International Journal of Health Care Quality Assurance Interdisciplinary HIV care – patient perceptions Brandon Vachirasudlekha Agnes Cha Leonard Berkowitz Bupendra Shah
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Article information: To cite this document: Brandon Vachirasudlekha Agnes Cha Leonard Berkowitz Bupendra Shah , (2014),"Interdisciplinary HIV care – patient perceptions", International Journal of Health Care Quality Assurance, Vol. 27 Iss 5 pp. 405 - 413 Permanent link to this document: http://dx.doi.org/10.1108/IJHCQA-01-2013-0007 Downloaded on: 31 January 2016, At: 23:05 (PT) References: this document contains references to 17 other documents. To copy this document: [email protected] The fulltext of this document has been downloaded 196 times since 2014*
Users who downloaded this article also downloaded: Pierre Batailler, Patrice François, Van Mô Dang, Elodie Sellier, Jean-Philippe Vittoz, Arnaud Seigneurin, Jose Labarere, (2014),"Trends in patient perception of hospital care quality", International Journal of Health Care Quality Assurance, Vol. 27 Iss 5 pp. 414-426 http://dx.doi.org/10.1108/IJHCQA-02-2013-0014 Susanne Maria Kristina Gustavsson, (2014),"Improvements in neonatal care; using experience-based co-design", International Journal of Health Care Quality Assurance, Vol. 27 Iss 5 pp. 427-438 http:// dx.doi.org/10.1108/IJHCQA-02-2013-0016
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Interdisciplinary HIV care – patient perceptions
Interdisciplinary HIV care
Brandon Vachirasudlekha Department of Pharmacy and Health Outcomes, Touro College of Pharmacy, New York, New York, USA Downloaded by CHALMERS UNIVERSITY OF TECHNOLOGY At 23:05 31 January 2016 (PT)
Agnes Cha Division of Pharmacy Practice, Long Island University Arnold & Marie Schwartz College of Pharmacy, Brooklyn, New York, USA
405 Received 20 January 2013 Revised 21 June 2013 Accepted 8 November 2013
Leonard Berkowitz Infectious Disease, The Brooklyn Hospital Center, Brooklyn, New York, USA, and
Bupendra Shah Division of Pharmaceutical Sciences, Long Island University Arnold & Marie Schwartz College of Pharmacy, Brooklyn, New York, USA Abstract Purpose – The purpose of this paper is to gauge patients’ service perceptions of an interdisciplinary human immunodeficiency virus (HIV) clinic, which uses infectious disease physicians, medical residents, clinical pharmacists, nurses, social workers and students in HIV primary-care delivery. Design/methodology/approach – Adult patients coming to the HIV clinic for a return visit to the interdisciplinary team completed a questionnaire based on a previously validated HIV-specific patient satisfaction study (n ¼ 104). Fourteen modified items assessing overall care-quality and ten original items assessing interdisciplinary services were included. Findings – Respondents reported high satisfaction levels with the clinic’s services. The mean score for the care-quality items was 3.79 ( possible 4). The interdisciplinary care items mean score was 3.69 ( possible 4). For non-physician disciplines, respondents indicated that nurses, pharmacists and social workers played important roles in their clinic care. Research limitations/implications – Bias associated with patient selection and survey methods limit the generalizability. The study has implications for measuring interdisciplinary care provided at HIV clinics. Originality/value – This HIV outpatient care interdisciplinary model is not widely in use. Results are important for those involved in HIV service development and improvement. Findings support integrating non-physician providers into routine outpatient HIV medical visits. Keywords Patient satisfaction, Quality assurance, Clinical pharmacy service, Health care surveys, HIV infections/drug therapy, Interdisciplinary health team Paper type Research paper
Introduction Healthcare services for people living with the human immunodeficiency virus (HIV) face numerous challenges related to HIV care’s growing complexity. These include several new antiretroviral therapies with distinctive dosing and administration requirements, prophylactic and treatment regimens for opportunistic infections (Njilele et al., 2012) and managing HIV in chronic comorbidity setting. Further complicating medical management are each patient’s unique social and psychological needs The authors thank all the staff who helped with this survey. Special thanks to Abigail Baim-Lance, PhD, researcher at the New York State Department of Health AIDS Institute.
