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Primary Care Logic Model

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Brendan Drew

on 23 February 2014

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Transcript of Primary Care Logic Model

Access
Primary Care Attributes
Primary Care Logic Model
Intermediate Outcomes
Patient-Oriented Outcomes
“Access is a shorthand term for a broad set of concerns that center on the degree to which individuals and groups are able to obtain needed services from the medical care system.” [IOM. Access to Health Care in America. Washington DC: National Academy Press; 1993.]
First-contact accessibility:
"The ease with which a person can obtain needed care (including advice and support) from the practitioner of choice within a time frame appropriate to the urgency of the problem." [Haggerty J, Burge F, Lévesque JF, Gass D, Beaulieu MD, Santor D. Operational definitions of attributes of primary health care: Consensus among Canadian experts. Ann Fam Med 2007;5:336-44.]
Accessibility-accommodation:
"The way primary health care resources are organized to accommodate a wide range of patients abilities to contact health care clinicians and reach health care services." [Haggerty J, Burge F, Lévesque JF, Gass D, Beaulieu MD, Santor D. Operational definitions of attributes of primary health care: Consensus among Canadian experts. Ann Fam Med 2007;5:336-44.]
Coordination
Definitions
“[Coordination] ensures the provision of a combination of health services and information that meets a patient’s needs. It also refers to the connection between, or the rational ordering of, those services, including the resources of the community.” [IOM. Primary Care: America’s Health in a New Era. Washington DC: National Academy Press; 1996.]
“The essence of coordination is the availability of information about prior problems and services and the recognition of that information as it bears on needs for current care.” [Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. New York: Oxford University Press; 1998.]
“Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of health care services.” [McDonald KM, Sundaram V, Bravata DM, Lewis R, Lin N, Kraft S, McKinnon M, Paguntalan H, Owens DK. Care Coordination. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies Vol 7. Technical Review 9. AHRQ Pub No 04(07)-0051-7. Rockville, MD: Agency for Healthcare Research and Quality; 2007.]
Constructs
Internal Coordination
Definitions
External Coordination
Sustained Care
Definitions
Longitudinality
Management Continuity
Informational Continuity
“[A provider of longitudinal care] serves as the source of care over a defined period of time regardless of the presence or absence of particular health-related problems or the type of problem. Having longitudinal care means that individuals in the population identify with a source of care as ‘theirs,’ that the provider or groups of providers at least implicitly recognize the existence of a formal or informal contract to be the regular source of person-focused (not disease-focused) care and that this relationship exists for a defined period of time or indefinitely until explicitly changed.” [Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. New York: Oxford U Press; 1998.]
“[Longitudinality of care] can be described as a locus of responsibility held over long periods of time – the regular source of care – but not necessarily related to the onset of presence of illness.” [Rogers J, Curtis P. The concept and measurement of continuity in primary care. Am J Public Health 1980;70:122-7.]
“Continuity of medical care is conceived as the extent to which services are received as part of a coordinated and uninterrupted succession of events consistent with the medical care needs of patients.” [Shortell SM. Continuity of medical care: Conceptualization and measurement. Med Care 1976;14:377-91.]
Usual provider continuity: Ratio of visits to the patient’s regular physician to the total number of visits to physicians per year [Breslau N, Reeb KG. Continuity of care in a university-based practice. J Medical Education 1975;50:965-9.]
Index of continuity of care: This value shows the continuity of care of an individual patient based on the total number of visits to a physician and the number of unreferred physicians seen, with a higher value corresponding to greater continuity of care. Unlike in many other of measures of continuity, seeing a physician referred by one's primary care physician does not have a negative effect on the rating of continuity of care. [Bice TW, Boxerman SB. A quantitative measure of continuity of care. Medical Care 1977;15:347-9.] (The COC index may also be considered a measure of coordination of care.)


Calculation of COC index:


Likelihood of continuity being present (LICON): The probability that the number of care providers seen is less than would be the case under random conditions given the patient’s level of utilization and the number or providers accessible [Steinwachs DM. Measuring provider continuity in ambulatory care: An assessment of alternative approaches. Med Care 1979;17:551-65.]
K index: This is a measure of continuity based on the average number of doctors seen per patient in a given time period. The numbers are normalized to create an index expressed as a percent ranging from 0-100%, with 0% corresponding to total discontinuity and 100% corresponding to complete continuity. [Ejlertsson G. Assessment of patient/doctor continuity in primary medical care. J R Coll Gen Pract Occas Pap 1980;10:7-10.]
A study in 1979 categorized continuity of patient care into three levels. Continuity of care was evaluated using these three levels in different areas of patient contact (office hour contacts, after-hours contacts, and inpatient contacts):
Level 1: The patient only interacted with his or her personal physician.
Level 2: The patient interacted with another physician on the same medical team.
Level 3: The patient interacted with a physician outside the medical team of his or her personal physician.
Modified, modified continuity index (MMCI): A measure of continuity that takes into account the number of providers seen by the patient and the total number of visits. The measure ranges from 0-1, with 1 being completely continuous. [Magill MK, Senf J. A new method for measuring continuity of care in family practice residencies. J Fam Prac 1987;24:165-8]


Calculation of MMCI:


Sequential nature of provider continuity (SECON): The fraction of sequential visit pairs when the patient sees the same provider [Steinwachs DM. Measuring provider continuity in ambulatory care: An assessment of alternative approaches. Med Care 1979;17:551-65.]
Rae approach (FRAC): This measure of continuity in a given time period has a range of 0-1 (0 = maximum continuity). [Roos LL, Roos NP, Gilbert P, Nicol JP. Continuity of care: Does it contribute to quality of care? Med Care 1980;18:174-84.]


Calculation of FRAC:


Visit-based measures [Eriksson EA, Mattsson LG. Quantitative measurement of continuity of care: Measures in use and an alternative approach. Med Care 1983;21:858-75.]:
Sequential continuity: The visit is assigned a value of 1 if the provider was also seen at the previous visit and 0 if otherwise
Known-provider continuity: The visit is assigned a value of 1 if the provider was seen before at some point in a given period of time and 0 if otherwise
Visit-based usual provider continuity: The visit is assigned a value of 1 if the provider seen is the usual provider by some prior definition and 0 if otherwise
Fraction-of-care continuity: The fraction of the number of visits to the provider seen at a specific visit to the total number of visits in a given period
“ The extent to which information about past care is used to make current care appropriate to the patient.” [Haggerty J, Burge F, Lévesque JF, Gass D, Pineault R, Beaulieu MD. Operational definitions of attributes of primary health care: Consensus among Canadian experts. Ann Fam Med 2007;5:336-44.]
“Continuity is a structural element (place, professional, medical record, or computer). The intent of continuity is to improve follow-up of patients’ problems and facilitate efficiency in diagnostic workup and management.” [Starfield B. Continuous confusion? Am J Pub Health 1980;70:117-9.]
Comprehensiveness
Definitions
“Because primary care focuses on meeting peoples’ needs, it must have available a range of services targeted to those needs and achieve a high level of performance in recognizing existing needs in its population. ‘Needs’ may be symptoms, dysfunctions, discomforts, or diseases; they also might be indicated preventive interventions or even health-promoting interventions.” [Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. New York: Oxford U Press; 1998.]
“Comprehensive care is intended to mean care of any health problem at a given stage of a person’s life. It includes ongoing care of patients in various care settings (eg., hospitals, nursing homes, clinicians’ offices, community sites, schools, and homes). Ideally, the primary care clinician listens to the patient, makes diagnoses, manages, and screens for other health care problems. The clinician educates and communicates with the patient and others who may be involved including other specialists when appropriate.”[IOM. Primary Care: America’s Health in a New Era. Washington DC: National Academy Press; 1996.]
Constructs
Areas of competency necessary for primary care
Care of the newborns, infants, children, adolescents, adults, and the elderly
Care of patients in ambulatory care, hospital care, home care, and nursing home/hospice care
Provision of the comprehensive preventive care, including:
Epidemiology of illness
Health promotion counseling
Prenatal care
Infant/child preventive care
Adolescent preventive care
Adult preventive care
Nutrition counseling
Family planning
Genetic counseling
Tobacco/drug counseling
Screening for cervical cancer/Papanicolau tests
Screening for other cancers
Prevention of heart disease
Immunization services
Treatment of common acute illnesses (musculoskeletal, gynecologic, urologic, ENT, ophthalmologic, dermatologic, and infectious) and training in emergency medicine
Treatment of chronic conditions (cardiovascular, endocrine, rheumatoid arthritis/osteoarthritis, pulmonary, skin, gastrointestinal, and genitourinary)
Treatment of common behavioral problems:
Depression
Anxiety disorders
Substance abuse
Others (stress, grief, etc.)
Other areas:
Community/public health
Patient education
Evaluation of undifferentiated problems
Evaluation of occupational/school health-related illnesses
Death and dying counseling
Risk management
[Rivo ML, Saultz JW, Wartman SA, DeWitt TG. Defining the generalist physician’s training. JAMA 1994;271:1499-504.]:
Primary care practitioners should provide long-term assistance to patients in issues outside of health services, including housing, nutrition, social services, and finding voluntary caregivers. [IOM. Primary Care: America’s Health in a New Era. Washington DC: National Academy Press; 1996.]
Measures
The following question is item from the Components of Primary Care Index (CPCI), which was designed to be completed by patients following a visit with their physician with responses on a five-point scale ranging from strongly disagree to strongly agree: “I go to this doctor [the primary care provider] for almost all of my medical care.”
An instrument was developed in 1996 to assess the preventive services provided by primary care facilities. Scores in comprehensiveness ranged from 0-3, with one point assigned for each type of care patients believed they could receive from their regular site of care (preventive, acute, and chronic). This was determined in a survey in which patients were asked whether they could go to the regular place of care for:
New problems such as a sprained ankle or flu
Flare-ups for ongoing health problems such as asthma or diabetes
A checkup, vaccination or Pap test
[Bindman AB, Grumbach K, Osmond D, Vranizan K, Stewart AL. Primary care and receipt of preventive services. J Gen Intern Med 1996;11:269-76.]
Percentage of visits made for an acute problem, routine chronic problem, flare-up chronic problem, pre-surgery or post-surgery/injury follow-up, and non-illness/preventive care [Binns HJ, Lanier D, Pace WD, Galliher JM, Ganiats TG, Grey M, Ariza AJ, Williams R. The Primary Care Network Survey and the National Ambulatory Medical Care Survey. Ann Fam Med 2007;5:39-47.]
Percentage of visits in which counseling/education on diet/nutrition, growth/development, tobacco use/exposure or any other area was provided [Binns HJ, Lanier D, Pace WD, Galliher JM, Ganiats TG, Grey M, Ariza AJ, Williams R. The Primary Care Network Survey and the National Ambulatory Medical Care Survey. Ann Fam Med 2007;5:39-47.]
Incidence and mortality rates from diseases for which preventive care or screening exists, such as cervical cancer [Campbell RJ, Ramirez AM. Cervical cancer rates and the supply of primary care physicians in Florida. Fam Med 2003;35:60-4.]
Percentage of physicians who comply with guidelines for clinical preventive and screening services, such as the American Cancer Society mammography guidelines [Costanza ME, Stoddard AM, Zapka JG, Gaw VP, Barth R. Physician compliance with mammography guidelines: Barriers and Enhancers. J AM Board Fam Pract 1992;5:143-52.]
Percentage of patients who receive common preventive services, such as influenza vaccinations, mammographies, or smoking cessation advice [Doescher MP, Saver BG, Fiscella K, Franks P. Preventive care: Does continuity count? J Gen Intern Med 2004;19:632-37.]
Number of referrals made by primary care physicians for conditions generally treated under primary care [Dolezal JM, Amundson LH, Sinning NJ, Hoody HJ. PriCare and ambulatory referrals. Continuing Education 1980 (Jan):84-9.].
Percentage of elderly patients who have had discussions with their primary care provider about life-sustaining treatment [Goold SD, Arnold RM, Siminoff LA. Discussions about limiting treatment in a geriatric clinic. J Am Geriatr Soc 1993;41:277-81.]
Percentage of physicians who feel comfortable discussing child-care issues [Wirth BS, Hausman CL. Physicians’ attitudes toward and knowledge of child care. Clinical Pediatrics 1993;32:718-24.]
Percentage of medical records that include screening and management information [McBride P, Underbakke G, Plane MB, Massoth K, Brown RL, Solberg LL, Ellis L, Schrott HG, Smith K, Swanson T, Spencer E, Pfeifer G, Knox A. Improving prevention systems in primary care practices. J Fam Prac 2000;49:115-25.]
Percentage of physicians who enquire about the extent to which health or emotional problems limit their patients’ everyday activities [Schor EL, Lerner DJ, Malspeis S. Physicians’ assessment of functional health status and well-being. Arch Intern Med 1995;155:309-14.]
Basic Measures
Top primary care diagnostic clusters
A study in 1994 used data from the National Ambulatory Medical Care Survey (NAMCS) to identify the top 20 diagnostic clusters that account for more than 50% of all visits to nonreferred physicians participating in the survey. This list is used to identify the extent to which different specialties provide comprehensive primary care [Rosenblatt RA, Hart LG, Gamliel S, Goldstein B, McClendon BJ. Identifying primary care disciplines by analyzing the diagnostic content of ambulatory care.]. These diagnostic clusters could be used to identify whether treatment of common acute illnesses and chronic conditions is being provided.
General medical examination
Acute upper respiratory tract infection
Hypertension
Prenatal care
Acute otitis media
Acute lower respiratory tract infection
Acute sprains and strains
Depression and anxiety
Diabetes mellitus
Lacerations and contusions
Malignant neoplasms
Degenerative joint disease
Acute sinusitis
Fractures and dislocations
Chronic rhinitis
Ischemic heart disease
Acne and diseases of sweat glands
Lower back pain
Dermatitis and eczema
Urinary tract infection
The Comprehensive Prevention Knowledge and Applications Survey Instrument
Person-
Centeredness

Definitions
Whole-person care
“Beyond the knowledge of disease is knowledge of the patient as a human being. Humanism is a core area of primary care practice.” [IOM. Primary Care: America’s Health in a New Era. Washington DC: National Academy Press; 1996.]
“Effective medical care is not limited to the treatment of disease itself; it must consider the context in which the illness occurs and in which the patient lives.” [Starfield B. Primary Care: Balancing Health Needs, Services, and Technology.
“In the goal-oriented [whole-person] model, assessment requires not only the identification of the client’s impairments, but also the elucidation of her or his values, wishes and hopes, preferences, strengths, resources, and beliefs. These form the basis for goal setting.” [Mold JW. An alternative conceptualization of health and health care: Its implications for geriatrics and gerontology. Educational Gerontology 1995;21:85-101.]
“Holistic care is described as a behavior that recognizes and values whole persons as well as the interdependence of their parts [McEvoy L, Duffy A. Holistic practice – A concept analysis. Nurse Educ Pract 2008;8:412-9.] The whole person is described as the biological, social, psychological, and spiritual aspects of an individual [McCormack B. A conceptual framework for person-centered practice with older people. Int J Nurs Pract 2003;9:202-9.]Providing holistic care allows the clinician to better understand how an illness affects the entire person and how to respond to the true needs of an individual [Mead N, Bower P. Patient-centeredness: A conceptual framework and review of the empirical literature. Soc Sci Med 2000;51:1087-1110.]” [Morgan S, Yoder LH. A concept analysis of person-centered care. J Holist Nurs 2012;30:6-15.]
Constructs
Family Context
“Knowledge of the family provides not only the context for evaluating patients’ problems and helping to sort out the likelihood of various possible diagnoses, but it is also important in deciding on an appropriate intervention because families may differ in their ability to carry out different treatments and management strategies. The family is likely to become even more important as knowledge about genetics increases and the possibilities for both prevention and management widen.” [Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. New York: Oxford University Press; 1998.]
“Physicians can no longer think of health as simply an individual issue. Humans are social beings, and our health is strongly influenced by our social context, especially our social relationships. The family is our most intimate current and past social environment. The family has a powerful influence on our health beliefs and behaviors, as well as on our overall mental and physical health. In turn, illness in the family affects family relationships and the health of other family members.” [Rakel RE. Textbook of Family Practice, 6th ed. Philadelphia: W.B. Saunders Co.; 2002.]
“Use of the term families in [the Institute of Medicine definition of primary care] acknowledges the care-giving roles, the concerns of family members, and the impact of family dynamics on health and illness… The committee uses the term family broadly to include a unit of individuals in a household and not necessarily a traditional nuclear family. Often a family member is a care giver – a parent caring for a child or an adult child caring for a parent. Unless clinicians can understand the nature of these relationships, they can miss opportunities to provide effective care of individual health care needs.” [IOM. Primary Care: America’s Health in a New Era. Washington DC: National Academy Press; 1996.]
Community Context
“In the broadest sense, primary care must also [in addition to the care provided to individuals] be linked to the larger community and environment in which people work and live. This also requires that primary care clinicians know the major causes of mortality and morbidity for the community served and that they be aware of what may be happening in the community… Individuals have particular health care needs; the community has a broader perspective that emphasizes improving health status and reforming the way care is delivered.” [IOM. Primary care: America’s Health in a New Era. Washington DC: National Academy Press; 1996.]
“An understanding of the distribution of health characteristics of the community and of resources available in the community provides a more extensive way of assessing health needs than an approach based only on interactions with patients or with families of patients.” [Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. New York: Oxford University Press; 1998.]
“[Community-oriented primary care is] the provision of primary care services to a defined community, coupled with systematic efforts to identify and address the major health problems of that community through effective modifications in both the primary care services and other appropriate community health programs.” [IOM. Community-Oriented Primary Care: A Practical Assessment, Vol. 1. Washington DC: National Academy Press; 1984.]
“Community-oriented primary care (COPC) is a process of improving a community’s health by using principles of public health, epidemiology, and primary care. Definitions of COPC have traditionally used these principles to describe a system of health care in which a targeted population or community is the focus.” [Longlett SK, Kruse JE, Wesley RM. Community-oriented primary care: Critical assessment and implications for resident education. J Am Board Fam Pract 2001;14:141-7.]
Whole-person care
Family context
Community context
Physician-Patient Partnership
Definitions
“[Physician-patient] partnership refers to the relationship established between the patient and clinician with the mutual expectation of continuation over time. It is predicated on the development of mutual trust, respect, and responsibility. A bond to someone you trust may be healing in and of itself. This relationship is essential when guiding patients through the health system.” [IOM. Primary Care: America’s Health in a New Era. Washington DC: National Academy Press; 1996.]
“The foundation of care given by practitioners is the relationship between the practitioner and the patient, a relationship vitally important to both. This relationship is a medium for the exchange of all forms of information, feelings, and concerns, a factor in the success of therapeutic regimens, and an essential ingredient in the satisfaction of both patient and practitioner. For patients, the relationship with their provider frequently is the most therapeutic aspect of the health care encounter.” [Tresolini CP and the Pew-Fetzer Task Force. Health Professions Education and Relationship-Centered Care. San Francisco: Pew Health Professions Commission; 1994.]
Empathic listening and responding
Respectfulness
“The extent to which health professionals and support staff meet users’ expectations about interpersonal treatment, demonstrate respect for the dignity of patients, and provide adequate privacy.” [Haggerty J, Burge F, Lévesque JF, Gass D, Pineault R, Beaulieu MD, Santor D. Operational definitions of attributes of primary health care: Consensus among Canadian experts. Ann Fam Med 2007;5:336-44.]
“The greatest deterrent to establishing patient rapport is an attitude of indifference or lack of interest by the physician. Patients should believe that their comments are being listened to, carefully considered, and taken seriously. They must believe that the physician values their comments and opinions before trusting him or her with information of a more personal nature. As long as the physician’s attitude toward the patient embodies respect, concern, and kindness and a sincere effort is made to understand the patient’s difficulties, the patient will overlook or forgive myriad other problems.” [Rakel RE. Textbook of Family Practice, 6th ed. Philadelphia: W.B. Saunders Company; 2002.]
Advocacy
“The extent to which clinicians represent the best interests of individual patients and patient groups in matters of health (including broad determinants) and health care” [Haggerty J, Burge F, Lévesque JF, Gass D, Pineault R, Beaulieu MD, Santor D. Operational definitions of attributes of primary health care: Consensus among Canadian experts. Ann Fam Med 2007;5:336-44.]
“The primary care clinician is an agent of the patient and his or her welfare” [IOM. Primary Care: America’s Health in a New Era. Washington DC: National Academy Press; 1996.]
Fewer preventable diseases
Earlier detection/ treatment
Better control of chronic diseases
More appropriate, effective consultations/ referrals
Better adherence to plans
Fewer diagnostic tests
Fewer hospitalizations and days in hospital
Greater patient safety
Fewer lawsuits
Fewer unnecessary and futile interventions
Increased length of life
Definitions
“The most common measure of health status especially at the population level is longevity or life expectancy and its converse, mortality. An important characteristic of the health of individuals is their life expectancy; the average life expectancy in a population is an important descriptor of the health status of a nation. Health care systems influence life expectancy, even though the latter is also affected by such other determinants as genetic structure, the social and physical environment, and personal behaviors.” [Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. New York: Oxford University Press; 1998.]
Constructs
Risk-adjusted sequential probability ratio test
Potential years of life lost (PYLL) between ages 1 and 70
Health Risk Appraisal (HRA) Instrument and Risk Engine
Improved quality of life
Definitions
“New ways of thinking about outcomes followed from the relatively recent realization that illness as defined by biophysiological characteristics is an inadequate representation of both impact of illness on people and impact of health services. The new focus is on the extent to which they are able to perform the activities of their lives and on health-related quality of life (HRQOL). Functional status is the representation of morbidity on the daily life of people. Thus, it considers how illness affects the way in which people perceive themselves and how it influences their professional and personal activities. HRQOL is a broader concept, taking into account how people feel about their lives and what they are able to do.” [Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. New York: Oxford University Press; 1998.]
“The general concept of quality of life encompasses a range of human experience: access to the daily necessities of life such as food and shelter, intrapersonal and interpersonal response to life events, and activities associated with professional fulfillment and personal happiness. A subcomponent of overall quality of life relates to health, so [health-related quality of life] focuses on the patient’s own perception of well-being, health, and the ability to function as a result of health status or disease experience.” [Ganz PA, Litwin MS, Hays RD, Kaplan RM. Measuring outcomes and health-related quality of life. Andersen RM, Rice TH, Kominski GF, eds. Changing the U.S. Health care System: Key Issues in Health Services Policy and Management, 3rd ed. San Francisco: John Wiley & Sons, Inc., 2007.]
Constructs
General Measures of Quality of Life
Constructs
First-contact accessibility
Convenient Location [Pandhi N, DeVoe JE, Schumacher JR, Bartels C, Thorpe CT, Thorpe JM, Smith MA. Number of first-contact access components required to improve preventive service receipt in primary care homes. J Gen Int Med 2012;27:677-84]
Measures
From the Primary Care Assessment Survey (abbreviated) [Safran DG, Kosinski M, Tarlov AR, Rogers WH, Taira DA, Lieberman N, Ware JE. The primary care assessment survey: Tests of data quality and measurement performance. Med Care 1998;36:728-39.]:
Convenience of the doctor’s office location
Convenient office hours [Pandhi N, DeVoe JE, Schumacher JR, Bartels C, Thorpe CT, Thorpe JM, Smith MA. Number of first-contact access components required to improve preventive service receipt in primary care homes. J Gen Int Med 2012;27:677-84]
Measures
From the Primary Care Assessment Survey (abbreviated) [Safran DG, Kosinski M, Tarlov AR, Rogers WH, Taira DA, Lieberman N, Ware JE. The primary care assessment survey: Tests of data quality and measurement performance. Med Care 1998;36:728-39.]:
Hours when the doctor’s office is open
From the Adult Primary Care Assessment Tool (regarding the patient’s usual primary care source) [Shi L, Starfield B, Xu J. Validating the Adult Primary Care Assessment Tool. J Fam Prac 2001;50:161.]:
Can you go there on Saturdays or Sundays?
