Why families change pediatricians. Factors causing dissatisfaction with pediatric care

Examining how physician factors influence patient satisfaction during clinical consultations about cancer prognosis and pain

Objective

Patient-physician communication affects cancer patients' satisfaction, health outcomes, and reimbursement for physician services. Our objective is to use machine learning to comprehensively examine the association between patient satisfaction and physician factors in clinical consultations about cancer prognosis and pain.

Methods

We used data from audio-recorded, transcribed communications between physicians and standardized patients (SPs). We analyzed the data using logistic regression (LR) and random forests (RF).

Results

The LR models suggested that lower patient satisfaction was associated with more in-depth prognosis discussion; and higher patient satisfaction was associated with a greater extent of shared decision making, patient being black, and doctor being young. Conversely, the RF models suggested the opposite association with the same set of variables.

Conclusion

Somewhat contradicting results from distinct machine learning models suggested possible confounding factors (hidden variables) in prognosis discussion, shared decision-making, and doctor age, on the modeling of patient satisfaction. Practitioners should not make inferences with one single data-modeling method and enlarge the study cohort to help deal with population heterogeneity.

Innovation

Comparing diverse machine learning models (both parametric and non-parametric types) and carefully applying variable selection methods prior to regression modeling, can enrich the examination of physician factors in characterizing patient-physician communication outcomes.

Measuring Quality of Care with Patient Satisfaction Scores

Quality of care is a multidimensional concept encompassing safety, efficiency, outcomes, and the patient experience. Traditional quality metrics, such as mortality rates, complication rates, and patient-reported outcomes, are time-consuming and cost-consuming to obtain and risk-stratify. The implications of reimbursement related to patient satisfaction and the ease of data collection have contributed to the perception that satisfaction is a global indicator of health-care quality; however, high satisfaction scores are not consistently correlated with traditional outcome and safety indicators. Higher patient satisfaction may be associated with increased costs of care. Costs may be further increased by the implementation of the satisfaction surveys themselves, which can increase imaging studies and prescriptions. Therefore, satisfaction surveys are not appropriate measures of overall quality of care. Accurate assessment of quality requires a multidimensional approach that includes specific measures for each domain.

Why parents use the emergency department during evening hours for nonemergent pediatric care

BACKGROUND

Emergency departments (EDs) are commonly used by pediatric patients for nonemergent reasons. There is little information regarding how parents perceive their use of the ED and primary care availability during evening hours.

METHODS

We conducted a survey of parental perspectives of ED use during evening hours. Participants were parents of pediatric patients (age 0-18 years) at a large quaternary medical center's ED presenting between 17:00 and 22:00 hours from January 15, 2013 to March 12, 2013.

RESULTS

Most patients had a primary care pediatrician (98/102, 96.1%); 80% of their pediatricians (78/98) did not have evening hour availability. Overall, 46.7% of parents would have preferred to go to their primary care pediatrician.

CONCLUSIONS

Many parents who expect outpatient treatment prefer to take their child to a primary care pediatrician during evening hours, but present to the ED because of lack of primary care access.

Importance of adherence in the outcome of juvenile idiopathic arthritis

Medical treatment of juvenile idiopathic arthritis (JIA) has advanced in the last decade, and improved prognosis is a reality in daily clinical practice. Despite this improvement in the quality of treatment, the outcome can still be compromised by modifiable factors, including delayed referral to a specialist, delayed drug treatment, poor adherence to treatment, and early interruption of drug treatment. In this review we discuss the most relevant aspects related to adherence to treatment in JIA, with emphasis on: factors that affect adherence to treatment; effect of poor adherence to treatment on JIA prognosis; when to suspect and how to assess poor adherence to treatment; and strategies to promote adherence to treatment, with an emphasis on information-reinforcement education. Besides presenting the findings of other authors, we also try to report our experience of this subject, which is still a challenge for health professionals.

Outpatient satisfaction: the role of nominal versus perceived communication

OBJECTIVE

To examine the simultaneous associations of parent and coder assessments of communication events with parent satisfaction.

STUDY SETTING

Five hundred twenty-two pediatrician-patient encounters.