International Journal of Health Care Quality Assurance Vol. 27 No. 5, 2014 pp. 405-413 r Emerald Group Publishing Limited 0952-6862 DOI 10.1108/IJHCQA-01-2013-0007
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(Green and Smith, 2004). Ultimately, in a patient-centerd healthcare model, satisfaction is one deciding factor about whether these challenges are successfully overcome by the provider. Patient satisfaction is believed to be associated with adherence to medical care, service use and improved clinical outcomes (Sullivan et al., 2000). Furthermore, ensuring patient approval is an essential for fostering patient-provider relationships and keeping patients engaged in their health (Sixma et al., 1998). Higher overall patient satisfaction and satisfaction with discharge planning are associated with lower hospital readmission rates for myocardial infarction, heart failure and pneumonia (Boulding et al., 2011). Dissatisfied patients are less likely to adhere to treatment recommendations (Roberts, 2002), which can result in worse outcomes for the individual and also for the healthcare system. Measuring patient satisfaction with healthcare services is recognized in the literature as a priority when aiming to deliver quality care and to maintain viability in the pay-for-performance and consumerism era (Riskind et al., 2011; Fottler et al., 1997). High patient satisfaction and quality outcome is a key competitive edge in healthcare delivery (Urden, 2002). Concerning care for persons living with HIV, healthcare staff need to meet their consumers’ approval and providers must capture patient attitudes to deliver excellent service from the patients’ perspective. Based on consumer satisfaction and business research, Sixma et al. (1998) developed measured care quality through the patients’ eyes by incorporating their perspective when developing satisfaction measurements. Healthcare-quality indicators can be generic, but a measure should also include items that are disease or patient specific. The resultant “quality of care through the patient’s eyes” (QUOTE) instruments were developed for several populations, including rheumatic patients, disabled persons, frail elderly persons, etc. A Netherlands research group built upon this framework and developed QUOTE-HIV, a questionnaire derived from the patients’ perspective to judge HIV care quality (Hekkink et al., 2003). Focus group discussions with patients living with HIV were the means by which the authors identified HIV-specific items for inclusion in the questionnaire. These aspects, which HIV patients identified as important when defining good quality care, were turned into 14 survey items and combined with 13 generic questions to form QUOTE-HIV. The questionnaire’s internal consistency was acceptable (Cronbach’s a 40.80). In the USA, Moore et al. (2010) used a modified QUOTE-HIV and conducted focus groups with HIV-positive African-Americans to assess the questionnaire’s usefulness in identifying patients’ healthcare-quality perceptions. The questionnaire was comprehensive, with questions addressing all patient concerns identified by the focus groups. Their work suggests that QUOTE-HIV is a suitable instrument for evaluating HIV care quality in the patient population they studied. Additionally, the authors reported 15 survey components that respondents considered important when measuring satisfaction: (1)
explaining medications using easy-to-understand language;
(2)
medication side effects;
(3)
providing information about how to take medications;
(4)
including the patient in treatment decisions;
(5)
sharing laboratory test results;
(6)
safeguarding patient privacy;
(7)
clarifying treatment advantages and disadvantages;
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(8)
having HIV expertise;
(9)
taking the patient seriously;
(10)
working efficiently;
(11)
allowing patient access to his/her medical records;
(12)
spending sufficient time with the patient;
(13)
using preventive measures to keep the patient healthy;
(14)
ensuring substitute providers; and
(15)
being easily accessible.
If patient satisfaction is to be a priority then HIV care providers may wish to strive toward prioritizing performance in these key areas based on the previous research. Interdisciplinary care in HIV and study purpose There is an increased emphasis on using an interdisciplinary approach to patient care (Panel on Antiretroviral Guidelines for Adults and Adolescents, 2013). Interdisciplinary care refers to collaboratively managing patient problems by providers from different disciplines working as a distinct unit. The literature proposes that interdisciplinary teams, by definition, should analyze, synthesize and harmonize links between disciplines into a coordinated and coherent whole (Choi and Pak, 2006). Spurred by the Patient Protection and Affordable Care Act and its medical home model concept, it is believed that interdisciplinary care will be the patient care model in the USA. Research on interdisciplinary care and how patients view care quality associated with interdisciplinary care has been limited. Thus, our purpose was to: assess overall patient satisfaction with care delivered by an interdisciplinary HIV clinic; and identify patients value the clinic’s interdisciplinary services. Methods Setting and participants The setting for this study is an urban community hospital’s outpatient clinic where interdisciplinary care is provided to HIV patients. Clinic staff aspire to provide more comprehensive care than traditional primary care staff provide by adding non-physician healthcare provider expertise, including on-site clinical pharmacists. Additionally, as a teaching hospital, the clinic is an opportunity for medical and pharmacy residents and students to participate. During a routine visit, nursing staff or medical assistants record the patients’ vital signs before they are seen by a medical resident who may be assisted by a pharmacist. The physical examination is performed, new complaints are assessed, medical histories are taken or confirmed and medication reconciliation and adherence are reviewed. Pharmacists assist in selecting optimal pharmacologic therapies, identifying contraindications and drug interactions and recognizing medications’ adverse effects. The team forms a preliminary plan to address patient needs and concerns. The patient’s designated primary care physician and the clinical pharmacist subsequently join the appointment. The findings and preliminary plan are presented in the patient’s presence. The attending physician shares his or her assessment and each medical problem is discussed with the patient with all team members present. Any additional input by the patient or providers is taken into consideration, and a final care-plan is decided upon by the team.