Can you go there on weekday evenings until 8 pm?
When you have to go there do you have to take off from work or school to go?
Short office waiting times [Pandhi N, DeVoe JE, Schumacher JR, Bartels C, Thorpe CT, Thorpe JM, Smith MA. Number of first-contact access components required to improve preventive service receipt in primary care homes. J Gen Int Med 2012;27:677-84]
Measures
From the Primary Care Assessment Survey (abbreviated) [Safran DG, Kosinski M, Tarlov AR, Rogers WH, Taira DA, Lieberman N, Ware JE. The primary care assessment survey: Tests of data quality and measurement performance. Med Care 1998;36:728-39.]:
How many minutes you wait to see the doctor once you arrive for your appointment
From the Adult Primary Care Assessment Tool (regarding the patient’s usual primary care source) [Shi L, Starfield B, Xu J. Validating the Adult Primary Care Assessment Tool. J Fam Prac 2001;50:161.]:
Once you get there, do you have to wait more than 30 minutes before you are checked by the doctor or nurse?
Percentage of patients with an office wait time of greater than 30 min [Forrest CB, Starfield B. Entry into primary care and continuity: The effects of access. Am J Public Health 1998;88:1330-6.]
Index of accessibility by frustration: A ratio of the desired amount of time for a patient to spend in a queue (e.g. waiting at a health center for an appointment or waiting for lab work) to the amount of time actually spent in the queue. The desired amount of time can be established from a patient’s perspective by use of a patient questionnaire or from a health professional’s perspective by getting a consensus from a task force/executive committee and/or the Delphi Method [Simon H, Reisman A, Javad S, Sachs D. An index of accessibility for ambulatory health services. Med Care 1979;17:894-901.]
Little delay between scheduling and appointment [Pandhi N, DeVoe JE, Schumacher JR, Bartels C, Thorpe CT, Thorpe JM, Smith MA. Number of first-contact access components required to improve preventive service receipt in primary care homes. J Gen Int Med 2012;27:677-84]
Measures
From the Primary Care Assessment Survey (abbreviated) [Safran DG, Kosinski M, Tarlov AR, Rogers WH, Taira DA, Lieberman N, Ware JE. The primary care assessment survey: Tests of data quality and measurement performance. Med Care 1998;36:728-39.]:
How quickly you can see doctor when you are sick and call for an appointment
From the Adult Primary Care Assessment Tool (regarding the patient’s usual primary care source) [Shi L, Starfield B, Xu J. Validating the Adult Primary Care Assessment Tool. J Fam Prac 2001;50:161.]:
When the office is open and you get sick, would someone from there see you the same day?
When the office is closed on Saturday or Sunday and you get sick, would someone there see you the same day?
When the office is closed and you get sick during the night, would someone there see/talk with you that night?
Do you have to wait a long time or talk to too many people to make an appointment when you need to?
Is it easy to get an appointment for a general checkup?
Percentage of patients with an appointment wait time of greater than 5 days [Forrest CB, Starfield B. Entry into primary care and continuity: The effects of access. Am J Public Health 1998;88:1330-6.]
Index of accessibility by urgency: A ratio of the actual time it takes to see a physician to the reasonable time it should take to see the physician given the urgency of the symptoms. A value greater than 1 indicates a lack of reasonable access.[Simon H, Reisman A, Javad S, Sachs D. An index of accessibility for ambulatory health services. Med Care 1979;17:894-901.]
Evaluation of scheduling: In a paper published in 2003, the following measures were suggested for the evaluation and monitoring of the advanced access model in primary health settings [Murray M, Berwick DM. Advanced access: Reducing waiting and delays in primary care. JAMA 2003;289:1035-40.]:
Demand: The total number of patients who call to schedule appointments on a given day, plus the number of walk-in patients, plus the number of follow-up appointments generated
Capacity: The number of appointment slots available per day multiplied by the number of clinicians
Panel size: The number of patients enrolled to a physician (in capitated primary care practice) or the number of patients a physician sees over the course of 18 months (in fee-for-service and mixed practices). Panel size can be used to estimate demand by assuming that in an average patient panel 0.7-0.8% of the panel will make an appointment each day. This assumption is not valid in panels of high-risk patients.
Third next available appointment: A measure of how long a patient must wait for an appointment. The third next available physical examination is used as the sentinel marker because it is usually the latest appointment scheduled. The first two available appointments are not used because they could be open due to other patients canceling.
Future open capacity: The number of open appointment slots divided by the total number of appointment slots over the next four weeks
Percentage of patients who schedule an appointment for the same day [Larizgoitia I, Starfield B. Reform of primary health care: The case of Spain. Health Policy 1997;41:121-37.]
Ability to choose one’s physician [Pandhi N, DeVoe JE, Schumacher JR, Bartels C, Thorpe CT, Thorpe JM, Smith MA. Number of first-contact access components required to improve preventive service receipt in primary care homes. J Gen Int Med 2012;27:677-84]
Sufficient time for appointments [Pandhi N, DeVoe JE, Schumacher JR, Bartels C, Thorpe CT, Thorpe JM, Smith MA. Number of first-contact access components required to improve preventive service receipt in primary care homes. J Gen Int Med 2012;27:677-84]
Average length of office visits [Berry LL, Seiders K, Wilder SS. Innovations in access to care: A patient-centered approach. Ann Intern Med 2003;139:568-74.]
Measures
Accessibility-Accommodation
Availability of group appointments for educational sessions when appropriate [Berry LL, Seiders K, Wilder SS. Innovations in access to care: A patient-centered approach. Ann Intern Med 2003;139:568-74.]
Information available by phone and email [Wasson J, Gaudette C, Whaley F, Sauvigne A, Baribeau P, Welch HG. Telephone care as a substitute for routine clinic follow-up. JAMA 1992;267:1788-93.]
Measures
From the Primary Care Assessment Survey (abbreviated) [Safran DG, Kosinski M, Tarlov AR, Rogers WH, Taira DA, Lieberman N, Ware JE. The primary care assessment survey: Tests of data quality and measurement performance. Med Care 1998;36:728-39.]:
Ability to get through to the doctor’s office by phone
Ability to speak to your doctor by phone when you have a question/need medical advice
From the Adult Primary Care Assessment Tool (regarding the patient’s usual primary care source) [Shi L, Starfield B, Xu J. Validating the Adult Primary Care Assessment Tool. J Fam Prac 2001;50:161.]:
When the office is closed, is there a phone number you can call when you get sick?
When the office is open, can you get advice quickly over the phone if you need to?
Percentage of patients who use email to communicate with their physician [Berry LL, Seiders K, Wilder SS. Innovations in access to care: A patient-centered approach. Ann Intern Med 2003;139:568-74.]
Appointments can be made easily over the phone [Simon H, Reisman A, Javad S, Sachs D. An index of accessibility for ambulatory health services. Med Care 1979;17:894-901.]
Measures
Average length of time patients spends on the phone making an appointment [Simon H, Reisman A, Javad S, Sachs D. An index of accessibility for ambulatory health services. Med Care 1979;17:894-901.]
Percentage of busy calls [Simon H, Reisman A, Javad S, Sachs D. An index of accessibility for ambulatory health services. Med Care 1979;17:894-901.]
Percentage of calls disconnected [Simon H, Reisman A, Javad S, Sachs D. An index of accessibility for ambulatory health services. Med Care 1979;17:894-901.]
Average length of hold time [Simon H, Reisman A, Javad S, Sachs D. An index of accessibility for ambulatory health services. Med Care 1979;17:894-901.]
Accessible to the disabled [Grabois EW, Nosek MA, Rossi D. Accessibility of primary care physicians’ offices for people with disabilities. Arch Fam Med 1999;8:44-51.]
Measures
[Grabois EW, Nosek MA, Rossi D. Accessibility of primary care physicians’ offices for people with disabilities. Arch Fam Med 1999;8:44-51.]
Percentage of physicians who cannot treat disabled patients for any of the following reasons:
Equipment not accessible
Not familiar with disability
Patient unable to enter premises (physical barriers)
Patient difficult to treat or handle
More comfortable referring patient, although usually treats condition
Percentage of physicians who:
Always treat patients with disabilities at a certain time of day
Require a driver’s license from patients who pay by check
Fail to provide auxiliary aids to patients (such as printed materials, sign language interpreters, large-print materials, audio recordings, videotapes with captioning, readers, telephones compatible with hearing aids, telecommunication relay services, typewriters/computers for the hearing impaired, computer diskettes, and Braille or other materials) or charged a fee for such services
Failed to provide an alternative means of communication in addition to failure to provide auxiliary aids
Will not see a patient with a disability outside their offices or charge a fee for this service
Percentage of physicians whose offices were built with a builder, architect, or contractor to oversee compliance with the Americans with Disabilities Act
Percentage of physicians whose offices have a continuous, unobstructed pedestrian path to its outside entrance, wheelchair-accessible restrooms, a water fountain, and/or a telephone
Percentage of physicians whose offices have the following accommodations for the disabled:
Ramps
Curb cuts in sidewalks and entrances
Accessible shelves
Raised markings on elevator buttons
Flashing alarm lights
Doors at least 815 mm wide
Offset hinges on doorways
Alternate to turnstile entrances
Accessible door hardware
Appropriate toilet partitions
Lavatory pipes
Raised toilet seats
Full-length bathroom mirror
Accessible paper towel dispenser
Designated accessible parking spaces
Accessible paper cup dispenser
No high-pile, low-density carpet
Interpreters available for non-English speakers [Baker DW, Parker RM, Williams MV, Coates WC, Pitkin K. Use and effectiveness of interpreters in an emergency department JAMA 1996;275:783-33.]
Measures
Percentage of office visits in which an interpreter should have been used (according to patients) but was not [Baker DW, Parker RM, Williams MV, Coates WC, Pitkin K. Use and effectiveness of interpreters in an emergency department. JAMA 1996;275:783-88.]
Percentage of interpreters who are professional (as opposed to nurses, doctors, or other informal interpreters) [Baker DW, Parker RM, Williams MV, Coates WC, Pitkin K. Use and effectiveness of interpreters in an emergency department. JAMA 1996;275:783-88.]
Provisions for those with poor literacy (such as audiotapes and videotapes) [Baker DW, Parker RM, Williams MV, Coates WC, Pitkin K. The health care experience of patients with low literacy. Arch Fam Med 1996;5:329-44.]
Health information is understandable to patients with poor health literacy [Koay K, Schofield P, Jefford M. Importance of health literacy in oncology. Asia Pac J Clin Oncol 2012;8:14-23.]
Accessible to vulnerable population groups [Blumenthal D, Mort E, Edwards J. The efficacy of primary care for vulnerable population groups. Health Serv Res 1995;273:1957-58.]
Gap (expressed as a percentage) in the mean number of visits to a physician per year of a vulnerable population group compared to that of the general population [Freeman HE, Blendon RJ, Aiken LH, Sudman S, Mullinix CF, Corey CR. Americans report on their access to health care. Health Affairs 1987;6:6-8.]
Odds ratio for preventable hospitalization of a vulnerable population to that of the general patient population [Parchman ML, Culler SD. Preventable hospitalizations in primary care shortage areas. Arch Fam Med 1999;8:487-91.]
Percentage of a vulnerable patient group (such as a minority) that receives common preventive care services (such as physical examinations, blood pressure management, cholesterol assessment, Papanicolau testing, screening mammography, and breast and prostate examinations) [DeLaet DE, Shea S, Carrasquillo O. Receipt of preventive services among privately insured minorities in managed care versus fee-for service insurance plans. J Gen Intern Med 2002;17:451-57.]
Physician visit rates per person per year in a patient population sub-group [Dutton DB. Explaining the low use of health services by the poor: Costs, attitudes, or delivery systems. Am Sociol Rev 1978;43:348-68.]
Percentage of physicians who refuse to treat a vulnerable population group, such as those infected with HIV [Lewis CE, Montgomery K. Primary care physicians’ refusal to care for patients infected with the human immunodeficiency virus. West J Med 1992;156:36-8.]
Measures
Cost is not a barrier to those needing access to medical care [Andrulis DP. Access to care is the centerpiece in the elimination of socioeconomic disparities in health. Ann Int Med 1998;129:412-16.]
Measures
From the Primary Care Assessment Survey (abbreviated) [Safran DG, Kosinski M, Tarlov AR, Rogers WH, Taira DA, Lieberman N, Ware JE. The primary care assessment survey: Tests of data quality and measurement performance. Med Care 1998;36:728-39.]:
Amount of money you pay for doctor visits
Amount of money you pay for medication and other prescribed treatments
Percentage of a population that report not receiving care for economic reasons [Freeman HE, Blendon RJ, Aiken LH, Sudman S, Mullinix CF, Corey CR. Americans report on their access to health care. Health Affairs 1987;6:6-8.]
Percentage of physicians willing to accept publicly insured continuing care patients [Cykert S, Kissling G, Layson R, Hansen C. Health insurance does not guarantee access to primary care: A national study of physicians’ acceptance of publicly insured patients. J Gen Intern Med 1995;10:345-8.]
Percentage of physicians who will treat Medicare patients [Lee DW, Gilis KD. Physician responses to Medicare physician payment reform: Preliminary results on access to care. Inquiry 1993;30:417-28.]
General indicators of access
From the Adult Primary Care Assessment Tool (regarding the patient’s usual primary care source) [Shi L, Starfield B, Xu J. Validating the Adult Primary Care Assessment Tool. J Fam Prac 2001;50:161.]:
Is it difficult for you to get medical care there when you think you need it?
Distribution of where a patient group receives regular care (private office or clinic, government clinic, hospital, or other) [Aday LA, Andersen RM. The national profile of access to medical care: Where do we stand? Am J Public Health 1984;74:1331-9.]
Percentage of a patient group that receives treatments associated with primary care in a year [Aday LA, Andersen RM. The national profile of access to medical care: Where do we stand? Am J Public Health 1984;74:1331-9.]
Systems-response ratio: A sample of a patient group is surveyed to find whether they experienced a given symptom over the course of a year and whether or not they saw a physician for this symptom. A group of physicians is then surveyed and asked how many patients out of 100 with the specified symptom should see a physician. Ratings from physicians can be attained separately to account for variables within the patient group, such as age. The physicians’ responses are adjusted to account for differences in opinion among physicians and the consistency of each physician’s ratings over time. The systems-response ration is calculated by first finding difference between the actual number of visits caused by a given symptom and the number of visits recommended by physicians. A ratio of this value to the number of visits recommended by physicians is multiplied by 100 to give the systems-response ratio. [Taylor DG, Aday LA, Andersen R. A social indicator of access to medical care. J Health Soc Behav 1975;16:39-49.]
Percentage of patients who fall into the following categories (as assessed by their care provider at the time of their visit) [Steinwachs DM, Yaffe R. Assessing the timeliness of ambulatory medical care. Am J Public Health 1978;68:547-56.]:
Medical care not indicated (does not need to be seen now and did not need to be seen earlier)
Medical care no longer needed (but should have been seen earlier)
Delayed care (still needs to be seen, but should have been seen earlier)
Timely care (should be seen now, but did not need to be seen earlier)
Self-rated access to care for patients (can be assessed on a five-point scale ranging from not at all difficult to extremely difficult) [Bindman AB, Grumbach K, Osmond D, Komaromy M, Vranizan K, Lurie N, Billings J, Stewart A. Preventable hospitalizations and access to health care. JAMA 1995;274:305-11.]
Rates of hospitalization in a patient population for ambulatory-care sensitive conditions [Ricketts TC, Randolph R, Howard HA, Pathman D, Carey T. Hospitalization rates as indicators of access to primary care. Health &Place 2001;7:27-38.]
Percentage of patients with a chronic illness without a physician visit in one year [Freeman HE, Blendon RJ, Aiken LH, Sudman S, Mullinix CF, Corey CR. Americans report on their access to health care. Health Affairs 1987;6:6-8.]
Coordination of services provided by different members of the team of practitioners within primary care [Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. New York: Oxford University Press; 1998.]
Measures
In 2004, a study was published that proposed a tool for evaluating the team performance of interdisciplinary health care teams and demonstrated its effectiveness in evaluating health care teams in the Program of All-Inclusive Care for the Elderly (PACE). The study asked team members to complete a survey with 59 items evaluating the team domains of leadership, coordination, communication, conflict management, and team cohesion within their interdisciplinary health care team on a 5-point Likert scale. An average score was calculated for each domain. Variables in the personal characteristics of respondents, team characteristics, and program characteristics were assessed and used as independent variables in regression models with team effectiveness as the dependent variable. [Temkin-Greener H, Gross D, Kunitz SJ, Mukamel D. Measuring interdisciplinary team performance in a long-term care setting. Medical Care 2004;42:472-81.] The original survey is given below.
Adoption of a medical records system facilitating fast and simple flow of accurate medical information [Rakel RE. The problem-oriented medical record. Textbook of Family Practice, 6th ed. Philadelphia: WB Saunders Co; 2002.]
Measures
Percentage of patients who had seen a physician in the past 2 years whose test results or medical records were not available at the time of a scheduled appointment. [Bodenheimer T. Coordinating care – A perilous journey through the health care system. NEJM 2008;358:1064-71.]
Tools that clearly define the roles and responsibilities of those involved in the patient’s care, such as practice guidelines, care programs, protocols, clinical pathways, and checklists [McDonald KM, Sundaram V, Bravata DM, Lewis R, Lin N, Kraft S, McKinnon M, Paguntalan H, Owens DK. Care Coordination. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies Vol 7. Technical Review 9. AHRQ Pub No 04(07)-0051-7. Rockville, MD: Agency for Healthcare Research and Quality; 2007.]
Tools that allow for the easy adjustment of care and the roles of those responsible for care, such as team meetings, consultations, and multidisciplinary patient rounds [McDonald KM, Sundaram V, Bravata DM, Lewis R, Lin N, Kraft S, McKinnon M, Paguntalan H, Owens DK. Care Coordination. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies Vol 7. Technical Review 9. AHRQ Pub No 04(07)-0051-7. Rockville, MD: Agency for Healthcare Research and Quality; 2007.]
Effective communication and coordination of services with referral specialists, care managers, allied health professionals, pharmacists, home health agencies, hospitals, long term care facilities, home health agencies, hospice providers, durable medical equipment companies, departments of motor vehicles, employers and teachers, insurance companies, and others [Bodenheimer T. Coordinating care – A perilous journey through the health care system. NEJM 2008;358:1064-71.]
Measures
Closed-loop referral rate: The percentage of physician-initiated referrals that resulted in a return of information about the referral [Holmes C, Kane R, Ford M, Fowler J. Toward the measurement of primary care. Millbank Q 1978;56:231-52]
Percentage of referrals in which information was sent by the primary care physician to the specialist or feedback was received [Bodenheimer T. Coordinating care – A perilous journey through the health care system. NEJM 2008;358:1064-71.]
Percentage of referrals in which the primary care physician and the specialist were satisfied with the information they received from each other [Bodenheimer T. Coordinating care – A perilous journey through the health care system. NEJM 2008;358:1064-71.]
Percentage of referrals in which specialist consultation reports are received by the primary care physician within four weeks of the specialist visit [Bodenheimer T. Coordinating care – A perilous journey through the health care system. NEJM 2008;358:1064-71.]
Percentage of emergency room visits in which information that included medical history and laboratory results was absent [Bodenheimer T. Coordinating care – A perilous journey through the health care system. NEJM 2008;358:1064-71.]
Percentage of adults seen in the emergency room who report that their regular physician was not informed of the care they received there [Bodenheimer T. Coordinating care – A perilous journey through the health care system. NEJM 2008;358:1064-71.]
Percentage of primary care physicians who receive information about discharge plans and medications of recently hospitalized patients [Bodenheimer T. Coordinating care – A perilous journey through the health care system. NEJM 2008;358:1064-71.]
Percentage of primary care physicians who are involved in discussions with hospital physicians about patients’ discharge plans, are notified of the discharge, and receive discharge summaries within 1 week of discharge [Bodenheimer T. Coordinating care – A perilous journey through the health care system. NEJM 2008;358:1064-71.]
Percentage of discharge summaries that include reports of laboratory results and list discharge medications [Bodenheimer T. Coordinating care – A perilous journey through the health care system. NEJM 2008;358:1064-71.]
Percentage of cases in which the primary care physician contacts or treats a patient discharged from the hospital before receiving a discharge summary [Bodenheimer T. Coordinating care – A perilous journey through the health care system. NEJM 2008;358:1064-71.]
Referral rates: rates of referral (request for the services of another person) per 100 office visits for primary care physicians [Brock C. Consultation and Referral Patterns of Family Physicians. J Fam Prac 1977;4:1129-1134.]
Consultation rates: Rates of requests for consultation per 1000 office visits. Consultation rates between facilities of the same specialty can be compared using the ration of their consultation rates. [Calman NS, Hyman RB, Licht W. Variability in consultation rates and practitioner level of diagnostic certainty. J Fam Prac 1992;35:31-38.]
The following items are from the Components of Primary Care Index. These items were responded to by patients following a visit with their physician and responded to on a five-point scale ranging from strongly disagree to strongly agree. [Flocke S. Measuring attributes of primary care: Development of a new instrument. J Fam Prac 1997;45:64-74.]
The doctor does not always know about care I have received at other places.
The doctor communicates with the other health care providers I see.
The doctor knows the results of my visits to other doctors.
The doctor always follows up on a problem I've had, either at the next visit or by phone.
The following are abbreviated items from the Primary Care Assessment Survey, a patient-completed questionnaire. Responses are on a Likert scale. [Safran DG, Kosinski M, Tarlov AR, Rogers WH, Taira DA, Lieberman N, Ware JE. The primary care assessment survey: Tests of data quality and measurement performance. Med Care 1998;36:728-39.]
Help your regular doctor gave you in deciding who to see for specialty care
Help your regular doctor gave you in getting an appointment for specialty care you needed
Regular doctor’s involvement in your care when being treated by specialist or when hospitalized
Regular doctor’s communication with specialists or other doctors who saw you
Help regular doctor gave you in understanding what specialists or other doctors said about you
Quality of specialists or other doctors that your regular doctor sent you to
The following are items from the Adult Primary Care Assessment Tool, a patient-completed questionnaire. The questions related to care from the patient’s usual primary care source. Responses are on a four-point Likert scale ranging from “definitely not” to “definitely.” [Shi L, Starfield B, Xu J. Validating the Adult Primary Care Assessment Tool. J Fam Prac 2001;50:161.]
Did your doctor suggest you go to the specialist or special services?
Did your doctor know you made these visits to the specialist or special services?
Did your doctor discuss with you different places you could have gone to get help with that problem?
Did your doctor or someone working with your doctor help you make the appointment for that visit?
Did your doctor write down any information for the specialist about the reason for the visit?
