Validating a model of patient satisfaction with emergency care

STUDY OBJECTIVE

We sought to validate a previously developed model of emergency department patient satisfaction in a general population using a standard mailed format. The study aims to export the findings of a comprehensive ED quality-of-care study to an easily measured patient population.

METHODS

A double-sided, single-page survey was mailed to all patients discharged home from 4 teaching hospital EDs during a 1-month period. Determinants of patient satisfaction were analyzed with a previously developed multivariate, ordinal logistic-regression model.

RESULTS

The mail survey response rate was 22.9% (2,373/10,381). The survey validates the importance of previously identified determinants of patient satisfaction, including age, help not received when needed, poor explanation of problem, not told about wait time, not told when to resume normal activity, poor explanation of test results, and not told when to return to the ED (P <.01). Greater age predicted higher patient satisfaction, whereas all other variables correlated with lower patient satisfaction. In contrast with prior findings, black race was not a significant predictor of satisfaction in the mail survey population. Low ratings of overall care are strongly correlated with reduced willingness to return (P <.0001).

CONCLUSION

A patient satisfaction model was previously developed from a comprehensive research survey of ED care. We demonstrate the generalizability of this model to a mail survey population and replicate the finding that satisfaction strongly predicts willingness to return. The response rate of this study is typical of commercial patient-satisfaction surveys. The validated model suggests that ED patient satisfaction improvement efforts should focus on a limited number of modifiable and easily measured factors.

Intention to discontinue care among primary care patients: influence of physician behavior and process of care

BACKGROUND

Specific elements of health care process and physician behavior have been shown to influence disenrollment decisions in HMOs, but not in outpatient settings caring for patients with diverse types of insurance coverage.

OBJECTIVE

To examine whether physician behavior and process of care affect patients' intention to return to their usual health care practice.

DESIGN

Cross-sectional patient survey and medical record review.

SETTING

Eleven academically affiliated primary care medicine practices in the Boston area.

PATIENTS

2,782 patients with at least one visit in the preceding year.

MEASUREMENT

Unwillingness to return to the usual health care practice.

RESULTS

Of the 2,782 patients interviewed, 160 (5.8%) indicated they would not be willing to return. Two variables correlated significantly with unwillingness to return after adjustment for demographics, health status, health care utilization, satisfaction with physician's technical skill, site of care, and clustering of patients by provider: dissatisfaction with visit duration (odds ratio [OR], 3.2; 95% confidence interval [CI], 1.4 to 7.4) and patient reports that the physician did not listen to what the patient had to say (OR, 8.8; 95% CI, 2.5 to 30.7). In subgroup analysis, patients who were prescribed medications at their last visit but who did not receive an explanation of the purpose of the medication were more likely to be unwilling to return (OR, 4.9; 95% CI, 1.8 to 13.3).

CONCLUSION

Failure of physicians to acknowledge patient concerns, provide explanations of care, and spend sufficient time with patients may contribute to patients' decisions to discontinue care at their usual site of care.

Influence of financial productivity incentives on the use of preventive care

PURPOSE

We examined whether physician factors, particularly financial productivity incentives, affect the provision of preventive care.

SUBJECTS AND METHODS

We surveyed and reviewed the charts of 4,473 patients who saw 1 of 169 internists from 11 academically affiliated primary care practices in Boston. We abstracted cancer risk factors, comorbid conditions, and the dates of the last Papanicolaou (Pap) smear, mammogram, cholesterol screening, and influenza vaccination. We obtained physician information including the method of financial compensation through a mailed physician survey. We used multivariable logistic regression to examine the association between physician factors and four outcomes based on Health Plan Employer Data and Information Set (HEDIS) measures: (1) Pap smear within the prior 3 years among women 20 to 75 years old; (2) mammogram in the prior 2 years among women 52 to 69 years old; (3) cholesterol screening within the prior 5 years among patients 40 to 64 years old; and (4) influenza vaccination among patients 65 years old and older. All analyses accounted for clus-tering by provider and site and were converted into adjusted rates.

RESULTS

After adjustment for practice site, clinical, and physician factors, patients cared for by physicians with financial productivity incentives were significantly less likely than those cared for by physicians without this incentive to receive Pap smears (rate difference, 12%; 95% confidence interval [CI]: 5% to 18%) and cholesterol screening (rate difference, 4%; 95% CI: 0% to 8%). Financial incentives were not significantly associated with rates of mammography (rate difference, -3%; 95% CI: -15% to 10%) or influenza vaccination (rate difference, -13%; 95% CI: -28% to 2%).

CONCLUSIONS

Our findings suggest that some financial productivity incentives may discourage the performance of certain forms of preventive care, specifically Pap smears and cholesterol screening. More studies are needed to examine the effects of financial incentives on the quality of care, and to examine whether quality improvement interventions or incentives based on quality improve the performance of preventive care.

Determinants of patient satisfaction and willingness to return with emergency care

STUDY OBJECTIVE

To identify emergency department process of care measures that are significantly associated with satisfaction and willingness to return.