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Pharmacists often provide medication-adherence counseling and education on lifestyle modifications for comorbid conditions. Patients are referred to on-site social workers whenever circumstances necessitate their services. Participants in the study were patients presenting to the interdisciplinary HIV outpatient clinic for routine follow-up visits between January and April of 2012. To be eligible, participants had to be at least 18 years and regularly seen by the interdisciplinary team. The study excluded first-time visitors to the clinic as we wanted to draw on all the participant’s experiences in the interdisciplinary clinic, rather than focus on their first impressions at an initial appointment. Survey A questionnaire with 24 questions was distributed to eligible patients while they waited for their appointment with the interdisciplinary care team. The survey was based on Hekkink et al. (2003) and Moore et al. (2010) and included 14 from 15 items identified by HIV-positive African-American focus groups in the Moore et al. (2010) study, as most important when measuring satisfaction with care. The one item excluded (specialist should have his/her replacement organized) was considered not applicable to the study context and setting. These 14 items formed the overall quality of care scale. Patients were also asked to respond to ten original items intended to measure the clinic’s individual interdisciplinary components and overall interdisciplinary HIV care perceptions. These ten new items asked whether patients agreed that pharmacists, nurses and social workers, respectively, played an important role in their care at the clinic. Patients were also asked whether they were comfortable having their health discussed in a large group, whether they received better care through a clinic team approach and if they would recommend this clinic to other people living with HIV who see a single provider. These items were reviewed for their face and content validity prior to their inclusion in the questionnaire. Questionnaires were primarily self-administered, though reading and language assistance was available upon request. Survey items were presented as multiple-choice items scored on a four-point forced choice Likert scale (1 – Never, 2 – Rarely, 3 – Sometimes, 4 – Always) with higher scores representing greater patient satisfaction. The final questionnaire scored as Flesch-Kincaid US Grade Level 6.9 using the readability tools available in Microsofts Word 2007. Responses were confidential and data collected from the forms were entered into a password-protected electronic document. Basic demographic information was requested from the patient but answering was optional. No information that uniquely identified patients was collected or disclosed and no clinical information about the respondent was tied to questionnaires. Data collection and entry was approved by the hospital’s Institution Review Board prior to its implementation. Descriptive statistics for all survey items were analyzed using IBMs SPSS Statistics version 19.0. Item factorability was examined and items were recoded to omit responses where no answer was selected. Summated scale scores and itemized mean scores were calculated for each scale. The care quality total score ranged from 1 to 56 (14 items, four-point scale anchor), whereas total score for the interdisciplinary care scale ranged from 1to 40 (ten items, four-point scale anchor). Results One hundred and four completed questionnaires were received (Table I). All respondents completed the questionnaire’s quality of care segment, while 100
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Sex Female Male No response Age 18-25 26-35 36-45 46-55 56-65 465 No response Race Black or African-American Caribbean American Hispanic or Latino White or Caucasian Other No response Have previously been treated at another HIV clinic Yes No No response
43 (41.3%) 40 (38.5%) 21 (20.2%) 2 9 11 40 29 1 12
(1.9%) (8.7%) (10.6%) (38.5%) (27.9%) (1.0%) (11.5%)
64 5 16 3 2 14
(61.5%) (4.8%) (15.4%) (2.8%) (1.9%) (13.5%)
33 (31.7%) 54 (51.9%) 17 (16.3%)
completed the interdisciplinary care segment. Forty-three females and 40 males were identified from those answering the gender question. The original QUOTE-HIV study had 55 respondents, so we felt a 100 minimum was adequate. Most patients were between 46 and 65 years, black or African-American and over half said the interdisciplinary clinic was the only clinic in which they have received HIV care. The scales’ internal consistency were measured using Cronbach’s a, which was 40.80 for the quality of care (Cronbach’s a ¼ 0.96) and interdisciplinary care (Cronbach’s a ¼ 0.89). The summated scale score (maximum 56) for the care quality scale was 53.08 (standard deviation (SD) ¼ 6.31), whereas the care quality scale itemized mean score was 3.79 indicating that participants were highly satisfied overall. Table II summarizes the mean satisfaction level for the individual care-quality items, which all scored between 3 and 4. Among the care-quality indicators, respondents reported that the interdisciplinary team consistently explained treatment consequences, worked efficiently, provided lab results, prevented future health problems, explained medications, included the patient in treatment decisions and protected their privacy. The summated scale score (maximum 40) for the interdisciplinary care scale was 36.85 (SD ¼ 4.64) and the itemized mean score was 3.69. Table III describes the mean satisfaction level for each interdisciplinary care item. Regarding the non-physician disciplines, respondents indicated that nurses, pharmacists and social workers played important roles in their care at the clinic, with mean satisfaction scores of 3.86 (SD ¼ 0.45), 3.74 (SD ¼ 0.60) and 3.71 (SD ¼ 0.68), respectively. When respondents were asked if they were comfortable having their health discussed in a large group during their visit, the mean satisfaction score was 3.1 (SD ¼ 1.07). Patients indicated that they received better care overall with the clinic’s team approach (3.73, SD ¼ 0.58) and that they preferred this
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Table I. Demographics
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Table II. Care quality items
Table III. Interdisciplinary care items
