Physicians as Intermediaries for Hospital
Quality Public Reports:
A study in mixed-methods research
David J. Miranda, PhD, CMS
Judith K. Barr, ScD, Qualidigm
Shula L. Bernard, PhD, RTI International
Tierney E. Giannotti, MPA, Qualidigm
Nancy Lenfestey, MHA, Qualidigm
Kevin Smith, MA, RTI International
Shoshanna Sofaer, DrPH, Baruch College
AcademyHealth Research Meeting,
June 2, 2007
Outline of Presentation
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Background
Research Questions
Interviews with Physicians
Survey of Physicians
Results & Discussion
Mixed-method Approach
Conclusion
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Background
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CMS work with Info Intermediaries
2001 Research as RI Plans public
reporting
RFP re MDs as Info Intermediaries
for consumers about hospital quality
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Research Questions
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How will physicians react to patients
who raise questions about hospital
quality?
Will physicians use quality reports in
talking with their patients?
What factors are important to
physicians in their assessment of
data reports?
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Qualitative Study: Overview
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Interviews:
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Round 1 – Face-to-face1 interviews - 25
physicians in three states/regions (CT, NC,
NYC)
Round 2 – Telephone interviews - 32
physicians in four states/regions with history of
public reporting (Los Angeles, CA; RI; Western
NY; WI)
Conducted winter/spring 2004 and 2005
Physicians:
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Specialties: Primary care, Cardiology,
Pulmonology
Recruited through physicians and other key
informants
1one
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phone interview
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Methods: Patient Scenarios
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Engaged physicians with a scenario of a
patient visit following a hospital referral
Hypothetical situations: patient questions
referral based on hospital quality report
Clinical soundness and relevance of
scenario validated by key informant
physician experts
Scenarios varied: clinical diagnosis,
patient age (65 or 80), clinical or patient
experience measure, physician specialty
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Physicians’ Responses:
Talking with Patients
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Reassure the patient
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Describe physician’s own experience
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“I would try to reassure the patient that Dr. X was
a very good doctor and that the clinical staff, the
nursing staff and so forth, are very good and would
do everything possible to keep them comfortable.”
“My first step is to reassure the patient that I’ve
practiced there for years; I’m completely
comfortable with the care provided and the
institution..."
Pay attention to patient
questions/preferences
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“Well, I want patients happy and satisfied. Generally, there
are a number of good places where they can get their
care…I would probably say, ‘That would be fine with me,’
based on their preference, as long as it was a reasonable
program.”
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Physicians’ Responses:
Talking with Patients (Round 2)
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Physicians described an approach
to discussions with patients
through dialogue and shared
decision making
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“I try to create a partnership between
myself and my patients, so that it is
very transparent as to what decisions
we’ll come to in regards to their care.”
Physician responses suggest they
may engage in several stages of
negotiation about referrals:
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Assess, Advise, Agree, Assist, Arrange
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Physician Interest, Concerns &
Perceived Barriers
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Concerns report may be too for patient
understanding
Physicians want to be intermediaries,
but lack time & lack of awareness of
report
Methodological rigor (e.g., sampling) &
source of data are physician concerns
Patient satisfaction measures considered
less meaningful than clinical measures,
volume & outcomes data
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National Survey: Overview
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Stratified random sample of physicians:
N=1,027
Specialties: family medicine/general
practice, internal medicine, cardiology
Mixed mode of data collection:
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Mailed surveys
Internet option
Telephone/Fax (for nonrespondents)
Purpose: to collect information about PCP
perceptions of hospital quality reports
and assessments of Hospital Compare
initiative
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Patient Interest in Quality Reports
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Few physicians (9%) reported that any
patients asked about hospital quality
reports in past 3 months
Many physicians reported that the Hospital
Compare website had utility and/or would
be something they recommend to patients
(69% at least somewhat likely to
recommend)
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Attitudes Toward
New Quality Measures
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67% of physicians reported that measures
of patient satisfaction and experience of
care would be useful to patients
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More useful than other quality indicators
Results differ from earlier qualitative
findings
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Different methodologies – sample size, data
collection methods, time of administration
Different questions asked – open-ended for
interviews; based on unexpected findings,
survey questions were constructed to assess
perceived utility for improving patient care
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Influencing Physician’s
Attitudes about Reports
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Physicians whose patients asked about
quality reports were more aware of
reports & thought the report more
important and more credible-->Inform
and educate physicians about report
Address concerns about report
methodology,data sources and
availability of reports
If patients are to raise quality concerns,
develop & test messages to help
physicians become aware and to
dialogue productively with patients
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Mixed Method Approach
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Interviews focused on hospital
quality dialogue; Survey focused on
Hospital Compare
Qualitative research led to survey
questions & design
Realistic scenarios hard to create
Differences re importance of patient
satisfaction
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Conclusions
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Interview findings suggest that physicians
are responsive to patient-initiated
discussions about quality
While few physicians say that patients
initiate discussion of quality reports,
survey findings suggest that patients raise
questions about hospital quality when
faced with hospitalization
Physicians can be meaningful patient
intermediaries if they are informed, if they
trust the data, and if patients initiate the
discussion
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Next Steps:
Messaging & Marketing
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New measures being added to Hospital
Compare: 30-day AMI and CHF mortality
in June 2007
HCAHPS in March 2008
Expected media and consumer attention
to Hospital Compare in light of HCAHPS
Prepare physicians for questions; alert
them to highly visible new public reports
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Contact Information
David J. Miranda, Ph.D.
Social Science Research Analyst
CMS Center for Beneficiary Choices
7500 Security Boulevard
Woodlawn, MD 21244
410-786-7819
david.miranda@cms.hhs.gov
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