Psychiatr Serv 54:1031-1033, July 2003
© 2003 American Psychiatric Association
A Survey of Psychiatric Outpatients on Quality of Care
Thomas Sheeran, Ph.D., M.E.
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Abstract
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Despite increased emphasis on the quality of health care and on the dissemination of information about quality to the public, expectations are equivocal about consumers' interest in such information. A total of 110 psychiatric outpatients were asked about how they selected their mental health provider and were surveyed about their views on the quality of mental health care. Most study participants believed that quality can vary by provider, viewed themselves as active consumers of health care, desired more information about quality, and stated that if they had information about quality they would use such information when selecting a provider. Nevertheless, few sought such information in finding their clinician. Lower educational level of the participant was associated with a lower rating of interest in clinician quality.
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Introduction
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The past few decades have seen tremendous growth in the area of health care quality improvement and management (1,2,3,4). In addition to ongoing efforts to provide information about quality to clinicians, administrators, insurers, and purchasers, there is increasing interest in disseminating such data to the public (5,6). However, expectations have been equivocal about health care consumers' knowledge about quality of care and willingness to make use of such information (1,6,7).
A review of the literature revealed few empirical evaluations of patients' understanding of, or interest in, information on health care quality. The study reported here surveyed psychiatric outpatients to determine how they selected their mental health care provider, whether information about the quality of mental health care would be of interest to them, and, if so, what type of quality-related information they would like to have.
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Methods
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The study was conducted between November 2001 and April 2002 in the outpatient psychiatry department of Rhode Island Hospital, a 719-bed, nonprofit general hospital and academic medical center affiliated with Brown Medical School in Providence. The study was approved by the hospital institutional review board. Patients who presented for treatment at the hospital's outpatient psychiatry practice were asked to complete a brief anonymous survey. Patients were excluded if they did not want to complete the survey, they did not speak English, or their capacity to complete the questionnaire was impaired by mental or neurologic dysfunction.
The final sample consisted of 110 patients—77 women (70 percent) and 33 men (30 percent)—ranging in age from 18 to 75 years (mean± SD=40.5±13.3 years). Fifty-one (46 percent) of the participants were married or cohabiting as if married. Nine participants (8 percent) had not completed high school, 62 (56 percent) had completed high school, and 36 (33 percent) had completed four years at a college or professional school. Three participants (3 percent) did not provide information about their education. The racial composition of the sample was predominantly white (93 participants, or 85 percent). All patients were covered by private medical insurance.
Because nonparticipants completed no paperwork, their demographic characteristics were unknown. However, demographic variables were compared between participants and a sample of 1,447 psychiatric patients from the same practice who had been asked to complete a symptom questionnaire before their regularly scheduled appointment. The two samples did not significantly differ in age, gender, education, marital status, or ethnicity.
The study participants completed a brief, anonymous questionnaire that inquired about how they selected their mental health provider and their perceptions of health care quality. The questionnaire was developed as a face-valid opinion survey. The survey items, listed in Table 1, were developed after qualitative discussions with patients and review with doctoral-level clinicians and researchers to clarify content and understandability.
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Table 1. Responses of 110 consumers to a survey on the quality of mental health care and information about quality
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Eighteen items asked patients about five areas: how the patients selected their mental health provider; whether they believed that quality of care varied by provider and their perceived degree of autonomy in selecting a provider; their perceived access to, satisfaction with, and desire for more quality-related information about providers; and which domains of quality were important to them. All items were scored on a 5-point Likert scale ranging from "strongly disagree" to "strongly agree" in the case of items 1 through 10 and from "not at all important" to "extremely important" in the case of items 11 through 18.
For each question, the frequencies of scores were calculated. Response rates were compared by using chi square goodness-of-fit tests with the null hypothesis that participants would be indifferent about the areas queried—that is, that the response distribution would be normally distributed, centered on a score of 3 on the Likert scale. To determine whether patient characteristics were related to response patterns, linear multiple regression analyses were conducted, with demographic variables entered as predictors of responses. Bonferroni-corrected significance levels of p<.001 were used to correct for experimentwise error.
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Results
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A majority of patients (84, or 76 percent) had selected their mental health provider by consulting their primary care physician, health plan, or friends or family members. A quarter (25 patients, or 23 percent) identified their provider by means of the telephone directory, their psychotherapist, or some other means. Almost none of the patients (one patient, or 1 percent) contacted their local licensing board, and none had used the Internet to find a mental health provider.