Did your doctor know what the results of the visit were?
After going to the specialist or special service, did your doctor talk with you about what happened at the visit?
Does your doctor seem interested in the quality of care you get from that specialist or special service?
Avoidance of unnecessary duplications of procedures [Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. New York: Oxford University Press; 1998.]
Measures
Percentage of adults with chronic illnesses who had seen a physician in the past two years whose physician ordered a duplicate test (number of physicians seen can be included) [Bodenheimer T. Coordinating care – A perilous journey through the health care system. NEJM 2008;358:1064-71.]
Supports that encourage coordination of care, such as co-location of care sites, information systems, and staffing decisions [McDonald KM, Sundaram V, Bravata DM, Lewis R, Lin N, Kraft S, McKinnon M, Paguntalan H, Owens DK. Care Coordination. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies Vol 7. Technical Review 9. AHRQ Pub No 04(07)-0051-7. Rockville, MD: Agency for Healthcare Research and Quality; 2007.]
Constructs
Primary care providers maintain their connection to patients throughout their experience in the health care system, whether it be in tertiary care centers, rehabilitation facilities, or other sites outside the primary care facility [Hennen BK. Continuity of care in family practice Part 1: Dimensions of continuity. J Fam Prac 1975;2:371-2.]
Longitudinality
The same primary care physician is seen over an extended period of time* [Safran DG, Kosinski M, Tarlov AR, Rogers WH, Taira DA, Lieberman N, Ware JE. The Primary Care Assessment Survey: Tests of data quality and measurement performance. Med Care 1998;36:728-39.]
Measures
Length of time a patient has seen the same physician as his or her regular doctor [Safran DG, Kosinski M, Tarlov AR, Rogers WH, Taira DA, Lieberman N, Ware JE. The primary care assessment survey: Tests of data quality and measurement performance. Med Care 1998;36:728-39.]
Patients receive care at a regular site and with the same primary care medical team (including practice nurses, receptionists, etc.) [Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. New York: Oxford U Press; 1998.]
Measures
Rate of practice turnover [Wall EM. Continuity of care and family medicine: Definition, determinants, and relationship to outcome. J Fam Prac 1981;13:655-64.]
Percentage of patients visiting a practice over a given time period who are old patients with old problems, old patients with new problems, or new patients [Starfield B. Continuous confusion? Am J Public Health 1980;70:117-9.]
When appropriate, the patient will seek care from a usual primary care provider rather than another health care professional [Breslau N, Reeb KG. Continuity of care in a university-based practice. J Medical Education 1975;50:965-9.]
Measures
The following are abbreviated items from the Primary Care Assessment Survey, a patient-completed questionnaire. Responses are on a Likert scale. [Safran DG, Kosinski M, Tarlov AR, Rogers WH, Taira DA, Lieberman N, Ware JE. The primary care assessment survey: Tests of data quality and measurement performance. Med Care 1998;36:728-39.]:
See your regular doctor for routine check-up
See your regular doctor when you are sick
The following are items from the Adult Primary Care Assessment Tool, a patient-completed questionnaire. The questions related to care from the patient’s usual primary care source. Responses are on a four-point Likert scale ranging from “definitely not” to “definitely.” [Shi L, Starfield B, Xu J. Validating the Adult Primary Care Assessment Tool. J Fam Prac 2001;50:161.]:
When you need a regular general check up, do you go to your doctor before going somewhere else?
When you have a new health problem, do you go to your doctor before going somewhere else?
When you see a specialist, does your doctor have to approve or give you a referral?
The primary care provider feels a sense of responsibility for the overall health of the patient that goes beyond a particular illness or the problems for which a patient might come in on a given visit [Hjortdahl P. Continuity of care: General practitioners’ knowledge about, and sense of responsibility toward their patients. Fam Prac 1992;9:3-8.]
Measures
A study in 1992 asked physicians to evaluate their feelings of medical responsibility toward a patient after a visit by choosing from one of three alternatives [Hjortdahl P. Continuity of care: General practitioners’ knowledge about, and sense of responsibility toward their patients. Fam Prac 1992;9:3-8.]:
“Feeling no medical responsibility beyond the present consultation”
“Limited either to the present episode of illness, or to a limited problem area for patients using several general practitioners”
“Having an overall, direct, or coordinative responsibility for the patient’s different medical needs”
Management Continuity
Measures
Information Continuity
Detailed information about the patient and his or her medical history is readily available to the physician in the form of a medical records system [Rogers J, Curtis P. The concept and measurement of continuity in primary care. Am J Public Health 1980;70:122-7.]
Measures
A 1992 study asked physicians to evaluate their knowledge about their patients on a five-point scale ranging from none to excellent knowledge in the following categories [Hjortdahl P. Continuity of care: General practitioners’ knowledge about, and sense of responsibility toward their patients. Fam Prac 1992;9:3-8.]:
Medical history
Personality
Social network
As part of the Diabetes Continuity of Care Scale, patients were asked to respond to the following item on a five-point scale ranging from strongly disagree to strongly agree: “The healthcare professionals I see have up-to-date information about me and my care.” [Dolovich LR, Nair KM, Ciliska DK, Lee HN, Birch S, Gafni A, Hunt DL. The Diabetes Continuity of Care Scale: The development and initial evaluation of a questionnaire that measures continuity of care from the patient perspective. Health Soc Care Community 2004;12:475-87.]
The physician makes use of the information available, with frequent references during patient visits to previous problems or issues [Wall EM. Continuity of care and family medicine: Definition, determinants, and relationship to outcome. J Fam Prac 1981;13:655-64.]
Measures
Number and percentage of visits in which reference is made to past problems [Wall EM. Continuity of care and family medicine: Definition, determinants, and relationship to outcome. J Fam Prac 1981;13:655-64.]
Respectfulness
The physician demonstrates respect for patients’ dignity and recognizes their right to privacy [Haggerty J, Burge F, Lévesque JF, Gass D, Pineault R, Beaulier MD, Santor D. Operational definitions of attributes of primary health care: Consensus among Canadian experts. Ann Fam Med 2007;5:336-44.]
From the Primary Care Assessment Survey (abbreviated) [Safran DG, Kosinski M, Tarlov AR, Rogers WH, Taira DA, Lieberman N, Ware JE. The primary care assessment survey: Tests of data quality and measurement performance. Med Care 1998;36:728-39.]:
Doctor’s caring and concern for you
Doctor’s respect for you
From the Ambulatory Care Experiences Survey [Safran DG, Karp M, Coltin K, Chang H, Li A, Ogren J, Rogers WH. Measuring patients’ experiences with individual primary care physicians: Results of a statewide demonstration project. J Gen Intern Med 2006;21:13-21.]:
How often did your personal doctor treat you with respect
How often was your personal doctor caring and kind
Percentage of plaintiff depositions for malpractice lawsuits in which deserting the patient or devaluing the patient and/or family views is identified [Beckman HB, Markakis KM, Suchman AL, Frankel RM. The doctor-patient relationship and malpractice: Lessons from plaintiff depositions. Arch Intern Med 1994;154:1365-70.]
Measures
The physician is willing to intervene on behalf of the patient in the health care system
Management Continuity
The physician is competent and ethical in providing care and acts in the patient’s best interests while respecting patient autonomy [Muirhead W. When four principles are too many: Bloodgate, integrity and an action-guiding model of ethical decision making in clinical practice. J Med Ethics 2012;38:195-6.]
Measures
From the Patient-Primary Care Provider Relationship Scale [Forrest CB, Shi L, von Schrader S, Ng J. Managed care, primary care, and the patient-practitioner relationship. J Gen Intern Med 2002;17:270-7.]: Patients were asked whether they…
Think their doctor may not refer them to a specialist when needed
Trust their doctor to put their medical needs above all other considerations
Think their doctor is strongly influenced by health insurance company rules when making decisions about medical care
Sometimes think that their doctor might perform unnecessary tests or procedures
From the Primary Care Assessment Survey [Safran DG, Kosinski M, Tarlov AR, Rogers WH, Taira DA, Lieberman N, Ware JE. The primary care assessment survey: Tests of data quality and measurement performance. Med Care 1998;36:728-39.]:
I completely trust my doctor’s judgments about my medical care
My doctor cares more about holding costs than about doing what is needed for my health
My doctor cares as much as I do about my health
If a mistake was made in my treatment, my doctor would try to hide it from me
All things considered, how much do you trust your doctor
From the Ambulatory Care Experiences Survey [Safran DG, Karp M, Coltin K, Chang H, Li A, Ogren J, Rogers WH. Measuring patients’ experiences with individual primary care physicians: Results of a statewide demonstration project. J Gen Intern Med 2006;21:13-21.]:
How often did your personal doctor put your best interests first when making recommendations about your care
Advocacy
The physician understands what health means to the patient and works with the patient to establish clear, attainable goals for health based on these beliefs [Mold JW, Blake GH, Becker LA. Goal-oriented medical care. Fam Med 1991;23:46-51.]
Measures
From the Adult Primary Care Assessment Tool [Shi L, Starfield B, Xu J. Validating the Adult Primary Care Assessment Tool. J Fam Prac 2001;50:161.]:
Does your doctor know what problems are most important to you?
The physician is aware of the patient’s spiritual beliefs and considers the patient’s spirituality when communicating and making decisions. Anandarajah G, Hight E. Spirituality and medical practice: Using the HOPE questions as a practice tool for spiritual assessment. Am Fam Physician 2001;63:81-9.]
Measures
Percentage of patients who report that their physicians have never discussed religious beliefs with them [King DE, Bushwick B. Beliefs and attitudes of hospital inpatients about faith healing and prayer. J Fam Pract 1994;39:349-52.]
The physician is aware of psychosocial issues in the patient’s life relevant to their health, such as caregiving tasks [Gulbrandsen P, Hjortdahl P, Fugelli P. General practitioners’ knowledge of their patients’ psychosocial problems: Multipractice questionnaire survey. BMJ 1997;314:1014-18.]
Measures
From the Adult Primary Care Assessment Tool [Shi L, Starfield B, Xu J. Validating the Adult Primary Care Assessment Tool. J Fam Prac 2001;50:161.]:
Does your doctor know you very well as a person?
Does your doctor know about your work or employment?
Would your doctor know if you had trouble getting or paying for medicines you needed?
The following items are from a questionnaire given to patients to assess the psychosocial problems they experienced. A questionnaire with mirror questions was then given to the patients’ primary care physicians to assess physicians’ awareness of these problems. [Gulbrandsen P, Hjortdahl P, Fugelli P. General practitioners’ knowledge of their patients’ psychosocial problems: Multipractice questionnaire survey. BMJ 1997;314:1014-18.]
Have you ever been weighed down by sorrow?
Do you have a demanding caregiving task in your private life?
Have you ever been subject to threats or violence from someone you know very well?
Is anyone that you feel close to subject to substance abuse?
Are you having a difficult conflict with someone that you feel close to?
Do you usually feel lonely?
Have you yourself been through family splitting?
Have you been unemployed for more than six months?
Do you feel that your job is a strain, physically or mentally?
From the Ambulatory Care Experiences Survey [Safran DG, Karp M, Coltin K, Chang H, Li A, Ogren J, Rogers WH. Measuring patients’ experiences with individual primary care physicians: Results of a statewide demonstration project. J Gen Intern Med 2006;21:13-21.]:
How would you rate your personal doctor’s knowledge of your responsibilities at home, work or school
How would you rate your personal doctor’s knowledge of you as a person, including values and beliefs important to you
The physician is aware of the patient’s social network and the effect it has on decision-making [Epstein RM, Street RL. Shared mind: Communication, decision making, and autonomy in serious illness. Ann Fam Med 2011;9:454-61.]
Measures
From the Adult Primary Care Assessment Tool [Shi L, Starfield B, Xu J. Validating the Adult Primary Care Assessment Tool. J Fam Prac 2001;50:161.]:
Does your doctor know who lives with you?
The physician is sensitive to the culture of patients and takes cultural considerations into account when communicating and making decisions [Haggerty J, Burge F, Lévesque JF, Gass D, Pineault R, Beaulier MD, Santor D. Operational definitions of attributes of primary health care: Consensus among Canadian experts. Ann Fam Med 2007;5:336-44.]
The physician understands, and takes into consideration when communicating and making decisions, the importance of a patient’s family in [Ransom DC. Research methodology of family-oriented care. Can Fam Physician 1991;37:2433-41.]:
Providing health care resources and support (such as shelter, money, and access to care)
Shaping the patient’s health-related habits (such as smoking, diet, and seat belt use)
Shaping the patient’s values and beliefs
The willingness of the patient to communicate certain health concerns
How the patient understands health information
Giving the patient a sense of purpose and obligation
Giving the patient love and care, which may have a strong impact on health care outcomes
Affecting the patients moods and emotions
Codependent behavior that may cause health risks
The patient’s sense of self-sacrifice and cooperation with the family in making health decisions
The possibility that the patient will view illness in a symbolic or purposeful way
The physician considers family history and genetics when making diagnoses and proposing treatments [Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. New York: Oxford University Press; 1998.]
Measures
From the Adult Primary Care Assessment Tool [Shi L, Starfield B, Xu J. Validating the Adult Primary Care Assessment Tool. J Fam Prac 2001;50:161.]:
Has your doctor asked about illness or problems that might run in your family?
When appropriate, the physician discusses a patient’s care with family members [Hendricks B, Marvel MK, Morphew P, North D, North S. Physicians’ usefulness ratings of family-oriented clinical tools. J Fam Prac 1993;37:30-4.]
Measures
From the Adult Primary Care Assessment Tool [Shi L, Starfield B, Xu J. Validating the Adult Primary Care Assessment Tool. J Fam Prac 2001;50:161.]:
Does your doctor ask your ideas and opinions when they are planning treatment/care for you or a family member?
In addition to treating health needs, the physician acts as a counselor and trusted figure when family issues arise such as divorce, remarriage, or family violence. [Rakel RE. Textbook of Family Practice, 6th ed. Philadelphia: W.B. Saunders Co.; 2002.]
The physician utilizes family-oriented clinical tools such as the following [Hendricks B, Marvel MK, Morphew P, North D, North S. Physicians’ usefulness ratings of family-oriented clinical tools. J Fam Prac 1993;37:30-4.]:
Family conferences: Planned meetings with family members to discuss a patient’s care
Genograms: Graphical depiction of a family history
Family charts/folders: Use of a separate chart or a folder for a family unit
Family APGAR (adaptation, partnership, growth, affection, and resolve): A 5-item survey that assesses family relations
Family counseling: Meetings with the family to discuss psychosocial and emotional issues
Measures
Percentage of physicians who use, or rate as useful (on a Likert scale), the family-oriented clinical tools above [Hendricks B, Marvel MK, Morphew P, North D, North S. Physicians’ usefulness ratings of family-oriented clinical tools. J Fam Prac 1993;37:30-4.]
Percentage of physicians who would place themselves into each of the following categories (taken from a survey administered to physicians)[Hendricks B, Marvel MK, Morphew P, North D, North S. Physicians’ usefulness ratings of family-oriented clinical tools. J Fam Prac 1993;37:30-4.]:
Level 1: I have little or no skill in conducting a family conference.
Level 2: I am skilled at conducting a family conference dealing with medical information and advice.
Level 3: I am skilled with a medically oriented family conference, and at dealing with the emotional responses of the family members.
Level 4: I am skilled with both medically oriented and emotionally-oriented family conferences, and I am able to make brief family systems interventions.
Level 5: I am skilled with the above medically and emotionally-oriented family conferences, brief interventions, and can conduct an ongoing series of intensive family therapy.
The physician is familiar with the following areas of knowledge in family-oriented care [Hendricks B, Marvel MK, Morphew P, North D, North S. Physicians’ usefulness ratings of family-oriented clinical tools. J Fam Prac 1993;37:30-4.]:
Family life cycle: The developmental stages of a family and their relationship to health
Family systems theory: Describes how the family functions as a social unit
Family characteristics of different cultures and their relationship to health
Chemical dependency and families: Identification and management of the effects of chemical dependency on families
Self-awareness of physician’s family background: Awareness of how one’s own family history and relationships can affect treatment of the patient
Measures
Percentage of physicians who use, or rate as useful (on a Likert scale), the above areas of knowledge [Hendricks B, Marvel MK, Morphew P, North D, North S. Physicians’ usefulness ratings of family-oriented clinical tools. J Fam Prac 1993;37:30-4.]
Multiple family members, ideally all, receive primary care from the same provider [Doescher MP, Peter F. Family care in the United States: A national profile. Med Care 1997;35:564-73.]
Measures
Percentage of families where all family members receive primary care from the same physician, practice, or health care center. [Doescher MP, Peter F. Family care in the United States: A national profile. Med Care 1997;35:564-73.]
Percentage of patients in a population who have at least one immediate family member who sees the same primary care physician [Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. New York: Oxford University Press; 1998.]
Percentage of married couples in a patient population who both receive primary care from the same physician [Doescher MP, Peter F. Family care in the United States: A national profile. Med Care 1997;35:564-73.]
Percentage of families in a patient population who fall into the following categories for generational provider congruence [Doescher MP, Peter F. Family care in the United States: A national profile. Med Care 1997;35:564-73.]:
Category 1 (Family Care): Provider congruence between at least one parent and one child
Category 2 (Individual Care): No provider cross-generational congruence, but at least one parent and at least one child have their own provider
Category 3 (Partial Care): At least one parent or at least one child has their own care provider, but not for both generations
Category 4 (No Care): No provider is identified for the family
The physician integrates use of clinical and epidemiological skills. [Abramson JH, Kark SL. Community-oriented primary care: Meaning and scope. Pp. 21-59 in: Community-Oriented Primary Care – New Directions for Health Service. Washington DC: National Academy Press; 1983.]
The population for which a physician feels responsible for providing care is well defined. He or she continually monitors the health state and needs for both the community as a whole and sub-populations such as expectant mothers. [Abramson JH, Kark SL. Community-oriented primary care: Meaning and scope. Pp. 21-59 in: Community-Oriented Primary Care – New Directions for Health Service. Washington DC: National Academy Press; 1983.]
Measures
From the Adult Primary Care Assessment Tool [Shi L, Starfield B, Xu J. Validating the Adult Primary Care Assessment Tool. J Fam Prac 2001;50:161.]:
Does your doctor know about health problems of your neighborhood?
How does your doctor or place of care get opinions/ideas from people that will help them provide better care? Do they…
Do surveys of their patients to see if the services are meeting people’s needs?
Do surveys in the community to find out about health problems that they should know about?
The following questions are taken from the 1999 Health System and Health Network surveys and were used to determine whether a health care facility had policies related to the health of the community. [Lee SD, Alexander JA, Bazzoli GJ. Whom do they serve? Community responsiveness among hospitals affiliated with health systems and networks. Med Care 2003;41:165-79.]
Does your system’s (network’s) mission statement include a focus on community benefit?
Does your system (network) have a written long-term plan for improving the health of its community?
Does your system (network) specifically have budgeted resources for its community benefit?
Does your system (network) use health status indicators for identified population to design new services or modify existing services?
Does your system (network) work with other local providers, public agencies, or community representatives to develop a written assessment of appropriate capacity for health services in the community?
Have you used the assessment to identify unmet health needs, excess capacity, or duplicative services in the community?
Does your system (network) either by itself or in cooperation with others disseminate reports to the community on quality and costs of health services?
Is managerial compensation of system (network) executives in part depending on improvement in community health?
The physician is aware of issues affecting the health of the community that may originate outside of the community. For example, air or water pollutants in the community may come from a distant city. He or she works to resolve these issues and is therefore a member of the “community of solution” outside the boundaries of the community for which he or she feels responsible for providing care. [National Commission on Community Health Services. Health Is a Community Affair. Cambridge: Harvard University Press; 1966.]
The physician is actively involved in the implementation of community health programs appropriate to the needs of the community, including programs targeted at health promotion, disease prevention, and curative, alleviative, or rehabilitative care. [Abramson JH, Kark SL. Community-oriented primary care: Meaning and scope. Pp. 21-59 in: Community-Oriented Primary Care – New Directions for Health Service. Washington DC: National Academy Press; 1983.]
The physician encourages community involvement in its health programs. [Abramson JH, Kark SL. Community-oriented primary care: Meaning and scope. Pp. 21-59 in: Community-Oriented Primary Care – New Directions for Health Service. Washington DC: National Academy Press; 1983.]
Community health programs are adapted to suit the culture of the patient population [Stone L. Cultural influences in community participation in health. Soc Sci Med 1992;35:409-17.]
The physician actively engages with the community and becomes acquainted with members of the community and their needs and concerns. [Abramson JH, Kark SL. Community-oriented primary care: Meaning and scope. Pp. 21-59 in: Community-Oriented Primary Care – New Directions for Health Service. Washington DC: National Academy Press; 1983.]
The physician works with institutions in the community, including hospitals, managed care organizations, schools, professional associations, community groups, and the media. [IOM. Primary Care and Public Health: Exploring Integration to Improve Population Health. Washington DC: National Academies Press; 2012.]
The following question is taken from the 1999 Health System and Health Network surveys, which were used to determine whether a health care facility had policies related to the health of the community. [Lee SD, Alexander JA, Bazzoli GJ. Whom do they serve? Community responsiveness among hospitals affiliated with health systems and networks. Med Care 2003;41:165-79.]
Does your system (network) work with other providers, public agencies, or community representatives to undertake a health status assessment of the community?
Data is freely shared between professionals in primary care and public health in compatible data systems. [IOM. Primary Care and Public Health: Exploring Integration to Improve Population Health. Washington DC: National Academies Press; 2012.]
Measures
The following question is taken from the 1999 Health System and Health Network surveys, which were used to determine whether a health care facility had policies related to the health of the community. [Lee SD, Alexander JA, Bazzoli GJ. Whom do they serve? Community responsiveness among hospitals affiliated with health systems and networks. Med Care 2003;41:165-79.]
Does your system (network) work with other providers to collect, track, and communicate clinical and health information across cooperating organizations?
Primary health care facilities employ a workforce capable of handling community health issues, possibly including public-health trained community health workers. [IOM. Primary Care and Public Health: Exploring Integration to Improve Population Health. Washington DC: National Academies Press; 2012.]
The following services were taken from a list of hospital services in the 1998 Hospital Survey data and identified by Lee et. al. as preventive and educational services contributing to community health [Lee SD, Alexander JA, Bazzoli GJ. Whom do they serve? Community responsiveness among hospitals affiliated with health systems and networks. Med Care 2003;41:165-79.]:
Community outreach
Crisis prevention
Child wellness
Fitness center
Health fair
Health information center
Health screening
Nutrition program
Occupation health
Patient education
Patient representative services
Social work
Support groups
Teen outreach services
Transportation services
Volunteer services
Life expectancy
Measures
Average life expectancy for a population [Kochanek KD, Xu J, Murphy SL, Miniño AM, Kung HC. Deaths: Final Data for 2009. National Vital Statistics Report; vol 60 no 3. Hyattsville, MD: National Center for Health Statistics; 2011.]
Mortality Rate
Measures
Death rates for the general population or a sub-group within that population distinguished by age, socioeconomic status, health behaviors, medical conditions, or other traits [Kochanek KD, Xu J, Murphy SL, Miniño AM, Kung HC. Deaths: Final Data for 2009. National Vital Statistics Report; vol 60 no 3. Hyattsville, MD: National Center for Health Statistics; 2011.]
