Assessing an innovative method to promote learning from patient narratives: Findings from a field experiment in ambulatory care

OBJECTIVE

To assess whether an online interactive report designed to facilitate interpretation of patients' narrative feedback produces change in ambulatory staff learning, behavior at the individual staff and practice level, and patient experience survey scores.

DATA SOURCES AND SETTING

We studied 22 ambulatory practice sites within an academic medical center using three primary data sources: 333 staff surveys; 20 in-depth interviews with practice leaders and staff; and 9551 modified CG-CAHPS patient experience surveys augmented by open-ended narrative elicitation questions.

STUDY DESIGN

We conducted a cluster quasi-experimental study, comparing 12 intervention and 10 control sites. At control sites, narratives were delivered free-form to site administrators via email; at intervention sites, narratives were delivered online with interactive tools for interpretation, accompanied by user training. We assessed control-versus-intervention site differences in learning, behavior, and patient experience scores.

DATA COLLECTION

Staff surveys and interviews were completed at intervention and control sites, 9 months after intervention launch. Patient surveys were collected beginning 4 months pre-launch through 9 months post-launch. We used control-versus-intervention and difference-in-difference analyses for survey data and thematic analysis for interview data.

PRINCIPAL FINDINGS

Interviews suggested that the interface facilitated narrative interpretation and use for improvement. Staff survey analyses indicated enhanced learning from narratives at intervention sites (29% over control sites' mean of 3.19 out of 5 across eight domains, p < 0.001) and greater behavior change at staff and practice levels (31% and 21% over control sites' means of 3.35 and 3.39, p < 0.001, respectively). Patient experience scores for interactions with office staff and wait time information increased significantly at intervention sites, compared to control sites (3.7% and 8.2%, respectively); however, provider listening scores declined 3.3%.

CONCLUSIONS

Patient narratives presented through structured feedback reporting methods can catalyze positive changes in staff learning, promote behavior change, and increase patient experience scores in domains of non-clinical interaction.

Learning from patients: The impact of using patients' narratives on patient experience scores

BACKGROUND

Enthusiasm has grown about using patients' narratives-stories about care experiences in patients' own words-to advance organizations' learning about the care that they deliver and how to improve it, but studies confirming association have not been published.

PURPOSE

We assessed whether primary care clinics that frequently share patients' narratives with their staff have higher patient experience survey scores.

APPROACH

We conducted a 1-year study of 5,545 adult patients and 276 staff affiliated with nine clinics in one health system. We used multilevel models to analyze survey data from patients about their experiences and from staff about exposure to useful narratives. We examined staff confidence in own knowledge as a moderator because confidence can influence use of new information sources.

RESULTS

Frequency of sharing useful narratives with staff was associated with patient experience scores for all measures, conditional on staff confidence in own knowledge ( p < .01). For operational measures (e.g., care coordination), increased sharing correlated with subsequently higher performance for more confident staff and lower performance or no difference for less confident staff, depending on measure. For relational measures (e.g., patient-provider communication), increased sharing correlated with higher scores for less confident staff and lower scores for more confident staff.

CONCLUSION

Sharing narratives with staff frequently is associated with better patient experience survey scores, conditional on confidence in knowledge.

PRACTICE IMPLICATIONS

Frequently sharing useful patient narratives should be encouraged as an organizational improvement strategy. However, organizations need to address how narrative feedback interacts with their staff's confidence to realize higher experience scores across domains.

Gaps in benefits, awareness, and comprehension that leave those with long COVID vulnerable

OBJECTIVES

The COVID-19 pandemic has left many suffering from long COVID, an episodic and debilitating chronic condition affecting people's ability to work and manage medical expenses. Though the Biden Administration has committed to conducting research and building support programs to alleviate the strain on those affected, in practice, static eligibility criteria for unemployment and disability benefits, patchy insurance coverage, and insufficient paid leave programs have left many people vulnerable. Given the magnitude of long COVID and the dearth to date of large-scale studies about its financial consequences, a focused qualitative analysis of lived experiences is warranted to understand and highlight gaps in the policy landscape.

METHODS

We conducted in-depth semi-structured interviews from 2020 to 2022 with 25 people with experience of long COVID living predominately in the Midwest.

RESULTS

Our inductive analysis revealed ways people became financially exhausted by uncertain medical care costs and precarious employment that left them trying, often alone, to access benefits. People described both experiences with workplace benefits and attempts to access federal benefits to address unstable employment situations created by protracted and uncertain functional impairments.

DISCUSSION

We explore pre- and post-pandemic era unemployment, disability, and insurance policies and offer recommendations for better supporting people with long COVID.

When Mistakes Multiply: How Inadequate Responses to Medical Mishaps Erode Trust in American Medicine

In this essay, we explore consequences of the systemic failure to track and to publicize the prevalence of patient-safety threats in American medicine. Tens of millions of Americans lose trust in medical care every year due to safety shortfalls. Because this loss of trust is long-lasting, the corrosive effects build up over time, yielding a collective maelstrom of mistrust among the American public. Yet no one seems to notice that patient safety is a root cause, because no one is counting. In addition to identifying the origins of this purblindness, we offer an alternative policy approach. This would call for government to transparently track safety threats through the systematic collection and reporting of patients' experiences. This alternative strategy offers real promise for stemming the erosion of trust that currently accompanies patient-safety shortfalls while staying consistent with Americans' preferences for a constrained government role with respect to medical care.

Evaluation of a protocol for eliciting narrative accounts of pediatric inpatient experiences of care

OBJECTIVE

To evaluate the measurement properties of a set of six items designed to elicit narrative accounts of pediatric inpatient experience.

DATA SOURCES

Data came from 163 participants recruited from a probability-based online panel of U.S. adults. Participants were family members of a child who had an overnight hospital stay in the past 12 months.

STUDY DESIGN

Cross-sectional survey with follow-up phone interviews.

