“Improvements in Patient Experience”–Really?

December 15, 2010

Hospitals improve their communication with patients when  patient survey results are publicly reported, say researchers with the RAND Corporation and the federal Centers for Medicare and Medicaid Services (CMS).

Writing in Health Affairs, the researchers report that hospitals participating in the first two rounds of annual reporting improved overall in eight of nine survey measures.  The measures comprised communication with nurses and doctors, staff responsiveness, communication about medicines, pain management, and discharge information.  The surveys took place in 2008 and 2009.

Hand-lettered sign reading, "Stop complaining"The problem is that none of the average improvements exceed one percent. And, physician communication didn’t improve at all–although, interestingly, it scored first or second both years, with four in five patients reporting positive experiences.

Surveying patients is now de rigueur (I took French but, alas, had to look up how to spell this phrase–I hope my use of it impresses you).  The federal survey program is widespread–the vast majority of hospitals now participate–allowing comparisons to be drawn across hospitals and over time.  Hospitals survey patients for marketing purposes and because CMS penalizes hospitals that fail to participate in the program.

CMS pushes the program to improve quality of care, which, in the view of many advocates of quality (this blogger being one), includes patient satisfaction.

Author Marc N. Elliott and colleagues say the result is “encouraging.”  This is because hospitals that take part in the program are improving.  The title of their article is probably an over-reach: “Hospital Survey Shows Improvements in Patient Experience.”  Elliott is a statistician and sounds a bit more interested in the use of statistical measures than in quality of care.

My problems with the results are: Read the rest of this entry »


Young Couple Challenges Surgeon at Bedside

December 13, 2010
young, friendly, confident-looking woman before a backdrop with Eleanor Roosevelt's name

"The Courage to Lead"

A young married couple whom we’ll call “Ted” and “Alice”–real-life friends of ours, with a 1 1/2-year old child–had questions for the attending physician, a surgeon, on Ted’s day of discharge from the hospital yesterday, six days after he underwent emergency abdominal surgery.

The hospital is more than 1,000 miles from home, so there would be little opportunity for normal followup.  Yet the surgeon was not much interested in answering questions.  “You have to trust me,” he said, finally.  “I’ve done this a thousand times.”

“But we haven’t!” said Alice.  “This is our first time.  And I’m the one who will have to care for him.”

Their main questions were the following:

  1. What should we do to manage pain?  Ted’s been on strong pain relievers all week, and now we don’t have a prescription for a pain drug.
  2. What about diet?  Today’s the first day Ted’s eaten any solid food, and we don’t know what he should eat or not eat.
  3. What kinds of complications should we be on the lookout for?  What should we do if they occur?
  4. We want to see our primary care physician back home as soon as possible, but how do we provide that doctor with a record of what went on here in the hospital?

Read the rest of this entry »

No One Wants To Be an “Adverse Event”

December 8, 2010

We cling to hope.  We assume our interaction with the health care system will work to our benefit and we can safely rely on the competence and good will of physicians, nurses, and other health professionals.  The problem is, we can’t.

Lots of evidence points to the stubborn pervasiveness of so-called “systemic” problems in quality of care.  A recent federal study, for example, found that 15,000 people on Medicare died in one month due to an adverse event–a medical error or other mistake, improper execution, or unintended consequence–suffered in a hospital.

photo of a man in a hospital bed with padding at his nose

Sinus Surgery

Another 119,000 hospitalized Medicare beneficiaries sustained a serious adverse event during the month, but survived it.  All told, one in seven hospital patients on Medicare suffered a serious adverse event–and an additional one in seven experienced an adverse event that caused only temporary harm.

The adverse events generated about $325 million in Medicare costs.  On an annual basis, this extrapolates (according to the study authors) to $4.4 billion in extra costs for the bankruptcy-skirting Medicare program.

There is no reason to believe that adverse events happen only to people on Medicare–if anything, Medicare is especially committed to improving quality and safety–or only to people in hospitals.

What this means is:  You are not immune from being linked to this grisly chain. You have to be on your guard.

Poor communication causes many, perhaps most, adverse events.  Most notably, medication errors result from misunderstandings about dosage, frequency, allergies, changes in orders, when to take the drug, how to administer it, and whether the patient is due for another dose.  Lapses in informing patients and staff about what they need to know also can cause dietary problems, infections, treatment complications, and all manners of bad things.

What can you do to keep from being a quality-of-care statistic (and not in a good way)?  If nothing else, take these three steps if you or a family member is in a hospital or other health facility:

  1. Ask questions about anything you don’t understand or that seems funny to you–a drug, test, or procedure that appears to differ from what a doctor or nurse had described, a change in routine that doesn’t make sense to you, or an intervention that appears to repeat something you just had.  Mention any contradictions between what different people tell you. Read the rest of this entry »

Other Patient-friendly Sites

November 10, 2010

Since you managed to find us, chances are you know of other patient-oriented websites and blogs.  I’m very interested in hearing about your experiences as a web-using patient.  Here are some sites that I recommend.