Death rates from specific diseases (cancer, heart disease, strokes, etc) [Kochanek KD, Xu J, Murphy SL, Miniño AM, Kung HC. Deaths: Final Data for 2009. National Vital Statistics Report; vol 60 no 3. Hyattsville, MD: National Center for Health Statistics; 2011.]
Standardized mortality ratio: Ratio of the number of observed deaths in a population to the number of expected deaths if the age-specific death rates were the same as in a standard population, multiplied by 100 [Age Standardised Rates. London Health Observatory. 3 Jul 2012. <http://www.lho.org.uk/LHO_Topics/Data/Methodology_and_Sources/AgeStandardisedRates.aspx>.]
In the early 20th century, a graph known as a control chart was developed by Walter Shewhart to distinguish between common-cause and special-cause variation. The graph has one line representing the mean and two lines representing the upper and lower limits of common-cause variation (set by Shewhart at 3 from the mean). Data points outside the control limits suggest special-cause variation. This method has been used to evaluate variation in mortality rates from pediatric cardiac surgery in different hospitals. Special-cause variation in this application indicates that hospitals outside the upper control limit possibly need to improve quality of care and that hospitals outside the lower control limit can be used as an example for care. [Mohammed MA, Cheng KK, Rouse A, Marshall T. Bristol, Shipman, and clinical governance: Shewhart’s forgotten lessons. Lancet 2001;357:463-7.]
Increased
productivity

“Absenteeism and disability costs should be recognized, at best, as a significant contributor to an incomplete estimate of the total loss of productivity resulting from health impairment. These costs only provide a partial measure of the total lost productivity for a group of employees whose health problems are so severe as to prevent them from working. What are seldom measured are the decrease in productivity for the much larger group of employees whose health problems have not necessarily led to absenteeism and the decrease in productivity for the disabled group before and after the absence period. This decrease may be captured by a measure of ‘presenteeism,’ the decrement in performance associated with remaining at work while impaired by health problems.” [Burton WN, Conti DJ, Chen CY, Schultz AB, Edington DW. The role of health risk factors and disease on worker productivity. J Occup Environ Med 1999;41:863-77.]
Definitions
Constructs
Reduced absence from work or school caused by health problems [Fendrick AM, Jinnett K, Parry T. Synergies at Work: Realizing the Full Value of Health Investments. National Pharmaceutical Council; 2011.]
Measures
Percentage of patients who report missing work or staying in bed due to illness in a given time period [Bansal M, Nair R, Bollu V. Comparing the impact of depression, diabetes, and anxiety on patient productivity and quality of life: Results from a national representative panel data. Value Health. Conference: ISPOR 12th Annual European Congress Paris France. Conference Start: 20091024 Conference End: 20091027. Conference Publication: (var.pagings). 12 (7) (pp A412), 2009. Date of Publication: October 2009.]
The following question was asked to cancer patients in a study to assess the effects of fatigue from anaemia on patient productivity. Work can refer to housework or volunteer work if the patient is unemployed. [Berndt E, Kallich J, McDermott A, Xu X, Lee H, Glaspy J. Reductions in anaemia and fatigue are associated with improvements in productivity in cancer patients receiving chemotherapy. Pharmacoeconomics 2005;23:505-14.]
During the past two weeks, for about how many hours were you unable to work because of your condition (productive time lost)?
Improved focus and performance (reduced presenteeism) at work, home, or school due to improved health [Fendrick AM, Jinnett K, Parry T. Synergies at Work: Realizing the Full Value of Health Investments. National Pharmaceutical Council; 2011.]
Measures
Patient’s ability to work (as assessed by a physician) on a scale of 0-100% [Sendi P, Schellenberg F, Unseghapand C, Kaufmann GR, Bucher HC, Weber R, Battegay M. Swiss HIV Cohort Study. Productivity costs and determinants of productivity in HIV-infected patients. Clin Ther 2004;26:791-800.]
Number of critical incidents (job-related accidents, injuries, special failures, and special successes) reported by workers in a given time period [Wang PS, Beck A, Berglund P, Leutzinger JA, Pronk N, Richling D, Schenk TW, Simon G, Stang P, Ustun TB, Kessler RC. Chronic medical conditions and work performance in the Health and Work Performance Questionnaire calibration surveys. J Occup Environ Med 2003;45:1303-11.]
Stanford Presenteeism Scale: The following items compose an abbreviated form of the Stanford Presenteeism Scale. Responses are on a five-point Likert scale (1 = strongly disagree, 5 = strongly agree) and a presenteeism score can be reported as the sum of the items. The items can be adapted for patients with a specific health problem by replacing “health problem” with a specific descriptor. [Koopman C, Pelletier KR, Murray JF, Sharda CE, Berger ML, Turpin RS, Hackleman P, Gibson P, Holmes DM, Bendel T. Stanford Presenteeism Scale: Health status and employee productivity. J Occup Environ Med 2002;44:14-20.]
Because of my health problem, the stresses of my job were much harder to handle. (reverse scored)
Despite having my health problem, I was able to finish hard tasks in my work.
My health problem distracted me from taking pleasure in my work. (reverse scored)
I felt hopeless about finishing certain work tasks, due to my health problem. (reverse scored)
At work, I was able to focus on achieving my goals despite my health problem.
Despite having my health problem, I felt energetic enough to complete all my work.
Reduced absence and improved performance in work or school for caregivers and family members of the sick [Fendrick AM, Jinnett K, Parry T. Synergies at Work: Realizing the Full Value of Health Investments. National Pharmaceutical Council; 2011.]
The following question was asked to cancer patients in a study to assess the effects of fatigue from anaemia on patient productivity. [Berndt E, Kallich J, McDermott A, Xu X, Lee H, Glaspy J. Reductions in anaemia and fatigue are associated with improvements in productivity in cancer patients receiving chemotherapy. Pharmacoeconomics 2005;23:505-14.]
During the past two weeks, for about how many hours did someone (family, friend or other person) care for you or help you with your daily tasks (e.g. shopping, child care or cleaning house) [caregiver time]?
Measures
Reduced loss in productivity to society due to premature death [Sendi P, Schellenberg F, Unseghapand C, Kaufmann GR, Bucher HC, Weber R, Battegay M. Swiss HIV Cohort Study. Productivity costs and determinants of productivity in HIV-infected patients. Clin Ther 2004;26:791-800.]
Improved end
of life quality

Definitions
“[A good death] is free from avoidable distress and suffering for patients, families, and caregivers; in general accord with patients’ and families’ wishes; and reasonably consistent with clinical, cultural, and ethical standards.” [IOM. Approaching Death: Improving Care at the End of Life. Washington DC: National Academy Press; 1997.]
Pain and distress in dying patients is minimized [IOM. Approaching Death: Improving Care at the End of Life. Washington DC: National Academy Press; 1997.]
Constructs
Measures
Brief Pain Inventory: This instrument was created to assess the severity of pain and its effect on the daily functions of patients with cancer, but it has been shown to be an effective measure of pain caused by a variety of clinical conditions. There are two forms of the survey, a short form and a long form. Copies of the instrument and further information can be obtained at <http://www.mdanderson.org/education-and-research/departments-programs-and-labs/departments-and-divisions/symptom-research/symptom-assessment-tools/brief-pain-inventory.html>. [The Brief Pain Inventory (BPI). University of Texas MD Anderson Cancer Center. Accessed 12 Jul 2012. <http://www.mdanderson.org/education-and-research/departments-programs-and-labs/departments-and-divisions/symptom-research/symptom-assessment-tools/brief-pain-inventory.html>.]
To the greatest extent possible, patients maintain normal mental and physical functioning [Singer PA, Martin DK, Kelner M. Quality end-of-life care: Patients’ perspectives. JAMA 1999;281:163-8.]
Ineffective and harmful treatments are not used in an attempt to prolong life [IOM. Approaching Death: Improving Care at the End of Life. Washington DC: National Academy Press; 1997.]
Measures
Percentage of incurably ill patients who received invasive nonpalliative treatments, invasive or complex diagnostic tests, or CPR in the 13-month period before they died [Ahronheim JC, Morrison RS, Baskin SA, Morris J, Meier DE. Treatment of the dying in the acute care hospital: Advanced dementia and metastatic cancer. Arch Intern Med 1996;156:2094-100.]
Percentage of patients that spent at least 10 days in an intensive care unit before death [The SUPPORT Principal Investigators. A Controlled Trial to Improve Care for Seriously III Hospitalized Patients: The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). JAMA 1995;274:1591-8.]
The following are taken from a list of potential indicators of the quality of end-of-life cancer care identified by an expert panel using the Delphi method. These measures can be obtained from Medicare data. [Earle CC, Park ER, Lai B, Weeks JC, Ayanian JZ, Block S. Identifying potential indicators of the quality of end-of-life cancer care from administrative data. J Clin Oncol 2003;21:1133-8.]
Frequency of emergency room visits for terminally ill patients
Number of hospital and ICU days near the end of life
Proportion of patients enrolled in hospice
Time interval between hospice enrollment and death
Respect is shown to the dying patient, family members, and those close to the patient [IOM. Approaching Death: Improving Care at the End of Life. Washington DC: National Academy Press; 1997.]
The patient remains closely connected to loved ones, possibly even strengthening relationships [Singer PA, Martin DK, Kelner M. Quality end-of-life care: Patients’ perspectives. JAMA 1999;281:163-8.]
The patient does not feel like a burden, financial or otherwise, to loved ones [Singer PA, Martin DK, Kelner M. Quality end-of-life care: Patients’ perspectives. JAMA 1999;281:163-8.]
The patient still finds meaning in life and is able to help others and/or fulfill a role in his or her family and society [Miyashita M, Morita T, Sato K, Hirai K, Shima Y, Uchitomi Y. Good Death Inventory: A measure for evaluating good death from the bereaved family member’s perspective. J Pain Symptom Manage 2008;35:486-98.]
If possible, the patient is able to choose where to die [Miyashita M, Morita T, Sato K, Hirai K, Shima Y, Uchitomi Y. Good Death Inventory: A measure for evaluating good death from the bereaved family member’s perspective. J Pain Symptom Manage 2008;35:486-98.]
Proportion of deaths in the home vs. the hospital [Earle CC, Park ER, Lai B, Weeks JC, Ayanian JZ, Block S. Identifying potential indicators of the quality of end-of-life cancer care from administrative data. J Clin Oncol 2003;21:1133-8.]
Measures
The patient feels prepared for death and knows what to expect as death approaches [Steinhauser KE, Clipp EC, McNeilly M, Christakis NA, McIntyre LM, Tulsky JA. In search of a good death: Observations of patients, families, and providers. Ann Intern Med 2000;132:825-32.]
The patient achieves a sense of “completion” before death, whether that requires a life review, religious or spiritual rituals, resolution of conflicts, or other actions [Steinhauser KE, Clipp EC, McNeilly M, Christakis NA, McIntyre LM, Tulsky JA. In search of a good death: Observations of patients, families, and providers. Ann Intern Med 2000;132:825-32.]
The patient does not feel abandoned by the medical system [IOM. Approaching Death: Improving Care at the End of Life. Washington DC: National Academy Press; 1997.]
The patient’s decisions about end of life care, or the decisions of the patient’s health care agent if the patient is incapable, are respected [Cordts GA, Finucane TE, Ferringo CH. Care at the end of life. Fiebach NH, Kern DE, Thomas PA, Ziegelstein RC, eds. Principles of Ambulatory Medicine. Philadelphia: Lippincott Williams & Wilkins; 2007.]
Measures
Percentage of patient deaths in which the physician knew when the patient preferred to avoid CPR [The SUPPORT Principal Investigators. A Controlled Trial to Improve Care for Seriously III Hospitalized Patients: The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). JAMA 1995;274:1591-8.]
The physician is honest and straightforward, but sensitive, in discussions with the patient about end-of-life care [Cordts GA, Finucane TE, Ferringo CH. Care at the end of life. Fiebach NH, Kern DE, Thomas PA, Ziegelstein RC, eds. Principles of Ambulatory Medicine. Philadelphia: Lippincott Williams & Wilkins; 2007.]
Measures
Percentage of discussions between physicians and patients about do-not-resuscitate orders (as assessed by audiotape) in which the following topics are addressed [Tulksy JA, Chesney MA, Lo B. How do medical residents discuss resuscitation with patients?. J Gen Intern Med 1995;10:436-42.]:
CPR
Mechanical ventilation
Chest compressions
Intensive care
Likelihood of survival after CPR
The patient’s personal values and goals of care
General measures of
end of life quality
QUAL-E: This 54-item questionnaire assesses the quality of life at the end of life for patients with a variety of terminal illnesses. Items relate to six domains of end of life quality: pain and symptom management, communication about treatment decisions, preparation for death, completion, contributing to others, and being known as a whole person. [Steinhauser KE, Bosworth HB, Clipp EC, McNeilly M, Christakis NA, Parker J, Tulksy JA. Initial assessment of a new instrument to measure quality of life at the end of life. J Palliat Med 2002;5:829-41.] The questionnaire can be viewed at <http://www.npcrc.org/files/news/QUAL-E.pdf>.
Needs at the End-of-Life Screening Tool (NEST): This instrument is a patient-completed questionnaire designed to assess quality of end of life care. It consists of thirteen questions in the domains of social needs, existential matters, symptoms, and therapeutic matters. [Emanuel LL, Alpert HR, Emanuel EE. Concise screening questions for the clinical assessments of terminal care: The Needs Near the End-of-Life Care Screening Tool. J Palliat Med 2001;4:465-74.] The questionnaire can be viewed at <http://www.npcrc.org/content/25/Measurement-and-Evaluation-Tools.aspx>.
Missoula-VITAS® Quality of Life Index: This instrument was designed to assess the quality of life of terminally ill patients. The respondent is allowed to weight the different dimensions of quality of life in the survey, and the wording of questions is intentionally subjective. [Byock IR, Merriman MP. Measuring quality of life for patients with terminal illness: The Missoula-VITAS® quality of life index. Palliat Med 1998;12:231-44.] The survey can be viewed at <http://www.dyingwell.com/MVQOLI.htm>. Registration is required before use.
Good Death Inventory: This instrument assesses 10 domains in patient end of life care from the perspective of the family member whose loved one had died: environmental comfort, life completion, dying in a favorite place, maintaining hope and pleasure, independence, physical and psychological comfort, good relationship with medical staff, not being a burden to others, good relationship with family, and being respected as an individual. [Miyashita M, Morita T, Sato K, Hirai K, Shima Y, Uchitomi Y. Good Death Inventory: A measure for evaluating good death from the bereaved family member’s perspective. J Pain Symptom Manage 2008;35:486-98.] A copy of this instrument is available at <https://ubir.buffalo.edu/xmlui/handle/10477/2898>.
General measures of productivity
World Health Organization Health and Work Performance Questionnaire (HPQ): This instrument was created assist employers in decisions regarding health care purchasing. The intended respondents are employees. A short form of the survey is available that specifically addresses absenteeism and presenteeism. Both the long and short-form versions of the HPQ and additional scoring and background information can be accessed at <http://www.hcp.med.harvard.edu/hpq/>. Using data from the short form, the following scores can be calculated for an individual in a 4-week or 7-day time period [The World Health Organization Health and Work Performance Questionnaire (HPQ). Harvard School of Medicine. 2005. <http://www.hcp.med.harvard.edu/hpq/>. Accessed 10 Jul 2012.]:
Absolute absenteeism: The difference between how many hours the employee should have worked and the number of hours he or she actually worked
Relative absenteeism: A ratio of absolute absenteeism to the number of hours the employee should have worked
Relative hours of work: A ratio of the number of hours the employee actually worked to the number of hours he or she should have worked
Absolute presenteeism: The employee’s self-rated overall job performance (on a scale of 0-10, 0 = worst possible, 10 = best possible) multiplied by 10
Relative presenteeism: A ratio of the employee’s self-rated overall job performance (on a scale of 0-10, 0 = worst performance, 10 = best performance) to the employee’s rating of the usual performance of other employees in a similar job (on a scale of 0-10, 0 = worst performance, 10 = best performance)
Work Productivity and Activity Impairment (WPAI) Questionnaire: This 6-item instrument allows for a quantitative assessment of health-related absenteeism, presenteeism, and daily activity impairment. Both general health and specific health problem versions are available. Both versions and additional information can be accessed at <http://www.reillyassociates.net/Index.html>. [Reilly Associates Health Outcomes Research. <http://www.reillyassociates.net/Index.html>. Accessed 10 Jul 2012.]
Structural Environment
Health care system
Practice context
Organization of
the practice

Governance and accountability
Quality improvement process
Resources and technical provisions
Provider remuneration
Funding
Information systems
Health human resources
Surrounding medical and social services
Population and community characteristics
Community integration
Health and human resources
Group composition
Training
Office infrastructure
Information technology
Medical technology
Office space design
Organizational structure and dynamics
Job descriptions and team functioning
Management and practice governance
Clinical information management
Organizational adaptiveness
Organizational culture
Practice integration
[Hogg W, Rowan M, Russell G, Geneau R, Muldoon L. Framework for primary care organizations: The importance of a structural domain. Int J Qual Health Care 2008;20:308-13.]
Increased satisfaction with care
Reduced health disparities
Reduced costs
Enhanced clinician well-being/ durability
Definitions
“An emphasis on satisfaction and information highlights the importance of patients’ and society’s preferences and values and implies that they should be elicited (or acknowledged) and taken into account in health care decisionmaking.” [IOM. Primary Care: America’s Health in a New Era. Washington DC: National Academy Press;1996.][IOM. Medicare: A Strategy for Quality Assurance, Vol.1. Washington DC: National Academy Press; 1990.]
“We define patient satisfaction as positive evaluations of distinct dimensions of the health care. (The care evaluated might be a single clinic visit, treatment throughout an illness episode, a particular health care setting or plan, or the health care system in general.)” [Linder-Pelz S. Toward a theory of patient satisfaction. Soc Sci Med 1982;16:577-82.]
Constructs
The patient finds value in the health care encounter and provides positive evaluations of the different aspects of the health care experience [Linder-Pelz S. Toward a theory of patient satisfaction. Soc Sci Med 1982;16:577-82.]
The patient feels his or her health care needs were addressed during the health care encounter [Blanchard CG, Labrecque MS, Ruckdeschel JC, Blanchard EB. Physician behaviors, patient perceptions, and patient characteristics as predictors of satisfaction of hospitalized adult cancer patients. Cancer 1990;65:186-92.]
Measures
Patients’ assessment of the extent to which their health care needs were met during a health care encounter on a 100 mm visual analog scale ranging from “not at all” to “extremely well” [Blanchard CG, Labrecque MS, Ruckdeschel JC, Blanchard EB. Physician behaviors, patient perceptions, and patient characteristics as predictors of satisfaction of hospitalized adult cancer patients. Cancer 1990;65:186-92.]
The patient’s positive expectations for care are met to the greatest extent possible [Sitzia J, Wood N. Patient satisfaction: A review of issues and concepts. Soc Sci Med 1997;45:1829-43.]
The patient believes he or she is receiving the amount and quality of care to which he or she is entitled [Linder-Pelz S. Toward a theory of patient satisfaction. Soc Sci Med 1982;16:577-82.]
The health care encounter compares favorably to those known to or previously experienced by the patient [Linder-Pelz S. Toward a theory of patient satisfaction. Soc Sci Med 1982;16:577-82.]
The patient is willing to return to or recommend the same care facility [Benkert R, Barkauskas V, Pohl J, Corser W, Tanner C, Wells M, Nagelkirk J. Patient satisfaction outcomes in nurse-managed centers. Outcomes Manag 2002;6:174-81.]
General Measures of Patient Satisfaction
Patient assessment of his or her satisfaction with care on a 100 mm visual analog scale ranging from “not at all satisfied” to “extremely satisfied” [Blanchard CG, Labrecque MS, Ruckdeschel JC, Blanchard EB. Physician behaviors, patient perceptions, and patient characteristics as predictors of satisfaction of hospitalized adult cancer patients. Cancer 1990;65:186-92.]
Patient assessment of his or her satisfaction with care on a Likert scale ranging from very poor to excellent [Shcoenfelder T, Klewer J, Kugler J. Determinants of patient satisfaction: A study among 39 hospitals in an in-patient setting in Germany. Int J Qual Health Care 2011;23:503-9.]
Michigan Academic Consortium Patient-Satisfaction Questionnaire (MAC-PSQ): This patient-completed questionnaire assesses patient satisfaction with items relating to patient perceptions of care, phone contact, and the patient’s willingness to return to or recommend the clinic. It was originally used to assess patient satisfaction in nurse-managed centers. [Benkert R, Barkauskas V, Pohl J, Corser W, Tanner C, Wells M, Nagelkirk J. Patient satisfaction outcomes in nurse-managed centers. Outcomes Manag 2002;6:174-81.] Addition information about the survey and obtaining a copy can be accessed at <http://apntoolkit.mcmaster.ca/index.php?option=com_content&view=article&id=315:michigan-academic-consortium-patient-satisfaction-questionnaire-mac-psq&catid=38:patient-satisfaction&Itemid=56>.
Consumer Assessment of Healthcare Providers and Systems (CAHPS): These patient-completed surveys were designed to evaluate patients’ experiences with health care. One category within the CAHPS surveys is the Clinician & Group Surveys, which relate to patients’ experiences with a specific care provider or office staff. Within this category, there is a 12-month survey to address long-term care and a visit survey that addresses the patient’s experience during a single office visit. The survey items provide a measure of general patient satisfaction along with patient assessment of other domains of the health care experience, including accessibility, communication, and informational continuity. Responses are on a four-point scale. Both the 12-month and visit versions of the survey, along with others, can be accessed at <https://cahps.ahrq.gov/surveys-guidance/cg/index.html>.
Primary Care Assessment Survey (PCAS): This 51-item patient-completed questionnaire provides an assessment of seven domains of primary care: accessibility, continuity, comprehensiveness, integration, clinical interaction, interpersonal treatment, and trust. [Safran DG, Kosinski M, Tarlov AR, Rogers WH, Taira DA, Lieberman N, Ware JE. The Primary Care Assessment Survey: Tests of data quality and measurement performance.] Additional information can be found at <http://academicdepartments.musc.edu/family_medicine/rcmar/pcas.htm>.
Primary Care Assessment Tool-Adult Edition (PCAT-AE): This 92-item patient-completed questionnaire provides an assessment of the following domains of primary care: first contact, longitudinality, comprehensiveness, coordination, family centeredness, community orientation, and cultural competence. Responses are on a four-point Likert scale. [Shi L, Starfield B, Xu J. Validating the Adult Primary Care Assessment Tool. J Fam Pract 2001;50:161.] Additional information about the instrument and contact information for obtaining a copy can be found at <http://www.jhsph.edu/research/centers-and-institutes/johns-hopkins-primary-care-policy-center/pca_tools.html>.
Components of Primary Care Index (CPCI): This 20-item patient-completed questionnaire provides an assessment of seven domains of primary care: comprehensiveness of care, accumulated knowledge, interpersonal communication, coordination of care, first contact, continuity belief, and longitudinality. Responses are on a five-point Likert scale and scale scores can be computed for each domain, as these scores have been shown to positively correlate to measures of patients overall satisfaction with care. The item content is given below. [Flocke SA. Measuring attributes of primary care: Development of a new instrument. J Fam Pract 1997;45:64-74.]
Comprehensiveness of care
I go to this doctor for almost all of my medical care.
