E225 1
Patient Preference and Perception of Care Provided by Advance Nurse Practitioners and Physicians in Outpatient Adult Congenital Clinics Timothy M. Maul, PhD,* Ali Zaidi, MD,† Vanessa Kowalski, CRNP,‡ Jenne Hickey, CRNP,† Renee Schnug, CRNP,† Morgan Hindes, BA,‡ and Stephen Cook, MD‡ *Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA; †Cardiology, The Columbus Ohio Adult Congenital Heart Program (COACH), Columbus, OH, USA; ‡The Adult Congenital Heart Disease Center, Heart Institute Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA, USA ABSTRACT
Objective. Nurse practitioners (NPs) have an established role for delivering competent care to patients in the primary care setting. The aim of this study was to compare satisfaction of patients managed by NPs vs. physicians in the outpatient adult congenital heart disease (CHD) clinic. Design. A prospective study conducted in two outpatient adult CHD clinics to assess patient satisfaction through standardized surveys. Demographic data included CHD diagnosis, age, and New York Heart Association functional class. All patients completed a Short-Form-12 to assess health status. Results. Of the 371 patients recruited (52% men; median age 29 years, severe CHD complexity 31.5%) and seen by NP (n = 187) or physician (n = 184), physician-managed practices had higher perceived: overall experience, courtesy of provider (P < 0.05) and confidence (trust) in provider (P < 0.1). Overall, patients reported satisfaction with an NP providing care (98%), the NP was able to effectively deal with illness/CHD (95%), and an increased chance (94%) or willingness to see an NP at a future visit. Only 73% reported an understanding of NP training and how an NP differed from a registered nurse. There was a stronger perception of how an NP differed from a physician (83%). Conclusion. Patient satisfaction was high regardless of whether care was provided by physicians or NPs. However, patients appear to make distinctions in what they believe the type of care each practitioner is best at providing. Patient education regarding competence of the different health care providers may continue to improve patient satisfaction. Key Words. Patient Satisfaction; Treatment Outcomes; Nurse Practitioner; Congenital Heart Disease; Adult; Quality Care
Introduction
I
ncreasing focus on health promotion and prevention has resulted in the introduction of the advance nurse practitioner (NP) within the primary care workforce.1 As a result, many practices have begun to shift aspects of primary care provision from physicians to NPs to reduce the demand for physicians, fill previously unmet health needs to improve health care efficiency and maintain quality of care.2 Nurse practitioners have now developed a reputation for delivering costC 2015 Wiley Periodicals, Inc. V © 2015
effective and competent health care. Prior research confirms that patients are highly satisfied with primary care provided by NPs.3 Guidelines for the delivery of regional adult congenital heart disease (CHD) care often includes a collaborative approach that requires an adult CHD cardiologist and two or several midlevel practitioners.4 The rapid growth of this population requires not only routine cardiovascular care provided by adult CHD specialists, but also rigorous outpatient education and support delivered by the advance NP in this clinical Congenit Heart Heart Dis. 2015;10:E225–E229 Congenit Dis. 2015;••:••–••
E226 2 environment.5,6 Prior studies have examined that patient satisfaction with general practitioners is determined by patient characteristics including age, gender, ethnic background, and health status.7–10 Presently, there is little research available about patient satisfaction or how patients perceive changes in skill mix in a tertiary care clinic. We sought to examine patient perception and satisfaction of care of the adult congenital patient no longer exclusively seen by the adult congenital physician. Methods
We performed a prospective, cross-sectional study at two outpatient adult CHD centers managed concurrently by physicians and advance NPs. At the Adult Congenital Heart Disease Center of University of Pittsburgh Medical Center, there is a physiciandirected adult CHD clinic with “ad-lib” supervision of NP-managed clinic patient visits provided by on-site adult CHD staff. Here, adult CHD patients are distributed equally between medical doctor (MD) and NP-managed clinics with an equal amount of time provided for each provider to evaluate both new and returning patients. In addition, there are dedicated adult CHD NP-managed clinics with consultation of the adult CHD cardiologist only at the request of the NP. Similarly, the Columbus Ohio Adult Congenital Heart Program has both physician-directed, supervised NP-managed and individual NP-managed clinics. To be eligible, adult patients (>18 years of age) with CHD were prospectively and consecutively enrolled at each center and had to be able to read and comprehend English. The Institutional Review Boards together with the Heart Institute, Children’s Hospital of Pittsburgh and Nationwide Children’s Hospital approved the study. All patients provided written informed consent to participate. Pertinent demographic data obtained during chart review included age, gender, level of education, ethnicity, New York Heart Association (NYHA) functional class and type and complexity of CHD. The complexity of CHD was categorized as mild, moderate or severe in accordance to the classification scheme proposed by the American College of Cardiology that considers the underling cardiac anomaly and postoperative status.11 An adaptation of a survey utilized to assess patient satisfaction with NPs was administered to each adult CHD patient to explore issues pertinent to this unique population, and included a Likert scale rating the overall experience.3,12 Reliability and 2015;10:E225–E229 Congenit Heart Dis. 2015;••:••–••
Maul et al. Table 1. Patient Satisfaction Survey Questions 1. 2. 3. 4.