The National Institute on Aging website has an excellent section, called “Talking with Your Doctor: A Guide for Older People.” The philosophy pretty much parallels what you find here and in our book–maybe with a little less detail, less reference to recent findings in the literature, and more tips geared to older patients, such as the suggestion to take your eyeglasses and hearing aid on your appointment.

smiling woman at a computer

Improved Method of Entering Patient Data

The Agency for Healthcare Research and Quality (AHRQ)–which soon could become a major part of the Department of Health and Human Services, equal to the FDA, NIH, or CDC, or could instead become a victim of partisan budget wrangling–promotes an approach to patient-centered care called CAHPS.  That’s short for “Consumer Assessment of Healthcare Providers and Systems.” The main idea is to use surveys of patients’ experiences to rate health care providers.  Check it out.  (Also see AHRQ’s quick tips.)

You know that major diseases have diverse websites and online discussion groups.  A good example is that of the Leukemia and Lymphoma Society.  One site that many people appear to find very useful is that of the Association of Cancer Online Resources (ACOR).  Patient advocates with an interest in cancer care speak highly of it.   Similarly, Caring Bridge is geared to helping patients and families, especially those affected by cancer.

Those of us who took part in tobacco control efforts learned to appreciate the activities of the American Cancer Society, as well as the American Heart Association and the American Lung Association.

Read the rest of this entry »

Why to Treat Your Doctor as a Person: 10 Tips

November 3, 2010

Several of our posts–and our book–assert that patients benefit by interacting cordially with their physician or other health professional.

Our general advice is to strike a balance between insensitivity and meekness.  For example, Section 8 of our book (the section on “Complaining to Your Doctor”) says:  “If you don’t express your feelings, you might start to tune out your physician, and you might stop working as an equal partner in your own health care.”

photo of a handsome, kind-looking physician in scrubsNew evidence, involving a surprising group of doctors, supports the idea that physicians are susceptible to the same pressures as the rest of us.  US News and World Report and HealthDay News summarize a study of 7,900 surgeons-a group sometimes thought of as typically machine-like and impersonal.  The study found that large percentages of surgeons are burnt out and depressed.

Conducted by Charles M. Balch and colleagues, the study appears in the November issue of the Journal of the American College of Surgeons.   The longer the hours worked by the surgeon, the more likely he or she is to meet the criteria for burnout and depression.  Accordingly, the burnout rate is 30 percent for surgeons who work less than 60 hours per week, 44 percent for those who work 60-80 hours, and 50 percent for those who work more than 80 hours.  (Yes, those are common work weeks for physicians.)

Burnout consists of such sentiments and reactions as feeling run-down and drained of physical and emotional energy, being prone to negative thinking about one’s job, being irritable, and feeling misunderstood.

A doctor who is prey to feelings like that is not going to respond well to a patient who appears confrontational, demanding, unsympathetic, or inconsiderate.  Fuhgeddabahdit.

Instead, try to get your doctor to view you in a positive light and drive those negative thoughts right out of his or her mind!  Here are ten tips: Read the rest of this entry »

Doctor Style, Research, and Other Weighty Matters

October 28, 2010

Today’s post starts with a summary of another study showing the importance of physician-patient communication, this time in the key and “massive” area of weight loss.  Then we veer into what may be the topic du jour in health policy: the very credibility of research results.  I think you’ll find the discussion interesting–and I’ll be interested in your reactions.

1906 print "Don't Be Fat" ad showing an overweight womanOne of our readers, Trish, noted a study report in the October issue of the  American Journal of Preventive Medicine that ties weight loss in overweight patients to the physician’s style of communication.  (Note, BTW, use of the word “preventive,” not the mouth-contorting “preventative.”)  Patients in the study tended to lose a significant amount of weight if their doctor used “motivational interviewing” that was tailored to the patient’s circumstances and readiness to change behavior.

But, patients tended not to lose weight if the doctor avoided the topic, or if the doctor spoke only in a general, prescriptive, or confrontational way about the importance of losing weight.  It seems we don’t respond well to robotic advice or to nannying.  Surprise.

Nicholas Bakalar reported on the study in the New York Times on October 25.  Bakalar emphasized that “cajoling and coaxing, scolding and reproach are all ineffective.”  What works is “collaborative discussion.”  The latter is exactly the type of conversation promoted in this blog and in our book.

The study, by Kathryn I. Pollak of Duke University and colleagues, involved 40 primary care physicians and 461 patients.

But, here’s the question:  Can we trust the results of studies like this? New findings show that shockingly large numbers of medical studies reflect the researchers’ biases and self-interests and produce inaccurate results.

Read the rest of this entry »

New Finding: Communication Prevents Death

October 25, 2010

The mortality rate among renal dialysis patients varies tremendously from one dialysis center to another.

Patient in wheel chair awaits dialysis

"Dialysis 3"

Even adjusted for how sick the patients are, mortality is as low as 10 percent in some places, and as high as 30 percent elsewhere.  And, a new study helps explains why.

“More activated and engaged patients,” better “physician communication,”  and “stronger interpersonal relationships” account for much of the difference, say the study report authors. Other factors are more competent dietitians and superior overall coordination and staff management.   Together, these factors explain about one-third of the difference in mortality rates between centers with high death rates and centers with low death rates.

The number of deaths prevented by the better-communicating dialysis centers is probably larger than you might expect.  It appears to run in the tens of thousands every year.  (The overall average mortality rate is about 20 percent.)  In 2008, Medicare alone paid for renal dialysis of more than 450,000 patients.

Read the rest of this entry »