STUDY DESIGN

Parents reported on post-visit satisfaction with care and whether four communication events occurred. Raters also coded communication events from videotapes. Multivariate analyses predicted parent satisfaction.

PRINCIPAL FINDINGS

Satisfaction was greater when parents perceived at least three communication events. Parent and coder reports were nearly uncorrelated. Coder-assessed communication events not perceived by parents were unrelated to parent satisfaction.

CONCLUSIONS

Parents are more satisfied when most or all of the expected parent-physician communications occur. A successful pediatrician-parent communication event is one that a parent recognizes as having occurred; it is not merely one that a trained observer says occurred.

Enhancing parent-provider communication in ambulatory pediatric practice

OBJECTIVE

To address the need for interventions to enhance parent-provider communication, the present study evaluated the effectiveness of a brief intervention to enhance interpersonal communication skills by pediatric and internal medicine/pediatric residents with parents of children seen in ambulatory practice.

METHODS

In a within-subjects, repeated measures research design, residents (N=28) participated in a 1-112h intervention designed to increase the use of effective communication skills with their patients' families (N=92). Three pediatric visits (one prior to and two following the intervention) were audio-taped and coded using Roter's Interaction Analysis System. Parents' perceptions of residents' communication skills and satisfaction with care were gathered.

RESULTS

Residents used more effective interpersonal communication skills following the intervention (p<.05). Parent satisfaction with care also increased (p<.01) with parents reporting greater satisfaction with distress relief (p=.01) and communication following the intervention (p=.05). However, parents' perceptions of resident communication did not change over time.

CONCLUSION

These findings suggest that a relatively brief intervention shows promise in improving the quality of care provided within a pediatric ambulatory care setting.

PRACTICE IMPLICATIONS

Training residents to increase their use of praise, empathy, and collaboration with families can be done within a brief intervention and may be associated with increased parental satisfaction with care.

Are pediatric practice settings adolescent friendly? An exploration of attitudes and preferences

This study describes adolescent preferences about offices and waiting. Fifty-four adolescents participated in 12 discussion groups, which were audiotaped and transcribed. The transcripts were analyzed qualitatively. Two themes emerged about the health care environment: (1) making the interior design less childish, more teen-oriented, and more home-like; and (2) decreasing waiting time and enhancing waiting experience by providing teen diversions (e.g., magazines, tv, games). Teens preferred that artwork portray realistic images, that medical paraphernalia be hidden, and that colors be neutral. Modifying interior décor, constructing smaller subwaiting areas, and incorporating diversions that are teen-oriented may help promote positive health care experiences and utilization by adolescents.

Research on the quality of parent-provider communication in pediatric care: implications and recommendations

This narrative review of the correlates of effective parent-provider communication and relevant interventions indicates that effective parent-provider communication is associated with parental satisfaction with care, adherence to treatment recommendations, and enhanced discussion of psychosocial concerns. Moreover, interventions designed to improve parent-provider communication resulted in more discussion of psychosocial concerns, better recall of information from the visit, and improved parent-provider communication. Recommendations for the development of more effective studies of parent-provider communication and relevant interventions in pediatric primary care include the need for theoretical models to help guide research, the development of reliable and valid self-report measures of communication, the assessment of clinically relevant correlates of parent-provider communication, and the study of children's roles in communication with their pediatricians.

How much explanation is enough? A study of parent requests for information and physician responses

OBJECTIVE

To examine the relationship between doctor-parent communication patterns and parents' perceptions that they were listened to by the doctor.

DESIGN

Cross-sectional, clinic-based survey. Before the visit, parents were asked about the strength of their desires/preferences for being listened to; after the visit, they were asked if their desires were fulfilled and to rate their satisfaction with care. Encounters were audiotaped, transcribed, and coded for parent requests for information and action and physician responses to those requests. Coding was performed using an adapted version of the Taxonomy of Requests by Patients (TORP). Physician responses to parental requests for information were coded as brief, moderate, or prolonged fulfillment or as partially fulfilled, ignored, or denied.

