Primary care patients often have an agenda when they visit their physicians, including concerns about the cause, seriousness, or prognosis of their problem, or expectations of what the physician will do at the clinic visit. Physicians often fail to recognize patients’ expectations for the visit. Increasing time constraints on visit lengths and the complexity of patients’ chronic medical problems may make physicians even less likely to elicit the patients’ agenda. Studies indicate that unmet expectations adversely affect compliance, satisfaction and other patient-centered outcomes that are important to health care systems like the VHA. Interactive voice response (IVR) is a novel computer technology that allows individuals to answer questions using a touch-tone telephone, and has recently been extended to health care for screening and monitoring purposes. However, IVR has never been evaluated as a method to elicit the concerns of patients with multiple chronic conditions.
The objectives of this study were to evaluate the acceptability and effectiveness of using interactive voice response (IVR) to elicit patients' pre-visit concerns and expectations for patients with two prevalent, chronic, disabling and expensive conditions in primary care, arthritis and diabetes. Specifically, we proposed to: 1) develop and implement a patient-centered IVR system in a VA Medical Center that elicits patients' generic pre-visit concerns and expectations; 2) conduct a randomized controlled trial of using IVR to obtain this information; and 3) evaluate the impact of IVR-obtained information on improving patient-centered outcomes such as satisfaction and health-related quality of life, as well as indicators of process of care, including visit-specific communication and unmet expectations.
This is a randomized, controlled trial of patients with diabetes and arthritis. Patients in the intervention group received pre-visit phone calls to assess their expectations for the visit. Control patients received pre-visit phone calls with appointment reminders.
We have completed all data collection of the 640 patients enrolled, and demonstrated successful implementation of an IVR system that elicited patient information prior to visits. We created a user-friendly, viable interface, which overcame technical problems such as contacting patients who have a call-intercept service on their telephone. However, the study did not find any changes in satisfaction (PSQ), disease specific measures of quality of life for arthritis (AIMS2) and diabetes (PAID), or clinical outcomes (hemoglobin A1C) over time between the control group and the intervention group. The AIMS2 Physical Component was measured at three time points. For the control patients, the expected mean scores were 3.37 at baseline; 3.36 at six months; and 3.26 at twelve months. For the intervention patients, the expected mean scores were 3.27 at baseline; 3.33 at six months; and 3.37 at twelve months. There were no statistical differences between control and intervention patient scores. The PAID score was measured at three time points. For the control patients, the expected mean scores were 14.9 at baseline; 15.1 at six months; and 18.1 at twelve months. For the intervention patients, the expected mean scores were 13.6 at baseline; 12.6 at six months; and 17.4 at twelve months. The PSQ quality of care was measured at three time points. For the control patients, the expected mean scores were 47.9 at baseline; 49.2 at six months; and 49.1 at twelve months. For the intervention patients, the expected mean scores were 48.8 at baseline; 49.0 at six months; and 49.7 at twelve months. There were no statistical differences between control and intervention patient scores over time. The Hemoglobin A1c was measured for diabetes patients twice, at baseline and study completion. The average difference in A1c from baseline to 12 months between control and intervention patients was .324 with a standard deviation of (1.282) and a p-value of 0.061.
Efficiency, customer satisfaction and a patient-centered approach to health care are priorities for the Department of Veteran Affairs as it must compete with other health systems for patients. However, these results suggest that IVR systems may not enhance the VHA's ability to address these outcomes successfully.
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