METHODS

Patient satisfaction and willingness to return at 5 urban, teaching hospital EDs were assessed. Baseline questionnaire, chart review, and 10-day follow-up telephone interviews were performed, and 38 process of care measures and 30 patient characteristic were collected for each respondent. Overall satisfaction was modeled with ordinal logistic regression. Willingness to return was modeled with logistic regression.

RESULTS

During a 1-month study period, 2,899 (84% of eligible) on-site questionnaires were completed. Telephone interviews were completed by 2,333 patients (80% of patients who completed a questionnaire). Patient-reported problems that were highly correlated with satisfaction included help not received when needed (odds ratio [OR] 0.345; 95% confidence interval [CI] 0.261 to 0.456), poor explanation of causes of problem (OR 0.434; 95% CI 0.345 to 0.546), not told about potential wait time (OR 0.479; 95% CI 0.399 to 0.577), not told when to resume normal activities (OR 0.691; 95% CI 0.531 to 0.901), poor explanation of test results (OR 0.647; 95% CI 0.495 to 0.845), and not told when to return to the ED (OR 0.656; 95% CI 0. 494 to 0.871). Other process of care measures correlated with satisfaction include nonacute triage status (OR 0.701, 95% CI 0.578 to 0.851) and number of treatments in the ED (OR 1.164 per treatment; 95% CI 1.073 to 1.263). Patient characteristics that significantly predicted less satisfaction included younger age and black race. Determinants of willingness to return include poor explanation of causes of problem (OR 0.328; 95% CI 0.217 to 0.495), unable to leave a message for family (OR 0.391; 95% CI 0.226 to 0. 677), not told about potential wait time (OR 0.561; 95% CI 0.381 to 0.825), poor explanation of test results (OR 0.541; 95% CI 0.347 to 0.846), and help not received when needed (OR 0.537; 95% CI 0.340 to 0.846). Patients with a chief complaint of hand laceration were less willing to return compared with a reference population of patients with abdominal pain. Willingness to return is strongly predicted by overall satisfaction (OR 2.601; 95% CI 2.292 to 2.951).

CONCLUSION

These data identify specific process of care measures that are determinants of patient satisfaction and willingness to return. Efforts to increase patient satisfaction and willingness to return should focus on improving ED performance on these identified process measures.

Differences in the quality of care for women with an abnormal mammogram or breast complaint

OBJECTIVE

To examine factors associated with variation in the quality of care for women with 2 common breast problems: an abnormal mammogram or a clinical breast complaint.

DESIGN

Cross-sectional patient survey and medical record review.

SETTING

Ten general internal medicine practices in the Greater Boston area.

PARTICIPANTS

Women who had an abnormal radiographic result from a screening mammogram or underwent mammography for a clinical breast complaint (N = 579).

MEASUREMENTS AND MAIN RESULTS

Three measures of the quality of care were used: (1) whether or not a woman received an evaluation in compliance with a clinical guideline; (2) the number of days until the appropriate resolution of this episode of breast care if any; and (3) a woman's overall satisfaction with her care. Sixty-nine percent of women received care consistent with the guideline. After adjustment, women over 50 years (odds ratio [OR], 1.58; 95% [CI], 1.06 to 2.36) and those with an abnormal mammogram (compared with a clinical breast complaint: OR, 1.75; 95% CI, 1.16 to 2.64) were more likely to receive recommended care and had a shorter time to resolution of their breast problem. Women with a managed care plan were also more likely to receive care in compliance with the guideline (OR, 1.72; 95% CI, 1.12 to 2.64) and have a more timely resolution. There were no differences in satisfaction by age or type of breast problem, but women with a managed care plan were less likely to rate their care as excellent (43% vs 53%, P <.05).

CONCLUSIONS

We found that a substantial proportion of women with a breast problem managed by generalists did not receive care consistent with a clinical guideline, particularly younger women with a clinical breast complaint and a normal or benign-appearing mammogram.

Obstacles to collaborative quality improvement: the case of ambulatory general medical care

OBJECTIVE

To assess the effectiveness of inter-site collaboration and report-card style feedback of quality measures on quality improvement in the outpatient setting and to identify major barriers to improvement.

DESIGN

A collaborative quality improvement effort consisting of a large cross-sectional data collection effort (chart reviews and patient surveys), feedback of comparative quality of care data to improvement teams, and collaboration between sites.

SETTING

Eleven primary care sites in the Boston area.

STUDY PARTICIPANTS

Quality improvement teams at each site with physician leaders.

INTERVENTION

Education about techniques of rapid-cycle quality improvement, coaching of on-site teams, and report-card style feedback of comparative site-specific quality of care data.

RESULTS

Multiple quality improvement projects were undertaken through this collaboration. However, though we were careful to educate teams on methods of continuous quality improvement and to name specific clinical leaders, the degree of collaboration and quality improvement fell short of expectations. Major impediments to improvement included lack of team members' time and resources, lack of incentives, and unempowered team leadership. The primary obstacle to collaboration was the diversity of sites and inability of teams to create interventions that were relevant to other sites.