The health care provider delivered quality care. The health care provider was friendly. I felt confidence (trust) with the health care provider. I felt free to discuss private thoughts with the health care provider. 5. The health care provider delivered safe medical care. 6. Rate the courtesy of the health care provider. 7. The health care provider offered a chance to ask questions about my care/condition. 8. The health care provider felt “rushed” during my visit. 9. The health care provider provided answers to my questions that were easy to understand. 10. I received as much information about my care/condition from my health care provider that I desired. 11. The health care provider provided information to care for my health/condition. 12. Rate your overall experience. I am clear about how a nurse practitioner is trained?* I am clear how a nurse differs from a nurse practitioner?* I am clear how a nurse practitioner differs from a doctor?* Describe the success of the nurse practitioner in dealing with your CHD.* I would be willing to see a nurse practitioner in the adult CHD in the future.* *Five questions included only nurse practitioner satisfaction surveys to assess clarity of the nurse practitioner role. CHD, congenital heart disease.
validity of the patient satisfaction component of the survey had been previously assessed with an internal consistency range of 0.79–0.88.3 This survey included a total of 12 items, with five additional questions to assess the clarity of the NP role (Table 1). Respondents rated each item on a 5-point Likert scale ranging from 1 (dissatisfied/ strongly disagree) to 5 (very satisfied/strongly agree). Well-validated measures were used to assess patient health status. The Short-Form 12 was administered to subjects to assess perceived physical and mental health.13
Statistical Analysis All statistical analysis was performed using the Statistical Package for the Social Sciences (Version 21.0, IBM Corp., Armonk, NY). Komolgorov– Smirnov tests for normality for all continuous variables were significant at the P < 0.05 level, and all results are therefore reported as median with interquartile range. Comparisons between MD and NP perceptions of care were performed using a Wilcoxon’s ranked sum test because of the ordered nature of the survey questions. Chisquared tests were used for comparisons of categorical demographic variables, and Mann– Whitney U-tests were used for comparisons of continuous demographic variables. Spearman ranked correlations were performed to investigate relationships between continuous variables.
E227 3
Patient Preference and Perception of Care Results
A total of 371 subjects were recruited from both outpatient adult CHD centers and seen by either NP (n = 187) or physician (n = 184). The group was 52% men, median age 29 years (interquartile range = 24–39). Baseline characteristics are summarized in Table 2. The two groups did not differ significantly with regards to gender, ethnicity, NYHA functional class or education. Patients demonstrated a weak (rho = −0.291) inverse correlation between Short-Form 12 Physical Health T-score and NYHA classification (P < 0.001). Other markers of physical health including Physical Functioning and Role Limitation were also significantly (P < 0.001) negatively correlated (rho = −0.371 and −0.314, respectively). Mental health T-scores were not significantly correlated with NYHA classification. Visit type included new and returning adult congenital patients. There was no
Table 2.
Patient Demographics (n = 371) MD Patients (n = 184 )
Variable Age (years) Gender (male) Ethnicity Caucasian CHD complexity Simple CHD Moderate CHD Complex CHD NYHA vlass I–II III–IV Education ≤High school >High school
29 (24–39.75) 96 (52%)
NP Patients (n = 187) 29 (24–29) 97 (52%)
P Value NS NS
168 (91%)
171 (91%)
NS
8 (4%) 98 (55%) 72 (40%)
8 (4%) 101 (56%) 72 (40%)
NS
160 (61%) 13 (47%)
105 (40%) 15 (53%)
NS
69 (38%) 115 (62%)
72 (38%) 115 (62%)
NS
CHD, congenital heart disease; NS, not significant; NYHA, New York Heart Association.
