Faculty Bibliography

BACKGROUND: Patient experience is an important quality indicator, and healthcare organizations spend considerable resources assessing patient satisfaction. Yet a view of patient experience gleaned from patient satisfaction measures tends to show high levels of reported satisfaction, with little variation. Unannounced standardized patients (USPs) have been used to assess providers' clinical skills, but can also provide other information about the healthcare encounter. This study examined the concordance between USP and patient reports of care at the same site. METHODS: Data was gathered at Bellevue Hospital Primary Care Clinic, a city safety-net hospital. USPs assess internal medicine residents training there, and complete a behaviorally anchored checklist of resident skills and interactions with other staff, wait times, ease of clinic navigation, and perceptions of team functioning. Data from 155 USP visits from July 2015-Oct 2016 was used in this study. Independently, as part of team-training efforts in the Primary Care Clinic, patient satisfaction surveys were collected, addressing similar issues. At the end of a clinic visit, research assistants unrelated to patient care asked patients to complete a 30-item survey. 118 surveys were completed between July-November 2016. 11 items appeared on both scales (though worded slightly different) and were used in this comparison. These included questions about clerical (CA) and patient care associates (PCA), and providers (MDs, NPs, PAs), provision of information, team functioning and clinic environment. Of the 11 items, 4 had the same response choices. 7 had differing numbers of responses (eg 4 vs 3 point Likert scales), evenly distributed across patient and USP scales. For each of these items, we collapsed items so to maximize positive ratings (eg. on a 4 point scale from poor to excellent, "good" and "excellent" were combined rather than "good" and "fair"). Chi-square analyses were computed to examine group differences. RESULTS: On chi-square analyses, 9 of the 11 items significantly differed between the USP and patient groups, with patients more likely to have positive ratings. These included rating PCAs as friendlier (x² = 8.67(1,206), p = .003) and providers better at answering questions (x² = 11.75 (2,265), p = .003); reporting that they received sufficient/clear instructions about medication refills and follow-up (x² = 29.5(2,264), p = .0001); finding the clinic atmosphere calmer than did USPs (x² = 10.5 (2,265), p=.005) and noting that the team functioned better (x² = 7.31(2,268), p = .026). There were no significant differences in willingness to recommend the clinic or on clarity of CAs' communication. CONCLUSIONS: Results of this study document the differing perspectives of patients and USPs. Consistent with previous work, patients in our study tended to rate most items higher than did the USPs. USPs provide a different, and likely a more critical look at the clinical setting and this information can enhance efforts to improve patient experience. (Table Presented)

BACKGROUND: Panel Management can expand prevention and chronic illness management beyond the office visit, but there is limited evidence for its effectiveness or guidance on how best to incorporate it into practice. OBJECTIVE: We aimed to test the effectiveness of incorporating panel management into clinical practice by incorporating Panel Management Assistants (PMAs) into primary care teams with and without panel management education. DESIGN: We conducted an 8-month cluster-randomized controlled trial of panel management for improving hypertension and smoking cessation outcomes among veterans. PATRICIPANTS: Twenty primary care teams from the Veterans Affairs New York Harbor were randomized to control, panel management support, or panel management support plus education groups. Teams included 69 clinical staff serving 8,153 hypertensive and/or smoking veterans. INTERVENTIONS: Teams assigned to the intervention groups worked with non-clinical Panel Management Assistants (PMAs) who monitored care gaps and conducted proactive patient outreach, including referrals, mail reminders and motivational interviewing by telephone. MAIN MEASURES: Measurements included mean systolic and diastolic blood pressure, proportion of patients with controlled blood pressure, self-reported quit attempts, nicotine replacement therapy (NRT) prescriptions, and referrals to disease management services. KEY RESULTS: Change in mean blood pressure, blood pressure control, and smoking quit rates were similar across study groups. Patients on intervention teams were more likely to receive NRT (OR = 1.4; 95 % CI 1.2-1.6) and enroll in the disease management services MOVE! (OR = 1.2; 95 % CI 1.1-1.6) and Telehealth (OR = 1.7, 95 % CI 1.4-2.1) than patients on control teams. CONCLUSIONS: Panel Management support for primary care teams improved process, but not outcome variables among veterans with hypertension and smoking. Incorporating PMAs into teams was feasible and highly valued by the clinical staff, but clinical impact may require a longer intervention.

Providers and patients bring different understandings of health and disease to their encounters in the hospital setting. The literature to date only infrequently addresses patient and provider concordance on the reported reason for hospitalization, that is, whether they express this reason in similar ways. An agreement or common ground between such understandings can serve as a basis for future communication regarding an illness and its treatment. We interviewed a convenience sample of patients on the medical wards of an urban academic medical center. We asked subjects to state the reason why their doctors admitted them to the hospital, and then compared their statement with the reason in the medical record. We defined concordance on reported reason for hospitalization as agreement between the patient's report and the reason abstracted from the chart. We interviewed and abstracted chart data from a total of 46 subjects. Concordance on reported reason for hospitalization was present in 24 (52%) and discordance in 17 (37%); 5 patients (11%) could not give any reason for their hospitalization. Among the 17 patients whose report was discordant with their chart, 12 (71%) reported a different organ system than was recorded in the chart. A significant proportion of medical inpatients could not state their physicians' reason for admission. In addition, patients who identify a different reason for hospitalization than the chart often give a different organ system altogether. Providers should explore patient understanding of the reason for their hospitalization to facilitate communication and shared decision making.