CONCLUSION

Despite ample quality of care data, quality improvement education, and a structured collaborative process, achieving quality improvement in the ambulatory setting is still a difficult challenge. Organizations need to find ways of overcoming the obstacles faced by improvement teams in order to maximize quality improvement.

Incidence and types of adverse events and negligent care in Utah and Colorado

BACKGROUND

The ongoing debate on the incidence and types of iatrogenic injuries in American hospitals has been informed primarily by the Harvard Medical Practice Study, which analyzed hospitalizations in New York in 1984. The generalizability of these findings is unknown and has been questioned by other studies.

OBJECTIVE

We used methods similar to the Harvard Medical Practice Study to estimate the incidence and types of adverse events and negligent adverse events in Utah and Colorado in 1992.

DESIGN AND SUBJECTS

We selected a representative sample of hospitals from Utah and Colorado and then randomly sampled 15,000 nonpsychiatric 1992 discharges. Each record was screened by a trained nurse-reviewer for 1 of 18 criteria associated with adverse events. If > or =1 criteria were present, the record was reviewed by a trained physician to determine whether an adverse event or negligent adverse event occurred and to classify the type of adverse event.

MEASURES

The measures were adverse events and negligent adverse events.

RESULTS

Adverse events occurred in 2.9+/-0.2% (mean+/-SD) of hospitalizations in each state. In Utah, 32.6+/-4% of adverse events were due to negligence; in Colorado, 27.4+/-2.4%. Death occurred in 6.6+/-1.2% of adverse events and 8.8+/-2.5% of negligent adverse events. Operative adverse events comprised 44.9% of all adverse events; 16.9% were negligent, and 16.6% resulted in permanent disability. Adverse drug events were the leading cause of nonoperative adverse events (19.3% of all adverse events; 35.1% were negligent, and 9.7% caused permanent disability). Most adverse events were attributed to surgeons (46.1%, 22.3% negligent) and internists (23.2%, 44.9% negligent).

CONCLUSIONS

The incidence and types of adverse events in Utah and Colorado in 1992 were similar to those in New York State in 1984. Iatrogenic injury continues to be a significant public health problem. Improving systems of surgical care and drug delivery could substantially reduce the burden of iatrogenic injury.

Drug complications in outpatients

OBJECTIVE

Outpatient drug complications have not been well studied. We sought to assess the incidence and characteristics of outpatient drug complications, identify their clinical and nonclinical correlates, and evaluate their impact on patient satisfaction.

DESIGN

Retrospective chart reviews and patient surveys.

SETTING

Eleven Boston-area ambulatory clinics.

PATIENTS

We randomly selected 2,248 outpatients, 20 to 75 years old.

MEASUREMENTS AND MAIN RESULTS

Among 2,248 patients reporting prescription drug use, 394 (18%) reported a drug complication. In contrast, chart review revealed an adverse drug event in only 64 patients (3%). In univariate analyses, significant correlates of patient-reported drug complications were number of medical problems, number of medications, renal disease, failure to explain side effects before treatment, lower medication compliance, and primary language other than English or Spanish. In multivariate analysis, independent correlates were number of medical problems (odds ratio [OR] 1.17; 95% confidence interval [95% CI] 1.05 to 1.30), failure to explain side effects (OR 1.65; 95% CI, 1.16 to 2.35), and primary language other than English or Spanish (OR 1.40; 95% CI, 1.01 to 1.95). Patient satisfaction was lower among patients who reported drug complications (P <.0001). In addition, 48% of those reporting drug complications sought medical attention and 49% experienced worry or discomfort. On chart review, 3 (5%) of the patients with an adverse drug event required hospitalization and 8 (13%) had a documented previous reaction to the causative drug.

CONCLUSIONS

Drug complications in the ambulatory setting were common, although most were not documented in the medical record. These complications increased use of the medical system and correlated with dissatisfaction with care. Our results indicate a need for better communication about potential side effects of medications, especially for patients with multiple medical problems.

Negligent care and malpractice claiming behavior in Utah and Colorado

BACKGROUND

Previous studies relating the incidence of negligent medical care to malpractice lawsuits in the United States may not be generalizable. These studies are based on data from 2 of the most populous states (California and New York), collected more than a decade ago, during volatile periods in the history of malpractice litigation.

OBJECTIVES

The study objectives were (1) to calculate how frequently negligent and nonnegligent management of patients in Utah and Colorado in 1992 led to malpractice claims and (2) to understand the characteristics of victims of negligent care who do not or cannot obtain compensation for their injuries from the medical malpractice system.

DESIGN

We linked medical malpractice claims data from Utah and Colorado with clinical data from a review of 14,700 medical records. We then analyzed characteristics of claimants and nonclaimants using evidence from their medical records about whether they had experienced a negligent adverse event.

MEASURES

The study measures were negligent adverse events and medical malpractice claims.