DATA COLLECTION/EXTRACTION METHODS

Participants completed an online (n = 129) or phone (n = 34) survey about their child's hospitalization experience. The survey contained closed-ended items from the Child Hospital Consumer Assessment of Healthcare Providers and Systems (Child HCAHPS) survey, followed by the six narrative items. Approximately 2 weeks after completing the survey, 47 participants additionally completed a one-hour, semi-structured phone interview, the results of which served as a "gold standard" for evaluating the fidelity of narrative responses. Qualitative content analysis was used to code narrative and interview responses for domains of patient experience and actionability.

PRINCIPAL FINDINGS

The average narrative was 248 words (SD = 319). Seventy-nine percent of narratives mentioned a topic included in the Child HCAHPS survey; 89% mentioned a topic not covered by that survey; and 75% included at least one detailed description of an actionable event. Overall, there was 66% correspondence between narrative and interview responses. Correspondence was higher on the phone than in the online condition (75% vs. 59%).

CONCLUSIONS

Narratives elicited from rigorously designed multi-item sets can provide detailed, substantive information about pediatric inpatient experiences that hospitals could use to improve child and family experiences during pediatric hospitalization. They add context to closed-ended survey item responses and provide information about experiences of care important to children and families that are not included in quantitative surveys.

Long-Term Stability of Coverage Among Michigan Medicaid Beneficiaries : A Cohort Study

BACKGROUND

Medicaid, the primary source of insurance coverage for disadvantaged Americans, was originally designed as a temporary safety-net program. No studies have used long-run data to assess the recent use of the program by beneficiaries.

OBJECTIVE

To assess patterns of short- and long-term enrollment among beneficiaries, using a 10-year longitudinal panel of Michigan Medicaid eligibility data.

DESIGN

Primary analyses assessing trends in Medicaid enrollment among cohorts of existing and new beneficiaries.

SETTING

Administrative records from Michigan Medicaid for the period 2011 to 2020.

PARTICIPANTS

3.97 million Medicaid beneficiaries.

MEASUREMENTS

Short- and long-term enrollment in the program.

RESULTS

The sample includes 3.97 million unique beneficiaries enrolled at some point between 2011 and 2020. Among a cohort of 1.23 million beneficiaries enrolled in 2011, over half (53%) were also enrolled in Medicaid in June 2020, spending, on average, two-thirds of that period (67%) on Medicaid. These beneficiaries, however, experienced substantial lapses in coverage, as only 25% were continuously enrolled throughout the period. Enrollment was less stable when assessed from the perspective of newly enrolled beneficiaries, of whom only 37% remained enrolled at the end of the study period.

LIMITATION

Primary estimates from a single state.

CONCLUSION

For many beneficiaries, Medicaid has served as their primary source of coverage for at least a decade. This pattern would justify increasing investments in the program to improve long-term health outcomes.

PRIMARY FUNDING SOURCE

Self-funded.

Envisioning Complex Futures: Collective Narratives and Reasoning in Deliberations over Gene Editing in the Wild

The development of technologies for gene editing in the wild has the potential to generate tremendous benefit, but also raises important concerns. Using some form of public deliberation to inform decisions about the use of these technologies is appealing, but public deliberation about them will tend to fall back on various forms of heuristics to account for limited personal experience with these technologies. Deliberations are likely to involve narrative reasoning-or reasoning embedded within stories. These are used to help people discuss risks, processes, and fears that are otherwise difficult to convey. In this article, we identify three forms of collective narrative that are particularly relevant to debates about modifying genes in the wild. Our purpose is not to privilege any particular narrative, but to encourage people involved in deliberations to make these narratives transparent. Doing so can help guard against the way some narratives-referred to here as "crafted narratives"-may be manipulated by powerful elites and concentrated economic interests for their own strategic ends.

Chronic Pain Secondary to a Cervical Intramedullary Ependymoma: A Case Report

Intramedullary spinal cord tumors (IMSCT) are a rare subset of neoplasms classified based on anatomical location. The most common presenting symptom is pain; however, the high prevalence of back pain in the general public secondary to common causes including degenerative disc disease or osteoarthritis, makes diagnosing spinal cord tumors a challenge. We present a case of a 43-year-old male with a cervical intramedullary ependymoma to discuss the clinical presentation, diagnosis, and treatment of these spinal tumors.

Polyphonic perspectives on health and care: Reflections from two decades of the DIPEx project

In this article we consider how an online resource that publishes the findings and video, audio and written extracts from narrative interview studies has developed as an international collaboration, currently including 14 countries worldwide. In the two decades since the initiative was founded, the robust, national qualitative studies for DIPEx International have branched out from patient information and support to learning and teaching, insights and service improvement and cross-national comparisons. Embracing the challenge to reflect plural discourses of illness, health and care in societies that appear increasingly polarised, the DIPEx collaboration presents polyphonic perspectives that stand as potential counters to reductive dualities. As a result the collaboration has established a collection of unique, international resources that can be leveraged to promote understanding and learning from people's experiences of illness and care.

Stumbling Into Adulthood: Learning From Depression While Growing Up

Depression manifests in distinct ways across the life course. Recent research emphasizes how depression impedes development during emerging adulthood. However, our study-based on 40 interviews with emerging adults from multiple regions in the United States, analyzed following grounded theory-suggests a more complex narrative. Increasing experience with cycles of depression can also catalyze (a) mature perspectives and coping mechanisms that protect against depression's lowest lows; (b) deeper self-knowledge and direction, which in turn promoted a coherent personal identity; and (c) emergence of a life purpose, which fostered attainment of adult roles, skill development, greater life satisfaction, and enriched identity. Our synthesis reveals how depression during emerging adulthood can function at once as toxin, potential antidote, and nutritional supplement fostering healthy development. Our central finding that young adults adapt to rather than recover from depression can also enrich resilience theory, and inform both social discourse and clinical practice.

Broadening Medical Students' Exposure to the Range of Illness Experiences: A Pilot Curriculum Focused on Depression Education

PROBLEM

Exposing medical students to a broad range of illness experiences is crucial for teaching them to practice patient-centered care, but students often have limited interaction with patients with diverse illness presentations.