The team caring for me [y] Explains my treatment’s advantages and disadvantages Works efficiently Gives me the lab tests results Helps prevent future health problems Tells me the possible medication side effects Tells me how I should take my HIV medications Explains medications using language I can understand Takes me seriously Takes enough time to talk to me Is available when I need them (by phone or in person) Includes me in decision making about the treatment that I receive Would allow me to look at my medical chart if I wanted to Protects my privacy (HIV status) There are team members who are HIV experts
3.8770.47 3.7970.55 3.8670.44 3.8270.52 3.6270.79 3.8270.68 3.8070.53 3.8370.51 3.8570.52 3.6670.71 3.8570.48 3.7170.67 3.9170.39 3.7570.57
Notes: 1 ¼ Never, 2 ¼ Rarely, 3 ¼ Sometimes, 4 ¼ Always
The doctors have helped me to better understand my disease The pharmacy team plays an important role in my care at this clinic Pharmacists at this clinic help me better understand how to take medications and what to expect when taking them A pharmacy team at this clinic has helped me to make sure I do not miss medications The nursing team plays an important role in my care at this clinic The social work team plays an important role in my care at this clinic I feel comfortable having my health discussed in a large group during my medical visit I believe I receive overall better care because of the team approach at this clinic I prefer this clinic over others because doctors, pharmacists, nurses and social workers work together as one team I would recommend this clinic to other people living with HIV who only see a single doctor
3.8270.52 3.7470.60 3.6470.77 3.6270.80 3.8670.45 3.7170.68 3.1071.07 3.7370.58 3.7970.55 3.8570.45
Notes: 1 ¼ Strongly disagree, 2 ¼ Somewhat disagree, 3 ¼ Somewhat agree, 4 ¼ Strongly agree
particular clinic owing to the interaction between physicians, pharmacists, nurses and social workers (3.79, SD ¼ 0.55). Most patients felt strongly about recommending this clinic to other HIV patients (3.85, SD ¼ 0.45). Discussion To our knowledge, this is the first study measuring HIV interdisciplinary care quality from the patient’s perspective. We used a modified, previously validated QUOTE-HIV questionnaire to assess users’ satisfaction with the clinic’s services. Both the survey’s overall satisfaction and interdisciplinary care components met face validity and passed the reliability test (Cronbach’s a40.80). Overall satisfaction scores for this particular interdisciplinary HIV clinic were high and represent a positive perception among patients. Choi and Pak (2007) examined several promoters and barriers for successful multidisciplinary teamwork. They noted that multidisciplinary teamwork is not always successful, nor is it always called for. However, multidisciplinary teamwork is successful when cultivated by: carefully selecting team members and leaders, personal commitment, physical proximity, institutional support, a common goal and shared
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vision, role clarity and communication. The clinic we observed demonstrates several characteristics that contribute toward operating a clinic that provides a positive patient experience. It is striking that our patients recognized different individual disciplines, which comprise the interdisciplinary care team at the study center. This information may support further specially trained, non-physician healthcare personnel integration into routine outpatient care for people living with HIV. Pharmacists play an enhanced role in this clinic’s routine operations because either HIV specialty trained or post-graduate resident staff meet each patient as part of the interdisciplinary team on most visits. Pharmacist interventions improve adherence rates to medications (Murray et al., 2007) and respondents to the study questionnaire indicated that pharmacists helped them to understand their medications and improve adherence. Patients also recognized that nurses and social workers play an important care-role. While our results are encouraging, there are limitations. Surveys designed using the QUOTE method include importance and quality ratings (Sixma et al., 1998). Our questionnaire focussed solely on measuring quality. We extrapolated from the previous literature on African-Americans living with HIV by Moore et al. (2010) to establish which items patients deemed most important and included these items. Since we did not capture importance ratings, our ability to prioritize quality improvement initiatives may be limited (Sixma et al., 1998). There may have been significant positive bias in our quality ratings owing to question structure and responses as a “4” represented highest satisfaction for all questions without exception. This was consistent with the QUOTE-HIV study design and we decided not to deviate from this form. This structure, however, may have enabled respondents to select identical responses to most or all questions without carefully evaluating each survey item and yield a highly satisfactory overall score. Respondents experiencing unsatisfactory clinic experiences with in the past may have already withdrawn from care. Moreover, our survey design did not provide respondents with free space in which to provide commentary or add qualifiers to any response, which may have added to the discussion, and results from this study may not translate to other settings owing to individual variability in personnel and clinic settings. Conclusion Those wishing to implement and enhance outpatient services for people living with HIV must continually seek opportunities to keep patients engaged and adherent to medical care. Suboptimal retention increases mortality in HIV infected patients (Giordano et al., 2007). According to Roberts (2002), interviews with HIV-positive patients revealed that high-quality patient-provider relationships support patient adherence to care, while poor relationships can hinder. Guidelines for HIV primary care from the Infectious Diseases Society of America recognize high-quality patientprovider relationships as an exceptionally important factor in a patient’s engagement and recommends identifying a primary provider for each patient while using a multidisciplinary model (Aberg et al., 2009). However, patients only somewhat agreed to feeling comfortable having their health discussed in a large group during medical visits. This may identify a hindrance when practicing in teaching hospitals. Patients were highly satisfied with their experiences at the clinic and survey’s results support an interdisciplinary model as an acceptable approach to delivering primary care to this population.
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Urden, L. (2002), “Patient satisfaction measurement: current issues and implications”, Lippincott’s Case Management: Managing the Process of Patient Care, Vol. 7 No. 5, pp. 194-200.
