| |
August 1997
Volume 61 |
Number 8
|
| |
|
| Measuring Outcome
From the Patient's Point of View |
Patrick K. Birmingham, M.D.
Over the past 10 to 15 years, there has been a rapidly increasing
emphasis and focus on patient input to the whole process of health
care, including pain management; so-called "patient-centered
care." The lead article of a recent six-part New England
Journal of Medicine series on quality of care stated, "...
the most important change has been a growing recognition and insistence
that care must be responsive to the preferences and values of
... individual patients ... their opinions about care are important
indicators of its quality."1
 Patients,
consumer groups, health care providers, private industry, government
agencies and other organizations have all become involved in this
process. A 1996 Consumer Reports questionnaire rating health
maintenance organizations (HMOs) elicited responses from more
than 20,000 subscribers.2 Consumer satisfaction with
choice and availability of physicians and how well the doctor
related to them formed an important part of overall health plan
ranking. HMOs recognize the marketplace value of positive membership
feedback and have used internally designed patient satisfaction
surveys to market and promote themselves. In response to concerns
about manipulation of survey design and patient responses, the
National Committee for Quality Assurance has proposed that HMOs
use outside consultants to administer a standardized questionnaire
to randomly chosen members.
The Joint Commission on Accreditation of Healthcare Organizations
in the United States and the Canadian Council of Health Facilities
Accreditation have promoted standards of care for the terminally
ill patient, stating that the care plan should be based in part
on the expressed desires of the patient and family.3
The Agency for Health Care Policy and Research (AHCPR) had patient
input on panels that created guidelines for acute and cancer pain
management. The AHCPR and others have emphasized that when developing
a quality assurance program to measure the effectiveness of such
guidelines, measurement of patient satisfaction with pain management
is a key item.4
Private industry also has recognized the importance of patient
input. Abbott Laboratories has developed a Total Quality Pain
Management™Program. The survey records patient demographics,
questions about pain duration and intensity, modality used, side
effects, patient satisfaction and the opportunity for open-ended
comments. A database of more than 6,500 adult postoperative patients
has been accumulated, with a pediatric pain version currently
being piloted and plans to include both cancer and chronic pain
patients.
For several years at Children's Memorial Medical Center in Chicago,
a group of parents has been meeting monthly on an informal basis
with hospital physicians and administrators to improve the medical
center's delivery of care. These parents of present or former
patients offer a very personal and very practical perspective.
Their viewpoint has proven so valuable that they have been formally
recognized as an official medical center board. They are now involved
not only in evaluation of ongoing care, but also in initial planning
or restructuring of care.
Validity of Patients' Assessment of Medical Care
A number of historical concerns have existed about the validity
of patients' assessments of their medical care. Patient satisfaction
might be a reflection of the quantity rather than the appropriateness
of health care services received; i.e., how much was done, rather
than if it was done well. Patient assessment may reflect more
about individual patient values and personality characteristics
than about the care itself, or about "softer" factors
such as whether the health care providers were simply nice to
them. Since patient assessments may disagree with more expert
judgments of medical care, the patient's view must be incorrect.5
A large recent body of research and interest in the science of
measuring patient assessments provides some answers to these concerns
[Table 1]. A review of more than 450
articles concluded that "most methods of measuring patient
assessments of their care are highly reproducible and accurate
indicators of the quality of care."6 A strong
and consistent relationship has been found between patient dissatisfaction
and nonadherence with medical regimens, decisions to switch physicians,
disenrollment from health plans and filing of frivolous malpractice
claims7 [Table 2].
The Medical Outcomes Study, a multisite study of more than 17,000
patients in three large urban centers across the country, compared
patient outcome and physician practice styles in different medical
care arrangements. One part of the study found use of brief patient
questionnaires very feasible in evaluating outpatient visits.
Most importantly, they found patient ratings very predictive of
which patients would leave their physician. Physicians with visit
ratings in the lowest 20 percent were nearly four times more likely
to be left by patients than physicians in the highest 20 percent.The
authors state that "considerable research supports the reliability
and validity of patient ratings as measures of accessibility and
quality of care."8
The Picker-Commonwealth Program for Patient-Centered Care explored
patient needs and concerns as defined by patients. One of the
seven important "dimensions of care" defined by patients
was physical comfort and the alleviation of pain. Interviews with
6,000 patients and 2,000 caregivers identified multiple pain management
problem events, including misleading information about the degree
of expected postoperative pain, delays in receiving pain medicine
and inadequate overall analgesia.9,10 In response to
these patient-identified issues, some of the involved centers
instituted or improved their pain service.
A review of chronic pain management outcomes emphasized the importance
of involving the patient in the design and mode of treatment.
