Patient Centeredness (continued)

Patients' Experience of Care

Using methods developed for the CAHPS® (Consumer Assessment of Healthcare Providers and Systems) survey,¹³⁰ the NHDR uses a composite measure that combines four measures of provider-patient communication into a single core measure. The four measures are: providers who sometimes or never listen carefully, explain things clearly, respect what patients say, and spend enough time with patients. Data are shown for adults and children.

Figure 2.46. Composite measure: Ambulatory patients age 18 and over who reported poor communication with health providers,* by race, ethnicity, and income, 2002-2006

          

* Average percentage of adults age 18 and over who had a doctor's office or clinic visit in the last 12 months and reported poor communication with health providers (i.e., that their health providers sometimes or never listened carefully, explained things clearly, showed respect for what they had to say, and spent enough time with them).

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2006.

Denominator: Civilian noninstitutionalized population age 18 and over.

Note: Data were insufficient for this analysis for Native Hawaiians and Other Pacific Islanders and for American Indians and Alaska Natives.

• In 2006, Blacks and Asians were more likely than Whites to report poor communication with their health providers (10.3% for Blacks and 13.1% for Asians compared with 9.5% for Whites; Figure 2.46). The difference between people of multiple race and Whites was not statistically significant.
• In 2006, the percentage reporting poor communication was higher for Hispanics than for non-Hispanic Whites (12.2% compared with 9.1%).
• In 2006, the percentage of adults who reported poor communication was higher for poor people than for high-income people (13.4% compared with 7.1%), and the gap observed for previous data years remained the same.

Racial and ethnic minorities are disproportionately of lower education levels. To distinguish the effects of race, ethnicity, and education on provider-patient communication, this measure is stratified by education level.

Figure 2.47. Composite measure: Adult ambulatory patients who reported poor communication with health providers,* by race and ethnicity, stratified by education, 2006

  

* Average percentage of adults age 18 and over who had a doctor's office or clinic visit in the last 12 months and reported poor communication with health providers (i.e., that their health providers sometimes or never listened carefully, explained things clearly, showed respect for what they had to say, and spent enough time with them).

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2006.

Denominator: Civilian noninstitutionalized population age 18 and over.

Note: Sample sizes were too small to provide estimates for Asians with less than a high school education and Asian high school graduates.

• The amount of education attained explains some of the racial and ethnic differences in provider-patient communication for patients age 18 and over (Figure 2.47).
• Among high school graduates, Blacks (12.3%) were more likely than Whites (10.0%) and Hispanics (13.8%) were more like than non-Hispanic Whites (9.5%) to report poor communication with their health providers.

Communication in children's health care can pose a particular challenge, as children are often less able to express their health care needs and preferences. Often, a third party (e.g., a parent or guardian) is involved in communication and decisionmaking. Optimal communication in children's health care can therefore have a significant impact on receipt of high-quality care and subsequent health status. This is especially true for children with special health care needs (CSHCN).

Figure 2.48. Composite measure: Children with ambulatory visits whose parents reported poor communication with health providers,* by race, ethnicity, and family income, 2002-2006

          

* Average percentage of children under age 18 who had a doctor's office or clinic visit in the last 12 months and whose parents or guardians reported poor communication with their child's health providers (i.e., that their health providers sometimes or never listened carefully, explained things clearly, respected what they had to say, and spent enough time with them).

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2006.

Denominator: Civilian noninstitutionalized population under age 18.

Note: Data for Asians (2005 only), multiple-race children (2006 only), Native Hawaiians and Other Pacific Islanders, and American Indians and Alaska Natives did not meet criteria for statistical reliability.

• Overall, the percentage of children whose parents or guardians reported poor communication with their health providers decreased from 6.7% in 2002 to 4.8% in 2006 (data not shown).
• In 2006, there were no statistically significant differences between Black and White children whose parents or guardians reported poor communication with their health providers (Figure 2.48).
• From 2002 to 2006, the difference between Hispanics and non-Hispanic Whites in the percentage of children whose parents or guardians reported poor communication with their health providers remained statistically significant. In 2006, the percentage of children whose parents or guardians reported poor communication with their health providers was still markedly higher for Hispanics than for non-Hispanic Whites (7.0% compared with 4.2%).
• In 2006, statistically significant differences among children whose parents or guardians reported poor communication persisted by income. Percentages remained higher for children from poor (7.7%), near-poor (6.8%), and middle-income (4.4%) families than for children from high-income families (2.6%).

Racial and ethnic minorities have disproportionately lower incomes. To distinguish the effects of race, ethnicity, and income on provider-patient communication, this measure is stratified by income level.