Accumulated knowledge
This doctor does not know my medical history very well.
This doctor knows a lot about the rest of my family.
This doctor clearly understands my health needs.
This doctor and I have been through a lot together.
Interpersonal communication
I can easily talk about personal things with this doctor.
I don’t always feel comfortable asking questions of this doctor.
This doctor always explains things to my satisfaction.
Sometimes, this doctor does not listen to me.
Coordination of care
This doctor does not always know about care I have received at other places.
This doctor communicates with the other health care providers I see.
This doctor knows the results of my visits to other doctors.
This doctor always follows up on a problem I’ve had, either at the next visit or by phone.
I want one doctor to coordinate all of the health care I receive
First contact
If I am sick, I would always contact a doctor in this office first.
Continuity belief
My medical care improves when I see the same doctor that I have seen before.
It is very important to me to see my regular doctor.
I rarely see the same doctor when I go for medical care.
Longitudinality
How many years have you been a patient of this physician.
Definitions
“The study committee defines disparities in health care as racial or ethnic differences in the quality of healthcare that are not due to access-related factors or clinical needs, preferences, and appropriateness of intervention.” [IOM. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington DC: National Academies Press; 2003.]
Constructs
Disparity in length of life of minority and non-minority patients
Measures
Disparity in mortality
Life expectancy of minority patients compared to non-minority patients [Ibrahim SA, Thomas SB, Fine MJ. Achieving health equity: An incremental journey. Am J Pub Health 2003;93:1619-21.]
Hazard ratio of minority patients to non-minority patients with the same medical condition, adjusted for smoking, alcohol consumption, body mass index, and socioeconomic position [McKenzie F, Jeffreys M. Do lifestyle or social factors explain ethnic/racial inequalities in breast cancer survival? Epidemiol Rev 2009;31:52-66.]
Disparity in the receipt of medical treatment
Odds ratio of referral for medical procedures (such as cardiac catheterization) for minority patients compared to non-minority patients with the same symptoms [Schulman KA, Berlin JA, Harless W, Kerner JF, Sistrunk S, Gersh BJ, Dubé R, Taleghani CK, Burke JE, Williams S, Eisenberg JM, Escarce JJ. The effect of race and sex on physicians’ recommendations for cardiac catheterization. NEJM 1999;340:618-26.]
Difference between minority and non-minority patients in hospital admission for lower extremity amputations per 1000 population age 18 and over [AHRQ. National Health Disparities Report, 2008.]
Difference in the percentage of minority and non-minority adults over age 40 with diagnosed diabetes who received hemoglobin A1c testing, dilated eye examination, and foot examination in the past year [AHRQ. National Health Disparities Report, 2008.]
Difference in the percentage of minority and non-minority adults with tuberculosis who complete treatment within one year of initiation of treatment [AHRQ. National Health Disparities Report, 2008.]
Difference in the percentage of minority and non-minority adults with a major depressive episode who received treatment for depression [AHRQ. National Health Disparities Report, 2008.]
Difference in the percentage of minority and non-minority adult surgery patients who received appropriate timing of antibiotics [AHRQ. National Health Disparities Report, 2008.]
Difference in the percentage of minority and non-minority adult hemodialysis patients with adequate dialysis (urea reduction ratio of 65% or higher) [AHRQ. National Health Disparities Report, 2008.]
Difference in the percentage of minority and non-minority dialysis patients registered on a waiting list for transplantation [AHRQ. National Health Disparities Report, 2008.]
Difference in the percentage of minority and non-minority short-stay nursing home residents with pressure sores [AHRQ. National Health Disparities Report, 2008.]
Difference in the percentage of minority and non-minority patients that receive preventive services [AHRQ. National Health Disparities Report, 2008.], such as:
Colorectal cancer screening for adults age 50 and over
All recommended vaccinations
Advice about physical activity
Advice to quit smoking for adult current smokers
Difference in the percentage of minority and non-minority patients for whom colorectal cancer is diagnosed at an advanced stage [AHRQ. National Health Disparities Report, 2008.]
Measures
Disparity in satisfaction with care of minority and non-minority patients
(See the patient-oriented outcome "satisfaction" for measures)
Disparity in the health-related quality of life of minority and non-minority patients*
Disparity in the productivity of minority and non-minority patients*
Disparity in the end of life quality of minority and non-minority patients*
*Disparities in these outcomes are not well documented and may not exist. However, they may pose a problem in the future and should be monitored.
“Empathy refers specifically to the ability of physicians to imagine that they are the patient who has come to them for help. An empathic physician imagines what it is like to think, feel, and suffer like the patient.” [Gianakos D. Empathy revisited. Arch Intern Med 1996;156:135-6.]
Authenticity/Congruence
“Patients are very sensitive to these [non-verbal] messages, and to inconsistencies between between physicians’ verbal and non-verbal communication. These inconsistencies can be seen as a ‘lack of genuineness,’ one of the ‘core conditions’ necessary for a good interpersonal relationship according to the client-centered approach.” [Ong LML, de Haes JCJM, Hoos AM, Lammes FB. Doctor-patient communication: A review of the literature. Soc Sci Med 1995;40:903-918.]
Interpersonal Relationship
Shared decision-making/goal-setting
“Shared decision making strives to involve both patients and clinicians in clinical decision-making using the best available evidence regarding treatment options to derive personalized estimates of risk and benefits for each choice.” [Coylewright M, Montori V, Ting HH. Patient-centered shared decision-making: A public imperative. Am J Med 2012;125:545-7.]
“An individual’s health goals can best be determined through the combined efforts of that individual and his or her health care provider(s) using the special information each brings to the relationship.” [Mold JW, Blake GH, Becker LA. Goal-oriented medical care. Fam Med 1991;23:46-51.]
Interpersonal relationship
Empathic listening and understanding
 The physician listens to and understands patient concerns [Haggerty J, Burge F, Lévesque JF, Gass D, Pineault R, Beaulier MD, Santor D. Operational definitions of attributes of primary health care: Consensus among Canadian experts. Ann Fam Med 2007;5:336-44.]
Measures
From the Adult Primary Care Assessment Tool [Shi L, Starfield B, Xu J. Validating the Adult Primary Care Assessment Tool. J Fam Prac 2001;50:161.]:
Do you think that the doctor or nurse understands what you say or ask?
Jefferson Scale of Empathy (JSE): This 20-item self-administered questionnaire was designed to measure empathy in physicians and other health professionals. Responses are on a 7-point Likert scale. [Jefferson Scale of Empathy. Jefferson Medical College. <http://www.jefferson.edu/jmc/crmehc/medical_education/jspe.html>. Accessed 15 Aug 2012.] Additional information on the surveys and order forms can be found at http://www.tju.edu/jmc/crmehc/medu/JSPE.cfm
Authenticity/Congruence
The clinician’s non-verbal communication (e.g. body language, tone of voice, facial expressions) are consistent with his or her verbal communication
Measures
From the Primary Care Assessment Survey (abbreviated) [Safran DG, Kosinski M, Tarlov AR, Rogers WH, Taira DA, Lieberman N, Ware JE. The primary care assessment survey: Tests of data quality and measurement performance. Med Care 1998;36:728-39.]:
Doctor’s friendliness and warmth toward you
Nonverbal communication in doctor-elderly patient transactions (NDEPT) tool: This instrument was developed to measure the nonverbal dimensions of clinical encounters between physicians and the elderly. Trained coders observed videotapes of clinical encounters and assessed, among other things [Gorawara-Bhat R, Cook MA, Sachs GA. Nonverbal communication in doctor-elderly patient transaction (NDEPT): Development of a tool. Patient Educ Couns 2007;66:223-34.]:
Interaction distance: Shortest shoulder-to-shoulder distance between the physician and patient at each stage of the medical encounter
Percentage of time the physician spent in an open or closed stance
Percentage of time the physician made eye contact with the patient
Percentage of time the physician smiled or frowned at the patient
Percentage of the time the physician accompanied verbal speech with a head nod or hand gesture
Number of times the physician touches the patient
Shared decision-making/goal-setting
The physician understands what health means to the patient and works with the patient to establish clear, attainable goals for health based on these beliefs [Mold JW, Blake GH, Becker LA. Goal-oriented medical care. Fam Med 1991;23:46-51.]
Measures
From the Adult Primary Care Assessment Tool [Shi L, Starfield B, Xu J. Validating the Adult Primary Care Assessment Tool. J Fam Prac 2001;50:161.]:
Does your doctor know what problems are most important to you?
The physician and patient engage in shared decision-making [Haggerty J, Burge F, Lévesque JF, Gass D, Pineault R, Beaulier MD, Santor D. Operational definitions of attributes of primary health care: Consensus among Canadian experts. Ann Fam Med 2007;5:336-44.]
Measures
The following items are from a patient questionnaire designed to assess the “participatory decision-making” style of physicians. Responses were on a five-point Likert scale with responses ranging from “definitely yes” to “definitely no” on the first item and “very often” to “not at all” on the second and third items. [Adams RJ, Smith BJ, Ruffin RE. Impact of physician’s participatory style in asthma outcomes and patient satisfaction. Ann Allergy Asthma Immunol 2001;86:263-71.]
If there were a choice between treatments, would your doctor ask you to help him to make the decision?
How often does your doctor make an effort to give you some control over your treatment?
How often does your doctor ask you to take some of the responsibility for your treatment?
The following questions were given to cancer patients whose physicians had made medical decisions about their follow-up cancer care in the past 12 months. [Arora NK, Weaver KE, Clayman ML, Oakley-Girvan I, Potosky AL. Physicians’ decision-making style and psychosocial outcomes among cancer survivors. Patient Educ Couns 2009;77:404-12.]
Physicians’ decision-making style scale (Response options: “yes, definitely,” “yes, somewhat,” or “no”): Did your follow-up care doctor…
Discuss the available options with you in a way you could understand?
Encourage you to ask questions or express any concerns you had about the available options?
Encourage you to ask questions or express any concerns you had about his or her recommendations?
Encourage you to give your opinion about the available options?
Involve you as much as you wanted in the decision-making process?
Decision-making participation self-efficacy scale: How confident are you that you would be able to…
Take part in a detailed discussion with your doctor about the different available options
Let your doctor know if you had any concerns or questions about his or her recommendation
Tell your doctor about the option you would prefer
Work out any differences of opinion with your doctor, should they exist
Take responsibility for making the final decision
From the Adult Primary Care Assessment Tool [Shi L, Starfield B, Xu J. Validating the Adult Primary Care Assessment Tool. J Fam Prac 2001;50:161.]:
Would your doctor let you look at your medical record if you want to?
Does your doctor call or send you the results of the lab tests?
Percentage of plaintiff depositions for malpractice lawsuits in which delivering information poorly or failing to understand the patient and/or family perspective is identified [Beckman HB, Markakis KM, Suchman AL, Frankel RM. The doctor-patient relationship and malpractice: Lessons from plaintiff depositions. Arch Intern Med 1994;154:1365-70.]
The patient feels comfortable expressing his or her concerns, whether physical or emotional [Epstein RM, Street RL. Shared mind: Communication, decision making, and autonomy in serious illness. Ann Fam Med 2011;9:454-61.]
From the Components of Primary Care Index [Flocke SA. Measuring attributes of primary care: Development of a new instrument. J Fam Pract 1997;45:64-74.]:
I can easily talk about personal things with this doctor
I don’t always feel comfortable asking questions of this doctor.
From the Primary Care Assessment Survey (abbreviated) [Safran DG, Kosinski M, Tarlov AR, Rogers WH, Taira DA, Lieberman N, Ware JE. The primary care assessment survey: Tests of data quality and measurement performance. Med Care 1998;36:728-39.]:
How often do you leave your doctor’s office with unanswered questions
Doctor’s patience with your questions or worries
I can tell my doctor anything
From the Adult Primary Care Assessment Tool [Shi L, Starfield B, Xu J. Validating the Adult Primary Care Assessment Tool. J Fam Prac 2001;50:161.]:
Does your doctor give you enough time to talk about your worries or problems?
From the Ambulatory Care Experiences Survey [Safran DG, Karp M, Coltin K, Chang H, Li A, Ogren J, Rogers WH. Measuring patients’ experiences with individual primary care physicians: Results of a statewide demonstration project. J Gen Intern Med 2006;21:13-21.]:
How often did you feel you could tell your personal doctor anything, even things you might not tell anyone else
From the Components of Primary Care Index [Flocke SA. Measuring attributes of primary care: Development of a new instrument. J Fam Pract 1997;45:64-74.]:
Sometimes, this doctor does not listen to me.
From the Patient-Primary Care Provider Relationship Scale [Forrest CB, Shi L, von Schrader S, Ng J. Managed care, primary care, and the patient-practitioner relationship. J Gen Intern Med 2002;17:270-7.]: Patients were asked…
How well their doctor listened to them
From the Primary Care Assessment Survey [Safran DG, Kosinski M, Tarlov AR, Rogers WH, Taira DA, Lieberman N, Ware JE. The primary care assessment survey: Tests of data quality and measurement performance. Med Care 1998;36:728-39.]:
Attention doctor gives to what you have to say
From the Ambulatory Care Experiences Survey [Safran DG, Karp M, Coltin K, Chang H, Li A, Ogren J, Rogers WH. Measuring patients’ experiences with individual primary care physicians: Results of a statewide demonstration project. J Gen Intern Med 2006;21:13-21.]:
How often did your personal doctor listen carefully to you
Measures
The physician explains health issues in a way that is understandable to the patient [Haggerty J, Burge F, Lévesque JF, Gass D, Pineault R, Beaulier MD, Santor D. Operational definitions of attributes of primary health care: Consensus among Canadian experts. Ann Fam Med 2007;5:336-44.]
Measures
From the Components of Primary Care Index [Flocke SA. Measuring attributes of primary care: Development of a new instrument. J Fam Pract 1997;45:64-74.]:
This doctor always explains things to my satisfaction.
From the Patient-Primary Care Provider Relationship Scale [Forrest CB, Shi L, von Schrader S, Ng J. Managed care, primary care, and the patient-practitioner relationship. J Gen Intern Med 2002;17:270-7.]: Patients were asked…
How well the doctor explained things
From the Primary Care Assessment Survey [Safran DG, Kosinski M, Tarlov AR, Rogers WH, Taira DA, Lieberman N, Ware JE. The primary care assessment survey: Tests of data quality and measurement performance. Med Care 1998;36:728-39.]:
Doctor’s explanations of your health problems or treatments
Doctor’s instructions about symptoms to report and when to seek further care
My doctor would always tell me the truth about my health, even if there was bad news
From the Adult Primary Care Assessment Tool [Shi L, Starfield B, Xu J. Validating the Adult Primary Care Assessment Tool. J Fam Prac 2001;50:161.]:
Are your questions to your doctor answered in ways that you can understand?
From the Ambulatory Care Experiences Survey [Safran DG, Karp M, Coltin K, Chang H, Li A, Ogren J, Rogers WH. Measuring patients’ experiences with individual primary care physicians: Results of a statewide demonstration project. J Gen Intern Med 2006;21:13-21.]:
How often did your personal doctor explain things in a way that was easy to understand
How often did your personal doctor give you clear instructions about what to do to take care of health problems or symptoms that were bothering you
How often did your personal doctor give you clear instructions about what to do if symptoms got worse or came back
Relevant information about the patient’s situation is shared with the patient, neither in insufficient quantity nor overload [Epstein RM, Street RL. Shared mind: Communication, decision making, and autonomy in serious illness. Ann Fam Med 2011;9:454-61.]
The physician is willing to acknowledge uncertainty [Epstein RM, Street RL. Shared mind: Communication, decision making, and autonomy in serious illness. Ann Fam Med 2011;9:454-61.]
Measures
From the Patient-Primary Care Provider Relationship Scale [Forrest CB, Shi L, von Schrader S, Ng J. Managed care, primary care, and the patient-practitioner relationship. J Gen Intern Med 2002;17:270-7.]: Patients were asked whether they…
My doctor sometimes pretends to know things when he/she is really not sure
Constructs
Definitions
“Physicians who are affected by the stresses of their work may go on to experience substance abuse, relationship troubles, depression, or even death. Results of emerging research show that physicians’ stress, fatigue, burnout, depression, or general psychological distress negatively affects health-care systems and patient care.” [Wallace JE, Lemaire JB, Ghali WA. Physician wellness: A missing quality indicator. Lancet 2009;374:1714-21.]
“A physician’s actually leaving a practice or organization may have the following consequences: (a) financial loss related to the costs of recruiting and relocation and lost revenues for the practice because of decreased patient visits as a new physician’s practice matures, (b) impaired morale for the practice or organization, as colleagues regret a coworker’s departure and must absorb workload, and (c) patient care costs, such as loss of continuity of care, and impaired patient satisfaction, because patients lose a trusted provider and must find an alternative with whom to develop a relationship.” [Misra-Herbert AD, Kay R, Stoller JK. A review of physician turnover: Rates, causes, and consequences. Am J Med Qual 2004;19:56-66.]
Constructs
Clinician well-being
Clinician stress [Dyrbye LN, Shanafelt TD. Physician burnout: A potential threat to successful health care reform. JAMA 2011;305:2009-10.]
Measures
Patient visits per hour per clinician (a measure of work intensity) [Bachman KH, Freeborn DK. HMO physicians’ use of referrals. Soc Sci Med 1999;48:547-57.]
Clinician self-assessment of stress on a 5-point scale [Glasheen JJ, Misky GJ, Reid MB, Harrison RA, Sharpe B, Auerbach A. Career satisfaction and burnout in academic hospital medicine. Arch Intern Med 2011;171:782-5.]
Perceived Stress Scale (PSS): This 10-item instrument measures perceived stress in the respondent based on his or her feelings in the past month. Responses are on a 5-point Likert scale. [Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav 1983;24:385-96.] Access to the survey can be found at <http://www.mindgarden.com/products/pss.htm>.
NASA Task Load Index (NASA-TLX): This instrument uses subjective assessment on the scales of mental demands, physical demands, temporal demands, own performance, effort, and frustration to derive an overall workload score. It is available in a paper format and as a computer application. [NASA TLX: Task Load Index. Accessed 13 Aug 2012. <http://humansystems.arc.nasa.gov/groups/TLX/index.html>.] Additional information and access to both versions of the survey is available at <http://humansystems.arc.nasa.gov/groups/TLX/index.html>.
Clinician mental health [Wallace JE, Lemaire JB, Ghali WA. Physician wellness: A missing quality indicator. Lancet 2009;374:1714-21.]
Measures
Symptom Checklist-90 (SCL-90): This 90-item survey is designed to evaluate psychological problems and symptoms of psychopathology on 9 general scales: somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. Responses are on a 5-point Likert scale. Additional information and access to the survey can be obtained at <http://psychcorp.pearsonassessments.com/HAIWEB/Cultures/en-us/Productdetail.htm?Pid=PAg514>. [Derogatis LR. Symptom Checklist-90-Revised (SCL-90-R®). Pearson. <http://psychcorp.pearsonassessments.com/HAIWEB/Cultures/en-us/Productdetail.htm?Pid=PAg514>. Accessed 9 Aug 2012.]
General Health Questionnaire (GHQ): This 12-item questionnaire serves as an indicator of depression, social dysfunction, anxiety, and somatic symptoms. Each item is a symptom of psychiatric morbidity, and responses are scored as 0 or 1 based on the frequency with which the symptom was experienced in the recent past. A total score of 4 or more indicates substantial psychiatric morbidity [Sargent MC, Sotile W, Sotile MO, Rubash H, Barrack RL. Stress and coping among orthopaedic surgery residents and faculty. J Bone Joint Surg Am 2004;86:1579-86.] Information about obtaining a copy of the GHQ can be found at <http://www.nwph.net/lifestylesurvey/userfiles/mental/things/GHQ12.pdf>.
Clinician health and coping behaviors [Wallace JE, Lemaire JB, Ghali WA. Physician wellness: A missing quality indicator. Lancet 2009;374:1714-21.]
Measures
Brief COPE: This 28-item questionnaire is derived from the longer COPE inventory, a measure of coping behaviors applicable to a broad range of stressful situations. It contains scales for active coping, planning, positive reframing, acceptance, humor, religion, using emotional support, using instrumental support, self-distraction, denial, venting, substance use, behavioral disengagement, and self-blame. Responses are on a 4-point Likert scale ranging from “I haven’t been doing this at all” to “I’ve been doing this a lot.” [Carver CS. You want to measure coping but your protocol’s too long: Consider the Brief COPE. Int J Behav Med 1997;4:92-100.] Additional information and access to the survey can be found at <http://www.psy.miami.edu/faculty/ccarver/sclBrCOPE.html>.
Percentage of physicians enrolled in physician health programs due to alcohol or other substance abuse [Berge KH, Seppala MD, Schipper AM. Chemical dependency and the physician. Mayo Clin Proc 2009;84:576-80.]
Clinician job satisfaction [Williams ES, Skinner AC. Outcomes of physician job satisfaction: A narrative review, implications, and directions for future research. Health Care Manage Rev 2003;28:119-39.]
Measures
Clinician’s rating on a 7-point scale from “not at all satisfied” to “completely satisfied” of [Wu CH, Griffin MA. Longitudinal relationships between core self-evaluations and job satisfaction. J Appl Psychol 2012;97:331-42.]:
Overall job satisfaction
Satisfaction with total pay
Satisfaction with security
Satisfaction with work itself
Satisfaction with work hours
The following items were adopted from the Warr-Cook-Wall job satisfaction scale for a study that measured job satisfaction of primary care team members. Responses are on a 7-point Likert scale. [Szecsenyi J, Goetz K, Campbell S, Broge B, Reuschenbach B, Wensing M. Is the job satisfaction of primary care team members associated with patient satisfaction. BMJ Qual Saf 2011;20:508-14.]
Amount of variety in job
Opportunity to use abilities
Freedom of working method
Amount of responsibility
Physical working condition
Hours of work
Income
Recognition for work
Colleagues and fellow workers
Overall job satisfaction
Clinician turnover
Measures
Clinician turnover rate, expressed as the percentage of physicians who leave a practice or medical organization in a given time period [Misra-Herbert AD, Kay R, Stoller JK. A review of physician turnover: Rates, causes, and consequences. Am J Med Qual 2004;19:56-66.]
Percentage of clinicians who stay at the same practice or medical organization for a certain time period (e.g. percentage who stay at a practice for two years, three years, etc.) [Misra-Herbert AD, Kay R, Stoller JK. A review of physician turnover: Rates, causes, and consequences. Am J Med Qual 2004;19:56-66.]
Percentage of clinicians who report they would change to another profession with a similar salary if it were possible [Heponiemi T, Kouvonen A, Vanska J, Halila H, Sinervo T, Kivimaki M, Elovainio M. The association of distress and sleeping problems with physicians’ intention to change profession: The moderating effect of job control. J Occup Health Psychol 2009;14:365-73.]
Percentage of clinicians who report intending to quit direct patient care in the next five years [Sibbald B, Bojke C, Gravelle H. National survey of job satisfaction and retirement intentions among general practitioners in England. BMJ 2003;326:22.]
General measures of well-being and durability
Clinicians’ assessment of their level of burnout, using their own definition of burnout, on a five-point scale ranging from “I enjoy my work. I have no symptoms of burnout” to “I feel completely burned out and often wonder if I can go on. I am at the point where I may need some changes or may need to see some sort of help.” [Rohland BM, Kruse GR, Rohrer JE. Validation of a single-item measure of burnout against the Maslach Burnout Inventory among physicians. Stress and Health 2004;20:75-9.]