This would encourage initial patient recruitment into a plan,
improve adherence with the treatment regimen and hopefully ensure
long-term maintenance of gains made during therapy.11
It is not only the patient but the parent or caregiver who can
provide important information. This is particularly true in cancer
and pediatric pain management. A survey of parental expectations
and perceptions following their child's surgery revealed high
expectations of good pain relief, unlike some adult studies where
mild-to-moderate postoperative pain was expected and accepted.12
Almost half the parents surveyed indicated a willingness to participate
in the actual administration of analgesics to their child; so-called
parent-assisted analgesia. This runs counter to a belief held
by some physicians that parents are often not comfortable with
this option and it therefore should not be offered.
A recent study comparing physician, oncology patient and public
attitudes toward euthanasia and physician-assisted suicide highlights
quite dramatically the importance of including patient input in
pain management and perhaps the ultimate medical outcome, death.13
Compared to the public and other cancer patients, those patients
in active pain at the time of the survey were significantly more
likely to find euthanasia and physician-assisted suicide unacceptable.
They viewed better pain management, not euthanasia, as the appropriate
response. This raises concerns that the consumer of legislation
designed for terminally ill patients in pain may actually be other
types of patients, as has been shown in at least one study.14
Conclusions
Patient involvement is a force that drives efforts to improve
acute and chronic pain management. Their perspective should be
considered an integral part in the evaluation and implementation
of pain treatment regimens. Patient assessments of medical care
are, for the most part, valid and reproducible. Outcome measures
designed and promoted by ASA should and do reflect the importance
of such patient input.
References:
- Blumenthal D. Quality of health care. N Engl J Med.
1996; 335:891-894.
- How good is your health plan? Consumer Reports. 1996;
61:28-42.
- Miaskowski C. Pain management: Quality assurance and changing
practice. In: Gebhart GF, Hammond DL, Jensen TS. eds. Proceedings
of the 7th World Congress on Pain. Seattle: IASP Press. 1994:75-96.
- Ward SE, Gordon D. Application of the American Pain Society
quality assurance standards. Pain. 1994; 56:299-306.
- Davies AR, Ware JE Jr. Involving consumers in quality of care
assessment. Health Affairs. 1988; 7:33-48.
- Ware JE Jr, Davies AR, Rubin HR. Patients' assessments of
their care. In: The quality of medical care: information for
consumers. Washington DC: US Congress, Office of Technology
Assessment. 1988:231-247. OTA-H-386.
- Kaplan SH, Ware JE. The Patient's Role in Health Care and
Quality Assessment. In: Goldfield N, Nash DB. eds. Providing
Quality Care. Philadelphia: American College of Physicians:
1989:25-68.
- Rubin HR, Gandek B, Rogers WH, Kosinski M, McHorney CA, Ware
JE Jr. Patients' rating of outpatient visits in different practice
settings: Results from the medical outcomes study. JAMA.
1993; 270:835-840.
- Gerteis M, Edgman-Levitan S, Walker JD, et al. What patients
really want. Health Mgt Q.1993; 15:2-6.
- Delbanco TL. Enriching the doctor-patient relationship by
inviting the patient's perspective. Ann Int Med. 1992;
116:414-418.
- Turk DC, Rudy TE. Neglected topics in the treatment of chronic
pain patients - relapse, noncompliance, and adherence enhancement.
Pain. 1991; 44:5-28.
- Romsing J, Walther-Larsen S. Postoperative pain in children:
A survey of parents' expectations and perceptions of their children's
experiences. Paediatric Anaesthesia. 1996; 6:215-218.
- Emanuel EJ, Fairchough DL, Daniels ER, Clarridge BR. Euthanasia
and physician-assisted suicide: Attitudes and experiences of
oncology patients, oncologists, and the public. Lancet. 1996;
347:1805-1810.
- van der Maas PJ, van Delden JJM, Pijnenborg L, Looman CWN.
Euthanasia and other medical decisions concerning the end of
life. Lancet. 1991; 338:669-674.
Table 1
Arguments in Favor of Involving Patients in Quality of Health
Care
- Patients don't need to be "experts" to provide valuable
information.
- Patient data may be easier/less expensive to collect than
other information sources.
- Patients provide information not otherwise
available.
- Patients' assessment of quality predicts their behavior.
Table 2
Consequences of Patient Dissatisfaction With Care
Consequence
Comment
- Disenrollment from health plan
Plans with lowest patient satisfaction ratings had disenrollment
rates 10 times higher than higher rated plans.
- Decision to switch physicians
Patients rating their technical/interpersonal care more favorably
are less likely to change physicians in subsequent years.
- Nonadherence
Patients rating their interpersonal care favorably are more
adherent with treatment recommendations.*
- Malpractice lawsuits
Poor relationship with physician is an important factor in filing
frivolous claims.
*Not consistent across all studies
Patrick K. Birmingham, M.D., is the Director
of Acute Pain Service and an Attending Physician in the Department
of Pediatric Anesthesia, Children's Memorial Hospital, and an
Assistant Professor of Anesthesiology at Northwestern University
Medical School, Chicago, Illinois.
E-mail the author.
return to top
|