Table 3.
difference between the percentage of new patients for physicians (44%) and NPs (43%). Classification of CHD complexity was not significantly different between the physician and NP-managed practices. Physician-managed practices had higher perceived satisfaction measured by percentage of “excellent” responses chosen for the following questions: (1) delivery of safe medical care (P < 0.05); (2) courtesy of provider (P < 0.05), (3) Receipt of Desired Information about the Health Condition (P < 0.05), (4) Quality of Care Received (P < 0.05), and (5) Overall Experience (P < 0.01). There was a trend towards lower Confidence/ Trust (P < 0.l) in the NP-managed practices (Table 3). Areas without differences between NPand physician-managed practices were: friendliness of the provider, ability to discuss private thoughts, opportunity to ask questions about care/ health condition by provider, quality of education materials provided to the patient, patient comprehension of provider explanations and lack of feeling rushed by provider. About half of respondents reported a “very good” understanding of how an NP had been trained or how an NP differed from a registered nurse. There was a similar reported lack of perception (50%) of how an NP differed from the physician. Overall, subjects reported satisfaction with the ability of the NP to effectively deal with underlying illness/CHD complexity (95%). This was moderately correlated (rho = 0.5, P < 0.001) with the confidence in the provider. Lastly, subjects reported an increased willingness (94%) to see the NP at a future visit in the outpatient adult CHD clinic. This, too, was moderately correlated with participant responses to the overall experience rating (rho = 0.47, P < 0.001).
Adult Congenital Patient Satisfaction Survey Results
Survey Question
Physician Clinic
NP Clinic
P Value
The health care provider delivered quality of care (very satisfied) Friendliness of provider (strongly agree) Confidence/trust in provider (strongly agree) Ability to discuss private thoughts (strongly agree) Delivery of safe medical care (strongly agree) Courtesy of provider (excellent) Receipt of desired information about health condition (strongly agree) Opportunities to ask questions with the provider (very frequently) Feeling rushed by provider (never) Received answers to questions—easy to understand (very frequently) Information/education received for care of CHD/health condition (about right) Overall experience rating (excellent)
90 95 91.3 82 94 94 86 75 84 81 94 90
82 91 85 77 88 87 77 78 83 76 92 79
Patient Preference and Perception of Care Provided by Advance Nurse Practitioners and Physicians in Outpatient Adult Congenital Clinics Timothy M. Maul, PhD,* Ali Zaidi, MD,† Vanessa Kowalski, CRNP,‡ Jenne Hickey, CRNP,† Renee Schnug, CRNP,† Morgan Hindes, BA,‡ and Stephen Cook, MD‡ *Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA; †Cardiology, The Columbus Ohio Adult Congenital Heart Program (COACH), Columbus, OH, USA; ‡The Adult Congenital Heart Disease Center, Heart Institute Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA, USA ABSTRACT
Objective. Nurse practitioners (NPs) have an established role for delivering competent care to patients in the primary care setting. The aim of this study was to compare satisfaction of patients managed by NPs vs. physicians in the outpatient adult congenital heart disease (CHD) clinic. Design. A prospective study conducted in two outpatient adult CHD clinics to assess patient satisfaction through standardized surveys. Demographic data included CHD diagnosis, age, and New York Heart Association functional class. All patients completed a Short-Form-12 to assess health status. Results. Of the 371 patients recruited (52% men; median age 29 years, severe CHD complexity 31.5%) and seen by NP (n = 187) or physician (n = 184), physician-managed practices had higher perceived: overall experience, courtesy of provider (P < 0.05) and confidence (trust) in provider (P < 0.1). Overall, patients reported satisfaction with an NP providing care (98%), the NP was able to effectively deal with illness/CHD (95%), and an increased chance (94%) or willingness to see an NP at a future visit. Only 73% reported an understanding of NP training and how an NP differed from a registered nurse. There was a stronger perception of how an NP differed from a physician (83%). Conclusion. Patient satisfaction was high regardless of whether care was provided by physicians or NPs. However, patients appear to make distinctions in what they believe the type of care each practitioner is best at providing. Patient education regarding competence of the different health care providers may continue to improve patient satisfaction. Key Words. Patient Satisfaction; Treatment Outcomes; Nurse Practitioner; Congenital Heart Disease; Adult; Quality Care
Introduction
I
ncreasing focus on health promotion and prevention has resulted in the introduction of the advance nurse practitioner (NP) within the primary care workforce.1 As a result, many practices have begun to shift aspects of primary care provision from physicians to NPs to reduce the demand for physicians, fill previously unmet health needs to improve health care efficiency and maintain quality of care.2 Nurse practitioners have now developed a reputation for delivering costC 2015 Wiley Periodicals, Inc. V © 2015