RESULTS

Eighteen patients from our study sample filed claims: 14 were made in the absence of discernible negligence and 10 were made in the absence of any adverse event. Of the patients who suffered negligent injury in our study sample, 97% did not sue. Compared with patients who did sue for negligence occurring in 1992, these nonclaimants were more likely to be Medicare recipients (odds ratio [OR], 3.5; 95% CI [CI], 1.3 to 9.6), Medicaid recipients (OR, 3.6; 95% CI, 1.4 to 9.0), > or =75 years of age (OR, 7.0; 95% CI, 1.7 to 29.6), and low income earners (OR, 1.9; 95% CI, 0.9 to 4.2) and to have suffered minor disability as a result of their injury (OR, 6.3; 95% CI, 2.7 to 14.9).

CONCLUSIONS

The poor correlation between medical negligence and malpractice claims that was present in New York in 1984 is also present in Utah and Colorado in 1992. Paradoxically, the incidence of negligent adverse events exceeds the incidence of malpractice claims but when a physician is sued, there is a high probability that it will be for rendering nonnegligent care. The elderly and the poor are particularly likely to be among those who suffer negligence and do not sue, perhaps because their socioeconomic status inhibits opportunities to secure legal representation.

Is the professional satisfaction of general internists associated with patient satisfaction?

BACKGROUND

The growth of managed care has raised a number of concerns about patient and physician satisfaction. An association between physicians' professional satisfaction and the satisfaction of their patients could suggest new types of organizational interventions to improve the satisfaction of both.

OBJECTIVE

To examine the relation between the satisfaction of general internists and their patients.

DESIGN

Cross-sectional surveys of patients and physicians.

SETTING

Eleven academically affiliated general internal medicine practices in the greater-Boston area.

PARTICIPANTS

A random sample of English-speaking and Spanish-speaking patients (n = 2,620) with at least one visit to their physician (n = 166) during the preceding year.

MEASUREMENTS

Patients' overall satisfaction with their health care, and their satisfaction with their most recent physician visit.

MAIN RESULTS

After adjustment, the patients of physicians who rated themselves to be very or extremely satisfied with their work had higher scores for overall satisfaction with their health care (regression coefficient 2.10; 95% confidence interval 0.73-3.48), and for satisfaction with their most recent physician visit (regression coefficient 1.23; 95% confidence interval 0.26-2.21). In addition, younger patients, those with better overall health status, and those cared for by a physician who worked part-time were significantly more likely to report better satisfaction with both measures. Minority patients and those with managed care insurance also reported lower overall satisfaction.

CONCLUSIONS

The patients of physicians who have higher professional satisfaction may themselves be more satisfied with their care. Further research will need to consider factors that may mediate the relation between patient and physician satisfaction.

Benchmarking and quality improvement: the Harvard Emergency Department Quality Study

PURPOSE

To determine whether feedback of comparative information was associated with improvement in medical record and patient-based measures of quality in emergency departments.

SUBJECTS AND METHODS

During 1-month study periods in 1993 and 1995, all medical records for patients who presented to five Harvard teaching hospital emergency departments with one of six selected chief complaints (abdominal pain, shortness of breath, chest pain, hand laceration, head trauma, or vaginal bleeding) were reviewed for the percent compliance with process-of-care guidelines. Patient-reported problems and patient ratings of satisfaction with emergency department care were collected from eligible patients using patient questionnaires. After reviewing benchmark information, emergency department directors designed quality improvement interventions to improve compliance with the process-of-care guidelines and improve patient-reported quality measures.

RESULTS

In the preintervention period, 4,876 medical records were reviewed (99% of those eligible), 2,327 patients completed on-site questionnaires (84% of those eligible), and 1,386 patients completed 10-day follow-up questionnaires (80% of a random sample of eligible participants). In the postintervention period, 6,005 medical records were reviewed (99% of those eligible), 2,899 patients completed on-site questionnaires (84% of those eligible), and 2,326 patients completed 10-day follow-up questionnaires (80% of all baseline participants). In multivariate analyses, adjusting for age, urgency, chief complaint, and site, compliance with process-of-care guidelines increased from 55.9% (preintervention) to 60.4% (postintervention, P = 0.0001). We also found a 4% decrease (from 24% to 20%) in the rate of patient-reported problems with emergency department care (P = 0.0001). There were no significant improvements in patient ratings of satisfaction.

CONCLUSION

Feedback of benchmark information and subsequent quality improvement efforts led to small, although significant, improvement in compliance with process-of-care guidelines and patient-reported measures of quality. The measures that relied on patient reports of problems with care, rather than patient ratings of satisfaction with care, seemed to be more responsive to change. These results support the value of benchmarking and collaboration.

The effect of change of health insurance on access to care

This study examines how changes in health insurance status affect patients and their care. Results show that, controlling for socioeconomic factors, condition, age, and urgency, patients who lost insurance and patients who changed insurance were more likely to delay seeking care within the four months after visiting an emergency department than people whose health insurance status did not change. Patients who lost coverage were more likely to report no primary care provider and were less likely to have recommended follow-up care within the four-month period. Loss of insurance also was associated with lower likelihood of vaccine use and check-ups in the prior year. The study confirms that a loss or change in health insurance in the prior year has a measurable effect on access to health care. The greatest impact was among patients who lost insurance, though patients who changed health plans also were more likely to delay seeking care than patients whose health insurance status did not change.

