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Patient Safety/Quality of Care

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Researchers confirm that ongoing doctor-patient relationships based on trust are critical for effective care

Primary care has been the focus of many changes in the health care delivery system over the past decade and a half. Primary care physicians (PCPs) hold a central role in patient care. Ideally, they are responsible for coordinating and integrating all aspects of the care provided to their patients. In some cases, they also share in the financial risk associated with providing care under a capitated payment arrangement.

Even within stable health plans, PCPs have felt pressure to increase productivity (see more patients per hour), decrease costs, and still keep patients satisfied. However, these actions may have eroded trust in the patient-doctor relationship and led some patients to switch doctors, according to two studies supported in part by the Agency for Healthcare Research and Quality (HS08841), which are summarized here.

Murphy, J., Chang, H., Montgomery, J.E., and others. (2001, February). "The quality of physician-patient relationships: Patients' experiences 1996-1999." Journal of Family Practice 50(2), pp. 123-129.

In this study, the researchers surveyed nearly 2,400 insured adults employed by the Commonwealth of Massachusetts who remained with one PCP during the 3-year study period from 1996-1999. The majority were women and white, ranging in age from 20 to 88 years, and had some college education. The participants completed questionnaires at the study's beginning and end, which included measures of primary care quality from the Primary Care Assessment Survey (PCAS). Four PCAS scales measured doctor-patient relationship quality (communication, interpersonal treatment, physician's knowledge of the patient, and patient trust), and four scales measured organizational features of care (financial access, organizational access, visit-based continuity, and integration of care).

There were significant declines in three of the four relationship scales: communication, interpersonal treatment, and trust. Improved physician's knowledge of the patient was not significant when adjustments were made for increased relationship duration. There was a significant decline in organizational access (patients' ability to reach their doctor's office by phone and to obtain timely appointments when sick), an increase in visit-based continuity (ability of patients to see their regular doctor for routine care and appointments when sick), and no significant changes in financial access and integration of care. Thus, patients felt they had better access to their own doctors, but the quality of the encounters was declining.

The declines in access to care and in three of the four indexes of physician-patient relationship quality are of concern, especially if they signify a trend, conclude the researchers. For example, the observed decline in interpersonal treatment could translate into a measurable decline in patients' attempts to adhere to their physicians' counseling about important lifestyle changes, such as smoking cessation and increased exercise.

Safran, D.G., Montgomery, J.A., Chang, H., and others. (2001, February). "Switching doctors: Predictors of voluntary disenrollment from a primary physician's practice." Journal of Family Practice 50(2), pp. 130-136.

This study showed that eight PCAS scales measuring primary care quality significantly predicted voluntary switching of doctors. One-fifth of the patients surveyed voluntarily left their PCP's practice during the study period. All eight scales independently predicted voluntary disenrollment, with the four relationship quality measures (communication, interpersonal treatment, physician's knowledge of the patient, and patient trust in the doctor) having somewhat large effects. A composite relationship quality factor most strongly predicted voluntary disenrollment (odds ratio, OR 1.6), and the two continuity scales (relationship duration and visit-based continuity) also significantly predicted disenrollment (OR 1.1). Organizational access and integration of care did not significantly predict disenrollment in the presence of these other variables.

These results suggest that although the patients put a high priority on being given timely and convenient access to their physician's office, the issue of who they are given access to and the quality of their connection with that clinician mattered more. Clearly, patients' trust in their physician, assessment of how well the doctor knows them, and the quality of communication and interpersonal treatment were the leading predictors of patients' loyalty to their PCP's practice.

These findings highlight the importance of the doctor-patient relationship in determining patients' loyalty to a physician's practice. The researchers suggest that in the race to the bottom line, medical practices and health plans cannot afford to ignore the fact that the essence of medical care involves the interaction of one human being with another.

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