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This article has been cited by:
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1. Rebecca Cope, Leonard Berkowitz, Rebecca Arcebido, Jun-Yen Yeh, Nathan Trustman, Agnes Cha. 2015. Evaluating the Effects of an Interdisciplinary Practice Model with Pharmacist Collaboration on HIV Patient Co-Morbidities. AIDS Patient Care and STDs 29, 445-453. [CrossRef]
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Article information: To cite this document: Brandon Vachirasudlekha Agnes Cha Leonard Berkowitz Bupendra Shah , (2014),"Interdisciplinary HIV care – patient perceptions", International Journal of Health Care Quality Assurance, Vol. 27 Iss 5 pp. 405 - 413 Permanent link to this document: http://dx.doi.org/10.1108/IJHCQA-01-2013-0007 Downloaded on: 31 January 2016, At: 23:05 (PT) References: this document contains references to 17 other documents. To copy this document: [email protected] The fulltext of this document has been downloaded 196 times since 2014*
Users who downloaded this article also downloaded: Pierre Batailler, Patrice François, Van Mô Dang, Elodie Sellier, Jean-Philippe Vittoz, Arnaud Seigneurin, Jose Labarere, (2014),"Trends in patient perception of hospital care quality", International Journal of Health Care Quality Assurance, Vol. 27 Iss 5 pp. 414-426 http://dx.doi.org/10.1108/IJHCQA-02-2013-0014 Susanne Maria Kristina Gustavsson, (2014),"Improvements in neonatal care; using experience-based co-design", International Journal of Health Care Quality Assurance, Vol. 27 Iss 5 pp. 427-438 http:// dx.doi.org/10.1108/IJHCQA-02-2013-0016
Access to this document was granted through an Emerald subscription provided by emerald-srm:115318 []
For Authors If you would like to write for this, or any other Emerald publication, then please use our Emerald for Authors service information about how to choose which publication to write for and submission guidelines are available for all. Please visit www.emeraldinsight.com/authors for more information.
About Emerald www.emeraldinsight.com Emerald is a global publisher linking research and practice to the benefit of society. The company manages a portfolio of more than 290 journals and over 2,350 books and book series volumes, as well as providing an extensive range of online products and additional customer resources and services. Emerald is both COUNTER 4 and TRANSFER compliant. The organization is a partner of the Committee on Publication Ethics (COPE) and also works with Portico and the LOCKSS initiative for digital archive preservation. *Related content and download information correct at time of download.
The current issue and full text archive of this journal is available at www.emeraldinsight.com/0952-6862.htm
Interdisciplinary HIV care – patient perceptions
Interdisciplinary HIV care
Brandon Vachirasudlekha Department of Pharmacy and Health Outcomes, Touro College of Pharmacy, New York, New York, USA Downloaded by CHALMERS UNIVERSITY OF TECHNOLOGY At 23:05 31 January 2016 (PT)
Agnes Cha Division of Pharmacy Practice, Long Island University Arnold & Marie Schwartz College of Pharmacy, Brooklyn, New York, USA
405 Received 20 January 2013 Revised 21 June 2013 Accepted 8 November 2013
Leonard Berkowitz Infectious Disease, The Brooklyn Hospital Center, Brooklyn, New York, USA, and
Bupendra Shah Division of Pharmaceutical Sciences, Long Island University Arnold & Marie Schwartz College of Pharmacy, Brooklyn, New York, USA Abstract Purpose – The purpose of this paper is to gauge patients’ service perceptions of an interdisciplinary human immunodeficiency virus (HIV) clinic, which uses infectious disease physicians, medical residents, clinical pharmacists, nurses, social workers and students in HIV primary-care delivery. Design/methodology/approach – Adult patients coming to the HIV clinic for a return visit to the interdisciplinary team completed a questionnaire based on a previously validated HIV-specific patient satisfaction study (n ¼ 104). Fourteen modified items assessing overall care-quality and ten original items assessing interdisciplinary services were included. Findings – Respondents reported high satisfaction levels with the clinic’s services. The mean score for the care-quality items was 3.79 ( possible 4). The interdisciplinary care items mean score was 3.69 ( possible 4). For non-physician disciplines, respondents indicated that nurses, pharmacists and social workers played important roles in their clinic care. Research limitations/implications – Bias associated with patient selection and survey methods limit the generalizability. The study has implications for measuring interdisciplinary care provided at HIV clinics. Originality/value – This HIV outpatient care interdisciplinary model is not widely in use. Results are important for those involved in HIV service development and improvement. Findings support integrating non-physician providers into routine outpatient HIV medical visits. Keywords Patient satisfaction, Quality assurance, Clinical pharmacy service, Health care surveys, HIV infections/drug therapy, Interdisciplinary health team Paper type Research paper
Introduction Healthcare services for people living with the human immunodeficiency virus (HIV) face numerous challenges related to HIV care’s growing complexity. These include several new antiretroviral therapies with distinctive dosing and administration requirements, prophylactic and treatment regimens for opportunistic infections (Njilele et al., 2012) and managing HIV in chronic comorbidity setting. Further complicating medical management are each patient’s unique social and psychological needs The authors thank all the staff who helped with this survey. Special thanks to Abigail Baim-Lance, PhD, researcher at the New York State Department of Health AIDS Institute.