Figure 2.49. Composite measure: Children with ambulatory visits whose parents reported poor communication with health providers,* by race and ethnicity, stratified by income, 2006

  

* Children under 18 years of age whose parents or guardians reported that their child's health providers sometimes or never listened carefully, explained things clearly, respected what they had to say, and spent enough time with them.

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2006.

Denominator: Civilian noninstitutionalized population under age 18.

Note: Sample sizes were too small for all income categories to provide estimates for Asians and Pacific Islanders or American Indians and Alaska Natives. Data were not available for middle- and high-income Blacks or high-income Hispanics.

• Socioeconomic factors may explain at least some of the racial and ethnic differences in provider-patient communication for patients under age 18 (Figure 2.49).
• In 2006, among poor people, there was no statistically significant difference between the percentage of Black and White children whose parents reported poor communication with their health providers.
• Among poor people, Hispanics were as likely as non-Hispanic Whites to report poor communication with their health providers.

Diversity of the Dental Professionals Workforce

In 2000, more than 30% of Americans identified themselves as members of racial or ethnic minority groups. It is estimated that by 2050, half of Americans will be members of minority groups.¹³¹ Minority providers are more likely than their White colleagues to practice in underserved minority communities.^132,133 Health care workforce diversity also is considered to be important for health care research, education, administration, and policy, both to provide role models and to shape a health care system that meets the needs of all individuals.

Diversity increases the opportunities for race—and language—concordant health care visits. It also can improve cultural competency at the system, organization, and provider levels in several ways. These include appropriate program design and policies, organizational commitment to culturally competent care, and cross-cultural education of colleagues.¹³⁴ As such, diversity is an important element of a patient-centered health care encounter.

Previous reports have presented data on diversity in the physician and nursing workforces. This year, the NHDR presents data on diversity in the dental professions workforce.

Three dental professions are presented in this analysis: dentists, dental hygienists, and dental assistants. Dentists diagnose and treat problems with teeth and tissues in the mouth, give advice, and administer preventive services. Most dentists practice solo, owning their own business and maintaining a support staff of other administrative and dental professionals. Dentists must receive a doctorate degree in dentistry before practicing unsupervised, usually requiring at least 8 years of education beyond high school.

Dental hygienists remove deposits from teeth, teach patients how to practice good oral hygiene, and provide other preventive dental care. They also examine patients' teeth and gums, recording the presence of diseases or abnormalities. To practice as a dental hygienist, one must complete a degree program with an accredited dental hygiene school and obtain a State license.

Dental assistants provide support for dentists and dental hygienists by performing a variety of patient care, office, and laboratory duties. Several training routes may lead to work as a dental assistant, including formal training at a technical college ranging from 1 to 2 years and on-the-job training.

In the coming years, demand for dental services is expected to increase, as well as delegation of work in dental settings. Thus, the overall growth rates for dental assistants and dental hygienists are expected to be higher compared with that of dentists and compared to job growth in the economy as a whole.

Figure 2.50. U.S. dentistry professionals compared with the U.S. population, by race/ethnicity, 2007

Key: AI/AN = American Indian or Alaska Native; NHOPI = Native Hawaiian or Other Pacific Islander.

Source: U.S. Census Bureau, American Community Survey, 2007.

Note: All racial groups are non-Hispanic.

• In 2007, 76.3% of the approximately 182,000 dentists in the United States were White; 3.5% were Black, 12.9% were Asian, and 6.4% were Hispanic (Figure 2.50). Compared with the general U.S. population, Whites and Asians were overrepresented and Blacks and Hispanics were underrepresented.
• In 2007, 88.9% of the approximately 155,000 dental hygienists were White; 2.2% were Black, 2.8% were Asian, and 4.8% were Hispanic. Relative to the U.S. population, Whites were overrepresented, and Blacks, Asians, and Hispanics were underrepresented.
• Also in 2007, there were about 314,000 dental assistants, of whom 69.2% were White, 6.5% were Black, 4.7% were Asian, and 17.8% were Hispanic. Relative to the U.S. population, Whites, Asians, and Hispanics were overrepresented, and Blacks were underrepresented.

Focus on Care Coordination

Health care in the United States is fragmented and difficult to navigate. Patients often receive medical services, treatments, and advice from multiple providers in many different care settings. Communication of important information among providers and between providers and patients frequently entails delays or inaccuracies or fails to occur at all.

Care coordination is defined as the deliberate organization of patient care activities between two or more participants involved in a patient's care to facilitate the appropriate delivery of health care services.^xx It is multidimensional and essential to preventing adverse events, ensuring efficiency, and making care patient centered.^135,136 Key elements of care coordination include integrating medical information from multiple sources and providers and managing patient transitions from one setting of care to another.