The response distributions for all items were significantly different from those that would have been expected by chance. A majority of study participants believed that the quality of health care can vary considerably and viewed themselves as able to select and switch their provider (items 1 to 7). In addition, patients reported that they were not satisfied with the amount of quality-related information available, wanted more information about the quality of their clinician, and wanted to have more control over provider selection through access to information about provider quality (items 7 to 10).
In addition to chi square tests, items that inquired about the degree of importance of various quality domains (items 11 to 18) were ranked according to the percentage of respondents who rated an item as very or extremely important. Patients placed relatively high importance on provider training, such as board certification, and interpersonal factors—for example, "my clinician is genuinely interested in me." Almost equally important, however, were objective measures of quality assurance, such as use of best diagnostic or treatment methods, application of current research, and ongoing quality assurance programs.
Multiple regression analysis, followed by post hoc Scheffe's comparisons, showed that education level was the only variable associated with item responses: patients who did not complete high school were less likely to indicate that the quality of their clinician's work was important to them (R2=.11, p<.001).
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Discussion and conclusions
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The focus of this study was to clarify how patients viewed themselves as consumers of mental health care and to assess their attitudes about clinician-focused quality information. The results suggest that patients are very interested in health care quality: a majority of the participants in this study understood that quality can vary, viewed themselves as active consumers of health care, expressed a desire for more information about the quality of care, and reported that they would make use of information about quality in selecting a provider.
Consistent with previous speculation (1), interest in the quality of health care was associated with educational level. However, contrary to the expectation that the most educated participants would also be the most interested in information about quality, education appears to have a basement effect rather than a ceiling effect. That is, it is not a matter of the most educated people taking an interest in health care quality, but rather of the least educated people not taking such an interest.
Importantly, it appears that patients have a high level of sophistication regarding health care quality and that they understand process and outcome perspectives in quality evaluation. Nevertheless, patients' actual (reported) behavior reflected a straightforward approach to selecting a provider: they sought referrals from their primary care physician or another professional, consulted friends and family members, and used the telephone directory or other general listings. This discrepancy may reflect measurement issues—for example, response biases—or may accurately reflect the notion that consumers are not yet ready to make use of data on quality (6,7,8,9). Alternatively, it may be that in the absence of standardized and universal quality-related provider data, patients will continue to defer to the opinions of other professionals and their family and friends or to select providers included in their insurance plans.
This study was limited by a number of factors. First, generalizability of the findings cannot be assumed, because the sample was relatively homogeneous—for example, in race and in health insurance status—and was drawn from a single treatment facility. The response biases inherent in face-valid surveys may limit inferences that can be made about participants' true opinions and behaviors. In addition, the study did not investigate the degree to which participants assumed quality management to be inherent in the system—for example, through gatekeeper functions or health plan quality assurance efforts. Additional research should address these shortcomings and, if possible, include standardized instruments and behavioral observations to clarify this complex issue.
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Footnotes
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Dr. Sheeran is affiliated with Cornell University Weill Medical College, 21 Bloomingdale Road, White Plains, New York 10605 (e-mail, tfs2{at}cornell.edu). At the time of this study he was affiliated with the department of psychiatry and human behavior at Brown Medical School and the department of outpatient psychiatry at Rhode Island Hospital in Providence.
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References
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- Blumenthal D: The future of quality measurement and management in a transforming health care system. JAMA 278:1622–1625, 1997[CrossRef][Medline]
- Blumenthal D, Epstein AM: The role of physicians in the future of quality management. New England Journal of Medicine 335:1328–1331, 1996[Free Full Text]
- Brook RH, McGlynn EA, Cleary PD: Measuring quality of care. New England Journal of Medicine 335:966–970, 1996[Free Full Text]
- Chassin MR: Improving the quality of care. New England Journal of Medicine 335:1060–1063, 1996[Free Full Text]
- Kizer K: Establishing health care performance standards in an era of consumerism. JAMA 286:1213–1217, 2001[Abstract/Free Full Text]
- Hibbard J, Jewett J: Will quality report cards help consumers? Health Affairs 16 (3):218–228, 1997
- How We Choose Doctors: What Is and What Could Be. Chicago, Midwest Business Group on Health, 2000
- Rosenthal GE, Chren M-M, Lasek RJ, et al: What patients should ask of consumers' guides to health care quality. Evaluation and the Health Professions 21:316–331, 1998[Abstract/Free Full Text]
- Schneider EC, Epstein AM: Influence of cardiac-surgery performance reports on referral practices and access to care: a survey of cardiovascular specialists. New England Journal of Medicine 335:251–256, 1996[Abstract/Free Full Text]
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Abstract
Introduction