International Journal of Health Care Quality Assurance Vol. 27 No. 5, 2014 pp. 405-413 r Emerald Group Publishing Limited 0952-6862 DOI 10.1108/IJHCQA-01-2013-0007
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(Green and Smith, 2004). Ultimately, in a patient-centerd healthcare model, satisfaction is one deciding factor about whether these challenges are successfully overcome by the provider. Patient satisfaction is believed to be associated with adherence to medical care, service use and improved clinical outcomes (Sullivan et al., 2000). Furthermore, ensuring patient approval is an essential for fostering patient-provider relationships and keeping patients engaged in their health (Sixma et al., 1998). Higher overall patient satisfaction and satisfaction with discharge planning are associated with lower hospital readmission rates for myocardial infarction, heart failure and pneumonia (Boulding et al., 2011). Dissatisfied patients are less likely to adhere to treatment recommendations (Roberts, 2002), which can result in worse outcomes for the individual and also for the healthcare system. Measuring patient satisfaction with healthcare services is recognized in the literature as a priority when aiming to deliver quality care and to maintain viability in the pay-for-performance and consumerism era (Riskind et al., 2011; Fottler et al., 1997). High patient satisfaction and quality outcome is a key competitive edge in healthcare delivery (Urden, 2002). Concerning care for persons living with HIV, healthcare staff need to meet their consumers’ approval and providers must capture patient attitudes to deliver excellent service from the patients’ perspective. Based on consumer satisfaction and business research, Sixma et al. (1998) developed measured care quality through the patients’ eyes by incorporating their perspective when developing satisfaction measurements. Healthcare-quality indicators can be generic, but a measure should also include items that are disease or patient specific. The resultant “quality of care through the patient’s eyes” (QUOTE) instruments were developed for several populations, including rheumatic patients, disabled persons, frail elderly persons, etc. A Netherlands research group built upon this framework and developed QUOTE-HIV, a questionnaire derived from the patients’ perspective to judge HIV care quality (Hekkink et al., 2003). Focus group discussions with patients living with HIV were the means by which the authors identified HIV-specific items for inclusion in the questionnaire. These aspects, which HIV patients identified as important when defining good quality care, were turned into 14 survey items and combined with 13 generic questions to form QUOTE-HIV. The questionnaire’s internal consistency was acceptable (Cronbach’s a 40.80). In the USA, Moore et al. (2010) used a modified QUOTE-HIV and conducted focus groups with HIV-positive African-Americans to assess the questionnaire’s usefulness in identifying patients’ healthcare-quality perceptions. The questionnaire was comprehensive, with questions addressing all patient concerns identified by the focus groups. Their work suggests that QUOTE-HIV is a suitable instrument for evaluating HIV care quality in the patient population they studied. Additionally, the authors reported 15 survey components that respondents considered important when measuring satisfaction: (1)
explaining medications using easy-to-understand language;
(2)
medication side effects;
(3)
providing information about how to take medications;
(4)
including the patient in treatment decisions;
(5)
sharing laboratory test results;
(6)
safeguarding patient privacy;
(7)
clarifying treatment advantages and disadvantages;
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(8)
having HIV expertise;
(9)
taking the patient seriously;
(10)
working efficiently;
(11)
allowing patient access to his/her medical records;
(12)
spending sufficient time with the patient;
(13)
using preventive measures to keep the patient healthy;
(14)
ensuring substitute providers; and
(15)
being easily accessible.
If patient satisfaction is to be a priority then HIV care providers may wish to strive toward prioritizing performance in these key areas based on the previous research. Interdisciplinary care in HIV and study purpose There is an increased emphasis on using an interdisciplinary approach to patient care (Panel on Antiretroviral Guidelines for Adults and Adolescents, 2013). Interdisciplinary care refers to collaboratively managing patient problems by providers from different disciplines working as a distinct unit. The literature proposes that interdisciplinary teams, by definition, should analyze, synthesize and harmonize links between disciplines into a coordinated and coherent whole (Choi and Pak, 2006). Spurred by the Patient Protection and Affordable Care Act and its medical home model concept, it is believed that interdisciplinary care will be the patient care model in the USA. Research on interdisciplinary care and how patients view care quality associated with interdisciplinary care has been limited. Thus, our purpose was to: assess overall patient satisfaction with care delivered by an interdisciplinary HIV clinic; and identify patients value the clinic’s interdisciplinary services. Methods Setting and participants The setting for this study is an urban community hospital’s outpatient clinic where interdisciplinary care is provided to HIV patients. Clinic staff aspire to provide more comprehensive care than traditional primary care staff provide by adding non-physician healthcare provider expertise, including on-site clinical pharmacists. Additionally, as a teaching hospital, the clinic is an opportunity for medical and pharmacy residents and students to participate. During a routine visit, nursing staff or medical assistants record the patients’ vital signs before they are seen by a medical resident who may be assisted by a pharmacist. The physical examination is performed, new complaints are assessed, medical histories are taken or confirmed and medication reconciliation and adherence are reviewed. Pharmacists assist in selecting optimal pharmacologic therapies, identifying contraindications and drug interactions and recognizing medications’ adverse effects. The team forms a preliminary plan to address patient needs and concerns. The patient’s designated primary care physician and the clinical pharmacist subsequently join the appointment. The findings and preliminary plan are presented in the patient’s presence. The attending physician shares his or her assessment and each medical problem is discussed with the patient with all team members present. Any additional input by the patient or providers is taken into consideration, and a final care-plan is decided upon by the team.