effective and competent health care. Prior research confirms that patients are highly satisfied with primary care provided by NPs.3 Guidelines for the delivery of regional adult congenital heart disease (CHD) care often includes a collaborative approach that requires an adult CHD cardiologist and two or several midlevel practitioners.4 The rapid growth of this population requires not only routine cardiovascular care provided by adult CHD specialists, but also rigorous outpatient education and support delivered by the advance NP in this clinical Congenit Heart Heart Dis. 2015;10:E225–E229 Congenit Dis. 2015;••:••–••
E226 2 environment.5,6 Prior studies have examined that patient satisfaction with general practitioners is determined by patient characteristics including age, gender, ethnic background, and health status.7–10 Presently, there is little research available about patient satisfaction or how patients perceive changes in skill mix in a tertiary care clinic. We sought to examine patient perception and satisfaction of care of the adult congenital patient no longer exclusively seen by the adult congenital physician. Methods
We performed a prospective, cross-sectional study at two outpatient adult CHD centers managed concurrently by physicians and advance NPs. At the Adult Congenital Heart Disease Center of University of Pittsburgh Medical Center, there is a physiciandirected adult CHD clinic with “ad-lib” supervision of NP-managed clinic patient visits provided by on-site adult CHD staff. Here, adult CHD patients are distributed equally between medical doctor (MD) and NP-managed clinics with an equal amount of time provided for each provider to evaluate both new and returning patients. In addition, there are dedicated adult CHD NP-managed clinics with consultation of the adult CHD cardiologist only at the request of the NP. Similarly, the Columbus Ohio Adult Congenital Heart Program has both physician-directed, supervised NP-managed and individual NP-managed clinics. To be eligible, adult patients (>18 years of age) with CHD were prospectively and consecutively enrolled at each center and had to be able to read and comprehend English. The Institutional Review Boards together with the Heart Institute, Children’s Hospital of Pittsburgh and Nationwide Children’s Hospital approved the study. All patients provided written informed consent to participate. Pertinent demographic data obtained during chart review included age, gender, level of education, ethnicity, New York Heart Association (NYHA) functional class and type and complexity of CHD. The complexity of CHD was categorized as mild, moderate or severe in accordance to the classification scheme proposed by the American College of Cardiology that considers the underling cardiac anomaly and postoperative status.11 An adaptation of a survey utilized to assess patient satisfaction with NPs was administered to each adult CHD patient to explore issues pertinent to this unique population, and included a Likert scale rating the overall experience.3,12 Reliability and 2015;10:E225–E229 Congenit Heart Dis. 2015;••:••–••
Maul et al. Table 1. Patient Satisfaction Survey Questions 1. 2. 3. 4.
The health care provider delivered quality care. The health care provider was friendly. I felt confidence (trust) with the health care provider. I felt free to discuss private thoughts with the health care provider. 5. The health care provider delivered safe medical care. 6. Rate the courtesy of the health care provider. 7. The health care provider offered a chance to ask questions about my care/condition. 8. The health care provider felt “rushed” during my visit. 9. The health care provider provided answers to my questions that were easy to understand. 10. I received as much information about my care/condition from my health care provider that I desired. 11. The health care provider provided information to care for my health/condition. 12. Rate your overall experience. I am clear about how a nurse practitioner is trained?* I am clear how a nurse differs from a nurse practitioner?* I am clear how a nurse practitioner differs from a doctor?* Describe the success of the nurse practitioner in dealing with your CHD.* I would be willing to see a nurse practitioner in the adult CHD in the future.* *Five questions included only nurse practitioner satisfaction surveys to assess clarity of the nurse practitioner role. CHD, congenital heart disease.
validity of the patient satisfaction component of the survey had been previously assessed with an internal consistency range of 0.79–0.88.3 This survey included a total of 12 items, with five additional questions to assess the clarity of the NP role (Table 1). Respondents rated each item on a 5-point Likert scale ranging from 1 (dissatisfied/ strongly disagree) to 5 (very satisfied/strongly agree). Well-validated measures were used to assess patient health status. The Short-Form 12 was administered to subjects to assess perceived physical and mental health.13
Statistical Analysis All statistical analysis was performed using the Statistical Package for the Social Sciences (Version 21.0, IBM Corp., Armonk, NY). Komolgorov– Smirnov tests for normality for all continuous variables were significant at the P < 0.05 level, and all results are therefore reported as median with interquartile range. Comparisons between MD and NP perceptions of care were performed using a Wilcoxon’s ranked sum test because of the ordered nature of the survey questions. Chisquared tests were used for comparisons of categorical demographic variables, and Mann– Whitney U-tests were used for comparisons of continuous demographic variables. Spearman ranked correlations were performed to investigate relationships between continuous variables.
