =2.5% were identified., Conclusions: With considerable national attention on the importance of patient-centered care, this project demonstrates the feasibility of obtaining highly reliable measures of patients' experiences with individual physicians and practices. The analytic findings underscore the validity and importance of looking beyond health plans to individual physicians and sites as we seek to improve health care quality.

Objective: To report rates of cost-related skipping of medications and other treatments, assess correlates of skipping, examine changes in skipping between 1998 and 2000, and identify factors associated with changes in skipping., Design, Setting, and Participants: Cross-sectional and longitudinal analyses of surveys of a probability sample of Medicare beneficiaries in 13 states in 1998 and 2000., Main Outcome Measure: Self-reported rates of skipping medications and other treatments., Results: Cost-related skipping rates increased from 9.5% in 1998 to 13.1% in 2000. In separate multivariable models using 1998 and 2000 data, higher out-of-pocket costs, lower physician-patient relationship quality, low income, and lacking prescription drug coverage were associated with more skipping (P<.05 for all). Better physical and mental health, and greater age were associated with less skipping (P<.05). HMO membership was not associated with higher rates of skipping in 1998 (P=.84), but was in 2000 (P<.0004). In longitudinal analyses, increased medication costs and HMO membership were associated with the observed increase cost-related skipping between 1998 and 2000., Conclusions: Cost-related skipping was associated with several factors, including drug coverage, poverty, poor health, and physician-patient relationship quality. The important role of physician-patient relationships in cost-related skipping has not been shown previously. Physicians should be aware of these risk factors for cost-related skipping, and initiate dialogue about problems paying for prescription medications and other treatments.

Objective: To examine changes in the quality of primary care experienced and reported by Medicare beneficiaries from 1998 to 2000., Design: Longitudinal observational study., Setting: Thirteen states with large, mature Medicare HMO markets., Participants: Probability sample of noninstitutionalized Medicare beneficiaries aged 65 and older enrolled in traditional Medicare (FFS) or a Medicare HMO., Measurements and Main Results: We examined 2-year changes in 9 measures derived from the Primary Care Assessment Survey (PCAS). The measures covered 2 broad areas of primary care performance: quality of physician-patient interactions (5 measures) and structural/organizational features of care (4 measures). For each measure, we computed the change in each beneficiary's score (1998 vs 2000) and standardized effect sizes (ES). Results revealed significant declines in 3 measures of physician-patient interaction quality (communication, interpersonal treatment, and thoroughness of physical exams; P < or = .0001). Physicians' knowledge of patients increased significantly over the 2-year period (P < or = .001). Patient trust did not change (P = .10). With regard to structural/organizational features of care, there were significant declines in financial access (P < or = .001), visit-based continuity (P < .001), and integration of care (P < or = .05), while organizational access increased (P < or = .05). With the exception of financial access, observed changes did not differ by system (FFS, HMO)., Conclusions: Over a 2-year period, the quality of seniors' interactions with their primary physicians declined significantly, as did other hallmarks of primary care such as continuity, integration of care, and financial access. This decline is in sharp contrast to the marked improvements in technical quality that have been measured over this period. In an era marked by substantial national investment in quality monitoring, measures of these elements of care are notably absent from the nation's portfolio of quality indicators.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.