APPROACH

The authors developed, implemented, and evaluated a self-directed online curriculum followed by a small-group discussion focused on depression education. The curriculum was based on a module created using the Database of Individual Patients' Experiences methodology. Findings from 40 interviews with young adults across the United States about their diverse experiences with depression were summarized online, and the summaries were illustrated by video, audio, and text clips. From August 2016 to April 2017, third-year students completed either this online curriculum and the usual clerkship curriculum or just the usual clerkship curriculum. These intervention and control groups completed pre- and postsurveys.

OUTCOMES

Students in the intervention group reported that the online curriculum influenced their thinking about depression (51/56) nearly as often as they reported that seeing patients in clinic did (53/56). They also reported greater decreases in personal stigmatizing attitudes toward depression than did students in the control group as measured by the Depression Stigma Scale (5.75-4.02, intervention; 6.50-5.65, control; P = .004). In open-ended responses, students in the intervention group were 13 times more likely to describe key lessons from the curriculum that reflected patient heterogeneity.

NEXT STEPS

Future collaborations include implementing and evaluating this curriculum at other medical schools and developing additional versions based on other illness experiences.

The interventional magnetic resonance imaging suite: Experience in the design, development, and implementation in a pre-existing radiology space and review of concepts

Background:

Intraoperative magnetic resonance imaging (ioMRI) has led to significant advancements in neurosurgery with improved accuracy, assessment of the extent of resection, less invasive surgical alternatives, and real-time confirmation of targeting as well delivery of therapies. The costs associated with developing ioMRI units in the surgical suite have been obstacles to the expansion of their use. More recently, the development of hybrid interventional MRI (iMRI) units has become a viable alternative. The process of designing, developing, and implementing operations for these units requires the careful integration of environmental, technical, and safety elements of both surgical and MR practices. There is a paucity of published literature providing guidance for institutions looking to develop a hybrid iMRI unit, especially with a limited footprint in the radiology department.

Methods:

The experience of designing, developing, and implementing an iMRI in a preexisting space for neurosurgical procedures at a single institution in light of available options and the literature is described.

Results:

The development of the unit was accomplished through the engagement of a multidisciplinary team of stakeholders who utilized existing guidelines and recommendations and their own professional experience to address issues including physical layout, equipment selection, operations planning, infection control, and oversight/review, among others.

Conclusion:

Successful creation of an iMRI program requires multidisciplinary collaboration in integrating surgical and MR practice. The authors’ aim is that the experience described in this article will serve as an example for facilities or neurosurgical departments looking to navigate the same process.

What Words Convey: The Potential for Patient Narratives to Inform Quality Improvement

Policy Points Narratives about patients' experiences with outpatient care are essential for quality improvement because they convey ample actionable information that both elaborates on existing domains within patient experience surveys and describes multiple additional domains that are important to patients. The content of narrative feedback from patients can potentially be translated to improved quality in multiple ways: clinicians can learn from their own patients, groups of clinicians can learn from the experience of their peers' patients, and health system administrators can identify and respond to patterns in patients' accounts that reflect systemic challenges to quality. Consistent investment by payers and providers is required to ensure that patient narratives are rigorously collected, analyzed fully, and effectively used for quality improvement.

CONTEXT

For the past 25 years, health care providers and health system administrators have sought to improve care by surveying patients about their experiences. More recently, policymakers have acted to promote this learning by deploying financial incentives tied to survey scores. This article explores the potential of systematically elicited narratives about experiences with outpatient care to enrich quality improvement.

METHODS

Narratives were collected from 348 patients recruited from a nationally representative Internet panel. Drawing from the literature on health services innovation, we developed a two-part coding schema that categorized narrative content in terms of (a) the aspects of care being described, and (b) the actionability of this information for clinicians, quality improvement staff, and health system administrators. Narratives were coded using this schema, with high levels of reliability among the coders.

FINDINGS

The scope of outpatient narratives divides evenly among aspects of care currently measured by patient experience surveys (35% of content), aspects related to measured domains but not captured by existing survey questions (31%), and aspects of care that are omitted from surveys entirely (34%). Overall, the narrative data focused heavily on relational aspects of care (43%), elaborating on this aspect of experience well beyond what is captured with communication-related questions on existing surveys. Three-quarters of elicited narratives had some actionable content, and almost a third contained three or more separate actionable elements.

CONCLUSIONS

In a health policy environment that incentivizes attention to patient experience, rigorously elicited narratives hold substantial promise for improving quality in general and patients' experiences with care in particular. They do so in two ways: by making concrete what went wrong or right in domains covered by existing surveys, and by expanding our view of what aspects of care matter to patients as articulated in their own words and thus how care can be made more patient-centered. Most narratives convey experiences that are potentially actionable by those committed to improving health care quality in outpatient settings.

Improving Patients' Choice of Clinician by Including Roll-up Measures in Public Healthcare Quality Reports: an Online Experiment

BACKGROUND

Public reports on healthcare quality typically include complex data. To lower the cognitive burden of interpreting these data, some report designers create summary, or roll-up, measures combining multiple indicators of quality into one score. Little is known about how the availability of roll-ups affects clinician choice.

OBJECTIVE

To determine how presenting quality scores at different levels of aggregation affects patients' clinician choices.

DESIGN

We conducted a simulated clinician-choice experiment, randomizing participants to three versions of a public reporting website and comparing their clinician choices. One version aggregated all clinician-level quality measures into roll-ups, the second provided disaggregated (drill-down) scores only, and the third offered both roll-ups and drill-downs.

PARTICIPANTS

Five hundred fifty panelists drawn from a probability-based Internet panel.

MAIN MEASURES

We assessed the amount of effort participants exerted by tracking the length of time spent on the website and the number of concrete actions taken on the website (e.g., clicking items). We evaluated decision quality by measuring whether participants selected a clinician who performed more poorly than others and incongruence between participants' stated preferences for dimensions of quality and their chosen clinician's performance on those dimensions.

