1. 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

2. 11/07/062 Outline of Presentation  Background  Research Questions  Interviews with Physicians  Survey of Physicians  Results & Discussion  Mixed-method Approach  Conclusion

3. 11/07/063 Background  CMS work with Info Intermediaries  2001 Research as RI Plans public reporting  RFP re MDs as Info Intermediaries for consumers about hospital quality

4. 11/07/064 Research Questions  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?

5. 11/07/065 Qualitative Study: Overview  Interviews: Round 1 – Face-to-face 1 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: Specialties: Primary care, Cardiology, Pulmonology Recruited through physicians and other key informants 1 one phone interview

6. 11/07/066 Methods: Patient Scenarios  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

7. 11/07/067 Physicians’ Responses: Talking with Patients Reassure the patient “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.” Describe physician’s own experience – “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 – “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.”

8. 11/07/068 Physicians’ Responses: Talking with Patients (Round 2)  Physicians described an approach to discussions with patients through dialogue and shared decision making “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: Assess, Advise, Agree, Assist, Arrange

9. 11/07/069 Physician Interest, Concerns & Perceived Barriers  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

10. 11/07/0610 National Survey: Overview  Stratified random sample of physicians: N=1,027  Specialties: family medicine/general practice, internal medicine, cardiology  Mixed mode of data collection: 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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12. 11/07/0612 Patient Interest in Quality Reports  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)

13. 11/07/0613 Attitudes Toward New Quality Measures  67% of physicians reported that measures of patient satisfaction and experience of care would be useful to patients More useful than other quality indicators  Results differ from earlier qualitative findings 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

14. 11/07/0614 Influencing Physician’s Attitudes about Reports  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

15. 11/07/0615 Mixed Method Approach  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

16. 11/07/0616 Conclusions  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

17. 11/07/0617 Next Steps: Messaging & Marketing  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

18. 11/07/0618 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