Clinician self-assessment of overall quality of life on a 4-point scale [Sargent MC, Sotile W, Sotile MO, Rubash H, Barrack RL. Stress and coping among orthopaedic surgery residents and faculty. J Bone Joint Surg Am 2004;86:1579-86.]
Maslach Burnout Inventory (MBI): This instrument is designed to assess professional burnout based on three general scales: emotional exhaustion, depersonalization, and personal accomplishment. Responses are on a Likert scale. [Maslach C, Jackson SE, Leiter MP, Schaufeli WB, Schwab RL. Maslach Burnout Inventory (MBI). Mind Garden, Inc. www.mindgarden.com/products/mbi.htm#ms. Accessed 9 Aug 2012.] Additional information and access to the survey is available at <http://www.mindgarden.com/products/mbi.htm#ms>.
Physician Worklife Survey: This instrument assesses clinician well-being and intention to stay at the same practice. It contains sections on medical training, characteristics of an ideal job, practice setting descriptors, workload characteristics, patient characteristics, revised facet and global satisfaction measures, physical and mental health, intention to leave, and sociodemographics. [Williams ES, Konrad TR, Linzer M, McMurray J, Pathman DE, Gerrity M, Schwartz MD, Scheckler WE, Van Kirk J, Rhodes E, Douglas J. Refining the measurement of physician job satisfaction: Results from the Physician Worklife Survey. Med Care 1999;37:1140-54.] The survey is given below.
Physician Worklife Survey:
Fewer low birth weight infants
Definitions
“The earlier detection of disease may lead to more cures or longer survival.” [Lee S, Huang H, Zelen M. Early detection of disease and scheduling of screening examinations. Stat Methods Med Res 2004;13:443-56.]
Constructs
Screening for diseases for which early detection is possible and important
The following diseases have been identified by the U.S. Preventive Services Task Force (USPSTF) as diseases for which screening is possible in a primary care setting. Please note that the USPSTF does not recommend screening for these diseases in all patients. Additional information about the benefits of each screening procedure and when its use is appropriate can be found at the USPSTF website: <http://www.uspreventiveservicestaskforce.org/>. [USPSTF. <http://www.uspreventiveservicestaskforce.org/>. Accessed 21 Aug 2012.]
 Cancer
Bladder
Breast
Cervical
Colorectal
Lung
Oral
Ovarian
Pancreatic
Prostate
Skin
Testicular
Thyroid
Heart and vascular diseases
Abdominal aortic aneurysm
Carotid artery stenosis
Coronary heart disease
Hypertension
Lipid disorders (cholesterol abnormalities, dyslipidemia)
Peripheral arterial disease
Infectious disease
Bacteriuria
Chlamydial infection
Gonorrhea
Hepatitis B virus infection
Hepatitis C virus infection
Herpes simplex, genital
HIV infection
Rubella
Syphilis
Tuberculosis
Injury and violence
Family violence
Intimate partner violence and elderly abuse
Mental health conditions and substance abuse
Alcohol misuse
Dementia (Alzheimer’s disease)
Depression
Drug use (illicit)
Metabolic, nutritional, and endocrine conditions
Diabetes mellitus
Hemochromatosis
Iron deficiency anemia
Obesity
Thyroid disease
Musculoskeletal disorders
Osteoporosis
Obstetric and gynecologic conditions
Bacterial vaginosis in pregnancy
Down syndrome
Gestational diabetes
Preeclampsia
Rh incompatibility
Rubella
Vision and hearing disorders
Glaucoma
Hearing loss
Impaired visual acuity
Miscellaneous
Chronic obstructive pulmonary disease
Dental and periodontal disease
Chronic kidney disease
Measures
Percentage of patients whose disease is diagnosed at an early stage in the disease progression. For example, percentage of patients with pancreatic cancer whose tumor is identified in Stage 1. [Liu J, Gao J, Du Y, Li Z, Ren Y, Gu J, Wang X, Gong Y, Wang W, Kong X. Combination of plasma mircoRNAs with serum CA19-9 for early detection of pancreatic cancer. Int J Cancer 2012;131:683-91.]
Average age at diagnosis (for congenital disorders) [Holzer L, Mihailescu R, Rodrigues-Degaeff C, Junier L, Muller-Nix C, Halfon O, Ansermet F. Community introduction of practice parameters for autistic spectrum disorders: Advancing early recognition. Journal of Autism & Developmental Disorders 2006;36:249-62.]
Rapid initiation of treatment once a disease is diagnosed
Measures
Average interval between the onset of symptoms and the start of treatment of a disease [Shiers D, Lester H. Early intervention for first episode psychosis. BMJ 2004;328:1451-2.]
Definitions
“[Adherence is] the extent to which a person’s behavior – taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider.” [WHO. Adherence to long-term therapies: Evidence for action. Geneva: World Health Organization; 2003.]
Constructs
Patient adherence to drug regimens [Norell SE. Accuracy of patient interviews and estimates by clinical staff in determining medication compliance. Soc Sci Med [E] 1981;15:57-61.]
Measures
Percentage of patients who report missing two or more doses of medication in the past 7 days [Norell SE. Accuracy of patient interviews and estimates by clinical staff in determining medication compliance. Soc Sci Med [E] 1981;15:57-61.]
Morisky Medication Adherence Scale: Below are the items from a patient-completed questionnaire to measure adherence to drug regimens. A score for medication adherence can be calculated by assigning a value of 0 to a response of “yes” and 1 to a response of “no.” A higher score indicates poorer adherence. [Morisky DE, Green LW, Levine DM. Concurrent and predictive validity of a self-reported measure of medication adherence. Med Care 1986;24:67-74.]
Do you ever forget to take your medicine?
Are you careless at times about taking your medicine?
When you feel better do you sometimes stop taking your medication?
Sometimes when you feel worse when you take the medicine, do you stop taking it?
Pill counts at office visits: (number of missing pills/number of pills prescribed)*100% [Matsui D, Hermann C, Klein J, Berkovitch M, Olivieri N, Koren G. Critical comparison of novel and existing methods of compliance assessment during a clinical trial of an oral iron chelator. J Clin Pharmacol 1994;34:944-49.]
Percentage of prescription refills obtained: (number of refills requested/number of expected refills)*100% [Elixhauser A, Eisen SA, Romeis JC, Homan SM. The effects of monitoring and feedback on compliance. Med Care 1990;28:882-93.]
Proportion of days covered (PDC): This estimate of drug regimen adherence is calculable using data from electronic pharmacy refill records. Each day in a given time period is categorized as a “yes” if the patient possessed one or more disease-specific medications on that day, as a “no” if not. The PDC is number of days counted as “yes” divided by the total number of days in the time period. [Matza LS, Park J, Coyne KS, Skinner EP, Malley KG, Wolever RQ. Derivation and validation of the ASK-12 Adherence Barrier Survey. Ann Pharmacother 2009;43:1621-30.]
Evaluation of patient daily diaries of medication intakes [Matsui D, Hermann C, Klein J, Berkovitch M, Olivieri N, Koren G. Critical comparison of novel and existing methods of compliance assessment during a clinical trial of an oral iron chelator. J Clin Pharmacol 1994;34:944-49.]
Medication Event Monitoring System (MEMS): This electronic device records the timing and frequency of the opening of a pill bottle. It has been used in various clinical trials to measure patient adherence to drug regimens. [Matsui D, Hermann C, Klein J, Berkovitch M, Olivieri N, Koren G. Critical comparison of novel and existing methods of compliance assessment during a clinical trial of an oral iron chelator. J Clin Pharmacol 1994;34:944-49.] Additional information about MEMS can be accessed at <http://www.aardexgroup.com/aardex_index.php?group=aardex>.
Percentage of a patient population on a drug regimen with biochemical indicators of adherence to the regimen. For example, concentration of ampicillin in the urine can be used as an indicator of adherence to an antibiotic regimen. [Hunter RH, Kotzan JA. Effect of obtrusive measures on antibiotic compliance. J Pharm Sci 1979;68:272-4.]
ASK-12 Adherence Barrier Survey: Below is a list of the items from the ASK-12 survey. This patient-completed questionnaire is derived from the longer ASK-20 survey and is a measure of the barriers and behaviors related to medication adherence. Responses are on a 5-point Likert scale. [Matza LS, Park J, Coyne KS, Skinner EP, Malley KG, Wolever RQ. Derivation and validation of the ASK-12 Adherence Barrier Survey. Ann Pharmacother 2009;43:1621-30.]
I just forget to take my medicines some of the time.
I run out of my medicine because I don’t get refills on time.
I feel confident that each one of my medicines will help me.
I know if I am reaching my health goals.
I have someone whom I can call with questions about my medicines.
My doctor/nurse and I work together to make decisions.
Taking medicines more than once a day is inconvenient.
Have you taken a medicine more or less often than prescribed?
Have you skipped or stopped taking a medicine because you didn’t think it was working?
Have you skipped or stopped taking a medicine because it made you feel bad?
Have you skipped, stopped, not refilled, or taken less medicine because of the cost?
Have you not had medicine with you when it was time to take it?
Patient adherence to recommended changes in health behaviors (modified diet, physical activity, smoking, etc) [WHO. Adherence to long-term therapies: Evidence for action. Geneva: World Health Organization; 2003.]
Measures
Percentage of patients who report making a recommended change in their health behaviors (e.g. quit smoking, exercise 3 times a week, reduce alcohol intake) [Benjamin R. The prevention imperative: Protecting the health and well-being of America’s families. America’s Health Rankings: A Call to Action for Individuals & Their Communities, 2011 ed. <http://www.americashealthrankings.org/SiteFiles/Reports/AHR%202011edition.pdf>. Accessed 16 Aug 2012.]
Percentage of patients with biological indications of adherence to recommended health behaviors. For example, mean weight gain and mean serum potassium level can serve as indicators of compliance with dietary recommendations. [Cummings KM, Becker MH, Kirscht JP, Levin NW. Intervention strategies to improve compliance with medical regimens by ambulatory hemodialysis patients. J Behav Med 1981;4:111-27.]
Missed appointments [Buckley HB. Nurse practitioner intervention to improve postpartum appointment keeping in an outpatient family planning clinic. J Am Acad Nurse Pract 1990;2:29-32.]
Measures
Percentage of appointments that are not kept by patients [Buckley HB. Nurse practitioner intervention to improve postpartum appointment keeping in an outpatient family planning clinic. J Am Acad Nurse Pract 1990;2:29-32.]
Percentage of patients that return for a follow-up appointment when one is scheduled [Blonna R, Legos P, Burlack P. The effects of an STD educational intervention on follow-up appointment keeping and medication-taking compliance. Sex Transm Dis 1989;16:198-200.]
Definitions
“A prevention-oriented approach can obviate the need for much curative care.” [Morse RM, Hefron WA. Preventive Health Care. Rakel RE, ed. Textbook of Family Practice, 6th ed. Philadelphia: WB Saunders Company; 2002.]
“Disease prevention is a growing national imperative, particularly as more American families struggle with the personal and financial implications of chronic illness.” [Benjamin R. The prevention imperative: Protecting the health and well-being of America’s families. America’s Health Rankings: A Call to Action for Individuals & Their Communities, 2011 ed. <http://www.americashealthrankings.org/SiteFiles/Reports/AHR%202011edition.pdf>. Accessed 16 Aug 2012.]
Constructs
Preventable infectious diseases
Infectious diseases that can be prevented by vaccinations, including the following [CDC. Vaccines & Preventable Diseases. <http://www.cdc.gov/vaccines/vpd-vac/>. Accessed 16 Aug 2012.]:
Anthrax
Cervical cancer
Diphtheria
Hepatitis A
Hepatitis B
Haemophilus influenzae type b
Human Papillomavirus
H1N1 flu
Influenza (seasonal flu)
Japanese encephalitis
Lyme disease
Measles
Meningococcal
Monkeypox
Mumps
Pertussis
Pneumococcal
Poliomyelitis
Rabies
Rotavirus
Rubella
Shingles
Smallpox
Tetanus
Tuberculosis
Typhoid fever
Varicella
Yellow fever
Infectious diseases that can be prevented by changing patient behaviors, such as HIV/AIDS and other STDs [National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. Strategic Plan 2010-2015. February 2010. <http://www.cdc.gov/nchhstp/docs/10_NCHHSTP%20strategic%20plan%20Book_semi%20final508.pdf>. Accessed 16 Aug 2012.]
Measures
Combined incidence in the patient population of the preventable infectious diseases listed below. Each disease is representative of a different mode of transmission. [Benjamin R. The prevention imperative: Protecting the health and well-being of America’s families. America’s Health Rankings: A Call to Action for Individuals & Their Communities, 2011 ed. <http://www.americashealthrankings.org/SiteFiles/Reports/AHR%202011edition.pdf>. Accessed 16 Aug 2012.]
Measles
Pertussis
Hepatitis A
Syphilis
Incidence of a specific preventable infectious disease, such as HIV, in the patient population per year [Benjamin R. The prevention imperative: Protecting the health and well-being of America’s families. America’s Health Rankings: A Call to Action for Individuals & Their Communities, 2011 ed. <http://www.americashealthrankings.org/SiteFiles/Reports/AHR%202011edition.pdf>. Accessed 16 Aug 2012.]
Non-infectious diseases preventable by improved patient health behaviors
Incidence of the diseases listed below. Under each disease are modifiable health risk factors associated with that disease outcome. [Danaei G, Ding EL, Mozaffarian D, Taylor B, Rehm J, Murray CJL, Ezzati M. The preventable causes of death in the United States: Comparative risk assessment of dietary, lifestyle, and metabolic risk factors. PLoS Med 2009;6(4):e1000058.]
Ischemic heart disease
High dietary trans fatty acids
Low dietary polyunsaturated fatty acids (in replacement of saturated fatty acids)
High dietary salt
Low intake of fruits and vegetables
Low dietary omega-3 fatty acids
High alcohol use
Physical inactivity
Tobacco smoking
Stroke
Low dietary polyunsaturated fatty acids
High dietary salt
Low intake of fruits and vegetables
Low dietary omega-3 fatty acids
High alcohol use
Physical inactivity
Tobacco smoking
Hypertensive disease
High dietary salt
High alcohol use
Tobacco smoking
Cancer
Stomach cancer
Low intake of fruits and vegetables
High dietary salt
Tobacco smoking
Lung cancer
Low intake of fruits and vegetables
Tobacco smoking
Colorectal cancer
Low intake of fruits and vegetables
High alcohol use
Physical inactivity
Esophagus, mouth, and pharynx cancer
Low intake of fruits and vegetables
High alcohol use
Tobacco smoking
Breast cancer
High alcohol use
Physical inactivity
Laryngeal cancer
High alcohol use
Liver cancer
High alcohol use
Tobacco smoking
Pancreas cancer
Tobacco smoking
Cervix uteri cancer
Tobacco smoking
Bladder cancer
Tobacco smoking
Leukemia
Tobacco smoking
Liver cirrhosis
High alcohol use
Acute and chronic pancreatitis
High alcohol use
Diabetes
Physical inactivity
High alcohol use
Tobacco smoking
Chronic obstructive pulmonary disease
Tobacco smoking
Diseases caused by modifiable community and environmental factors
Measures
Average amount of fine particulate matter (in micrograms per cubic meter) in the air [Benjamin R. The prevention imperative: Protecting the health and well-being of America’s families. America’s Health Rankings: A Call to Action for Individuals & Their Communities, 2011 ed. <http://www.americashealthrankings.org/SiteFiles/Reports/AHR%202011edition.pdf>. Accessed 16 Aug 2012.]
Incidence of occupational fatalities or injuries in the patient population [Benjamin R. The prevention imperative: Protecting the health and well-being of America’s families. America’s Health Rankings: A Call to Action for Individuals & Their Communities, 2011 ed. <http://www.americashealthrankings.org/SiteFiles/Reports/AHR%202011edition.pdf>. Accessed 16 Aug 2012.]
Incidence of unintentional child injury at home in the patient population [Pearson M, Garside R, Moxham T, Anderson R. Preventing unintentional injuries to children in the home: A systematic review of the effectiveness of programmes supplying and/or installing home safety equipment. Health Promotion International 2011;26:376-92.]
Percentage of homes in the patient population with health hazards such as high radon levels, lead paint, or lack of a functioning fire alarm system [CDC. A health home for everyone: The guide for families and individuals. <http://www.cdc.gov/nceh/lead/publications/Final_Companion_Piece.pdf>. Accessed 17 Aug 2012.]
Definitions
“Adverse pregnancy outcomes are generally more common in the United States than in other developed countries. Low-birth-weight infants, born after a preterm birth or secondary to intrauterine growth restriction, account for much of the increased morbidity, mortality, and cost.” [Goldenberg RL, Culhane JF. Low birth weight in the United States. Am J Clin Nutr 2007;85:584S-590S.]
“In 1948, the World Health Organization (WHO) defined prematurity as a birth weight of 2,500 grams (5 pounds, 8 ounces) or less… Because of the higher accuracy of measure of birth weight [as opposed to gestational age], until recently, most researchers have continued to use birth weight cutoffs to designate infant risks. These include very low birth weight (VLBW) infants, whose birth weights are less than 1,500 grams (3 pounds, 5 ounces), and extremely low birth weight (ELBW) infants, whose birth weights are less than 1,000 grams (2 pounds, 3 ounces).” [IOM. Preterm Birth: Causes, Consequences, and Prevention. Washington DC: National Academies Press; 2007.]
Constructs
Prematurity
Measures [IOM. Preterm Birth: Causes, Consequences, and Prevention. Washington DC: National Academies Press; 2007.]
Percentage of births at less than 37 completed weeks of gestation (all preterm births)
Percentage of births at less than 32 completed weeks of gestation (greatest risk of morbidity and mortality)
Percentage of births at 32-36 completed weeks of gestation (majority of preterm births)
Intrauterine growth retardation
Measures
Percentage of infants with a small-for-gestational age (SGA) birth weight (less than the 10th percentile of birth weight for that gestational age) [IOM. Preterm Birth: Causes, Consequences, and Prevention. Washington DC: National Academies Press; 2007.]
Indicators of Prematurity and/or Intrauterine Growth Retardation
Measures [IOM. Preterm Birth: Causes, Consequences, and Prevention. Washington DC: National Academies Press; 2007.]
Percentage of infants with a birth weight of less than 2,500 grams (low birth weight
Percentage of infants with a birth weight of less than 1,500 grams (very low birth weight)
Percentage of infants with a birth weight of less than 1,000 grams (extremely low birth weight)
Definitions
“Chronic diseases – such as heart disease, stroke, cancer, diabetes, and arthritis – are among the most common, costly, and preventable health problems in the U.S.” [CDC. Chronic Diseases and Health Promotion. <http://www.cdc.gov/chronicdisease/overview/index.htm>. Accessed 27 Aug 2012.]
“Chronic care takes place within 3 overlapping galaxies: (1) the entire community, with its myriad resources and numerous public and private policies; (2) the health care system, including its payment structures; and (3) the provider organization, whether an integrated delivery system, a small clinic, or a loose network of physician practices. Within this trigalactic universe, the workings of which may help or hinder optimal chronic care, the chronic care model identifies 6 essential elements: community resources and policies, health care organization, self-management support, delivery system design, decision support, and clinical information systems.” [Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA 2002;288:1775-9.]
Constructs
Processes of effective chronic disease control (adapted from the chronic care model)
Use of links to community-based resources (senior centers, self-help groups, etc.) for the control of chronic disease [Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA 2002;288:1775-9.]
Prioritization of chronic care management by the provider organization [Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA 2002;288:1775-9.]
Measures
Percentage of practices that provide data to their physicians on the quality of their care for patients with common chronic illnesses [Rittenhouse DR, Shortell SM, Gillies RR, Casalino LP, Robinson JC. Improving chronic illness care: Findings from a national study of care management processes in large physician practices. Med Care Res Rev 2010;67:301-20.]
Patient Experience of Continuity of Care Instrument
This 34-item patient-completed questionnaire was developed to assess management, informational, and relational continuity of care for patients. The items relate to the 9 dimensions of continuity listed below. Both evaluative and reporting items are used. A copy of the instrument is available at http://www.annfammed.org/content/10/5/443/suppl/DC1. [Haggerty JL, Roberge D, Freeman GK, Beaulieu C, Bréton M. Validation of a generic measure of continuity of care: When patients encounter several clinicians. Ann Fam Med 2012;10:443-51.]
Main clinician
Coordinator role
Comprehensive knowledge of patient
Confidence and partnership
Various clinicians
Confidence in team
Role clarity and coordination within clinic
Role clarity and coordination between clinics
Information gap between clinicians
Patient as partner
Care plan
Self-management information provided.
Continuity
Self-management of chronic illness by the patient [Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA 2002;288:1775-9.]
Measures
Percentage of practices that send reminders for preventive or follow-up care directly to a majority of patients with common chronic illnesses [Rittenhouse DR, Shortell SM, Gillies RR, Casalino LP, Robinson JC. Improving chronic illness care: Findings from a national study of care management processes in large physician practices. Med Care Res Rev 2010;67:301-20.]
Partners in Health Scale: This 12-item patient-completed survey was designed as a measure of patients’ knowledge and behaviors about self-management of their chronic conditions. Responses are on an 8-point Likert scale. [Petkov J, Harvey P, Battersby M. The internal consistency and construct validity of the partners in health scale: Validation of a patient rated chronic condition self-management measure. Qual Life Res 2010;19:1079-85.] Additional information is available at <http://www.risen.org.au/HealthProfessional/HPR_PIH.asp>.
Effective structuring of the medical practice for the management of chronic illness [Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA 2002;288:1775-9.]
Measures
Percentage of practices that make available nonphysician staff who are specially trained and designated to educate patients in managing common chronic illnesses [Rittenhouse DR, Shortell SM, Gillies RR, Casalino LP, Robinson JC. Improving chronic illness care: Findings from a national study of care management processes in large physician practices. Med Care Res Rev 2010;67:301-20.]
Percentage of practices that provide nurse care managers whose primary job is to coordinate and improve the quality of care for patients with common chronic illnesses [Rittenhouse DR, Shortell SM, Gillies RR, Casalino LP, Robinson JC. Improving chronic illness care: Findings from a national study of care management processes in large physician practices. Med Care Res Rev 2010;67:301-20.]
Integration of evidence-based clinical practice guidelines for chronic care [Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA 2002;288:1775-9.]
Measures
Percentage of practices that provide the majority of physicians with guideline-based reminders for services patients with common chronic illnesses should receive at the time of seeing the patient [Rittenhouse DR, Shortell SM, Gillies RR, Casalino LP, Robinson JC. Improving chronic illness care: Findings from a national study of care management processes in large physician practices. Med Care Res Rev 2010;67:301-20.]
Use of clinical information systems for the monitoring of chronic illness [Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA 2002;288:1775-9.]
Measures
Percentage of practices that maintain an electronic registry or list of patients with common chronic illnesses [Rittenhouse DR, Shortell SM, Gillies RR, Casalino LP, Robinson JC. Improving chronic illness care: Findings from a national study of care management processes in large physician practices. Med Care Res Rev 2010;67:301-20.]