KEY RESULTS

Participants seeing drill-downs alone (mean = 14.9) or with roll-ups (mean = 19.2) took more actions than those who saw roll-ups alone (mean = 10.5) (ps < 0.05). However, participants seeing only drill-downs made poorer choices than those who saw roll-ups alone or with drill-downs. More participants seeing drill-downs chose a clinician who was outperformed (36.3% versus 23.4% [roll-up] and 25.6% [drill-down + roll-up], ps < 0.05) and made choices incongruent with stated preferences (51.2% versus 45.6% [roll-up] and 47.5% [drill-down + roll-up], ps < 0.05). The distinction between roll-up and drill-down was somewhat stronger for sicker participants.

CONCLUSIONS

Our results suggest that roll-ups in healthcare quality reports, alone or as a complement to drill-downs, can help patients make better decisions for themselves.

A Rigorous Approach to Large-Scale Elicitation and Analysis of Patient Narratives

Patient narratives have emerged as promising vehicles for making health care more responsive by helping clinicians to better understand their patients' expectations, perceptions, or concerns and encouraging consumers to engage with information about quality. A growing number of websites incorporate patients' comments. But existing comments have fragmentary content, fail to represent less vocal patients, and can be manipulated to "manage" providers' reputations. In this article, we offer the first empirical test of the proposition that patient narratives can be elicited rigorously and reliably using a five-question protocol that can be incorporated into large-scale patient experience surveys. We tested whether elicited narratives about outpatient care are complete (report all facets of patient experience), balanced (convey an accurate mix of positive and negative events), meaningful (have a coherent storyline), and representative (draw fulsome narratives from all relevant subsets of patients). The tested protocol is strong on balance and representativeness, more mixed on completeness and meaningfulness.

A cross-sectional study assessing the association between online ratings and clinical quality of care measures for US hospitals: results from an observational study

Background

Little is known about the usefulness of online ratings when searching for a hospital. We therefore assess the association between quantitative and qualitative online ratings for US hospitals and clinical quality of care measures.

Methods

First, we collected a stratified random sample of 1000 quantitative and qualitative online ratings for hospitals from the website RateMDs. We used an integrated iterative approach to develop a categorization scheme to capture both the topics and sentiment in the narrative comments. Next, we matched the online ratings with hospital-level quality measures published by the Centers for Medicare and Medicaid Services. Regarding nominally scaled measures, we checked for differences in the distribution among the online rating categories. For metrically scaled measures, we applied the Spearman rank coefficient of correlation.

Results

Thirteen of the twenty-nine quality of care measures were significantly associated with the quantitative online ratings (Spearman p = ±0.143, p < 0.05 for all). Thereof, eight associations indicated better clinical outcomes for better online ratings. Seven of the twenty-nine clinical measures were significantly associated with the sentiment of patient narratives (p = ±0.114, p < 0.05 for all), whereof four associations indicated worse clinical outcomes in more favorable narrative comments.

Conclusions

There seems to be some association between quantitative online ratings and clinical performance measures. However, the relatively weak strength and inconsistency of the direction of the association as well as the lack of association with several other clinical measures may not enable the drawing of strong conclusions. Narrative comments also seem to have limited potential to reflect the clinical quality of care in its current form. Thus, online ratings are of limited usefulness in guiding patients towards high-performing hospitals from a clinical point of view. Nevertheless, patients might prefer different aspects of care when choosing a hospital.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-2886-3) contains supplementary material, which is available to authorized users.

Choosing Doctors Wisely: Can Assisted Choice Enhance Patients’ Selection of Clinicians?

We conducted a simulated clinician-choice experiment, comparing choices and decision-making processes of participants ( N = 688) randomized among four experimental arms: a conventional website reporting only quantitative performance information, a website reporting both qualitative (patient comments) and quantitative information, the second website augmented by a decision aid (labeling of patient comments), and the decision-aided website further augmented by the presence of a trained navigator. Introducing patient comments enhanced engagement with the quality information but led to a decline in decision quality, particularly the consistency of choices with consumers’ stated preferences. Labeling comments helped erase the decline in decision quality, although the highest percentage of preference-congruent choices was seen in the navigator arm. Engagement with the quality information and satisfaction with choices available were likewise highest in the navigator arm. Findings held for high- and low-skilled decision makers. Thus, navigator assistance may be a promising strategy for equitably promoting higher quality choices in information-rich contexts.

Racial and Ethnic Disparities in the Use of High-Volume Hospitals

Differences in the source of care could contribute to racial and ethnic disparities in health status. This study looks at a major metropolitan area and examines racial and ethnic differences in the use of high-volume hospitals for 17 services for which there is a documented positive volume-outcome relationship. Focusing on the hospitalizations of New York City area residents in the periods 1995-1996 and 2001–2002, we found, after controlling for socioeconomic characteristics, insurance coverage, proximity of residence to a high-volume hospital, and paths to hospitalization, that minority patients were significantly less likely than whites to be treated at high-volume hospitals for most volume-sensitive services. The largest disparities were between blacks and whites for cancer surgeries and cardiovascular procedures.

"Oh, the Places You'll Go" by Bringing Developmental Science Into the World!

Urie Bronfenbrenner and Ernest Boyer argued for leaving the laboratory to conduct rigorous developmental research in the real world where children are found-in the places they go. Contributions to this special issue meet Bronfenbrenner and Boyer's call while at the same time recognizing the continued importance of laboratory research. These articles range from a review of research on the arts to a language intervention in Senegal to large-scale dissemination and intervention projects designed to communicate the best developmental science to families, public agencies, and schools. Together these articles illustrate how we can study development in the world and enrich our work on the factors that promote development. Taking this path presents us with a set of additional hurdles to be addressed, such as how to communicate with the public and how to scale up our interventions in the face of diversity along many dimensions.

Using "roll-up" measures in healthcare quality reports: perspectives of report sponsors and national alliances

OBJECTIVES

To understand the views of prominent organizations in the field of healthcare quality on the topic of reporting roll-up measures that combine indicators of multiple, often disparate, dimensions of care to consumers.

