Patient Assessment of Primary Care Quality
Patient Assessment of Primary Care Quality
The concept of evidence-based medicine is predicated on the assumption that the goal of health care is to improve outcomes. Two of the more important health outcomes are enhanced quality of life and prolongation of survival. To the extent that effectiveness is defined in terms of those outcomes, our results suggest that older patients' ratings of their primary care on the CPCI questionnaire are not good measures of effectiveness of care. If this is true, then patient satisfaction scores should probably not be relied on as measures of clinical effectiveness, although they might still be regarded as subjective indicators of other aspects of quality. Of course, we can say nothing about the relationship of CPCI scores to other important outcomes such as enhanced personal growth and development, enhanced family stability, or a more comfortable dying process.
These results should not be too surprising. Patients often, very naturally, value immediate comfort more than future health, particularly the cost of future health. Primary care physicians in the private sector are under pressure to please patients because they are, after all, customers. The subject matter is complex, and so physician personality traits and confidence can be easily mistaken for clinical competence.
Studies of student ratings of teachers' performance are illuminating. Students have been found to be accurate judges of certain aspects of teaching including "how clear, interesting, respectful, and fair" a teacher is as well as how well the teacher was able to motivate them to learn the material. However, students are not able to provide reliable information on the quality of the course objectives, the content of the course, or the course assignments. Translating this to the clinical arena, patients are the best judges of their experience of care but can probably not be relied on to accurately assess the appropriateness of clinical evaluations and recommendations.
This study was limited in several ways. Patient satisfaction surveys are notorious for both ceiling (leftward skew) and halo (generally positive feelings toward PCPs raise all subscale scores) effects. We transformed the scores to address the skew, we looked at total CPCI scores as well as the subscales, and we controlled for duration of the patient–PCP relationship, but those were only partial remedies.
Severity of illness and its reflection in patients' need for and experience with certain primary care functions (eg, coordination) are difficult to measure. Although we used a 2-step process, first stratifying and then controlling for number of chronic conditions, similar but not identical to commonly used methods and the General Health subscale of the SF-36, we are not confident that we removed all the confounding caused by this factor. Weiner and colleagues have described a more comprehensive measure, but unfortunately, we did not have all the data required for this measure.
There was a high dropout rate over the 4 years of the study, resulting in a large number of missing values for HRQoL beyond baseline. This reduced our chance to find associations. The growth curve analysis used all the data that were available, however. The QWB-SA is fairly sensitive to small changes, but perhaps not sensitive enough to detect weak associations between CPCI scores and changes in HRQoL over short periods of time. We believe that we captured all or very nearly all deaths, so those calculations should not have been affected.
Wechose to exclude individuals who changed doctors during the first 4 years of the study, reasoning that those patients would be less likely to have time to benefit from the care they were evaluating. A potential disadvantage of this decision is that poor rating of the functions of primary care might prompt patients to change physicians; perhaps this is further truncating the spread of scores that already seem to be skewed toward the positive rating. In fact, in a previous analysis of OKLAHOMA studies data, the accumulated knowledge, communication, and family orientation subscale scores did predict change in PCP.
This is the first study to attempt to determine whether the CPCI can discriminate between better or worse primary care. Only a few other published studies have reported the results of analyses of associations between patient assessments of the quality of their primary care and outcomes. Safran, using an instrument similar to the CPCI, found, in a cross-sectional analysis of employed adults, that patient perceptions of their physicians' whole-person knowledge about them was associated with adherence to physician recommendations regarding behavioral risk factors. There were also small but statistically significant associations between trust, communication, thoroughness of examinations, physician's knowledge of the patient, and integration of care and patient-reported improvements in health status over the previous 4 years. In this study, the researchers used the physical and mental health subscale scores from the Medical Outcomes Study's SF-12, chronic medical diagnoses from a list of 21 conditions, and behavioral risk factors.
In a separate study using the same instrument, however, there was no consistent association between patients' assessment of primary care quality and clinician or practice performance on the HEDIS quality- of-care measures. The authors concluded that "clinical quality and patient experience are distinct but related domains that require separate measures and improvement initiatives."
Kerse and colleagues studied adults being cared for in primary care practices in New Zealand. Patients completed a waiting room survey about attributes of their relationship with their PCP before a visit. They were then interviewed by phone 4 days later and queried about adherence to medications prescribed at the index visit. They found that PCP–patient concordance was associated with subsequent adherence. Most recently, Bertakis and Azari found that patient-centered primary care encounters were associated with lower costs of care over the subsequent year. However, patient satisfaction was not associated with more objectively rated patient-centered care based on scored videotaped encounters.
The strengths of our study include its prospective cohort design and our 2-step process of controlling for severity of illness (stratification, then statistical adjustment within the strata). For the survival analyses, our average period of follow-up was reasonably long, and a substantial proportion (34%) had died. Although the average duration of follow-up for quality of life was relatively short, the participants were all over the age of 65 years, making short-term changes in quality of life more likely.