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Pharmacists often provide medication-adherence counseling and education on lifestyle modifications for comorbid conditions. Patients are referred to on-site social workers whenever circumstances necessitate their services. Participants in the study were patients presenting to the interdisciplinary HIV outpatient clinic for routine follow-up visits between January and April of 2012. To be eligible, participants had to be at least 18 years and regularly seen by the interdisciplinary team. The study excluded first-time visitors to the clinic as we wanted to draw on all the participant’s experiences in the interdisciplinary clinic, rather than focus on their first impressions at an initial appointment. Survey A questionnaire with 24 questions was distributed to eligible patients while they waited for their appointment with the interdisciplinary care team. The survey was based on Hekkink et al. (2003) and Moore et al. (2010) and included 14 from 15 items identified by HIV-positive African-American focus groups in the Moore et al. (2010) study, as most important when measuring satisfaction with care. The one item excluded (specialist should have his/her replacement organized) was considered not applicable to the study context and setting. These 14 items formed the overall quality of care scale. Patients were also asked to respond to ten original items intended to measure the clinic’s individual interdisciplinary components and overall interdisciplinary HIV care perceptions. These ten new items asked whether patients agreed that pharmacists, nurses and social workers, respectively, played an important role in their care at the clinic. Patients were also asked whether they were comfortable having their health discussed in a large group, whether they received better care through a clinic team approach and if they would recommend this clinic to other people living with HIV who see a single provider. These items were reviewed for their face and content validity prior to their inclusion in the questionnaire. Questionnaires were primarily self-administered, though reading and language assistance was available upon request. Survey items were presented as multiple-choice items scored on a four-point forced choice Likert scale (1 – Never, 2 – Rarely, 3 – Sometimes, 4 – Always) with higher scores representing greater patient satisfaction. The final questionnaire scored as Flesch-Kincaid US Grade Level 6.9 using the readability tools available in Microsofts Word 2007. Responses were confidential and data collected from the forms were entered into a password-protected electronic document. Basic demographic information was requested from the patient but answering was optional. No information that uniquely identified patients was collected or disclosed and no clinical information about the respondent was tied to questionnaires. Data collection and entry was approved by the hospital’s Institution Review Board prior to its implementation. Descriptive statistics for all survey items were analyzed using IBMs SPSS Statistics version 19.0. Item factorability was examined and items were recoded to omit responses where no answer was selected. Summated scale scores and itemized mean scores were calculated for each scale. The care quality total score ranged from 1 to 56 (14 items, four-point scale anchor), whereas total score for the interdisciplinary care scale ranged from 1to 40 (ten items, four-point scale anchor). Results One hundred and four completed questionnaires were received (Table I). All respondents completed the questionnaire’s quality of care segment, while 100
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Sex Female Male No response Age 18-25 26-35 36-45 46-55 56-65 465 No response Race Black or African-American Caribbean American Hispanic or Latino White or Caucasian Other No response Have previously been treated at another HIV clinic Yes No No response
43 (41.3%) 40 (38.5%) 21 (20.2%) 2 9 11 40 29 1 12
(1.9%) (8.7%) (10.6%) (38.5%) (27.9%) (1.0%) (11.5%)
64 5 16 3 2 14
(61.5%) (4.8%) (15.4%) (2.8%) (1.9%) (13.5%)
33 (31.7%) 54 (51.9%) 17 (16.3%)
completed the interdisciplinary care segment. Forty-three females and 40 males were identified from those answering the gender question. The original QUOTE-HIV study had 55 respondents, so we felt a 100 minimum was adequate. Most patients were between 46 and 65 years, black or African-American and over half said the interdisciplinary clinic was the only clinic in which they have received HIV care. The scales’ internal consistency were measured using Cronbach’s a, which was 40.80 for the quality of care (Cronbach’s a ¼ 0.96) and interdisciplinary care (Cronbach’s a ¼ 0.89). The summated scale score (maximum 56) for the care quality scale was 53.08 (standard deviation (SD) ¼ 6.31), whereas the care quality scale itemized mean score was 3.79 indicating that participants were highly satisfied overall. Table II summarizes the mean satisfaction level for the individual care-quality items, which all scored between 3 and 4. Among the care-quality indicators, respondents reported that the interdisciplinary team consistently explained treatment consequences, worked efficiently, provided lab results, prevented future health problems, explained medications, included the patient in treatment decisions and protected their privacy. The summated scale score (maximum 40) for the interdisciplinary care scale was 36.85 (SD ¼ 4.64) and the itemized mean score was 3.69. Table III describes the mean satisfaction level for each interdisciplinary care item. Regarding the non-physician disciplines, respondents indicated that nurses, pharmacists and social workers played important roles in their care at the clinic, with mean satisfaction scores of 3.86 (SD ¼ 0.45), 3.74 (SD ¼ 0.60) and 3.71 (SD ¼ 0.68), respectively. When respondents were asked if they were comfortable having their health discussed in a large group during their visit, the mean satisfaction score was 3.1 (SD ¼ 1.07). Patients indicated that they received better care overall with the clinic’s team approach (3.73, SD ¼ 0.58) and that they preferred this
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Table I. Demographics
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Table II. Care quality items
Table III. Interdisciplinary care items