STUDY DESIGN

This study used a semi-structured, qualitative interview design.

METHODS

We conducted 30- to 60-minute semi-structured telephone interviews with representatives of 10 organizations that sponsor public healthcare quality reports and 3 national alliances representing multiple stakeholder groups. We conducted a thematic analysis of interview transcriptions to identify common issues and concerns related to reporting roll-up measures.

RESULTS

Among sponsors reporting roll-up measures, current practices for calculating and reporting these measures are diverse. The main perceived benefit of reporting roll-up measures is that they simplify large amounts of complex information for consumers. The main concern is the potential for consumers to misunderstand the measures and what associated roll-up scores communicate about provider performance. Report sponsors and national alliances feel that more guidance and research on the methods for producing and reporting scores for roll-up measures are needed.

CONCLUSIONS

The results of the interviews elucidate the need for research focused on construction and reporting of roll-up measures. Studies are needed to determine if roll-up measures are indeed perceived by consumers as being less complex and easier to understand.

Educating, Enrolling, And Engaging: The State Of Marketplace Consumer Assistance Under The Affordable Care Act

Programs created under the Affordable Care Act to connect consumers to health care coverage represent an unprecedented public-sector investment. State-level implementation of these programs has varied greatly, making it possible to learn from differences in strategy and performance. In this article we assess the current state of Marketplace enrollment assistance, synthesizing evidence from published evaluations (largely derived from grey literature) and analyses of data from nationwide surveys of assisters. Synthesis of this evidence suggests that assister programs play a vital role supporting consumers in the new Marketplaces, particularly when assisters maintain extended ongoing relationships with consumers; assisters come from and are situated within communities they serve; local programs are well coordinated; and postenrollment issues can be addressed. Stable funding commitments, year-round employment, and enriched training were identified as crucial long-run strategies for building a more professional assister workforce and stronger infrastructure.

CAHPS and Comments: How Closed-Ended Survey Questions and Narrative Accounts Interact in the Assessment of Patient Experience

Objectives:

To investigate whether content from patient narratives explains variation in patients’ primary care provider (PCP) ratings beyond information from the closed-ended questions of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Clinician and Group Survey and whether the relative placement of closed- and open-ended survey questions affects either the content of narratives or the CAHPS composite scores.

Methods:

Members of a standing Internet panel (N = 332) were randomly assigned to complete a CAHPS survey that was either preceded or followed by a set of open-ended questions about how well their PCP meets their expectations and how they relate to their PCP.

Results:

Narrative content from healthier patients explained only an additional 2% beyond the variation in provider ratings explained by CAHPS composite measures. Among sicker patients, narrative content explained an additional 10% of the variation. The relative placement of closed- and open-ended questions had little impact on narratives or CAHPS scores.

Conclusion:

Incorporating a protocol for eliciting narratives into a patient experience survey results in minimal distortion of patient feedback. Narratives from sicker patients help explain variation in provider ratings.

Measuring Community Benefits Provided by Nonprofit and For-Profit HMOs

Despite the dramatic shift from nonprofit to for-profit ownership in the managed care industry, little is known about the implications for health plans' relations with the communities in which they operate. This paper provides the first comprehensive comparison of the community benefit activities of nonprofit and for-profit health maintenance organizations (HMOs). We develop a conceptual framework for identifying these activities and provide evidence from a nationally representative survey of plans fielded in 1999. We find that nonprofit plans exceed their for-profit counterparts on some, but not all, aspects of community benefit activity. The most consistent ownership-related differences involve redistributive programs (subsidized services and general philanthropy), commitments to medical research, and services that benefit the entire local population, beyond the plan's enrollees. Other forms of community benefits show mixed or modest differences between nonprofit and for-profit plans. Unexpectedly, for-profit plans actually appear more active in helping consumers deal with information asymmetries. The paper concludes with a discussion of implications for policy and future research.

Incomplete Markets and Imperfect Institutions: Some Challenges Posed by Trust for Contemporary Health Care and Health Policy

As contemporary health policy promotes evidence-based practices using targeted incentives, policy makers may lose track of vital aspects of care that are difficult to measure. For more than a half century, scholars have recognized that these latter aspects play a crucial role in high-quality care and equitable health system performance but depend on the potentially frail reed of providers' trustworthiness: that is, their commitment to facets and outcomes of care not easily assessed by external parties. More recently, early experience with pay for performance in health settings suggests that enhancing financial rewards for the measurable undermines providers' commitment to the unmeasurable, degrading the trustworthiness of their practices. Reformers have looked to revised professional norms or reorganized practice arrangements to bolster the intrinsic motivations required for trustworthiness. We suggest here that these responses are likely to prove inadequate. We propose that they be complemented by a renewed policy-making commitment to nonprofit ownership among health care providers, insurers, and integrated delivery systems. We identify some of the concerns raised in the past with ownership-based policies and propose a set of responses. If these are pursued in combination, they hold the promise of a sustainable ownership-based policy reform for the United States.

MRI contrast agent concentration and tumor interstitial fluid pressure

The present work describes the relationship between tumor interstitial fluid pressure (TIFP) and the concentration of contrast agent for dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI). We predict the spatial distribution of TIFP based on that of contrast agent concentration. We also discuss the cases for estimating tumor interstitial volume fraction (void fraction or porosity of porous medium), ve, and contrast volume transfer constant, K(trans), by measuring the ratio of contrast agent concentration in tissue to that in plasma. A linear fluid velocity distribution may reflect a quadratic function of TIFP distribution and lead to a practical method for TIFP estimation. To calculate TIFP, the parameters or variables should preferably be measured along the direction of the linear fluid velocity (this is in the same direction as the gray value distribution of the image, which is also linear). This method may simplify the calculation for estimating TIFP.

Hospital Quality Reporting in the United States: Does Report Card Design and Incorporation of Patient Narrative Comments Affect Hospital Choice?