SETTING

Two private pediatric practices, 1 community based and 1 university based.

PARTICIPANTS

Ten of 13 eligible physicians (participation rate, 77%) and 306 of 356 eligible parents (participation rate, 86%) who sought care for their children's respiratory illnesses. Parents were invited to participate if they spoke and read English and if their child was 2-10 years old, had a chief complaint of cold symptoms, and was seeing one of the participating physicians. Complete data were obtained for 287 doctor-parent encounters (94%).

RESULTS

Before the visit, 74% of parents reported that they considered it necessary for the physician to listen to their ideas about their child's illness. Among these parents, 62% (n = 130) reported after the visit that the physician had listened to their ideas. As the proportion of moderate-length responses to parent requests for information increased, parents were significantly more likely to report being listened to (P <.05). Multivariate results indicated a 59% probability of parents reporting that they were listened to when given moderate-length responses, 45% when given brief responses, 39% when given prolonged responses, and 12% when requests for information were only partially fulfilled, ignored, or denied. The length of response to parent requests for information was not related to overall parent satisfaction.

CONCLUSIONS

Parents who received moderate-length answers to their questions were most likely to report that they were listened to. Although it is assumed that lengthier, in-depth explanations result in higher satisfaction, this study suggests that more doctor talk does not necessarily constitute better communication.

Perceptions of quality of care and the decision to leave a practice

Little is known about how patients' perceptions of quality of care influence behavioral outcomes such as decisions to change the source of their care. We surveyed patients suspected of leaving a primary care internal medicine practice at an urban teaching hospital to examine their reasons for leaving, and to investigate whether decisions to leave were related to perceived quality of care. Of 185 respondents, 27 (15%) had left to follow their doctor to another practice. The other 98 (53%) patients who had left the practice cited reasons such as a change of insurance (51), physician care (31), practice operation (27), parking and transportation (24), physician departure (19), and geographic moves (17). Responses to global assessment items and a physician care rating scale were more closely associated with the decision to leave than were ratings of other specific aspects of care.

Practical considerations when treating children with antimicrobials in the outpatient setting

Over the past decade new antimicrobial agents have been introduced used to treat common paediatric infectious diseases such as acute otitis media and sinusitis. These agents vary with respect to their mechanism of action, dosage and duration of therapy, cost, taste and type of adverse effects. More recently, there has been concern about the overuse of antibiotics and increasing bacterial resistance, particularly Streptococcus pneumoniae, to these agents. Dosage and duration of therapy, cost, taste, and adverse effects play important roles in determining success or failure of antimicrobial medications in paediatric patients. Use of potential alternatives and adjuncts to antimicrobial treatment, such as vaccination, control of environmental risk factors, surgical techniques and alternative medical therapies may also be employed, and the practitioner must ascertain if their paediatric patients are being treated by any of these methods. Rather than listing the therapeutic challenges for all common outpatient paediatric infectious diseases, acute otitis media (accounting for over 50% of the antimicrobial prescriptions dispensed in childhood) is used to illustrate each issue. Clinicians are faced with a growing number of possible antimicrobial choices; concomitantly, there is increasing concern that these agents are overused. When prescribing antimicrobial agents, we need to be familiar with what we can do to optimise the care we provide. By avoiding inappropriate or trivial use of antimicrobials, we can preserve and even strengthen our armamentarium against disease. Simple strategies can improve compliance with therapeutic regimens and improve parental satisfaction.

Comparison of self-referred and physician-referred patients to a pediatric diagnostic center

Self-referral of children by parents without the knowledge of the child's regular physician can lead to redundant or unnecessary testing and difficulty in arranging follow-up care. This study was designed to investigate reasons for self-referral in a hospital-based pediatric diagnostic center. During the study period, 59 patients were referred by their regular physicians and 51 were self-referred. In multiple-choice questionnaires completed by 85% of the parents, nearly half (18/39; 46%) of those who were self-referred but only 2/51 (4%) of physician-referred parents said the child's regular physician was unconcerned about the medical problem. Further study on the causes for this perception is needed before recommendations can be made to physicians about demonstrating their concern to families.