Impact of language barriers on patient satisfaction in an emergency department

OBJECTIVE

To examine patient satisfaction and willingness to return to an emergency department (ED) among non-English speakers.

DESIGN

Cross-sectional survey and follow-up interviews 10 days after ED visit.

SETTING

Five urban teaching hospital EDs in the Northeastern United States.

PATIENTS

We surveyed 2,333 patients who presented to the ED with one of six chief complaints.

MEASUREMENTS AND MAIN RESULTS

Patient satisfaction, willingness to return to the same ED if emergency care was needed, and patient-reported problems with care were measured. Three hundred fifty-four (15%) of the patients reported English was not their primary language. Using an overall measure of patient satisfaction, only 52% of non-English-speaking patients were satisfied as compared with 71% of English speakers (p < .01). Among non-English speakers, 14% said they would not return to the same ED if they had another problem requiring emergency care as compared with 9.5% of English speakers (p < .05). In multivariate analysis adjusting for hospital site, age, gender, race/ethnicity, education, income, chief complaint, urgency, insurance status, Medicaid status, ED as the patient's principal source of care, and presence of a regular provider of care, non-English speakers were significantly less likely to be satisfied (odds ratio [OR] 0.59; 95% confidence interval [CI] 0.39, 0.90) and significantly less willing to return to the same ED (OR 0.57; 95% CI 0.34, 0.95). Non-English speakers also were significantly more likely to report overall problems with care (OR 1.70; 95% CI 1.05, 2.74), communication (OR 1.71; 95% CI 1.18, 2.47), and testing (OR 1.77; 95% CI 1.19, 2.64).

CONCLUSIONS

Non-English speakers were less satisfied with their care in the ED, less willing to return to the same ED if they had a problem they felt required emergency care, and reported more problems with emergency care. Strategies to improve satisfaction among this group of patients may include appropriate use of professional interpreters and increasing the language concordance between patients and providers.

Hospital admissions through the emergency department: does insurance status matter?

PURPOSE

To assess the effect of insurance status on the probability of admission and subsequent health status of patients presenting to emergency departments.

SUBJECTS AND METHODS

We performed a prospective cohort study of patients with common medical problems at five urban, academic hospital emergency departments in Boston and Cambridge, Massachusetts. The outcome measure for the study was admission to the hospital from the emergency department and functional health status at baseline and follow-up.

RESULTS

During a 1-month period, 2,562 patients younger than 65 years of age presented with either abdominal pain (52%), chest pain (19%) or shortness of breath (29%). Of the 1,368 patients eligible for questionnaire, 1,162 (85%) completed baseline questionnaires, and of these, 964 (83%) completed telephone follow-up interviews 10 days later. Fifteen percent of patients were uninsured and 34% were admitted to the hospital from the emergency department. Uninsured patients were significantly less likely than insured patients to be admitted, both when adjusting for urgency, chief complaint, age, gender and hospital (odds ratio = 0.5, 95% confidence interval 0.3 to 0.7), and when additionally adjusting for comorbid conditions, lack of a regular physician, income, employment status, education and race (odds ratio = 0.4, 95% confidence interval 0.2 to 0.8). However, there were no differences in adjusted functional health status between admitted and nonadmitted patients by insurance status, either at baseline or at 10-day follow-up.

CONCLUSIONS

Uninsured patients with one of three common chief complaints appear to be less frequently admitted to the hospital than are insured patients, although health status does not appear to be affected. Whether these results reflect underutilization among uninsured patients or overutilization among insured patients remains to be determined.

Nonurgent emergency department visits: the effect of having a regular doctor

OBJECTIVES

The authors assess the association between having a regular doctor and presentation for nonurgent versus urgent emergency department visits while controlling for potential confounders such as sociodemographics, health status, and comorbidity.

METHODS

A cross-sectional study was conducted in emergency departments of five urban teaching hospitals in the northeast. Adult patients presenting with chest pain, abdominal pain, or asthma (n = 1696; 88% of eligible) were studied. Patients completed a survey on presentation, reporting sociodemographics, health status, comorbid diseases, and relationship with a regular doctor. Urgency on presentation was assessed by chart review using explicit criteria.

RESULTS

Of the 1,696 study participants, 852 (50%) presented with nonurgent complaints. In logistic regression analyses, absence of a relationship with a regular physician was an independent correlate of presentation for a nonurgent emergency department visit (odds ratio 1.6; 95% confidence interval 1.2, 2.2) when controlling for age, gender, marital status, health status, and comorbid diseases. Race, lack of insurance, and education were not associated with nonurgent use.

CONCLUSIONS

Absence of a relationship with a regular doctor was correlated with use of the emergency department for selected nonurgent conditions when controlling for important potential confounders. Our study suggests that maintaining a relationship with a regular physician may reduce nonurgent use of the emergency department regardless of insurance status or health status.

The effect of supervision of residents on quality of care in five university-affiliated emergency departments

PURPOSE

To assess the impact of direct supervision of resident physicians by attending physicians on quality of care in emergency departments.

