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Understanding Variation in Quality Indicator Adherence and Patient Satisfaction in the Department of veterans Affairs
Stolzman K, Meterko MM, Mohr DC, Shwartz M, White RA. Understanding Variation in Quality Indicator Adherence and Patient Satisfaction in the Department of veterans Affairs. Poster session presented at: AcademyHealth Annual Research Meeting; 2009 Jan 1; Chicago, IL.
Research Objective: The delivery of health care depends not only on the skills of individual providers but also on the coordination of the teams in which they practice and the structure of the work setting. We sought to determine the amount of variation in primary care adherence to quality indicators and patient satisfaction accounted for at the provider, primary care team, and medical center levels.
Study Design: Data from the Department of Veterans Affairs (VA) External Peer Review Program (EPRP) was used to calculate a single measure of provider adherence using twelve key performance indicators of high quality care associated with diabetes, cancer, acute myocardial infarction, hypertension and immunizations. Data from the Survey of Healthcare Experiences of Patients (SHEP) was used to calculate a composite measure of outpatient satisfaction. Both the SHEP and EPRP programs are administered by the VA Office of Quality and Performance. On average data was provided by 7.9 and 17.4 patients per provider for EPRP and SHEP, respectively. Hierarchical linear models including random intercepts only with no explanatory variables were used to partition the variability in each compliance measure by level.
Population Studied: The EPRP measures were obtained from 37,304 patients of 4,715 primary care providers within 1,274 teams at 128 medical centers. The SHEP measures were obtained from 83,454 patients of 4,784 providers within 1,318 teams at 129 medical centers. VA outpatients who were included in the EPRP or SHEP programs in FY2007 were subsequently matched to a primary care team. Providers were assigned to teams based on their assignment in the Primary Care Management Module (PCMM).
Principle Findings: Mean provider adherence across all patients was 83.0% (SD 26.9%; inter-quartile range: 75.0%-100%). Mean patient satisfaction was 84.0% (SD: 18.7%; inter-quartile range: 76.6%-98.1%). For provider adherence the percent of variance accounted for at the provider, team and medical center level was 2.5%, 0.8% and 0.7%, respectively. For patient satisfaction the percent variance accounted for at the provider, team, and medical center level was 4.0%, 2.0%, and 2.4%, respectively.
Conclusions: Overall, both provider adherence and patient satisfaction were quite high. In both of these domains, differences between patients were the predominant source of variance. The percent of variance in either domain accounted for by differences between providers would generally be regarded as noteworthy but small. Team and medical level factors each accounted for less than one percent of variance in provider adherence. Regarding patient satisfaction, the percentages of variance accounted for at the provider, team and medical center levels were roughly double those observed for adherence, and medical center factors appeared relatively more important than team level factors.
Implications for Policy, Delivery or Practice: Provider, team and medical center level characteristics vary in their respective influence on both the care and satisfaction of patients. These findings can help managers improve provider adherence and patient satisfaction by targeting interventions at specific organizational levels in the VA.