OBJECTIVE

To explore the impact of hospital report card design and incorporation of patient narrative comments on consumers' choices of hospitals.

DATA SOURCES

Primary data collected from an online survey with 1,350 respondents in February, 2015.

STUDY DESIGN

A randomized 2 (narrative comments: yes, no) × 3 (design: representation of clinical performance in textual, star, numerical formats) between-subject online-based cross-sectional experiment.

PRINCIPAL FINDINGS

In 51 percent of all cases, respondents selected the hospital with the best clinical results. Report cards with a numerical design induced choices more focused on clinical ratings (56.0 percent chose the highest rated hospital) than those with textual information (48.1 percent) or star ratings (47.3 percent) (p < .001). Report cards without narrative comments (49.7 percent) and with narratives (51.4 percent) were not associated with significant difference in selecting top-rated clinical hospitals (p = .376). But there were significant interactions affecting choice of hospitals among exposure to narratives, formatting of clinical performance, and respondents' education.

CONCLUSIONS

Consumers have a difficult time synthesizing quality data in various formats. Hospital report cards continue to pose challenging choices, especially for those with limited education. Narrative comments in their earliest emerging forms do not seem to be altering hospital choice as much as the literature has suggested for other providers, but they may have consequential impact on the choices of certain subsets of consumers.

Breaking Narrative Ground: Innovative Methods for Rigorously Eliciting and Assessing Patient Narratives

OBJECTIVE

To design a methodology for rigorously eliciting narratives about patients' experiences with clinical care that is potentially useful for public reporting and quality improvement.

DATA SOURCES/STUDY SETTING

Two rounds of experimental data (N = 48 each) collected in 2013-2014, using a nationally representative Internet panel.

STUDY DESIGN

Our study (1) articulates and operationalizes criteria for assessing narrative elicitation protocols; (2) establishes a "gold standard" for assessment of such protocols; and (3) creates and tests a protocol for narratives about outpatient treatment experiences.

DATA COLLECTION/EXTRACTION METHODS

We randomized participants between telephone and web-based modalities and between protocols placed before and after a closed-ended survey.

PRINCIPAL FINDINGS

Elicited narratives can be assessed relative to a gold standard using four criteria: (1) meaningfulness, (2) completeness, (3) whether the narrative accurately reflects the balance of positive and negative events, and (4) representativeness, which reflects the protocol's performance across respondent subgroups. We demonstrate that a five-question protocol that has been tested and refined yields three- to sixfold increases in completeness and four- to tenfold increases in meaningfulness, compared to a single open-ended question. It performs equally well for healthy and sick patients.

CONCLUSIONS

Narrative elicitation protocols suitable for inclusion in extant patient experience surveys can be designed and tested against objective performance criteria, thus advancing the science of public reporting.

Helicobacter pylori infection in patients with selective immunoglobulin a deficiency

Selective immunoglobulin A (IgA) deficiency (IgAD) is the most common primary immunodeficiency in the western world. The aim of the study was to investigate the prevalence and clinical characteristics of Helicobacter pylori-infected dyspeptic patients with IgAD. Case samples were drawn from all subjects ≥ 12 years of age (n = 104729) who had undergone serum total IgA measurements during 2004-14 for any reason at Leumit Healthcare Services (Israel) and had serum total IgA < 0·07 g/l. The control group was comprised of a random sample of remaining patients with a case-control ratio of 10 controls for each case. The dyspeptic diseases were identified and retrieved from Leumit Health Care Services electronic database using specific ICD-9-CM diagnostic codes. The case group included 347 subjects and the control group 3470 subjects. There were no significant differences in the prevalence of patients with dyspepsia [84 (24·2%) versus 821 (23·6%) for cases and controls, respectively]. Additionally, there was no difference in a proportion of dyspeptic H. pylori-positive subjects [59 (17·1%) versus 524 (15·1%)] between the case and control groups. Only 59 (17%) among the 347 IgAD patients underwent gastroscopy. A significantly larger proportion of case subjects experienced several forms of gastritis [13 (61·9%) versus 38 (21·6%), P < 0·001), duodenal ulcers [seven (33·3%) versus 19 (10·8%); P = 0·01] and nodular lymphoid hyperplasia (NLH) [two (9·5%) versus none; P = 0·011]. IgAD is not associated with increased prevalence of H. pylori-associated dyspepsia; nevertheless, H. pylori-infected dyspeptic IgAD subjects experience more EGD-proved gastritis, duodenal ulcers and NLH.

Using Patient-Reported Information to Improve Clinical Practice

OBJECTIVE

To assess what is known about the relationship between patient experience measures and incentives designed to improve care, and to identify how public policy and medical practices can promote patient-valued outcomes in health systems with strong financial incentives.

DATA SOURCES/STUDY SETTING

Existing literature (gray and peer-reviewed) on measuring patient experience and patient-reported outcomes, identified from Medline and Cochrane databases; evaluations of pay-for-performance programs in the United States, Europe, and the Commonwealth countries.

STUDY DESIGN/DATA COLLECTION

We analyzed (1) studies of pay-for-performance, to identify those including metrics for patient experience, and (2) studies of patient experience and of patient-reported outcomes to identify evidence of influence on clinical practice, whether through public reporting or private reporting to clinicians.

PRINCIPAL FINDINGS

First, we identify four forms of "patient-reported information" (PRI), each with distinctive roles shaping clinical practice: (1) patient-reported outcomes measuring self-assessed physical and mental well-being, (2) surveys of patient experience with clinicians and staff, (3) narrative accounts describing encounters with clinicians in patients' own words, and (4) complaints/grievances signaling patients' distress when treatment or outcomes fall short of expectations. Because these forms vary in crucial ways, each must be distinctively measured, deployed, and linked with financial incentives. Second, although the literature linking incentives to patients experience is limited, implementing pay-for-performance systems appears to threaten certain patient-valued aspects of health care. But incentives can be made compatible with the outcomes patients value if: (a) a sufficient portion of incentives is tied to patient-reported outcomes and experiences, (b) incentivized forms of PRI are complemented by other forms of patient feedback, and (c) health care organizations assist clinicians to interpret and respond to PRI. Finally, we identify roles for the public and private sectors in financing PRI and orchestrating an appropriate balance among its four forms.