METHOD

In 1993, compliance with process-of-care guidelines was measured for 3,667 patients cared for by residents in five emergency departments in Boston and Cambridge, Massachusetts. Those patients presented with abdominal pain, asthma/COPD, chest pain, hand laceration, head trauma, or vaginal bleeding. A follow-up survey to assess patient satisfaction and reported problems with care was completed by 1,094 randomly sampled patients.

RESULTS

In multivariate analysis, residents directly supervised by attending physicians had significantly (p < .0001) higher adjusted mean percentage compliance with guidelines (64%) than did residents alone (55%). Better compliance was also associated with higher level of training of the resident and greater patient urgency. There was no significant difference between supervised and unsupervised residents in either adjusted patient satisfaction or reported problems with care.

CONCLUSIONS

Direct supervision of residents in emergency departments is significantly associated with better compliance with guidelines, regardless of level of training. However, direct supervision was not shown to influence patients' experience with care.

Insurance or a regular physician: which is the most powerful predictor of health care?

OBJECTIVES

This study compared the relative effects on access to health care of relationship with a regular physician and insurance status.

METHODS

The subjects were 1952 nonretired, non-Medicare patients aged 18 to 64 years who presented with 1 of 6 chief complaints to 5 academic hospital emergency departments in Boston and Cambridge, Mass, during a 1-month study period in 1995. Access to care was evaluated by 3 measures: delay in seeking care for the current complaint, no physician visit in the previous year, and no emergency department visit in the previous year.

RESULTS

After clinical and socioeconomic characteristics were controlled, lacking a regular physician was a stronger, more consistent predictor than insurance status of delay in seeking care (odds ratio [OR] = 1.6, 95% confidence interval [CI] = 1.2, 2.1), no physician visit [OR] = 4.5%, 95% CI = 3.3, 6.1), and no emergency department visit (OR = 1.8, 95% CI = 1.4, 2.4). For patients with a regular physician, access was no different between the uninsured and the privately insured. For privately insured patients, those with no regular physician had worse access than those with a regular physician.

CONCLUSIONS

Among patients presenting to emergency departments, relationship with a regular physician is a stronger predictor than insurance status of access to care.

Differences in the professional satisfaction of general internists in academically affiliated practices in the greater-Boston area. Ambulatory Medicine Quality Improvement Project Investigators

Managed care has created more professional constraints for general internists. We surveyed 198 general internists at 12 academically affiliated practices in the greater-Boston area to examine professional satisfaction. Overall, these physicians were moderately satisfied (mean of 59.1 on a 100-point scale). Before adjustment, women had lower overall satisfaction than men, as well as poorer satisfaction with the domains of career concerns and patient access. Gender had no independent effect on satisfaction after adjustment for age, income, percentage of time providing direct patient care, work status, and site. Younger physicians also had lower overall satisfaction, and these differences remained after adjustment. Improvements in professional satisfaction may be required to ensure the continued recruitment of young physicians, particularly women, into general internal medicine.

Patient-specific predictors of ambulance use

STUDY OBJECTIVE

To determine patient-specific socioeconomic and health status characteristics for patients arriving by ambulance at an emergency department.

METHODS

Ambulance use among adult ED patients presenting with abdominal pain, chest pain, head trauma, or shortness of breath was studied at five urban teaching hospitals in the north-eastern United States. Cross-sectional analysis within a prospective cohort study of 4,979 consecutive patients was performed using an interval sequence subset of 2,315 patients (84% of those eligible) to whom questionnaires were administered. Ambulance use (21% of surveyed patients; 26% of all patients) was analyzed with logistic regression.

RESULTS

Predictors of ambulance use included age greater than 65 years (odds ratio [OR], 1.95; 95% confidence interval [CI], 1.34 to 2.82); clinical severity (OR, 3.11; 95% CI, 2.27 to 4.25); poverty (OR, 1.40; 95% CI, 1.08 to 1.83); physical function (OR, 1.05; 95% CI, 1.02 to 1.09 for each point of worsening function on a 12-point physical function scale); and various types of health insurance coverage. Race, sex, education, Medicaid coverage, frequency of ED use, living arrangements, and primary physician availability were not predictive in multivariate analysis of surveyed patients.

CONCLUSION

Ambulance use varies by age, clinical severity, income, patient-specific characteristics of physical function, and type of health insurance. Medicaid coverage and frequent ED use are not predictive of increased ambulance use.

Relation between negligent adverse events and the outcomes of medical-malpractice litigation

BACKGROUND

We have previously shown that in New York State the initiation of malpractice suits correlates poorly with the actual occurrence of adverse events (injuries resulting from medical treatment) and negligence. There is little information on the outcome of such lawsuits, however. To assess the ability of malpractice litigation to make accurate determinations, we studied 51 malpractice suits to identify factors that predict payment to plaintiffs.

METHODS

Among malpractice claims that we reviewed independently in an earlier study, we identified 51 litigated claims and followed them over a 10-year period to determine whether the malpractice insurer had closed the case. We obtained detailed summaries of the cases from the insurers and reviewed the litigation files if the outcome of a case differed from the outcome predicted in our original review.

