Asking patients could provide quality answers

A move toward engaging patients in their care may result in better adherence to treatment.

By Susan J. Landers — Posted Jan. 22, 2007

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Who cares what patients think? Everyone who cares about quality health care. At least that was the message of a recent Washington, D.C., briefing exploring issues of access, patient engagement in care and physician communication.

Patient-centered care is increasingly regarded as an important part of good medicine, deserving a place beside clinical technique when it comes to rating the treatment provided by physicians and hospitals, said experts at last month's event, organized by the Alliance for Health Reform. The Alliance is a nonpartisan, nonprofit group that advocates for affordable health care for all.

The best way to determine what patients want is to ask them. That's what the federal Agency for Healthcare Research and Quality decided when it began its Consumer Assessment of Healthcare Providers and Systems survey in 1995.

The surveys are considered important measures in an era of pay-for-performance and accountability. Survey data are used by the National Committee on Quality Assurance and Medicare, said Charles Darby, co-project officer on the CAHPS survey. The data are available to federal employees and TRICARE members. "We can say that 138 million Americans are enrolled in health plans for which CAHPS data are collected," Darby said.

The project's ultimate goal is quality improvement, he said. There are two broad types of quality measures: clinical measures, and those that judge the interpersonal aspects of care. CAHPS surveys focus on the latter. "The kinds of things measured by CAHPS can only be answered by the patients," Darby said.

There are now surveys for hospitals, clinicians, nursing homes, dialysis centers and health plans.

Avoid communication failure

Among the questions asked on the standard instruments developed by the agency is one about how well doctors communicate. "Communication is foremost," Darby said. "Does the doctor listen? Does he or she spend enough time with you? Can you get an appointment when you need it?"

Other items focus on a physician's coordination of a patient's care with specialists, patient involvement with their own care and issues of cultural competence, including interpreter availability. Health literacy also is covered with queries on the degree to which the physician or nurse helps the patient understand information.

CAHPS surveys are now starting to gather patients' views on electronic medical records, Darby said.

The Commonwealth Fund, a nonprofit, New York-based foundation that supports health research, has been promoting patient-centered care for about 20 years, said Karen Davis, PhD, the fund's president.

She defined such care as integrated and comprehensive and noted that research findings show that patients who have such care have better medical outcomes. "Patients want to be engaged," she said.

As evidence, Dr. Davis pointed to a study by John Wasson, MD, professor of community and family medicine at Dartmouth Medical School in Hanover, N.H. He found that the collaborative approach to care had a positive effect on blood pressure control in patients with hypertension and on the number of patients screened for bowel cancer.

Patients also report that they often are frustrated when making their way through the medical system and strongly desire a medical home, she said. Plus, "worries about privacy aside, patients all want doctors involved in their care to have access to their medical records."

Ninety-six percent of about 1,000 adults surveyed by the Commonwealth Fund recently said they wanted care from their different physicians to be well-coordinated, and 93% said they want all their physicians to be able to view their medical records, Dr. Davis said.

Massachusetts began a statewide project in 1995 to measure patients' health care experiences. It was and continues to be a collaborative effort of the Massachusetts Medical Society, the Massachusetts Hospital Assn. and others, said Melinda Karp, the project's director of programs.

The resulting data apply to "any doctor who has patients," she said. "Patient experiences resonate with people more than clinical measures."

A 2006 survey of about 150,000 patients in nearly 500 primary care practices in the state provides a mixed message, she said. Although most physicians scored well in communication, the disconnect came when patients emerged from the examining room. More than a third of patients said care coordination was poor and that their physicians didn't always have important information in their medical histories.

Also, although most patients were content with care received from their doctor, when they saw nurse practitioners or physician assistants, they were "not too happy," Karp said.

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Keeping it simple and clear

Communicating complex information clearly and effectively is a challenge, but it is critical for ethical, high-quality care. Many people who read or hear standard health information do not fully understand it. In the United States today:

More than 22 million people speak English less than "very well."

More than 34 million people were born in another country.

More than 95 million people have literacy levels below what they need to understand even basic written health information, such as how often to take a medicine.

Source: "Improving Communication -- Improving Care," an ethical force program consensus report published by the AMA

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External links

Massachusetts Health Quality Partners (link)

Agency for Healthcare Research and Quality's Consumer Assessment of Healthcare Providers and Systems program (link)

Commonwealth Fund (link)

Alliance for Health Reform (link)

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