CONCLUSIONS

Unless public policies are attentive to patients' perspectives, stronger financial incentives for clinicians can threaten aspects of care that patients most value. Certain policy parameters are already clear, but additional research is required to clarify how best to collect patient narratives in varied settings, how to report narratives to consumers in conjunction with quantified metrics, and how to promote a "culture of learning" at the practice level that incorporates patient feedback.

Interstitial hydraulic conductivity and interstitial fluid pressure for avascular or poorly vascularized tumors

A correct description of the hydraulic conductivity is essential for determining the actual tumor interstitial fluid pressure (TIFP) distribution. Traditionally, it has been assumed that the hydraulic conductivities both in a tumor and normal tissue are constant, and that a tumor has a much larger interstitial hydraulic conductivity than normal tissue. The abrupt transition of the hydraulic conductivity at the tumor surface leads to non-physical results (the hydraulic conductivity and the slope of the TIFP are not continuous at tumor surface). For the sake of simplicity and the need to represent reality, we focus our analysis on avascular or poorly vascularized tumors, which have a necrosis that is mostly in the center and vascularization that is mostly on the periphery. We suggest that there is an intermediary region between the tumor surface and normal tissue. Through this region, the interstitium (including the structure and composition of solid components and interstitial fluid) transitions from tumor to normal tissue. This process also causes the hydraulic conductivity to do the same. We introduce a continuous variation of the hydraulic conductivity, and show that the interstitial hydraulic conductivity in the intermediary region should be monotonically increasing up to the value of hydraulic conductivity in the normal tissue in order for the model to correspond to the actual TIFP distribution. The value of the hydraulic conductivity at the tumor surface should be the lowest in value.

Quantum-classical transition and quantum activation of ratchet currents in the parameter space

The quantum ratchet current is studied in the parameter space of the dissipative kicked rotor model coupled to a zero-temperature quantum environment. We show that vacuum fluctuations blur the generic isoperiodic stable structures found in the classical case. Such structures tend to survive when a measure of statistical dependence between the quantum and classical currents are displayed in the parameter space. In addition, we show that quantum fluctuations can be used to overcome transport barriers in the phase space. Related quantum ratchet current activation regions are spotted in the parameter space. Results are discussed based on quantum, semiclassical, and classical calculations. While the semiclassical dynamics involves vacuum fluctuations, the classical map is driven by thermal noise.

Context-based strategies for engaging consumers with public reports about health care providers

Efforts to engage consumers in the use of public reports on health care provider performance have met with limited success. Fostering greater engagement will require new approaches that provide consumers with relevant content at the time and in the context they need to make a decision of consequence. To this end, we identify three key factors influencing consumer engagement and show how they manifest in different ways and combinations for four particular choice contexts that appear to offer realistic opportunities for engagement. We analyze how these engagement factors play out differently in each choice context and suggest specific strategies that sponsors of public reports can use in each context. Cross-cutting lessons for report sponsors and policy makers include new media strategies such as a commitment to adaptive web-based reporting, new metrics with richer emotional content, and the use of navigators or advocates to assist consumers with interpreting reports.

National hospice survey results: for-profit status, community engagement, and service

IMPORTANCE The impact of the substantial growth in for-profit hospices in the United States on quality and hospice access has been intensely debated, yet little is known about how for-profit and nonprofit hospices differ in activities beyond service delivery. OBJECTIVE To determine the association between hospice ownership and (1) provision of community benefits, (2) setting and timing of the hospice population served, and (3) community outreach. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional survey (the National Hospice Survey), conducted from September 2008 through November 2009, of a national random sample of 591 Medicare-certified hospices operating throughout the United States. EXPOSURES For-profit or nonprofit hospice ownership. MAIN OUTCOMES AND MEASURES Provision of community benefits; setting and timing of the hospice population served; and community outreach. RESULTS A total of 591 hospices completed our survey (84% response rate). For-profit hospices were less likely than nonprofit hospices to provide community benefits including serving as training sites (55% vs 82%; adjusted relative risk [ARR], 0.67 [95% CI, 0.59-0.76]), conducting research (18% vs 23%; ARR, 0.67 [95% CI, 0.46-0.99]), and providing charity care (80% vs 82%; ARR, 0.88 [95% CI, 0.80-0.96]). For-profit compared with nonprofit hospices cared for a larger proportion of patients with longer expected hospice stays including those in nursing homes (30% vs 25%; P = .009). For-profit hospices were more likely to exceed Medicare's aggregate annual cap (22% vs 4%; ARR, 3.66 [95% CI, 2.02-6.63]) and had a higher patient disenrollment rate (10% vs 6%; P &lt; .001). For-profit were more likely than nonprofit hospices to engage in outreach to low-income communities (61% vs 46%; ARR, 1.23 [95% CI, 1.05-1.44]) and minority communities (59% vs 48%; ARR, 1.18 [95% CI, 1.02-1.38]) and less likely to partner with oncology centers (25% vs 33%; ARR, 0.59 [95% CI, 0.44-0.80]). CONCLUSIONS AND RELEVANCE Ownership-related differences are apparent among hospices in community benefits, population served, and community outreach. Although Medicare's aggregate annual cap may curb the incentive to focus on long-stay hospice patients, additional regulatory measures such as public reporting of hospice disenrollment rates should be considered as the share of for-profit hospices in the United States continues to increase.

Explaining racial/ethnic disparities in use of high-volume hospitals: decision-making complexity and local hospital environments

Racial/ethnic minorities are less likely to use higher-quality hospitals than whites. We propose that a higher level of information-related complexity in their local hospital environments compounds the effects of discrimination and more limited access to services, contributing to racial/ethnic disparities in hospital use. While minorities live closer than whites to high-volume hospitals, minorities also face greater choice complexity and live in neighborhoods with lower levels of medical experience. Our empirical results reveal that it is generally the overall context associated with proximity, choice complexity, and local experience, rather than differential sensitivity to these factors, that provides a partial explanation of the disparity gap in high-volume hospital use.