The team caring for me [y] Explains my treatment’s advantages and disadvantages Works efficiently Gives me the lab tests results Helps prevent future health problems Tells me the possible medication side effects Tells me how I should take my HIV medications Explains medications using language I can understand Takes me seriously Takes enough time to talk to me Is available when I need them (by phone or in person) Includes me in decision making about the treatment that I receive Would allow me to look at my medical chart if I wanted to Protects my privacy (HIV status) There are team members who are HIV experts
3.8770.47 3.7970.55 3.8670.44 3.8270.52 3.6270.79 3.8270.68 3.8070.53 3.8370.51 3.8570.52 3.6670.71 3.8570.48 3.7170.67 3.9170.39 3.7570.57
Notes: 1 ¼ Never, 2 ¼ Rarely, 3 ¼ Sometimes, 4 ¼ Always
The doctors have helped me to better understand my disease The pharmacy team plays an important role in my care at this clinic Pharmacists at this clinic help me better understand how to take medications and what to expect when taking them A pharmacy team at this clinic has helped me to make sure I do not miss medications The nursing team plays an important role in my care at this clinic The social work team plays an important role in my care at this clinic I feel comfortable having my health discussed in a large group during my medical visit I believe I receive overall better care because of the team approach at this clinic I prefer this clinic over others because doctors, pharmacists, nurses and social workers work together as one team I would recommend this clinic to other people living with HIV who only see a single doctor
3.8270.52 3.7470.60 3.6470.77 3.6270.80 3.8670.45 3.7170.68 3.1071.07 3.7370.58 3.7970.55 3.8570.45
Notes: 1 ¼ Strongly disagree, 2 ¼ Somewhat disagree, 3 ¼ Somewhat agree, 4 ¼ Strongly agree
particular clinic owing to the interaction between physicians, pharmacists, nurses and social workers (3.79, SD ¼ 0.55). Most patients felt strongly about recommending this clinic to other HIV patients (3.85, SD ¼ 0.45). Discussion To our knowledge, this is the first study measuring HIV interdisciplinary care quality from the patient’s perspective. We used a modified, previously validated QUOTE-HIV questionnaire to assess users’ satisfaction with the clinic’s services. Both the survey’s overall satisfaction and interdisciplinary care components met face validity and passed the reliability test (Cronbach’s a40.80). Overall satisfaction scores for this particular interdisciplinary HIV clinic were high and represent a positive perception among patients. Choi and Pak (2007) examined several promoters and barriers for successful multidisciplinary teamwork. They noted that multidisciplinary teamwork is not always successful, nor is it always called for. However, multidisciplinary teamwork is successful when cultivated by: carefully selecting team members and leaders, personal commitment, physical proximity, institutional support, a common goal and shared
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vision, role clarity and communication. The clinic we observed demonstrates several characteristics that contribute toward operating a clinic that provides a positive patient experience. It is striking that our patients recognized different individual disciplines, which comprise the interdisciplinary care team at the study center. This information may support further specially trained, non-physician healthcare personnel integration into routine outpatient care for people living with HIV. Pharmacists play an enhanced role in this clinic’s routine operations because either HIV specialty trained or post-graduate resident staff meet each patient as part of the interdisciplinary team on most visits. Pharmacist interventions improve adherence rates to medications (Murray et al., 2007) and respondents to the study questionnaire indicated that pharmacists helped them to understand their medications and improve adherence. Patients also recognized that nurses and social workers play an important care-role. While our results are encouraging, there are limitations. Surveys designed using the QUOTE method include importance and quality ratings (Sixma et al., 1998). Our questionnaire focussed solely on measuring quality. We extrapolated from the previous literature on African-Americans living with HIV by Moore et al. (2010) to establish which items patients deemed most important and included these items. Since we did not capture importance ratings, our ability to prioritize quality improvement initiatives may be limited (Sixma et al., 1998). There may have been significant positive bias in our quality ratings owing to question structure and responses as a “4” represented highest satisfaction for all questions without exception. This was consistent with the QUOTE-HIV study design and we decided not to deviate from this form. This structure, however, may have enabled respondents to select identical responses to most or all questions without carefully evaluating each survey item and yield a highly satisfactory overall score. Respondents experiencing unsatisfactory clinic experiences with in the past may have already withdrawn from care. Moreover, our survey design did not provide respondents with free space in which to provide commentary or add qualifiers to any response, which may have added to the discussion, and results from this study may not translate to other settings owing to individual variability in personnel and clinic settings. Conclusion Those wishing to implement and enhance outpatient services for people living with HIV must continually seek opportunities to keep patients engaged and adherent to medical care. Suboptimal retention increases mortality in HIV infected patients (Giordano et al., 2007). According to Roberts (2002), interviews with HIV-positive patients revealed that high-quality patient-provider relationships support patient adherence to care, while poor relationships can hinder. Guidelines for HIV primary care from the Infectious Diseases Society of America recognize high-quality patientprovider relationships as an exceptionally important factor in a patient’s engagement and recommends identifying a primary provider for each patient while using a multidisciplinary model (Aberg et al., 2009). However, patients only somewhat agreed to feeling comfortable having their health discussed in a large group during medical visits. This may identify a hindrance when practicing in teaching hospitals. Patients were highly satisfied with their experiences at the clinic and survey’s results support an interdisciplinary model as an acceptable approach to delivering primary care to this population.
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