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

Policy Points Narratives about patients' experiences with outpatient care are essential for quality improvement because they convey ample actionable information that both elaborates on existing domains within patient experience surveys and describes multiple additional domains that are important to patients. The content of narrative feedback from patients can potentially be translated to improved quality in multiple ways: clinicians can learn from their own patients, groups of clinicians can learn from the experience of their peers' patients, and health system administrators can identify and respond to patterns in patients' accounts that reflect systemic challenges to quality. Consistent investment by payers and providers is required to ensure that patient narratives are rigorously collected, analyzed fully, and effectively used for quality improvement.CONTEXTFor the past 25 years, health care providers and health system administrators have sought to improve care by surveying patients about their experiences. More recently, policymakers have acted to promote this learning by deploying financial incentives tied to survey scores. This article explores the potential of systematically elicited narratives about experiences with outpatient care to enrich quality improvement.METHODSNarratives were collected from 348 patients recruited from a nationally representative Internet panel. Drawing from the literature on health services innovation, we developed a two-part coding schema that categorized narrative content in terms of (a) the aspects of care being described, and (b) the actionability of this information for clinicians, quality improvement staff, and health system administrators. Narratives were coded using this schema, with high levels of reliability among the coders.FINDINGSThe scope of outpatient narratives divides evenly among aspects of care currently measured by patient experience surveys (35% of content), aspects related to measured domains but not captured by existing survey questions (31%), and aspects of care that are omitted from surveys entirely (34%). Overall, the narrative data focused heavily on relational aspects of care (43%), elaborating on this aspect of experience well beyond what is captured with communication-related questions on existing surveys. Three-quarters of elicited narratives had some actionable content, and almost a third contained three or more separate actionable elements.CONCLUSIONSIn a health policy environment that incentivizes attention to patient experience, rigorously elicited narratives hold substantial promise for improving quality in general and patients' experiences with care in particular. They do so in two ways: by making concrete what went wrong or right in domains covered by existing surveys, and by expanding our view of what aspects of care matter to patients as articulated in their own words and thus how care can be made more patient-centered. Most narratives convey experiences that are potentially actionable by those committed to improving health care quality in outpatient settings.

BackgroundPublic reports on healthcare quality typically include complex data. To lower the cognitive burden of interpreting these data, some report designers create summary, or roll-up, measures combining multiple indicators of quality into one score. Little is known about how the availability of roll-ups affects clinician choice.ObjectiveTo determine how presenting quality scores at different levels of aggregation affects patients' clinician choices.DesignWe conducted a simulated clinician-choice experiment, randomizing participants to three versions of a public reporting website and comparing their clinician choices. One version aggregated all clinician-level quality measures into roll-ups, the second provided disaggregated (drill-down) scores only, and the third offered both roll-ups and drill-downs.ParticipantsFive hundred fifty panelists drawn from a probability-based Internet panel.Main MeasuresWe assessed the amount of effort participants exerted by tracking the length of time spent on the website and the number of concrete actions taken on the website (e.g., clicking items). We evaluated decision quality by measuring whether participants selected a clinician who performed more poorly than others and incongruence between participants' stated preferences for dimensions of quality and their chosen clinician's performance on those dimensions.Key ResultsParticipants seeing drill-downs alone (mean=14.9) or with roll-ups (mean=19.2) took more actions than those who saw roll-ups alone (mean=10.5) (ps<0.05). However, participants seeing only drill-downs made poorer choices than those who saw roll-ups alone or with drill-downs. More participants seeing drill-downs chose a clinician who was outperformed (36.3% versus 23.4% [roll-up] and 25.6% [drill-down + roll-up], ps<0.05) and made choices incongruent with stated preferences (51.2% versus 45.6% [roll-up] and 47.5% [drill-down + roll-up], ps<0.05). The distinction between roll-up and drill-down was somewhat stronger for sicker participants.ConclusionsOur results suggest that roll-ups in healthcare quality reports, alone or as a complement to drill-downs, can help patients make better decisions for themselves.