E227 3
Patient Preference and Perception of Care Results
A total of 371 subjects were recruited from both outpatient adult CHD centers and seen by either NP (n = 187) or physician (n = 184). The group was 52% men, median age 29 years (interquartile range = 24–39). Baseline characteristics are summarized in Table 2. The two groups did not differ significantly with regards to gender, ethnicity, NYHA functional class or education. Patients demonstrated a weak (rho = −0.291) inverse correlation between Short-Form 12 Physical Health T-score and NYHA classification (P < 0.001). Other markers of physical health including Physical Functioning and Role Limitation were also significantly (P < 0.001) negatively correlated (rho = −0.371 and −0.314, respectively). Mental health T-scores were not significantly correlated with NYHA classification. Visit type included new and returning adult congenital patients. There was no
Table 2.
Patient Demographics (n = 371) MD Patients (n = 184 )
Variable Age (years) Gender (male) Ethnicity Caucasian CHD complexity Simple CHD Moderate CHD Complex CHD NYHA vlass I–II III–IV Education ≤High school >High school
29 (24–39.75) 96 (52%)
NP Patients (n = 187) 29 (24–29) 97 (52%)
P Value NS NS
168 (91%)
171 (91%)
NS
8 (4%) 98 (55%) 72 (40%)
8 (4%) 101 (56%) 72 (40%)
NS
160 (61%) 13 (47%)
105 (40%) 15 (53%)
NS
69 (38%) 115 (62%)
72 (38%) 115 (62%)
NS
CHD, congenital heart disease; NS, not significant; NYHA, New York Heart Association.
Table 3.
difference between the percentage of new patients for physicians (44%) and NPs (43%). Classification of CHD complexity was not significantly different between the physician and NP-managed practices. Physician-managed practices had higher perceived satisfaction measured by percentage of “excellent” responses chosen for the following questions: (1) delivery of safe medical care (P < 0.05); (2) courtesy of provider (P < 0.05), (3) Receipt of Desired Information about the Health Condition (P < 0.05), (4) Quality of Care Received (P < 0.05), and (5) Overall Experience (P < 0.01). There was a trend towards lower Confidence/ Trust (P < 0.l) in the NP-managed practices (Table 3). Areas without differences between NPand physician-managed practices were: friendliness of the provider, ability to discuss private thoughts, opportunity to ask questions about care/ health condition by provider, quality of education materials provided to the patient, patient comprehension of provider explanations and lack of feeling rushed by provider. About half of respondents reported a “very good” understanding of how an NP had been trained or how an NP differed from a registered nurse. There was a similar reported lack of perception (50%) of how an NP differed from the physician. Overall, subjects reported satisfaction with the ability of the NP to effectively deal with underlying illness/CHD complexity (95%). This was moderately correlated (rho = 0.5, P < 0.001) with the confidence in the provider. Lastly, subjects reported an increased willingness (94%) to see the NP at a future visit in the outpatient adult CHD clinic. This, too, was moderately correlated with participant responses to the overall experience rating (rho = 0.47, P < 0.001).
Adult Congenital Patient Satisfaction Survey Results
Survey Question
Physician Clinic
NP Clinic
P Value
The health care provider delivered quality of care (very satisfied) Friendliness of provider (strongly agree) Confidence/trust in provider (strongly agree) Ability to discuss private thoughts (strongly agree) Delivery of safe medical care (strongly agree) Courtesy of provider (excellent) Receipt of desired information about health condition (strongly agree) Opportunities to ask questions with the provider (very frequently) Feeling rushed by provider (never) Received answers to questions—easy to understand (very frequently) Information/education received for care of CHD/health condition (about right) Overall experience rating (excellent)
90 95 91.3 82 94 94 86 75 84 81 94 90
82 91 85 77 88 87 77 78 83 76 92 79