The Affordable Care Act's plan for consumer assistance with insurance moves states forward but remains a work in progress

The Affordable Care Act provides support for state-run consumer assistance programs to help privately insured consumers who experience problems with their coverage. Its provisions signify the first national commitment to such assistance and to using cases aggregated by these state programs to inform policy. We interviewed state-level administrators and analyzed program documents to assess whether federal support for state-run consumer assistance programs achieved certain goals. We found that some federally supported programs made substantial progress in supporting and empowering patients by reorienting state agencies to become active advocates for their citizens. Yet progress across the country was inconsistent, and there was little evidence that programs addressed systemic problems experienced by consumers. On balance, the consumer assistance provisions of health care reform do not yet ensure protection for all privately insured Americans because of uneven implementation-a problem likely to be of further concern as coverage is expanded and health insurance exchanges come on line in 2014. At the same time, the demonstrated impact of consumer assistance programs in the most innovative states is arguably a useful "proof of concept" for this young federal program.

Complexity, public reporting, and choice of doctors: a look inside the blackest box of consumer behavior

Health care consumers often make choices that are imperfectly informed and inconsistent with their expressed preferences. Past research suggests that these shortcomings become more pronounced as choices become more complex, through either additional options or more performance metrics. But it is unclear why this is true: Consumer choice remains a "black box" that research has scarcely illuminated. In this article, we identify four pathways through which complexity may impair consumer choice. We examine these pathways using data from an experiment in which consumers (hypothetically) selected a primary care physician. Some of the loss of decision quality accompanying more complex choice sets can be explained by consumers' skills and decision-making style, but even after accounting for these factors, complexity undermines the quality of decision making in ways that cannot be fully explained. We conclude by discussing implications for report designers, sponsors, and policy makers aspiring to promote consumer empowerment and health care quality.

Making the best of hard times: how the nation's economic circumstances shaped the public's embrace of health care reform

The U.S. Congress enacted expansive (and expensive) health care reforms amid the worst economic downturn since the Great Depression. Public acquiescence provided crucial political cover; elites on both sides struggled mightily to sway popular opinion. Were reformers' efforts made easier or more difficult by the tough economic times? Using newly available data on Americans' perceptions of economic insecurity and attitudes toward public policy, this article explores the relationship between economic circumstances and political attitudes. The findings suggest that the Great Recession both facilitated and impeded efforts to rally the public in favor of reform: perceptions of past declines in the U.S. economy bolstered government intervention, but household economic insecurity both distracted attention from large medical expenses (which otherwise legitimized collective action) and undermined Americans' support for additional government spending. Equally consequential, reformers' efforts to adapt to economic stringency by portraying reform as exclusively about affordability missed opportunities for broadening popular support for these interventions; in the longer run this may, unless corrected, prove a decisive misstep in shepherding the Patient Protection and Affordable Care Act through its long time line of implementation.

Phenomenological model of interstitial fluid pressure in a solid tumor

Tumor interstitial fluid pressure (TIFP) has the potential to predict tumor response to nonsurgical cancer treatments, including radiation therapy. At present the only quantitative measures available are of limited use, since they are invasive and yield only point measurements. We present the mathematical framework for a quantitative, noninvasive measure of TIFP. The model describes the distribution of interstitial fluid pressure in three distinct tumor regions: vascularized tumor rim, central tumor region, and normal tissue. A relationship between the TIFP and the fluid flow velocity at the periphery of a tumor is presented. This model suggests that a measure of fluid flow rate from a tumor into normal tissue reflects TIFP. We demonstrate that the acquisition of serial images of a tumor after the injection of a contrast agent can provide a noninvasive and potentially quantitative measure of TIFP.

News media framing of childhood obesity in the United States from 2000 to 2009

The American public holds mixed views about the desirability of government action to combat childhood obesity. The framing of coverage by news media may affect citizens' views about the causes of childhood obesity and the most appropriate strategies for addressing the problem. We analyzed the content of a 20% random sample of news stories on childhood obesity published in 18 national and regional news sources in the United States over a 10-year period (2000-2009). News media coverage patterns indicated that by 2003, childhood obesity was firmly on the news media's agenda and remained so until 2007, after which coverage decreased. We identified changes in news media framing over time and significant differences according to news source. News coverage of causes of childhood obesity that were linked to the food and beverage industry increased in the early years of the study but then decreased markedly in later years. Similarly, mention of solutions to the problem of childhood obesity that involved restrictions on the food and beverage industry followed a reverse U-shaped pattern over the 10-year study period. News stories consistently mentioned individual behavioral changes most often as a solution to the problem of childhood obesity. Television news was more likely than other news sources to focus on behavior change as a solution, whereas newspapers were more likely to identify system-level solutions such as changes that would affect neighborhoods, schools, and the food and beverage industry.

Using standardized encounters to understand reported racial/ethnic disparities in patient experiences with care

OBJECTIVE

To assess the extent to which racial/ethnic differences in ratings of patient experiences with health care represent true differences versus differences in expectations, how scales are used, or how identical physician-patient interactions are perceived by members of different groups.

STUDY SETTING

Primary data collection from a nationally representative online panel (n=567), including white, African American, and Latino respondents.

STUDY DESIGN

We administered questions on expectations of care, a series of written vignettes, a video-depicted doctor-patient interaction, and modified CAHPS Clinician and Group Doctor Communication items.

PRINCIPAL FINDINGS

Different groups reported generally similar expectations regarding physicians' behaviors and provided similar mean responses to CAHPS communication items in response to standardized encounters.

CONCLUSIONS

Preliminary evidence suggests that unlike more subjective global ratings, reported disparities in more specific and objective CAHPS composites may primarily reflect differences in experiences, rather than differences in expectations and scale use, adding to our confidence in using the latter to assess disparities.