Letters Health AffairsVol. 38, No. 6: Community Care For High-Need Patients Physician Information: The Authors ReplyMark Schlesinger, Lise Rybowski, and Dale Shaller AffiliationsYale School of Public Health New Haven, ConnecticutSeveryn Group Ashburn, VirginiaShaller Consulting Group Stillwater, MinnesotaPUBLISHED:June 2019Free Accesshttps://doi.org/10.1377/hlthaff.2019.00496AboutSectionsView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsDownload Exhibits TOPICSQuality of careEthnic disparitiesMedicareWe thank Asghar Shah and coauthors for suggesting some caution in interpreting the findings from our surveys of consumer exposure to physician quality information (Mar 2019). We agree that despite growing consumer engagement with comments and quality metrics, such information remains unevenly distributed across communities, often exacerbating other barriers to care.However, we do not believe that this uneven exposure detracts from the significance of our finding that nonwhite population groups were more likely to report exposure to comparative information on physician quality. First, while quantitative physician quality scores may not be available everywhere, qualitative information in the form of patients’ comments about health care providers is widely available and easily accessible online. Second, heightened exposure was evident for every minority group and every form of quality information—and in most cases, the gaps in exposure grew larger over time. Third, these gaps emerged in part because minority respondents more actively sought information on physician quality, as documented in our survey data. The heightened propensity for minority Americans to seek out information was large (odds ratio: 1.38–1.66 across specific subgroups), significant, and persisted even after other sociodemographic characteristics were controlled for.The Shahs are correct that the fact that these groups were exposed to information means only that they were aware of it—not that they were able to use it. But given that our findings controlled for differences in educational attainment and health care exposure due to serious or chronic illness, we see no reason to presume that minority consumers who actively seek information on clinician quality will be any less capable than similar white consumers of interpreting that information. Of course, being better informed does not necessarily mean being fully informed, nor does it guarantee that all patients will make equally robust choices when selecting a doctor. Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Article Metrics History Published online 3 June 2019 Information© 2019 Project HOPE—The People-to-People Health Foundation, Inc.PDF downloadRelated articlesPhysician Quality Information03 Jun 2019Health Affairs

Consumers choosing a health-care provider have access to diverse information including narratives by patients about their prior experiences. However, little research has examined how narratives might improve or impede the use of information about the quality of providers’ performance. This paper describes a conceptual framework for examining mechanisms by which narrative information might influence consumer judgments and decisions about providers. We conducted a conceptual review of risk communication and behavioral decision research. We synthesized the literature to form the foundation of a conceptual framework for assessing how narrative information about provider quality impacts consumer decisions about providers. We identified four key characteristics of narratives (convey emotion; explain logic; provide relational information; and capture naturalistic experience) that may address four consumer needs (avoid surprise and regret; recognize dominant options; motivate to act or not act; and make multi-attribute tradeoff decisions). We also identified three main functions of narratives (provide a simple, powerful cue; imbue quality information with meaning; and stimulate cognition and behavior) in four decision contexts (short-term treatments; external disruptions; chronic illness; problematic experiences). A rigorous research program can be derived from the conceptual framework to generate evidence-based recommendations about whether and how patient narratives might encourage: (1) more reasoned decisions; (2) consistency with a patient’s own values/preferences; and (3) engagement with provider quality information. Research results can be used then to develop robust guidance for health communicators reporting diverse and often incommensurate performance metrics.

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

OBJECTIVES:To understand the views of prominent organizations in the field of healthcare quality on the topic of reporting roll-up measures that combine indicators of multiple, often disparate, dimensions of care to consumers.STUDY DESIGN:This study used a semi-structured, qualitative interview design.METHODS:We conducted 30- to 60-minute semi-structured telephone interviews with representatives of 10 organizations that sponsor public healthcare quality reports and 3 national alliances representing multiple stakeholder groups. We conducted a thematic analysis of interview transcriptions to identify common issues and concerns related to reporting roll-up measures.RESULTS:Among sponsors reporting roll-up measures, current practices for calculating and reporting these measures are diverse. The main perceived benefit of reporting roll-up measures is that they simplify large amounts of complex information for consumers. The main concern is the potential for consumers to misunderstand the measures and what associated roll-up scores communicate about provider performance. Report sponsors and national alliances feel that more guidance and research on the methods for producing and reporting scores for roll-up measures are needed.CONCLUSIONS:The results of the interviews elucidate the need for research focused on construction and reporting of roll-up measures. Studies are needed to determine if roll-up measures are indeed perceived by consumers as being less complex and easier to understand.

