Medical Care Research and Review

Twenty-one million Americans are limited in English proficiency (LEP), but little is known about the effect of medical interpreter services on health care quality. Asystematic literature review was conducted on the impact of interpreter services on quality of care. Five database searches yielded 2,640 citations and a final database of 36 articles, after applying exclusion criteria. Multiple studies document that quality of care is compromised when LEP patients need but do not get interpreters. LEP patients' quality of care is inferior, and more interpreter errors occur with untrained ad hoc interpreters. Inadequate interpreter services can have serious consequences for patients with mental disorders. Trained professional interpreters and bilingual health care providers positively affect LEP patients' satisfaction, quality of care, and outcomes. Evidence suggests that optimal communication, patient satisfaction, and outcomes and the fewest interpreter errors occur when LEP patients have access to trained professional interpreters or bilingual providers.

Patient-centered care (PCC) has been studied for several decades. Yet a clear definition of PCC is lacking, as is an understanding of how specific PCC processes relate to patient outcomes. We conducted a systematic review of the PCC literature to examine the evidence for PCC and outcomes. Three databases were searched for all years through September 2012. We retained 40 articles for the analysis. Results found mixed relationships between PCC and clinical outcomes, that is, some studies found significant relationships between specific elements of PCC and outcomes but others found no relationship. There was stronger evidence for positive influences of PCC on satisfaction and self-management. Future research should examine specific dimensions of PCC and how they relate to technical care quality, particularly some dimensions that have not been studied extensively. Future research also should identify moderating and mediating variables in the PPC–outcomes relationship.

Many Latinos have limited English proficiency and this may negatively affect their use of health care services. To examine this, the authors interviewed 465 Spanish-speaking Latinos and 259 English speakers of various ethnicities who presented to a public hospital emergency department with nonurgent medical problems to assess previous physician visits, sociodemographic characteristics, and level of English proficiency. The proportion of patients who reported no physician visit during the 3 months before study enrollment was not related to English proficiency. However, among the 414 patients who saw a physician at least once, Latinos with fair and poor English proficiency reported approximately 22 percent fewer physician visits (p = 0.020 and p = 0.015, respectively) than non-Latinos whose native language was English, even after adjusting for other determinants of physician visits. The magnitude of the association between limited English proficiency and number of physician visits was similar to that for having poor health, no health insurance, or no regular source of care.

Previous reviews of research on electronic health record (EHR) data quality have not focused on the needs of quality measurement. The authors reviewed empirical studies of EHR data quality, published from January 2004, with an emphasis on data attributes relevant to quality measurement. Many of the 35 studies reviewed examined multiple aspects of data quality. Sixty-six percent evaluated data accuracy, 57% data completeness, and 23% data comparability. The diversity in data element, study setting, population, health condition, and EHR system studied within this body of literature made drawing specific conclusions regarding EHR data quality challenging. Future research should focus on the quality of data from specific EHR components and important data attributes for quality measurement such as granularity, timeliness, and comparability. Finally, factors associated with poor or variability in data quality need to be better understood and effective interventions developed.

The authors examined health care coverage for Veterans' Health Administration (VHA) enrollees and how their reliance on VHA care varies by coverage, using the largest and most detailed survey of veterans using VHA services ever conducted. The results showed that a majority of veterans who use VHA services have alternative health care coverage and that most of them use both VHA and non-VHA health care. The findings have important implications for quality of care and coordination of care.

The authors developed and empirically tested a model reflecting a system of interrelations among patient loyalty, trust, and satisfaction as they are related to patients' intentions to stay with a primary care physician (PCP) and recommend the doctor to other people. They used a structural equation modeling approach. The fit statistics indicate a well-fitting model: root mean square error of approximation = .022, goodness-of-fit index = .99, adjusted goodness-of-fit index = .96, and comparative fit index = 1.00. The authors found that patient trust and good interpersonal relationships with the PCP are major predictors of patient satisfaction and loyalty to the physician. Patients need to trust the PCP to be satisfied and loyal to the physician. The authors also found that patient trust, satisfaction, and loyalty are strong and significant predictors of patients' intentions to stay with the doctor and to recommend the PCP to others.

Patient involvement in decisions is central to patient-centered care. Yet many important decisions must be made in complex, ambiguous clinical situations in which all possible options cannot be known, evidence is inadequate to inform patients’ preferences fully, and/or patients are unclear about their desired level of involvement. In these situations, preferences are shaped by affect, framing, and “collaborative cognition” among clinicians, patients, and their families; thus, decisions are often relational, dynamic, iterative, provisional, and/or conditional. Clinicians can help patients achieve greater autonomy by engaging both intuitive and deliberative decision-making processes (“whole mind”) and involving others in exploring, clarifying, and co-constructing patients’ preferences (“shared mind”). Clinical and interpersonal relationships can promote effective decision making through developing a shared attentional focus, tailoring information, and identifying conditions under which provisional preferences might change. Information technology and health systems offer untapped potential to deepen the relationships and conversations within which decisions are made.

The performance of medical groups is receiving increased attention. Relatively little conceptual or empirical work exists that examines the various dimensions of medical group performance. Using a national database of 693 medical groups, this article develops a scorecard approach to assessing group performance and presents a theory-driven framework for differentiating between high-performing versus low-performingmedical groups. The clinical quality of care, financial performance, and organizational learning capability of medical groups are assessed in relation to environmental forces, resource acquisition and resource deployment factors, and a quality-centered culture. Findings support the utility of the performance scorecard approach and identification of a number of key factors differentiating high-performing from low-performing groups including, in particular, the importance of a quality-centered culture and the requirement of outside reporting from third party organizations. The findings hold a number of important implications for policy and practice, and the framework presented provides a foundation for future research.

Prior research documents differences in patient-reported experiences by patient characteristics. Using nine measures of patient experience from 1,203,229 patients discharged in 2006-2007 from 2,684 acute and critical access hospitals, the authors find that adjusted hospital scores measure distinctions in quality for the average patient with high reliability. The authors also find that hospital “ranks” (the relative scores of hospitals for patients of a given type) vary substantially by patient health status and race/ ethnicity/language, and moderately by patient education and age ( p < .05 for almost all measures). Quality improvement efforts should examine hospital performance with both sicker and healthier patients, because many hospitals that do well with one group (relative to other hospitals) may not do well with another. The experiences of American Indians/Alaska Natives should also receive particular attention. As HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) data accumulate, reports that drill down to hospital performance for patient subtypes (especially by health status) may be valuable.

Pay for performance (P4P) has become a popular approach to performance improvement in health care. Most of the P4P literature has focused on the United States and there is limited insight in the characteristics of major programs initiated in other countries. This article systematically describes and reviews P4P programs outside the United States. Our literature search identified 13 programs initiated in 9 countries. Although the programs share many similarities, they differ in several important respects, also when compared with the typical P4P program in the United States. In addition, there are clearly possibilities to increase incentive strength and minimize incentives for undesired behavior. In part, observed heterogeneity will be a consequence of contextual differences, but design choices often also seem to be made arbitrarily. In designing their programs, purchasers are hampered by limited knowledge of the influence of specific design choices and effective strategies to mitigate undesired behavior.