General measure of the implementation of the chronic care model
Assessment of Chronic Illness Care (ACIC): This 28-item survey is designed to assist health organizations in evaluating the quality of chronic illness care based on the six components of the chronic care model. [Bonomi AE, Wagner EH, Glasgow RE, VonKorff M. Assessment of Chronic Illness Care (ACIC): A practical tool to measure quality improvement. Health Serv Res 2002;37:791-820.] Additional information and access to the survey can be obtained at <http://www.ihi.org/knowledge/Pages/Tools/ACICSurvey.aspx>.
Quality indicators based on disease-specific clinical guidelines: Information on disease-specific clinical practice guidelines is available from the National Guideline Clearinghouse at <http://www.guideline.gov/index.aspx>.
Improved functioning
Definitions
“Functioning is an umbrella term encompassing all body functions, activities and participation; similarly, disability serves as an umbrella term for impairments, activity limitations, or participation restrictions.” [WHO. International Classification of Functioning, Disability and Health: Short Version. Geneva: WHO; 2001.]
“The definition of functional status can best be summarized as activities performed by an individual to realize needs of daily living in many aspects of life including physical, psychological, social, spiritual, intellectual, and roles. Level of performance is expected to correspond to normal expectations in the individual’s nature, structure, and conditions.” [Wang TJ. Concept analysis of functional status. Int J Nurs Stud 2004;41:457-62.]
Constructs
Conceptualization of functional status used in common instruments
The ICF: The International Classification of Functioning, Disability and Health (ICF) was published by the World Health Organization to provide a standardized framework for describing health status. The ICF checklist can be used by clinicians to profile an individual patient’s functional health status. It addresses the patient’s body functions and structures, activities and participation, and environmental factors that may enhance or inhibit functioning. [WHO. International Classification of Functioning, Disease and Health (ICF). <http://www.who.int/classifications/icf/en/>. Accessed 28 Aug 2012.] Additional information and access to the questionnaire can be obtained at <http://www.who.int/classifications/icf/icfapptraining/en/index.html>.
Body functions
Mental functions
Sensory functions and pain
Voice and speech functions
Functions of the cardiovascular, haematological, immunological, and respiratory systems
Functions of the digestive, metabolic, and endocrine systems
Genitourinary and reproductive functions
Neuromusculoskeletal and movement-related functions
Functions of the skin and related structures
Body structures
Structures of the nervous system
The eye, ear and related structures
Structures involved in voice and speech
Structures of the cardiovascular, immunological and respiratory systems
Structures related to the digestive, metabolic and endocrine systems
Structures related to the genitourinary and reproductive systems
Structures related to movement
Skin and related structures
Activities and participation
Learning and applying knowledge
General tasks and demands
Communication
Mobility
Self-care
Domestic life
Interpersonal interactions and relationships
Major life areas
Community, social, and civic life
Environmental factors
Products and technology
Natural environment and human-made changes to environment
Support and relationships
Attitudes
Services, systems and policies
The Barthel Index: This 10-item survey is a measure of functional status based on the domains listed below. Responses can be used to calculate a score out of 100 for the subject, with a higher score indicating greater ability for independent functioning. [Mahoney FI, Barthel D. Functional evaluation: The Barthel Index. Md State Med J 1965;14:61-5.] A copy of the Barthel Index with scoring information is available at <http://www.strokecenter.org/wp-content/uploads/2011/08/barthel.pdf>.
Feeding
Bathing
Grooming
Dressing
Bowels
Bladder
Toilet use
Transfers (bed to chair and back)
Mobility (on level surfaces)
Stairs
The SF-36: The SF-36 is a 36-item patient-completed survey designed to measure health status in the Medical Outcomes Study. The items assess the eight health concepts listed below. [Ware JE, Sherbourne CD. The MOS 36-item Short-Form Health Survey: I. Conceptual framework and item selection. Med Care 1992;30:473-83.] Shorter versions of the instrument, the SF-12 and the SF-8 can be used to assess the same 8 domains. [SF Health Surveys. QualityMetric. Accessed 11 Jul 2012. <http://www.qualitymetric.com/WhatWeDo/SFHealthSurveys/tabid/184/Default.aspx>.] Additional information and requests for use of the SF surveys can be found at <http://www.qualitymetric.com/WhatWeDo/SFHealthSurveys/tabid/184/Default.aspx>.
Limitations in physical activities because of health problems
Limitations in social activities because of physical or emotional problems
Limitations in usual role activities because of physical health problems
Bodily pain
General mental health
Limitations in usual role activities because of emotional problems
Vitality
General health perceptions
Functional Independence Measure: The Functional Independence Measure (FIM) is an 18-item assessment of patients’ physical and mental functional status based on the 6 domains listed below. Items are rated on a 7-point scale ranging from complete dependence to complete independence [Granger CV, Karmarkar AM, Graham JE, Deutsch A, Niewczyk P, DiVita MA, Ottenbacher KJ. The Uniform Data System for Medical Rehabilitation: Report of patients with traumatic spinal cord injury discharged from rehabilitation programs in 2002-2010. Am J Med Phys Rehabil 2012;91:289-99.] Additional information about the FIM and obtaining copies of the questionnaire can be found at <http://www.udsmr.org/Default.aspx>.
Self-care
Sphincter control
Transfer
Locomotion
Communication
Social cognition
Functional Status Questionnaire: This patient-completed questionnaire assesses functional status based on the six subscales listed below. Scale scores range from 0 to 100, with 100 indicating completely functional status. Five single question items at the end are scored separately. [Jette AM, Davies AR, Cleary PD, Calkins DR, Rubenstein LV, Fink A, Kosecoff J, Young RT, Brook RH, Delbanco TL. The functional status questionnaire: Reliability and validity when used in primary care. J Gen Intern Med 1986;1:143-9. (Erratum, J Gen Intern Med 1986;1:427.)] A copy of the functional status questionnaire can be obtained at <http://www.cercle-d-excellence-psy.org/fileadmin/Restreint/FSQ.pdf>.
Basic activities of daily living
Intermediate activities of daily living
Psychological function
Work performance
Social activity
Quality of interaction
Sickness Impact Profile model of functioning: The Sickness Impact Profile-68 (SIP-68) is a 68-item patient-completed survey designed as a generic measure of patient health status that addresses the subscales listed below. Two responses are possible for each item: “applies to my situation” or “does not apply to my situation.” [Post MWM, de Bruin A, de Witte L, Schrijvers A. The SIP68: A measure of health-related functional status in rehabilitation medicine. Arch Phys Med Rehabil 1996;77:440-5.] Additional information can be found at <http://www.scireproject.com/outcome-measures/sickness-impact-profile-68-sip-68>.
Somatic autonomy
Mobility control
Psychic autonomy and communication
Social behavior
Emotional stability
Mobility range
Fewer unplanned visits
Definitions
“Unplanned care is given to people at short notice with emergency, urgent or unexpected health needs and can be anything from a person badly injured in a road traffic accident to a child with a rash.” [NHS. Unplanned care priorities: Public consultation document. <http://www.doncastercvs.org.uk/UserFiles/File/health/Unplanned_Care_Priorities_Consultation_Document.pdf>. Accessed 5 Sept 2012.]
Constructs
Unplanned office visits
Measures
Percentage of office visits that were not made according to a previously scheduled appointment [Heidbüchel H, Lioen P, Foulon S, Huybrechts W, Ector J, Willems R, Ector H. Potential role of remote monitoring for scheduled and unscheduled evaluations of patients with an implantable defibrillator. Europace 2008;10:351-7.]
Mean number of office visits per patient in a given time period in which the time interval between the decision to see the patient and the office visit was less than 24 hours [Landolina M, Perego GB, Lunati M, Curnis A, Guenzati G, Vicentini A, Parati G, Borghi G, Zanaboni P, Valsecchi S, Marzegalli M. Remote monitoring reduces healthcare use and improves quality of care in heart failure patients with implantable defibrillators: The evolution of management strategies of heart failure patients with implantable defibrillators (EVOLVO) study. Circulation 2012;125:2985-92.]
Mean number of office visits per patient in a given time period in which immediate prescriptions for rescue medications (e.g. antibiotics within 3 days of the office visit claim) are given [Akazawa M, Biddle AK, Stearns SC. Economic assessment of early initiation of inhaled corticosteroids in chronic obstructive pulmonary disease using propensity score matching. Clin Ther 2008;30 Spec No:1003-16.]
Visits to the emergency department
Measures
Visits to the emergency department for ambulatory care sensitive conditions.
Percentage of emergency department visits that are for ambulatory care sensitive conditions, such as those listed below [Oster A, Bindman AB. Emergency department visits for ambulatory care sensitive conditions: Insights into preventable hospitalizations. Med Care 2003;41:198-207.]
Asthma
Chronic obstructive lung disease
Congestive heart failure
Diabetes mellitus
Hypertension
Total visits to the emergency department
Measures
Mean number of emergency department visits per patient in a given time period [Landolina M, Perego GB, Lunati M, Curnis A, Guenzati G, Vicentini A, Parati G, Borghi G, Zanaboni P, Valsecchi S, Marzegalli M. Remote monitoring reduces healthcare use and improves quality of care in heart failure patients with implantable defibrillators: The evolution of management strategies of heart failure patients with implantable defibrillators (EVOLVO) study. Circulation 2012;125:2985-92.]
Definitions
“Minimizing inappropriate diagnostic testing not only controls costs but also improves patients’ health by reducing the potential harms inherent in unnecessary testing or procedures. These harms can be direct – for example, radiation exposure from imaging studies that are not indicated or complications from invasive diagnostic procedures – or indirect – such as when an unneeded test finds an incidental, clinically unimportant abnormality and initiates a cascade of further testing, procedures, or treatment. At the same time, reducing unnecessary testing improves the population’s health by conserving financial resources, thus reducing the ultimate need to control costs by withholding other, appropriate care.” [Weinberger SE. Educating trainees about appropriate and cost-conscious diagnostic testing. Academic Medicine 2011;86:1352.]
“Tests should be ordered with a specific goal in mind. That is, the test should be ordered to obtain the answer to a question that will make a difference in the care of the patient. It is vital to remember that the adverse effects of a test or procedure include not only allergic reactions, the discomfort of injections, and cost, but also such risks as increased anxiety and false positive results that may propagate an unwanted and harmful cascade.” [Mold JW, Stein HF. The cascade effect in the clinical care of patients. NEJM 1986;314:512-4.]
Constructs
Diagnostic tests for routine preventive health exams [Merenstein D, Daumit GL, Powe NR. Use and costs of nonrecommended tests during routine preventive health exams. Am J Prev Med 2006;30:521-7.]
Measures
Percentage of routine office visits for preventive health exams in which diagnostic tests given a “D” rating (not recommended for routine preventive health exams) by the U.S. Preventive Services Task Force (USPSTF) were ordered [Merenstein D, Daumit GL, Powe NR. Use and costs of nonrecommended tests during routine preventive health exams. Am J Prev Med 2006;30:521-7.] An up-to-date list of USPSTF guidelines can be found at <http://www.uspreventiveservicestaskforce.org/index.html>.
Non-routine diagnostic tests ordered in response to patients’ symptoms or to confirm a diagnosis [Kline JA, Mitchell AM, Kabrhel C, Richman PB, Courtney DM. Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism. J Thromb Haemost 2004;8:1247-55.]
Measures
Percentage of visits in which clinical practice guidelines for testing were followed [Mancuso CA. Impact of new guidelines on physicians’ ordering of preoperative tests. J Gen Intern Med 1999;14:166-72.] Current clinical practice guidelines for treating a number of conditions are available from the National Guideline Clearinghouse at <http://guideline.gov/index.aspx>.
Duplicative diagnostic tests [Stewart BA, Fernandes S, Rodriguez-Huertas E, Landzberg M. A preliminary look at duplicate testing associated with lack of electronic health record interoperability for transferred patients. J Am Med Inform Assoc 2010;17:341-4.]
Measures
Percentage of patients who received a non-clinically indicated duplicated diagnostic test in a given time period [Stewart BA, Fernandes S, Rodriguez-Huertas E, Landzberg M. A preliminary look at duplicate testing associated with lack of electronic health record interoperability for transferred patients. J Am Med Inform Assoc 2010;17:341-4.]
Total number of diagnostic tests [Stewart M, Brown JB, Donner A, McWhinney IR, Oates J, Weston WW, Jordan J. The impact of patient-centered care on outcomes. J Fam Pract 2000;49:796-804.]
Measures
Percentage of patients who received any type of diagnostic test in a given time period [Stewart M, Brown JB, Donner A, McWhinney IR, Oates J, Weston WW, Jordan J. The impact of patient-centered care on outcomes. J Fam Pract 2000;49:796-804.]
Definitions
"Avoidable hospitalizations are defined as episodes of inpatient care associated with a relatively significant probability of preventability through use of effective ambulatory care. Therefore, consistently high or increasing rates of such hospitalizations imply potential primary-care-related deficiencies.” [Pracht EE, Orban BL, Comins MM, Large JT, Asin-Oostburg V. The relative effectiveness of managed care penetration and the healthcare safety net in reducing avoidable hospitalizations. J Healthc Qual 2011;33:42-51.]
Constructs
Hospital admissions
Measures
Hospital admissions for ambulatory care sensitive conditions
Rate of hospitalization for the following ambulatory care sensitive (ACS) conditions (these conditions were shown by Weissman et al to be ambulatory care sensitive, some studies use different conditions to identify ambulatory care sensitive admissions) [Kozak LJ, Hall MJ, Owings MF. Trends in avoidable hospitalizations, 1980-1998. Health Aff 2001;20:225-32.][Weissman JS, Gatsonis C, Epstein AM. Rates of avoidable hospitalization by insurance status in Massachusetts and Maryland. JAMA 1992;268:2388-94.]:
Ruptured appendix
Asthma
Cellulitis
Congestive heart failure
Diabetes
Gangrene
Hypokalemia
Immunizable conditions
Malignant hypertension
Pneumonia
Pyelonephritis
Perforated or bleeding ulcer
All hospital admissions
Measures
Percentage of patients admitted to a hospital in a given time period [Wolinsky FD, Wyrwich KW, Jung SC, Gurney JG. The risk of hospitalization for acute myocardial infarction among older adults. J Gerontol A Biol Sci Med Sci 1999;54:M254-61.]
Length of stay in the hospital
Measures
Average number of hospital days per admission in a given time period [Schimmel EM. The hazards of hospitalization. 1964. Qual Saf Health Care 2003;12:58-64.]
Hospital readmissions
Measures
Percentage of patients who are discharged from a hospital and rehospitalized within 30 days [Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. (Erratum appears in NEJM 2011;364:1582). NEJM 2009;360:1418-28.]
Definitions
“[Healthcare] costs are both high and rising rapidly. Key evidence of costs being high comes from analysis on variations in spending per person, both internationally (the United States has much higher costs than other advanced countries) and geographically within the United States. In addition, there is no evidence that better outcomes are associated with higher spending.” [Ginsburg PB. High and rising health care costs: Demystifying U.S. health care spending. Research Synthesis Report No. 16. Robert Wood Johnson Foundation. Oct 2008.]
“Costs of care are indirectly related to quality because they influence what services are affordable. Because the monetary resources available for health services are not boundless even in wealthy countries, money spent on less effective services or on services to less needy populations leaves less money available for more effective services especially for populations in greater need of them. Thus costs of care are powerfully related to inequities in the distribution of the effectiveness of health services according to the ‘inverse care law’ by which those in least need of services receive the most.” [Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. New York: Oxford University Press; 1998.][Hart JT. The inverse care law. Lancet 1971;1:405-12.]
“The primary care model is widely believed to be less expensive than specialty medicine, in part because payments to primary care clinicians are lower and in part because primary care clinicians tend to use fewer resources than other specialists.” [IOM. Primary Care: America’s Health in a New Era. Washington DC: National Academy Press; 1996.]
Constructs
Physician/clinical services
Average total costs per visit
Measures
Average total expenditures per patient per given time period: Sum of the prices for all services listed on the patient’s claims for a given time period [Fiscella K, Franks P, Zwanziger J, Mooney C, Sorbero M, Williams G. Risk aversion and costs: A comparison of family physicians and general internists. J Fam Pract 2000;49:12-7.]
Average allowed amount per visit for a given time period: Sum of the amount paid for a visit, the copayment, the deductible, and the amount withheld for the risk pool. [Fiscella K, Franks P, Zwanziger J, Mooney C, Sorbero M, Williams G. Risk aversion and costs: A comparison of family physicians and general internists. J Fam Pract 2000;49:12-7.]
Average copayment for physician office visits for a given time period [Health Research & Educational Trust: Health Affairs. Kaiser Family Foundation. <http://www.kff.org/insurance/090210nr.cfm?RenderForPrint=1>. Accessed 15 Aug 2012.]
Average costs for procedures
Measures
Average costs for diagnostic tests per patient per given time period [Cherkin DC, Rosenblatt RA, Hart LG, Schneeweiss R, LoGerfo J. The use of medical resources by residency-trained family physicians and general internists: Is there a difference? Med Care 1987;25:455-69.]
Average costs for imaging per patient per given time period [Nelson B. A spike in cancer imaging costs. Cancer cytopathol 2010;118:174.]
Average costs for other services (refer to the primary care attribute “Comprehensiveness” for a list of services provided by primary care physicians) per patient per given time period [Parry D, Fitzmaurice D, Raftery J. Anticoagulation management in primary care: A trial-based economic evaluation. British Journal of Haematology 2000;111:530-3.]
The following factors should be included when considering the costs of physician/clinical services [Finkler SA, Ward DM. Issues in Cost Accounting for Health Care Organizations, 2nd ed. Gaithersburg: Aspen Publishers, Inc; 1999.]:
Materials (gauze, table paper, EKG machine paper, etc.)
Labor costs (both for the physician and other health employees)
Fixed overhead
Malpractice and other insurances
Rent
Utilities
RN/manager and secretary
Benefits (pension, health insurance, social security)
Office equipment depreciation
Reception area
Clerical equipment
Telephone
Copy machine
Medical records and billing system
Other
Given below is a sample budget developed by Jackie Durrett, MBA, FACMPE, and Garth Splinter, MD, MBA, at the Family Medicine Center of the University of Oklahoma Health Sciences Center. This budget is used to teach residents in family medicine to calculate total revenue, total expenses, and net income.
Prescription for Health Expenditure Calculation: This instrument was developed to assist primary care physicians and practices in measuring the cost of health behavior change interventions. It has potential to be used for the collection of expenditure data on a broad variety of practice innovations. The instrument consists of a patient flow diagram; tables to chart start-up expenses, staff salaries, and office expenses; and a field guide. The physician/practice records the number of patients who complete each step of the intervention in the flow diagram. Operating expenses, nonrecurring expenses, and overhead expenses are calculated before and after the intervention and compared. Office managers from practice-based research networks in a study reported a mean time of 93 minutes to assemble the expenditure data and complete the instrument [Krist AH, Cifuentes M, Dodoo MS, Green LA. Measuring primary care expenses. J Am Board Fam Med 2010;23:376-83.]. Additional information and access to the instrument can be found at <http://www.prescriptionforhealth.org/results/toolkit.html>.
Hospital Services
Measures
Adjusted expenses per inpatient day: This value is the average comprehensive costs of inpatient care per day. Calculation of total expenses should include room and board, administrative costs, nursing salaries, and the costs of ancillary medical services. This data can be obtained from the federal database Hospital Cost Report Information System (HCRIS). [Halpern NA, Pastores SM, Greenstein RJ. Critical care medicine in the United States 1985-2000: An analysis of bed numbers, use, and costs. Crit Care Med 2004;32:1254-9.]
Russell equation: This equation is used to distinguish between critical care and non-critical care inpatient costs. Critical care medicine (CCM) includes intensive, coronary, burn intensive, surgical intensive, and all other special care units. Non-CCM covers all other (adult, pediatric, and nursery) beds. The equation is: Adjusted expenses per inpatient day=(([nonCCM inpatient days][nonCCM costs per day] )+([CCM inpatient days][CCM costs per day]))/(Hospital inpatient days). Once the adjusted expenses per inpatient day (see above for a description), non-CCM inpatient days, and CCM inpatient days are known, non-CCM and CCM costs per day can be calculated by assuming a 3:1 CCM/non-CCM cost ratio. [Halpern NA, Pastores SM, Greenstein RJ. Critical care medicine in the United States 1985-2000: An analysis of bed numbers, use, and costs. Crit Care Med 2004;32:1254-9.]
Pharmaceuticals
Measures
Mean/median expenses per patient per given time period for prescription medications [AHRQ. Medical Expenditure Panel Survey. Accessed 8 Aug. 2012. <http://meps.ahrq.gov/mepsweb/>.]
Average patient out-of-pocket spending on prescription drugs in a given time period [Gellad WF, Donohue JM, Zhao X, Zhang Y, Banthin JS. The financial burden from prescription drugs has declined recently for the nonelderly, although it is still high for many. Health Aff 2012;31:408-16.]
Spending on over-the-counter medications per patient per given time period
Other health services
Measures
Mean/median expenses per patient per given time period for the provision of [AHRQ. Medical Expenditure Panel Survey. Accessed 8 Aug. 2012. <http://meps.ahrq.gov/mepsweb/>.]:
Emergency room services
Home health services
Other medical equipment and services
Measures of total healthcare costs
Average patient health insurance premiums [Gresenz CR, Laugesen MJ, Yesus A, Escarce JJ. Relative affordability of health insurance premiums under CHIP expansion programs and the ACA. J Health Polit Policy Law 2011;36:859-77.]
Average patient health insurance premiums as a percentage of household income [Gresenz CR, Laugesen MJ, Yesus A, Escarce JJ. Relative affordability of health insurance premiums under CHIP expansion programs and the ACA. J Health Polit Policy Law 2011;36:859-77.]
Average total patient out-of pocket expenses [Gellad WF, Donohue JM, Zhao X, Zhang Y, Banthin JS. The financial burden from prescription drugs has declined recently for the nonelderly, although it is still high for many. Health Aff 2012;31:408-16.]
Total Medicare spending per enrollee per year [Chernew ME, Sabik L, Chandra A, Newhouse JP. Would having more primary care doctors cut health spending growth? Health Aff 2009;28:1327-35.]
Medical Expenditure Panel Survey (MEPS): This collection of surveys collects data on the cost and use of health care and health insurance coverage. It contains questionnaires for household members, public and private sector employers, physicians, hospitals, home health agencies, and pharmacies [AHRQ. Medical Expenditure Panel Survey. Accessed 8 Aug. 2012. <http://meps.ahrq.gov/mepsweb/>.] Additional information and access to the questionnaires can be found at <http://meps.ahrq.gov/mepsweb/>.
Total medical expenditures per patient per year for the top five most costly conditions (according to 2009 data) [AHRQ. Trends in healthcare costs and concentration of medical expenditures: <http://www.ahrq.gov/about/nac2012/nac0712/cohenmeyers/cohenmeyerssl13.htm>. Accessed 15 Aug 2012.]:
Heart disease
Cancer
Mental disorders
Trauma-related disorders
COPD, asthma
Total medical expenditures per year for patients with 0-1,2-3, or 4 or more chronic conditions [AHRQ. Trends in healthcare costs and concentration of medical expenditures. <http://www.ahrq.gov/about/nac2012/nac0712/cohenmeyers/cohenmeyerssl13.htm>. Accessed 15 Aug 2012.]
End-of-Life Expenditures Index (EOL-EI): Age-race-sex-adjusted spending (using standardized national prices) on physician and hospital services of patients who died in the past 3.5 years. End-of-life spending is used as a measure of costs because it should be unrelated to regional differences in illness. [Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. Part 1: The content, quality, and accessibility of care. Ann Intern Med 2003;138:273-87.]