BACKGROUND:Patients' comments about doctors are increasingly available on the internet. The effects of these anecdotal accounts on consumers' engagement with reports on doctor quality, use of more statistically reliable performance measures, and ability to choose doctors wisely are unknown. OBJECTIVE:To examine the effects of providing patient comments along with standardized performance information in a web-based public report. DESIGN:Participants were randomly assigned to view 1 of 6 versions of a website presenting comparative performance information on fictitious primary care doctors. Versions varied by the combination of information types [Consumer Assessment of Healthcare Providers and Systems (CAHPS), Healthcare Effectiveness Data and Information Set (HEDIS), and patient comments] and number of doctors. PARTICIPANTS:A random sample of working-age adults (N=848) from an online panel representing the noninstitutionalized population of the United States. MAIN MEASURES:Time spent and actions taken on the website, probing of standardized measures, and decision quality (chosen doctor rated highest on quantifiable metrics, chosen doctor not dominated by another choice). Secondary outcomes were perceived usefulness and trustworthiness of performance metrics and evaluations of the website. KEY RESULTS:Inclusion of patient comments increased time spent on the website by 35%-42% and actions taken (clicks) by 106%-117% compared with versions presenting only CAHPS and HEDIS measures (P<0.01). It also reduced participants' attention to standardized measures (eg, percentage of time probing HEDIS measures dropped by 67%, P<0.01). When patient comments were present, fewer participants chose the doctor scoring highest on standardized metrics (44%-49% vs. 61%-62%, P<0.01). CONCLUSIONS:Including patient comments in physician performance reports enhances consumers' engagement but reduces their attention to standardized measures and substantially increases suboptimal choices. More research is needed to explore whether integrated reporting strategies could leverage the positive effects of patient comments on consumer engagement without undermining consumers' use of other important metrics for informing choice among doctors.

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

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

OBJECTIVE:To assess the extent to which racial/ethnic differences in ratings of patient experiences with health care represent true differences versus differences in expectations, how scales are used, or how identical physician-patient interactions are perceived by members of different groups.STUDY SETTING:Primary data collection from a nationally representative online panel (n=567), including white, African American, and Latino respondents.STUDY DESIGN:We administered questions on expectations of care, a series of written vignettes, a video-depicted doctor-patient interaction, and modified CAHPS Clinician and Group Doctor Communication items.PRINCIPAL FINDINGS:Different groups reported generally similar expectations regarding physicians' behaviors and provided similar mean responses to CAHPS communication items in response to standardized encounters.CONCLUSIONS:Preliminary evidence suggests that unlike more subjective global ratings, reported disparities in more specific and objective CAHPS composites may primarily reflect differences in experiences, rather than differences in expectations and scale use, adding to our confidence in using the latter to assess disparities.

OBJECTIVE:To examine racial/ethnic differences in the use of high-volume hospitals and surgeons for 10 surgical procedures with documented associations between volume and mortality.DESIGN:Cross-sectional regression analysis.SETTING:New York City area hospital discharge data, 2001-2004.PATIENTS:Adults from 4 racial/ethnic categories (white, black, Asian, and Hispanic) who underwent surgery for cancer (breast, colorectal, gastric, lung, or pancreatic resection), cardiovascular disease (coronary artery bypass graft, coronary angioplasty, abdominal aortic aneurysm repair, or carotid endarterectomy), or orthopedic conditions (total hip replacement).MAIN OUTCOME MEASURE:Treatment by a high-volume surgeon at a high-volume hospital.RESULTS:There were 133 821 patients who underwent 1 of the 10 procedures. For 9 of the 10 procedures, black patients were significantly (P < .05) less likely (after adjustment for sociodemographic characteristics, insurance type, proximity to high-volume providers, and comorbidities) to be operated on by a high-volume surgeon at a high-volume hospital and more likely to be operated on by a low-volume surgeon at a low-volume hospital. Asian and Hispanic patients, respectively, were significantly less likely to use high-volume surgeons at high-volume hospitals for 5 and 4 of the 10 procedures and more likely to use low-volume surgeons at low-volume hospitals for 3 and 5 of the 10 procedures.CONCLUSIONS:Minority patients in New York City are doubly disadvantaged in their surgical care; they are substantially less likely to use both high-volume hospitals and surgeons for procedures with an established volume-mortality association. Better information is needed about which providers minority patients have access to and how they select them.

Over the past twenty years, Medicare has been transformed from a single-payer insurer into a hybrid of complementary public and private insurance arrangements. Despite creating ongoing controversy, these changes have resulted in an ironic and largely overlooked strategic potential: Medicare's evolving hybrid form makes it the most promising vehicle for overcoming the historical obstacles to universal health insurance in the United States. To make this surprising case, we first explore the distinctive political dynamics of programs that, like today's Medicare, are hybrids of public and private arrangements. We then consider how these political dynamics might circumvent past barriers to universal health insurance. Finally, we discuss the strengths and weaknesses of alternative pathways through which Medicare could be expanded to promote health security.

With the aging of the population, healthcare executives are paying increased attention to fostering safe and high-quality care for older adults who become hospitalized. The Hospital Elder Life Program (HELP) is an evidence-based program that has been shown to be cost-effective in reducing episodes of delirium, functional decline, and long-term nursing home placement for older hospitalized adults. Senior administrators are known to play a role in quality improvement, but little is known about their roles in adopting clinical improvement programs such as HELP. Therefore, we conducted a mixed-methods study of 63 hospitals at different stages of adopting HELP to identify key roles and motivations of senior management to adopt HELP and the perceived impact of HELP on patient and staff outcomes. Our findings can be used by hospital management teams as they identify ways to influence and benefit from efforts to improve clinical quality, safety, and the experiences of older adults treated in their hospitals.