RESULTS

Of the 51 malpractice cases, 46 had been closed as of December 31, 1995. Among these cases, 10 of 24 that we originally identified as involving no adverse event were settled for the plaintiffs (mean payment, $28,760), as were 6 of 13 cases classified as involving adverse events but no negligence (mean payment, $98,192) and 5 of 9 cases in which adverse events due to negligence were found in our assessment (mean payment, $66,944). Seven of eight claims involving permanent disability were settled for the plaintiffs (mean payment, $201,250). In a multivariate analysis, disability (permanent vs. temporary or none) was the only significant predictor of payment (P=0.03). There was no association between the occurrence of an adverse event due to negligence (P = 0.32) or an adverse event of any type (P=0.79) and payment.

CONCLUSIONS

Among the malpractice claims we studied, the severity of the patient's disability, not the occurrence of an adverse event or an adverse event due to negligence, was predictive of payment to the plaintiff.

Predictors of atrial fibrillation after coronary artery surgery. Current trends and impact on hospital resources

BACKGROUND

Atrial fibrillation (AF) after coronary artery bypass surgery (CABG) is the most common sustained arrhythmia. Its pathophysiology is unclear, and its prevention and management remain suboptimal. The aim of this prospective study was to determine the current incidence of AF, identify its clinical predictors, and examine its impact on resource utilization.

METHODS AND RESULTS

Over a 12-month period ending July 31, 1994, a CABG procedure was performed on 570 consecutive patients (age range, 32 to 87 years; median age, 67 years; 232 [41%] were > or = 70 years; 175 [31%] were women; 173 [30%] were diabetics; 364 [65%] required nonelective surgery; 86 [15%] had had a prior CABG; and 86 [15%] had had prior percutaneous transluminal coronary angioplasty). AF occurred in 189 patients (33%). The median age for patients with AF was 71 years compared with 66 for patients without (P = .0001). Multivariate logistic regression analysis (odds ratio, +/- 95% CI, P value) was used to identify the following independent predictors of postoperative AF: increasing age (age 70 to 80 years [OR = 2; CI, 1.3 to 3; P = .002], age > 80 years [OR = 3; CI, 1.6 to 5.8; P = .0007]), male gender (OR = 1.7; CI, 1.1 to 2.7; P = .01), hypertension (OR = 1.6; CI, 1.0 to 2.3; P = .03), need for an intraoperative intraaortic balloon pump (OR = 3.5; CI, 1.2 to 10.9; P = .03), postoperative pneumonia (OR = 3.9; CI, 1.3 to 11.5; P = .01), ventilation for > 24 hours (OR = 2; CI, 1.3 to 3.2; P = .003), and return to the intensive care unit (OR = 3.2; CI, 1.1 to 8.8; P = .03). The mean length of hospital stay after surgery was 15.3 +/- 28.6 days for patients with AF compared with 9.3 +/- 19.6 days for patients without AF (P = .001). The adjusted length of hospital stay attributable to AF was 4.9 days, corresponding to > or = $10 055 in hospital charges.

CONCLUSIONS

AF remains the most common complication after CABG and consequently is a drain on hospital resources. Concerted efforts to reduce the incidence of AF and the associated increased length of stay would result in substantial cost saving and decrease patient morbidity.

Patient noncompliance with medical advice after the emergency department visit

STUDY OBJECTIVE

To determine the correlates of compliance with follow-up appointments and prescription filling after an emergency department visit.

METHODS

This prospective cohort study was undertaken as part of the Emergency Department Quality Study evaluation of five urban teaching hospital EDs in the northeastern United States. Of 2,757 eligible patients who presented with abdominal pain, asthma, chest pain, hand lacerations, head trauma, or first-trimester vaginal bleeding and were enrolled during 1-month period, 2,315 (84%) completed on-site baseline questionnaires. Information about diagnoses, socioeconomic status, discharge instructions, insurance status, and primary care was obtained from the on-site patient surveys and from reviews of medical records. A 76% random sample of patients who completed the questionnaire was generated, and 1,386 patients (79% of the sample) were interviewed by telephone approximately 10 days after their ED visit to determine compliance with follow-up appointments and prescription filling.

RESULTS

Of the 1,386 patients interviewed at 10 days, 914 (66%) had been discharged from the ED, and 408 (45%) of those discharged recalled being advised to take a medication. Fifty of these patients (12%) reported that they did not obtain the medication. Significant independent correlates of not filling prescriptions were lack of insurance (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.1 to 5.5) and dissatisfaction with discharge instructions (OR, 2.8; 95% CI, 1.2 to 6.4). Two hundred thirty-five (26%) of the discharged patients said they were given follow-up appointments and did not have an appointment pending at the time of the interview; 77 (33%) of these patients reported having missed their appointment. The only significant independent correlate of missing follow-up appointments was being given a telephone number to call instead of leaving the ED with an appointment scheduled (OR, 3.8; 95% CI, 1.7 to 8.8).

