Effect of Student Involvement on Patient Perceptions of Ambulatory Care Visits

OBJECTIVE: To determine if patient satisfaction with ambulatory care visits differs when medical students participate in the visit. DESIGN: Randomized controlled trial. SETTING: Academic general internal medicine practice. PARTICIPANTS: Outpatients randomly assigned to see an attending physician only (N = 66) or an attending physician plus medical student (N = 68). MEASUREMENTS AND MAIN RESULTS: Patient perceptions of the office visit were determined by telephone survey. Overall office visit satisfaction was higher for the “attending physician only” group (61% vs 48% excellent), although this was not statistically significant (P = .16). There was no difference between the study groups for patient ratings of their physician overall (80% vs 85% excellent; P = .44). In subsidiary analyses, patients who rated their attending physician as “excellent” rated the overall office visit significantly higher in the “attending physician only” group (74% vs 55%; P = .04). Among patients in the “attending physician plus medical student” group, 40% indicated that medical student involvement “probably” or “definitely” did not improve their care, and 30% responded that they “probably” or “definitely” did not want to see a student at subsequent office visits. CONCLUSIONS: Although our sample size was small, we found no significant decrement in patient ratings of office visit satisfaction from medical student involvement in a global satisfaction survey. However, a significant number of patients expressed discontent with student involvement in the visit when asked directly. Global assessment of patient satisfaction may lack sensitivity for detection of dissatisfaction. Future research in this area should employ more sensitive measures of patient satisfaction

Design and Testing of a Tool for Evaluating the Quality of Diabetes Consumer-Information Web Sites

BACKGROUND: Most existing tools for measuring the quality of Internet health information focus almost exclusively on structural criteria or other proxies for quality information rather than evaluating actual accuracy and comprehensiveness. OBJECTIVE: This research sought to develop a new performance-measurement tool for evaluating the quality of Internet health information, test the validity and reliability of the tool, and assess the variability in diabetes Web site quality. METHODS: An objective, systematic tool was developed to evaluate Internet diabetes information based on a quality-of-care measurement framework. The principal investigator developed an abstraction tool and trained an external reviewer on its use. The tool included 7 structural measures and 34 performance measures created by using evidence-based practice guidelines and experts' judgments of accuracy and comprehensiveness. RESULTS: Substantial variation existed in all categories, with overall scores following a normal distribution and ranging from 15% to 95% (mean was 50% and median was 51%). Lin's concordance correlation coefficient to assess agreement between raters produced a rho of 0.761 (Pearson's r of 0.769), suggesting moderate to high agreement. The average agreement between raters for the performance measures was 0.80. CONCLUSIONS: Diabetes Web site quality varies widely. Alpha testing of this new tool suggests that it could become a reliable and valid method for evaluating the quality of Internet health sites. Such an instrument could help lay people distinguish between beneficial and misleading information

The suitability of consumers' assessments of physician and hospital performance as indicators of the quality of care

This report discusses briefly several distinctions were important for the review of the suitability of data from consumer as indicators of quality of care

Why do patients and families request transfers to tertiary care? a qualitative study

Interhospital transfers comprise a significant and increasing proportion of admissions to tertiary care centers. Patient dissatisfaction with the quality of hospital care may play an important role in these trends. The objective of this study was to describe why and how patients and surrogates request transfers to tertiary care. We interviewed 32 patients transferred to the Johns Hopkins Hospital, a US tertiary care center, or their surrogate decision-makers using a semi-structured, open-ended, iterative protocol. We used ethnographic decision modeling to develop an influence diagram of the decision. We contrasted subjects' perceptions of situations where patients did and did not request transfer to describe the threshold for requesting transfer. Subjects reported three major influences on the request to transfer to tertiary care: the quality of care at the community hospital compared to the tertiary center; the severity and potential consequences of the current illness; and their relationship with community hospitals, physicians, and tertiary care. Subjects' perceptions of the quality differential between community hospitals and tertiary centers focused on communication and medical errors rather than specialized care, hospital volume, or teaching status. Thresholds for when patients requested transfers were influenced by relationships with community hospitals and physicians and previous experience with tertiary care. This model provides a framework for understanding requests to transfer to tertiary care. Further investigation into the elements we have described might provide insights into improvements in the quality of care at community hospitals that might reduce the rates of requests for transfer. Our results also highlight the importance of including patient or surrogate perspectives in evaluations of the appropriateness of care.Hospital transfer Tertiary care Patient decision-making Ethnography Influence diagram USA

Patients\u27 ratings of outpatient visits in different practice settings. Results from the Medical Outcomes Study

OBJECTIVE: To determine how patients in different kinds of practices--solo or single specialty (SOLO), multispecialty group (MSG), or health maintenance organizations (HMOs)--and with fee-for-service (FFS) or prepaid physician payment arrangements evaluate their medical care. DESIGN: Survey of adult outpatients after office visits, with sample weighted to represent population of patients visiting physicians in each practice type. SETTING: Offices of 367 internists, family practitioners, endocrinologists, cardiologists, and nurse practitioners, in HMOs (prepaid only), MSGs (prepaid and FFS), and SOLO practices (prepaid and FFS). PATIENTS: Adults (N = 17,671) at start of the Medical Outcomes Study. OUTCOME MEASURES: Overall rating of the visit (five choices from excellent to poor). A random half of the sample also rated the provider\u27s technical skills, personal manner, and explanations of care as well as time spent during the visit, the appointment wait, the office wait, the convenience of the office location, and telephone access. RESULTS: Fifty-five percent of patients rated their visit overall as excellent, 32% very good, 11% good, and 2% fair or poor. Patients of SOLO practitioners were more likely (64%) to rate their visit excellent than MSG (48%) or HMO (49%) patients (P \u3c .001). Patients of SOLO practitioners rated all aspects of care better than HMO patients did, most markedly appointment waits (64% vs 40% excellent; P \u3c .0001) and telephone access (64% vs 33% excellent; P \u3c .0001). Within SOLO and MSG practices, FFS patients rated most specific aspects better than prepaid patients, but these differences were not statistically significant and were inconsistent across cities. Adjusting for patients\u27 demographics, diagnoses and self-rated health did not change results. Physicians with visit ratings in the lowest 20% were nearly four times as likely to be left by patients within 6 months than physicians in the highest 20% (16.7% vs 4.6%; P \u3c .001). CONCLUSION: Of the five practice type and payment method combinations, SOLO FFS patients rated their visits best and HMO patients worst. Whether FFS or prepaid, care was rated better in small than in large practices. Our study shows that a brief visit rating form can be used to compare practice settings and health plans, and that patient ratings predict what proportion of patients, on average, will leave their physicians in the next several months