Background: The effective translation of scientific evidence into clinical practice is paramount to improving the quality and safety of patient care. However, little is known about the patterns of diffusion of evidence-based programmes in healthcare.Objectives: To study the pattern of diffusion of an evidence-based programme to improve the quality and safety of care for hospitalised older adults.Methods: The diffusion of the Hospital Elder Life Program ( HELP), a multifaceted programme to reduce delirium in hospitalised adults, was examined. Using a survey of all hospitals that contacted the HELP Dissemination Project for more than 2 years, the proportion of hospitals that adopted the programme, the programme fidelity to the original design in terms of structure and process, and the perceived reasons for non-adoption were identified.Results: Programme fidelity was highest among structural features (eg, staffing levels); programme modifications were more commonplace in processes of care ( eg, the participation of volunteers in patient care interventions). Senior management support and the programme expense were the most commonly cited reasons for non-adoption of HELP.Conclusion: Diffusion and take-up rates for this evidence-based programme were substantial; however, programme fidelity was not complete and some hospitals did not adopt the programme at all. Clinicians, researchers and funding agents seeking to promote effective translation of research should be realistic about diffusion rates and recognise the critical ingredient of senior management support to propel adoption of evidence-based programmes to improve quality and safety.

OBJECTIVES: To examine key factors that influence sustainability in the diffusion of the Hospital Elder Life Program ( HELP) as an example of an evidence-based, multifaceted, innovative program to improve care for hospitalized older adults.DESIGN: Longitudinal, qualitative study between November 2000 and November 2003 based on 102 in-depth interviews every 6 months during HELP implementation.SETTING: Thirteen hospitals implementing HELP.PARTICIPANTS: Forty-two hospital staff members ( physician, nursing, volunteer, and administrative staff) implementing HELP, conducted 102 interviews.MEASUREMENTS: Staff experiences sustaining the program, including challenges and strategies that they viewed as successful in addressing these challenges.RESULTS: Of the 13 hospitals studied, 10 were sustaining HELP at the end of the study period; three terminated the program (after 24 months, 12 months, and 6 months). Critical factors were identified as influencing whether the program was sustained: the presence of clinical leadership, the ability and willingness to adapt the original HELP protocols to local hospital circumstances and constraints, and the ability to obtain longer-term resources and funding for HELP.CONCLUSION: Recognizing the need for sustained clinical leadership and funding as well as the inevitable modifications required to sustain innovative programs can promote more-realistic goals and expectations for health services researchers, clinicians, and policy makers in their laudable efforts to translate research into practice.

For this study, the authors conducted case studies of four varied clinical programs to learn key factors influencing the diffusion and adoption of evidence-based innovations in health care. They found that the success and speed of the adoption/diffusion process depend on: the roles of senior management and clinical leadership; the generation of credible supportive data; an infrastructure dedicated to translating the innovation from research into practice; the extent to which changes in organizational culture are required; and the amount of coordination needed across departments or disciplines. The translation process also depends on the characteristics and resources of the adopting organization, and on the degree to which people believe that the innovation responds to immediate and significant pressures in their environment.

Objectives: To describe the process of adoption of an evidence-based, multifaceted, innovative program into the hospital setting, with particular attention to issues that promoted or impeded its implementation. This study examined common challenges faced by hospitals implementing the Hospital Elder Life Program (HELP) and strategies used to address these challenges.Design: Qualitative study design based on in-depth, open-ended telephone interviews.Setting: Nine hospitals implementing HELP throughout the United States.Participants: Thirty-two key staff members (physician, nursing, volunteer, and administrative staff) who were directly involved with the HELP implementation.Measurements: Staff experiences implementing the program, including challenges and strategies they viewed as successful in overcoming challenges of implementation.Results: Six common challenges faced hospital staff: (1) gaining internal support for the program despite differing requirements and goals of administration and clinical staff, (2) ensuring effective clinician leadership, (3) integrating with existing geriatric programs, (4) balancing program fidelity with hospital-specific circumstances, (5) documenting positive outcomes of the program despite limited resources for data collection and analysis, and (6) maintaining the momentum of implementation in the face of unrealistic time frames and limited resources. Strategies perceived to be successful in addressing each challenge are described.Conclusion: Translating research into clinical practice is challenging for staff across disciplines. Developing strategies to address common challenges identified in this study may facilitate the adoption of innovative programs within healthcare organizations.