CONCLUSION

Not having an appointment made before leaving the ED was an independent correlate of missing follow-up appointments. Lack of insurance and dissatisfaction with discharge instructions were independent correlates of not filling prescriptions.

Do the poor sue more? A case-control study of malpractice claims and socioeconomic status

OBJECTIVE

To evaluate whether socioeconomic status is associated with risk of malpractice claims, particularly among those who have suffered medical injury.

DESIGN

Case-control study.

SETTING

Fifty-one hospitals in New York State.

METHODS

The presence and severity of medical injury, defined as disability at the time of discharge or prolongation of the hospitalization caused by medical treatment as opposed to the disease process, were assessed through review of approximately 31,000 hospital records in New York in 1984. These sampled records were then linked to formal malpractice claims. To estimate the risk of malpractice claims by age, gender, race, insurance status, and income, we conducted a case-control study of claimant cases matched with nonclaimant controls. The cases were all those patients who filed malpractice claims referring to alleged malpractice during a sampled hospitalization. Physician reviewers had previously judged the level of disability that resulted from the medical injury. Claimants (n = 51) were each matched with five nonclaimant controls on the basis of injury. Noninjured cases were matched with noninjured controls and injured cases were matched with injured controls.

RESULTS

We found that poor patients (odds ratio [OR], 0.2; 95% confidence interval [CI], 0.03 to 0.8) and uninsured patients (OR, 0.1; 95% CI, 0.005 to 0.9) were significantly less likely to file malpractice claims, after controlling for the severity of medical injury. Among patients who suffered medical injury, the elderly (OR, 0.2; 95% CI, 0.03 to 0.9) were also less likely to file claims. Gender and race were not independently associated with risk of malpractice claims.

CONCLUSIONS

Poor and uninsured patients are significantly less likely to sue for malpractice, even after controlling for the presence of medical injury. Fear of malpractice risk should not be a significant factor in the decision to serve the poor. Tort reforms that would protect physicians who serve the medically indigent from malpractice suits may not be warranted.

The effect of hospital financial characteristics on quality of care

OBJECTIVE

To assess the relationship among hospital financial characteristics, patient payer mix, and the incidence of negligent medical injuries.

DESIGN

Retrospective medical record review linked to hospital financial reports.

SETTING

Acute care hospitals in New York State in 1984.

POPULATION

Stratified, random sample of 30,195 medical records from 51 acute care hospitals.

MAIN OUTCOME MEASURES

Hospital rates of medical injury and substandard care were developed from reviews of 30,195 medical records at 51 acute care hospitals in New York in 1984. Hospital-level variables representing financial status, hospital staffing, and the proportion of self-pay and Medicaid hospital discharges were compiled from a variety of secondary sources.

RESULTS

The likelihood of negligent medical injury was highest in those hospitals with the lowest inpatient operating costs per hospital discharge (odds ratio, 2.8; 95% confidence interval, 1.5 to 5.5). The effect of low inpatient operating costs was marked among hospitals in financial distress, many of which served indigent populations.

CONCLUSIONS

Patients admitted to hospitals that are unable to expend sufficient resources on patient care may be at higher risk of substandard care. Further study of the effect of hospital financial status on quality of care appears to be warranted.

Sociodemographic determinants in the hospitalization decision: evaluation of an emergency department interhospital transfer policy

STUDY OBJECTIVES

To evaluate an emergency department's "treat and transfer" policy during a two-month period of reduced inpatient capacity by determining the number and characteristics of transferred patients not admitted as planned to the receiving hospital.

DESIGN

Matched case-control analysis.

SETTING

Public hospital adult ED.

TYPE OF PARTICIPANTS

Patients transferred to other hospitals for admission.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Twelve percent of patients (16 of 135) were not admitted after transfer during the first month, and 8% during the two-month period. Only IV drug use was found to be significantly associated with an increased risk of discharge without admission (odds ratio = 9.5; 95% confidence interval, 1.9 to 47.8).

CONCLUSION

Patients transferred from the public hospital ED resulted in admission to the receiving hospital in 92% of transfers. A history of IV drug use was the only characteristic found to be associated with discharge without admission to the accepting hospital.

Socioeconomic status and risk for substandard medical care

OBJECTIVE

To assess whether the socioeconomic status of the patient was associated with the risk of adverse events, defined as medical injuries caused by medical management, and the proportion of these events that resulted from substandard care.

SETTING

51 hospitals in New York State.

METHODS

Rates of medical injury and substandard care by gender, race, income, and payer status were developed from reviews of 30,195 medical records in New York in 1984. We evaluated these socioeconomic parameters in a multivariate analysis, while controlling for hospital-level factors.

RESULTS

We found that uninsured patients (odds ratio, 2.35; 95% confidence interval, 1.40 to 3.95) were at greater risk for substandard care. The characteristics of the hospitals to which patients were admitted did not affect this result. Race, gender, and income were not independently associated with risk for medical injury or substandard care in multivariate analyses.

CONCLUSION

Our findings suggest that the uninsured are at greater risk for suffering medical injury due to substandard medical care.