Acute Care Expenditure Index (AC-EI): This index was developed by use of a linear regression model as an alternative to the end-of-life expenditures index for measuring regional variations in Medicare spending. It is a measure of age-, race-, sex-, and illness-adjusted spending on physician and hospital resources in the first 6 months following index hospitalization by patients in a U.S. hospital referral region (HRR) with an acute care episode. The index is calculated with the following equation: Uij = ZI + Wjj + vij, where Uij is the total hospital and physician resource use by patient i in HRR j; ZI is a vector of patient covariates including demographic, severity, and comorbidity measures; is the effects of patient-level factors on utilization; Wj is the coefficient estimating regional intensity in HRR j; j is a set of HRR-level indicator variables; and vij are patient-level error terms. [Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. Part 1: The content, quality, and accessibility of care. Ann Intern Med 2003;138:273-87.]
Affirming Clinician-Patient Interactions
Definitions
“Safety is a fundamental principle of patient care and a critical component of quality management. Its improvement demands a complex system-wide effort, involving a wide range of actions in methodologies, performance improvement, environmental safety and risk management. It embraces nearly all health-care disciplines and actors, and thus requires a comprehensive multi-faceted approach to identifying and managing actual and potential risks to patient safety and quality of care improvements.” [65th World Health Assembly. Technical session on patient safety hosted by the Supreme Council of Health, Qatar. Briefing Note: Making health care safer. <http://www.who.int/patientsafety/WHA_PSP-Briefing-Note_23-May_2012.pdf>. Accessed 11 Sept 2012.]
“An adverse event is an injury resulting from a medical intervention, or in other words, it is not due to the underlying condition of the patient.” [IOM. To Err Is Human: Building a Safer Health System. Washington DC: National Academies Press; 2000.]
Constructs
Healthcare incidents that threaten patient safety but do not result in injury [Reid M, Estacio R, Albert R. Injury and death associated with incidents reported to the patient safety net. Am J Med Qual 2009;24:520-4.]
Measures
Incidents that did not result in patient injury because of chance alone [Reid M, Estacio R, Albert R. Injury and death associated with incidents reported to the patient safety net. Am J Med Qual 2009;24:520-4.]
Incidence of events reported by healthcare staff that could have resulted in patient injury but did not because of chance alone [Reid M, Estacio R, Albert R. Injury and death associated with incidents reported to the patient safety net. Am J Med Qual 2009;24:520-4.]
Incidents in which patient injury was prevented by active recovery efforts of the care providers [Reid M, Estacio R, Albert R. Injury and death associated with incidents reported to the patient safety net. Am J Med Qual 2009;24:520-4.]
Measures
Incidence of events reported by healthcare staff in which patient injury could have occurred but was prevented by the efforts of care providers [Reid M, Estacio R, Albert R. Injury and death associated with incidents reported to the patient safety net. Am J Med Qual 2009;24:520-4.]
Organizational Attributes
Clinical Attributes
Integration
Adverse events that result in patient injury [Wakefield JG, Jorm CM. Patient safety – A balanced measurement framework. Aust Health Rev 2009;33:382-9.]
Measures
Percentage of patients in a given time period who experience a healthcare-related adverse event identifiable in their medical records that leads to [Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, Newhouse JP, Weiler PC, Hiatt HH. Incidence of adverse events and negligence in hospitalized patients: Results of the Harvard Medical Practice Study I. Qual Saf Health Care 2004;13:145-52.]:
Minimal impairment: Recovery 1 month
Moderate impairment: Recovery 1-6 months
Moderate impairment: Recovery > 6 months
Permanent impairment
Death
Incidence of a specific healthcare-related adverse event (e.g. catheter-related bloodstream infections) in the patient population [National Patient Safety Foundation. Definitions and Hot Topics. <http://www.npsf.org/for-healthcare-professionals/resource-center/definitions-and-hot-topics/>. Accessed 11 Sept 2012.]
Percentage of patients in a given time period who report needing to return for a second visit to the doctor due to complications in treatment [Mira JJ, Nebot C, Lorenzo S, Pérez-Jover V. Patient report on information given, consultation time and safety in primary care. Qual Saf Health Care 2010;19:1-4.]
Definitions
“Knowing when to refer requires courage and humility. Courage is the ability to act competently and wisely without being swayed by irrational fears. Some family practice [and other primary care] physicians, motivated by unrealistic fears of mistakes and exposure, refer too early. Humility is the willingness to recognize one’s actual limitations and to act accordingly. Some family practice physicians, unaware of their limitations, refer too late. A proper combination of courage and humility, along with good working relationships with specialists, can prevent most of the problems involved in referring too early or to late.” [Holleman WL, Brody BA. Ethics in Family Practice. In: Textbook of Family Practice. Rakel RE, ed. Philadelphia: WB Saunders Company; 2002.]
“The increasing attention to and use of gatekeepers compels attention to the nature of subspecialty care as well as primary care. Research will provide planners with the basis for formalizing criteria for referrals so that reasons other than medical need should be reduced. Specification of justifiable criteria for referral will also facilitate the development of systems to enhance the ability of primary care physicians to coordinate care – a major corollary of a rational gatekeeper role.” [Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. New York: Oxford University Press; 1998.]
Constructs
Appropriateness of referrals/consultations
Measures
Percentage of total referrals made by primary care physicians in a given time period that are deemed appropriate by the care provider receiving the referral [Slade M, Gask L, Leese M, McCrone P, Montana C, Powell R, Stewart M, Chew-Graham C. Failure to improve appropriateness of referrals to adult community mental health services – lessons from a multi-site cluster randomized controlled trial. Fam Pract 2008;25:181-90.]
Percentage of total referrals that are appropriate according to clinical practice guidelines [Kyne G, Maxwell S, Brameld K, Harrison K, Goldblatt J, O’Leary P. Compliance with professional guidelines with reference to familial cancer services. Aust N Z J Public Health 2011;35:226-30.] Current clinical practice guidelines are available from the National Guideline Clearinghouse at <http://guideline.gov/index.aspx>.
Percentage of consultations between a primary care provider and specialist in which a clear clinical question (containing subject information, a specific issue to address, and an action to be taken by the consultant) is identifiable in chart review [Conley J, Jordan M, Ghali WA. Audit of the consultation process on general internal medicine services. Qual Saf Health Care 2009;18:59-62.]
Timeliness of referrals/consultations
Measures
Percentage of patients with a specific disease referred to a specialty care provider within a time frame appropriate to the disease (e.g. percentage of patients with rheumatoid arthritis referred for appropriate treatment within 6 months of disease onset) [Suter LG, Fraenkel L, Holmboe ES. What factors account for referral delays for patients with suspected rheumatoid arthritis? Arthritis Rheum 2006;55:300-5.]
Total number of referrals/consultations
Measures
Percentage of office visits in a given time period in which a consultation is requested [Byrd JC, Moskowitz MA. Outpatient consultation: Interaction between the general internist and the specialist. J Gen Intern Med 1987;2:93-8.]
Percentage of office visits in a given time period in which the patient is referred to another source of care [Ilboudo TP, Chou YJ, Huang N. Assessment of providers’ referral decisions in rural Burkina Faso: A retrospective analysis of medical records. BMC Health Serv Res 2012;12:54.]
Definitions
“Most clinicians, when invited to do so, have no trouble recalling special moments of closeness and intimacy with patients. Although such moments may seem to be chance occurrences that are pleasant but sporadic by-products of clinical activity, they are perceived nevertheless as being both therapeutic and personally valuable. Indeed, given their intensity and their widespread occurrence, they bear closer inspection.” [Suchman AL, Matthews DA. What makes the patient-doctor relationship therapeutic? Exploring the connexional dimension of medical care. (Erratum appears in Ann Intern Med 1988;109:173). Ann Intern Med 1988;108:125-30.]
“The internists in our study [asked to share stories about meaningful work-related experiences] wrote about miracles and mistakes, sharing their own lives and their patients’ lives, witnessing profound experiences, and receiving acknowledgement for a job well done. Through these events, they were rewarded unexpectedly with a deeper appreciation of what it means to be a human being and a doctor, and of how their caring actions, not just their technical ability, was so important to their patients.” [Horowitz CR, Suchman AL, Branch WT Jr, Frankel RM. What do doctors find meaningful about their work? Ann Intern Med 2003;138:772-5.]
Constructs
Patients express gratitude to the clinician [Albury WR, Weisz GM. The medical ethics of Erasmus and the physician-patient relationship. Med Humanit 2001;27:35-41.]
Measures
Expression of Gratitude in Relationships scale: This 3-item questionnaire assesses how often one expresses gratitude to a close relationship partner. It has been used to measure expressions of gratitude between close friends and romantic partners. Please note that this instrument has not been validated for use in assessing the physician-patient relationship. Responses are on a 5-point Likert scale (1 = never, 5 = very frequently). [Lambert NM, Clark MS, Durtschi J, Finchman FD, Graham SM. Benefits of expressing gratitude: Expressing gratitude to a partner changes one’s view of the relationship. Psychol Sci 2010;21:574-80.] A copy of the instrument is available at <http://natelambert.info/index.php?option=com_content&view=article&id=6>.
Clinicians are shown kindness by patients and encouraged to share their own emotions and life experiences [Horowitz CR, Suchman AL, Branch WT Jr, Frankel RM. What do doctors find meaningful about their work? Ann Intern Med 2003;138:772-5.]
Clinicians are a witness to the humanity of patients during profound emotional events [Horowitz CR, Suchman AL, Branch WT Jr, Frankel RM. What do doctors find meaningful about their work? Ann Intern Med 2003;138:772-5.]
Clinicians feel the care they provide is valued by their patients [Horowitz CR, Suchman AL, Branch WT Jr, Frankel RM. What do doctors find meaningful about their work? Ann Intern Med 2003;138:772-5.]
Tasteful humor builds rapport between the clinician and the patient [Rakel RE. Establishing Rapport. In: Textbook of Family Practice, 6th ed. Rakel RE,ed. Philadelphia: WB Saunders Company; 2002.]
Clinicians are respected in their communities and feel a sense of belonging and fulfillment from actively participating in both health and non-health-related activities [Pathman DE, Steiner BD, Williams E, Riggins T. J Fam Pract 1998;46:293-303.]
General Measures of Affirming Interactions
Personal Meaning in Patient Care Scale: This instrument consists of the 6 items listed below. It was developed to measure the sense of personal meaning clinicians derive from patient care. Clinicians respond to each item on a 4-point Likert scale ranging from 1 = “not at all” to 4 = “a great deal.” A total score can be calculated by summing the responses to individual items. [Geller G, Bernhardt BA, Carrese J, Rushton CH, Kolodner K. What do clinicians derive from partnering with their patients? A reliable and valid measure of “personal meaning in patient care.” Patient Educ Couns 2008;72:293-300.]
Patients entrust me with their stories
Offering patients a protected environment in which to relax and reflect
Feeling deep connections with my patients
Being with people in their most vulnerable state
“Bearing witness” to events in the lives of my patients and their families
Taking away a little of my patients’ loneliness
Encounter-Specific Physician Satisfaction Scale: The abbreviated form of this instrument consists of the items listed below. It was developed as a questionnaire to measure a clinician’s satisfaction with a specific encounter with a patient. The items can be categorized into four domains of physician satisfaction: interactive, personal, professional, and contextual. Responses are on a 5-point Likert scale. [Shore BE, Franks P. Physician satisfaction with patient encounters: Reliability and validity on an encounter-specific questionnaire. Med Care 1986;24:580-9.]
Interpersonal:
The patient seemed satisfied with how things went
The patient was able to be very open with me
I don’t believe this patient appreciated my efforts at all
Overall rapport with this patient was very high
Professional:
After this encounter, I think I have a good understanding of what is going on
Personal:
This visit made me feel good about being a doctor
I felt frustrated by this encounter
I was disappointed with how things went
Overall, I was satisfied with this patient encounter
Contextual:
I am having a terrible day
Other things were on my mind during this encounter
My previous patient encounter went very well
I felt pressed by other commitments during this visit
I was too busy today to spend enough time with this patient
Things have been going smoothly for me today with nurses, secretaries, and other physicians
Definitions
“The physician has no absolute protection against a medical malpractice suit. Compassionate, competent, conscientious physicians can diminish, but not eliminate, the risk of a suit. Practicing reflective medicine can reduce patient injury and dissatisfaction, and it can represent the best prophylaxis against malpractice litigation.” [Roberts RG, Swanson K. Risk Management. In: Textbook of Family Practice, 6th ed. Rakel RE, ed. Philadelphia: WB Saunders Company; 2002.]
Constructs
Frequency of lawsuits [Danzon PM. The frequency and severity of medical malpractice claims: New evidence. Law Contemp Probl 1986;49:57-84.]
Measures
Number of malpractice claims per clinician in a given time period [Danzon PM. The frequency and severity of medical malpractice claims: New evidence. Law Contemp Probl 1986;49:57-84.]
Percentage of clinicians sued in a given time period
Severity of lawsuits [Danzon PM. The frequency and severity of medical malpractice claims: New evidence. Law Contemp Probl 1986;49:57-84.]
Measures
Average malpractice jury award [Danzon PM. The frequency and severity of medical malpractice claims: New evidence. Law Contemp Probl 1986;49:57-84.]
Validity of lawsuits [Localio AR, Lawthers AG, Brennan TA, Laird NM, Hebert LE, Peterson LM, Newhouse JP, Weiler PC, Hiatt HH. Relation between malpractice claims and adverse events due to negligence: Results of the Harvard Medical Practice Study III. NEJM 1991;325:245-51.]
Measures
Percentage of malpractice claims that involve an apparent negligent injury to the patient evident in his or her medical records [Localio AR, Lawthers AG, Brennan TA, Laird NM, Hebert LE, Peterson LM, Newhouse JP, Weiler PC, Hiatt HH. Relation between malpractice claims and adverse events due to negligence: Results of the Harvard Medical Practice Study III. NEJM 1991;325:245-51.]
Definitions
“Overuse occurs when a health care service is provided under circumstances in which its potential for harm exceeds the possible benefit. Prescribing an antibiotic for a viral infection like a cold, for which antibiotics are ineffective, constitutes overuse.” [Chassin MR, Galvin RW. The urgent need to improve health care quality: Institute of Medicine National Roundtable on Health Care Quality. JAMA 1998;280:1000-5.]
“We propose that… the noun ‘futility’ and the adjective ‘futile’ be used to describe any effort to achieve a result that is possible but that reasoning or experience suggests is highly improbable and that cannot be systematically produced.” [Schneiderman LJ, Jecker NS, Jonsen AR. Medical futility: Its meaning and ethical implications. Ann Intern Med 1990;112:949-54.]
Constructs
Inappropriate use of current treatments/interventions
Measures
Percentage of patients with a specific disease who receive treatment that is not consistent with clinical guidelines [Lenz O, Sadhu S, Fornoni A, Asif A. Overutilization of central venous catheters in incident hemodialysis patients: Reasons and potential resolution strategies. Semin Dialysis 2006;19:543-50.]
Futile end-of-life treatments/interventions
Measures
Percentage of patients with dementia or dementia with terminal illness or in a coma with a small chance of recovery or persistent vegetative state for whom the following life-sustaining treatments are withheld or withdrawn [Alpert HR, Emanuel L. Comparing utilization of life-sustaining treatments with patient and public preferences. J Gen Intern Med 1998;13:175-81.]
Cardiopulmonary resuscitation
Mechanical ventilation
Artificial hydration
Artificial nutrition
Major surgery
Hemodialysis
Antibiotics
Number of patient-bed days of ICU care in a given time period for patients with the following indications of futility of care [Halevy A, Neal RC, Brody BA. The low frequency of futility in an adult intensive care unit setting. Arch Intern Med 1996;156:100-4.]:
Likelihood of mortality at more than 90%, 95%, and 99% probabilities as assessed by the Acute Physiology and Chronic Health Evaluation II (APACHE II) [Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: A severity of disease classification system. Crit Care Med 1985;13:818-29.]
Any of the below lethal conditions:
Any metastatic cancer described as failing first-line therapy and/or requiring second-line therapy
A history of, and current, liver failure and 2 clinical indicators
A prehospital history of New York Heart Association class IV heart failure and a current ejection fraction of less than 20%
A history of home oxygen therapy and current intubation
Acquired immunodeficiency syndrome with a CD4 cell count of less than 0.05E9/L
Medical records showing the patient was vegetative or comatose for at least 1 month before admission to the ICU or evaluation showing the patient met the criteria for poor neurological outcome after an anoxic event
Percentage of patients that spent at least 10 days in an intensive care unit before death [The SUPPORT Principal Investigators. A Controlled Trial to Improve Care for Seriously III Hospitalized Patients: The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). JAMA 1995;274:1591-8.]
The following are taken from a list of potential indicators of the quality of end-of-life cancer care identified by an expert panel using the Delphi method. These measures can be obtained from Medicare data. [Earle CC, Park ER, Lai B, Weeks JC, Ayanian JZ, Block S. Identifying potential indicators of the quality of end-of-life cancer care from administrative data. J Clin Oncol 2003;21:1133-8.]
Frequency of emergency room visits for terminally ill patients
Number of hospital and ICU days near the end of life
Proportion of patients enrolled in hospice
Time interval between hospice enrollment and death
Mechanisms
The patient is minimally limited by health problems, both physical and emotional, in performing meaningful activities [Durch J, Bailey L, Stofo M (eds). Improving Health in the Community: A Role for Performance Monitoring. Washington DC: National Academy Press; 1997.]
The patient’s goals for health are met to the greatest extent possible [Mold JW, Blake GH, Becker LA. Goal-oriented medical care. Fam Med 1991;23:46-51.]
The patient feels positive about his or her well-being and health status [Ganz PA, Litwin MS, Hays RD, Kaplan RM. Measuring outcomes and health-related quality of life. Andersen RM, Rice TH, Kominski GF, eds. Changing the U.S. Health care System: Key Issues in Health Services Policy and Management, 3rd ed. San Francisco: John Wiley & Sons, Inc., 2007.]
Measures:
Rating scales in which the patient evaluates his or her own quality of life (for example, on a scale of 0-100, with 100 being perfect quality of life) [Hyland ME, Sodergren SC. Development of a new type of global quality of life scale, and comparison of performance and preference for 12 global scales. Qual Life Res 1996;5:469-80.]
Measure Yourself Medical Outcome Profile (MYMOP): This instrument consists of two patient-completed questionnaires, an initial and a follow-up. The patient is asked to list two symptoms (related to the same health issue) that he or she considers to be the most important and a daily activity that is affected by these symptoms. The patient then ranks the severity of the symptoms, their effect on the daily activity, and his or her general sense of wellbeing in the past week on a seven-point scale. The follow-up form asks the exact same question. The instrument allows patients to evaluate their quality of life based on the outcomes most important to them. All of the forms can be accessed at <http://sites.pcmd.ac.uk/mymop/index.php?c=welcome>. [MYMOP Overview. MYMOP. Accessed 9 Jul 2012. <http://sites.pcmd.ac.uk/mymop/index.php?c=welcome>.]
EuroQol instrument: This patient-completed questionnaire assesses health status. It consists of five scales: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. Under each scale, the respondent selects the statement that best describes their current health state. Respondents also assess their own health state on a thermometer calibrated from zero (“worst imaginable health state”) to 100 (“best imaginable health state”). [Brooks R. EuroQol: The current state of play. Health Policy 1996;37:53-72.] Copies of the EuroQol instrument and additional information can be obtained at <http://www.euroqol.org/home.html>. Registration is required for use.
Health Utilities Index (HUI): This instrument was designed as a patient-reported measure of health status and health-related quality of life. There are currently two systems for the Health Utilities Index, the HUI2 and the HUI3, with the HUI3 offering more detailed descriptive data. The surveys are available in 15-item and 40-item formats. Responses are used to generate a score ranging from 0.00 (dead) to 1.00 (perfect health) [Horsman J, Furlong W, Feeny D, Torrance G. The Health Utilities Index (HUI®): Concepts, measurement properties and applications. Health Qual Life Outcomes 2003;1:54.] Additional information and requests for use of the instrument can be found at <http://www.healthutilities.com/>.
Quality of Well-Being Scale-Self Administered (QWB-SA): This instrument was designed to measure quality of life for the specific purpose of calculating quality-adjusted life years. The most recent version is a patient self-administered questionnaire. It assesses the patient’s quality of life over the past 3 days based on chronic and acute physical symptoms, mental health symptoms and behaviors, mobility, and physical and social activity. Responses are used to calculate a score ranging from 0 (death) to 1.0 (completely well). [Seiber WJ, Groessl EJ, David KM, Ganiats TG, Kaplan RM. Quality of Well-Being Self-Administered (QWB-SA) Scale: User’s Manual. <https://hoap.ucsd.edu/qwb-info/QWB-Manual.pdf>. Accessed 5 Sept 2012.] Additional information and access to copies of the survey can be found at <https://hoap.ucsd.edu/qwb-info/>. Please note that it is necessary for those who wish to administer the survey and collect and analyze data to sign a Copyright Agreement.
The 15D© Quality of Life Questionnaire: This patient-completed questionnaire is designed to assess health-related quality of life. It consists of 15 scales: mobility, vision, hearing, breathing, sleeping, eating, speech, elimination, usual activities, mental function, discomfort and symptoms, depression, distress, vitality, and sexual activity. Under each scale, respondents select the item that best describes their current health status. [Harri S. The 15D instrument of health-related quality of life: Properties and applications. Ann Med 2001;33:328-36.] More information and access to the survey can be obtained at <http://15d-instrument.net/15d>. Registration is required for use.
Assessment of Quality of Life Instrument: This patient-completed questionnaire was designed using psychometric procedures to assess health-related quality of life. In questions under the domains of illness, independent living, social relationships, physical senses, and psychological well-being, respondents select the option that best describes their health status. [Hawthorne G, Richardson J, Osborne R. The Assessment of Quality of Life instrument: A psychometric measure of health-related quality of life. Qual Life Res 1999;8:209-24.] Additional information and access to the survey can be obtained at <http://www.psychiatry.unimelb.edu.au/centres-units/cpro/aqol/index.html>. Registration is required for use.
Experienced Continuity of Care for Diabetes Mellitus (ECC-DM): This 19-item instrument is a disease-specific measure of management of a chronic condition. Items are grouped into the 4 subdomains of longitudinal continuity, flexible continuity, relational continuity, and cross-boundary continuity (These subdomains correspond to sustained care, accessibility, clinician-patient partnership, and coordination, respectively, as defined in this model. A score can be calculated from the responses ranging from 0-100, with 100 corresponding to better disease management [Gulliford MC, Naithani S, Morgan M. Measuring continuity of care in diabetes mellitus: An experience-based measure. Ann Fam Med 2006;4:548-55.] Additional information and a copy of the instrument can be found at <http://www.netscc.ac.uk/hsdr/files/project/SDO_FR_08-1209-014_V01.pdf>.
Increased capacity
Greater efficiency
Fewer errors
Increased delivery of preventive services
Informed/activated patients
Greater trust in clinicians
Increased family support
Greater focus on outcomes
Enhanced clinician learning
Close relationships with consultants/resources
Reduced clinician and patient anxiety
Greater understanding; Higher quality decisions
Positive psycho-physiological effects
Investment
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