Discussion
The concept of evidence-based medicine is predicated on the assumption that the goal of health care is to improve outcomes. Two of the more important health outcomes are enhanced quality of life and prolongation of survival. To the extent that effectiveness is defined in terms of those outcomes, our results suggest that older patients' ratings of their primary care on the CPCI questionnaire are not good measures of effectiveness of care. If this is true, then patient satisfaction scores should probably not be relied on as measures of clinical effectiveness, although they might still be regarded as subjective indicators of other aspects of quality. Of course, we can say nothing about the relationship of CPCI scores to other important outcomes such as enhanced personal growth and development, enhanced family stability, or a more comfortable dying process.
These results should not be too surprising. Patients often, very naturally, value immediate comfort more than future health, particularly the cost of future health. Primary care physicians in the private sector are under pressure to please patients because they are, after all, customers. The subject matter is complex, and so physician personality traits and confidence can be easily mistaken for clinical competence.
Studies of student ratings of teachers' performance are illuminating. Students have been found to be accurate judges of certain aspects of teaching including "how clear, interesting, respectful, and fair" a teacher is as well as how well the teacher was able to motivate them to learn the material. However, students are not able to provide reliable information on the quality of the course objectives, the content of the course, or the course assignments. Translating this to the clinical arena, patients are the best judges of their experience of care but can probably not be relied on to accurately assess the appropriateness of clinical evaluations and recommendations.
This study was limited in several ways. Patient satisfaction surveys are notorious for both ceiling (leftward skew) and halo (generally positive feelings toward PCPs raise all subscale scores) effects. We transformed the scores to address the skew, we looked at total CPCI scores as well as the subscales, and we controlled for duration of the patient–PCP relationship, but those were only partial remedies.
Severity of illness and its reflection in patients' need for and experience with certain primary care functions (eg, coordination) are difficult to measure. Although we used a 2-step process, first stratifying and then controlling for number of chronic conditions, similar but not identical to commonly used methods and the General Health subscale of the SF-36, we are not confident that we removed all the confounding caused by this factor. Weiner and colleagues have described a more comprehensive measure, but unfortunately, we did not have all the data required for this measure.
There was a high dropout rate over the 4 years of the study, resulting in a large number of missing values for HRQoL beyond baseline. This reduced our chance to find associations. The growth curve analysis used all the data that were available, however. The QWB-SA is fairly sensitive to small changes, but perhaps not sensitive enough to detect weak associations between CPCI scores and changes in HRQoL over short periods of time. We believe that we captured all or very nearly all deaths, so those calculations should not have been affected.
Wechose to exclude individuals who changed doctors during the first 4 years of the study, reasoning that those patients would be less likely to have time to benefit from the care they were evaluating. A potential disadvantage of this decision is that poor rating of the functions of primary care might prompt patients to change physicians; perhaps this is further truncating the spread of scores that already seem to be skewed toward the positive rating. In fact, in a previous analysis of OKLAHOMA studies data, the accumulated knowledge, communication, and family orientation subscale scores did predict change in PCP.
This is the first study to attempt to determine whether the CPCI can discriminate between better or worse primary care. Only a few other published studies have reported the results of analyses of associations between patient assessments of the quality of their primary care and outcomes. Safran, using an instrument similar to the CPCI, found, in a cross-sectional analysis of employed adults, that patient perceptions of their physicians' whole-person knowledge about them was associated with adherence to physician recommendations regarding behavioral risk factors. There were also small but statistically significant associations between trust, communication, thoroughness of examinations, physician's knowledge of the patient, and integration of care and patient-reported improvements in health status over the previous 4 years. In this study, the researchers used the physical and mental health subscale scores from the Medical Outcomes Study's SF-12, chronic medical diagnoses from a list of 21 conditions, and behavioral risk factors.
In a separate study using the same instrument, however, there was no consistent association between patients' assessment of primary care quality and clinician or practice performance on the HEDIS quality- of-care measures. The authors concluded that "clinical quality and patient experience are distinct but related domains that require separate measures and improvement initiatives."
Kerse and colleagues studied adults being cared for in primary care practices in New Zealand. Patients completed a waiting room survey about attributes of their relationship with their PCP before a visit. They were then interviewed by phone 4 days later and queried about adherence to medications prescribed at the index visit. They found that PCP–patient concordance was associated with subsequent adherence. Most recently, Bertakis and Azari found that patient-centered primary care encounters were associated with lower costs of care over the subsequent year. However, patient satisfaction was not associated with more objectively rated patient-centered care based on scored videotaped encounters.
The strengths of our study include its prospective cohort design and our 2-step process of controlling for severity of illness (stratification, then statistical adjustment within the strata). For the survival analyses, our average period of follow-up was reasonably long, and a substantial proportion (34%) had died. Although the average duration of follow-up for quality of life was relatively short, the participants were all over the age of 65 years, making short-term changes in quality of life more likely.