The focus on care coordination in this year's NHDR is a first attempt to provide data on this important topic. This section does not attempt to provide a comprehensive framework for care coordination; nor does it provide an exhaustive list of potential measures. Rather, it provides examples where some information is available. AHRQ hopes that this section will stimulate productive discussions in the area of care coordination, including development and use of valid, reliable, and feasible quality measures. AHRQ hopes that this chapter will be the first step in an evolving national discussion on measuring care coordination.

Integration of Information

Patients often seek care from many providers. Medical information generated in different settings may not be sent to a patient's primary care provider. Actively gathering and managing all of a patient's medical information is an important part of care coordination. Tasks include ensuring that patients are informed of important findings such as test results, primary care doctors are informed of care from specialists, and providers within a practice have access to needed information.

No national survey gathers information about these aspects of care coordination. To help fill this gap, we examined subnational data-gathering activities and identified the Massachusetts Health Quality Partners (MHQP) Patient Experience Survey as a unique source of this information. MHQP is an independent organization established in 1995, comprising a broad-based coalition of physicians, hospitals, health plans, purchasers, consumers, academics, and government agencies. These groups work together to promote improvement in the quality of health care services in Massachusetts.

In 2007, MHQP conducted a mail and Internet survey of commercially insured adult and pediatric patients' experiences of care. The survey included patients being served in primary care practices with at least three doctors.^xxi Several questions related directly to coordination of information across providers and patients. The survey was completed by 51,000 adult patients and 20,000 parents of pediatric patients receiving care in more than 400 medical practices in Massachusetts. The response rate was 42%.

Figure 2.51. Patients who reported that they always received test results, commercially insured adults ages 18-64 in primary care practices, Massachusetts, 2007

Key: AI/AN = American Indian or Alaska Native; HS = high school.

Source: Massachusetts Health Quality Partners, Patient Experience Survey, 2007.

Note: Respondents limited to patients who received a test in the past year.

• Of adult patients who were sent for a blood test, x-ray, or other test by their personal primary care doctor, 68% reported that someone from the doctor's office followed up to give them the test results (Figure 2.51).
• Black, Hispanic, and Asian patients were less likely to receive followup on test results than White patients.
• Patients with less than a high school education were less likely to receive followup than patients with some college education.

Figure 2.52. Parents of patients who reported that they always received test results, commercially insured children under age 18 in primary care practices, Massachusetts, 2007

Key: HS = high school.

Source: Massachusetts Health Quality Partners, Patient Experience Survey, 2007.

Note: Respondents limited to patients who received a test in the past year. Education refers to the parents. Data were insufficient for this analysis for American Indians and Alaska Natives.

• Of children who were sent for a test, 69% of parents reported that someone from the doctor's office followed up to give the test results (Figure 2.52).
• Black, Hispanic, and Asian children were less likely to receive followup on test results than White children.
• Children whose parents had less than a high school education were less likely to receive followup than children whose parents had some college education.

Transitions of Care

As health care conditions and needs change, patients often need to be moved from one setting to another. These transitions of care place patients at heightened risk of adverse events. Important information may be lost or miscommunicated as responsibility is delivered to new parties.

A common transition of care is discharge from the hospital, with approximately 39 million community hospital discharges occurring each year.¹³⁷ Discharge from a hospital typically indicates improvement in a patient's condition so that the patient no longer needs inpatient care. It also means that the patient and family need to resume responsibility for the patient's daily activities, diet, medications, and other treatments. The patient also needs to visit his or her personal doctor and know what to do if his or her condition deteriorates.

Discharge instructions can help ensure that a patient receives the information needed to stay healthy after leaving the hospital. The NHDR reports on a measure that tracks receipt of written discharge instructions among adult patients hospitalized for heart failure. This measure reflects these patients' perceptions of the discharge information they received.

Figure 2.53. Adult hospital patients with heart failure who were given complete written discharge instructions, 2005-2007

Key: AI/AN = American Indian or Alaska Native.

Source: Centers for Medicare & Medicaid Services, Medicare Quality Improvement Organization Program, 2005-2007.

Denominator: Adult patients hospitalized with a principal diagnosis of heart failure.

Note: Complete written discharge instructions needed to address all of the following: activity level, diet, discharge medications, followup appointment, weight monitoring, and actions to take if symptoms worsen.

• From 2005 to 2007, the percentage of adult hospital patients with heart failure who were given complete written discharge instructions improved from 57.5% to 76.0% (Figure 2.53). Improvements were observed among all racial groups.
• In all years, Hispanics and AI/ANs were less likely than Whites to receive complete written discharge instructions.

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^xx This definition was derived from a review of multiple definitions from various sources. For more information, refer to Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies: Volume 7—Care Coordination, available at http://www.ahrq.gov/clinic/tp/caregaptp.htm.
^xxi The survey and results are available at http://www.mhqp.org/quality/pes/pesMASumm.asp?nav=031600.

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