Better Patient Ambulatory Care Experience

In its landmark 2001 report “Crossing the quality chasm: A new health system for the 21st century,” the Institute of Medicine (IOM) Committee on Quality of Health Care in America (1) identified patient-centered care as one of six fundamental aims of the US health care system. The IOM characterized patient-centered care as that which is “responsive to the needs, values and expressed preferences” of individuals and their caregivers, and they proposed six domains that contribute to patient-centered care, including (1) respect of patients’ preferences and needs; (2) information, communication, and education; (3) coordination of care; (4) physical comfort; (5) emotional support; and (6) engagement of family. Over the past two decades, patient centeredness has been adopted as a measure of quality by the Centers for Medicaid and Medicare and the British National Health Service, and it serves as a guiding principle of the Patient Protection and Affordable Care Act, including the Patient Centered Outcomes Research Institute.

Patient experience surveys, such as the Ambulatory Care Experience Survey (ACES) and the Consumer Assessment of Health Providers and Systems Clinician and Group Survey, are validated instruments that attempt to capture patient experience objectively, providing actionable data that can be used to set patient-centered performance improvement goals for individual providers, clinical groups, and health systems. They are also used for patient reporting, allowing patients more consumer choice in selection of health care providers or clinical sites. Patient experience surveys are often distinguished from patient satisfaction surveys, which capture how pleased patients are with aspects of their experience.

Although improving patient experience has an inherent value to patients and families in its own right, there are reasons to believe that good patient experience in ambulatory care settings can translate into more appropriate health care utilization and improved health outcomes. The study by Cedillo-Couvert et al. (2) in this issue of the Clinical Journal of the American Society of Nephrology (CJASN) provides new evidence to this field of inquiry by linking patient experience in primary care and health outcomes among individuals with nondialysis-requiring kidney disease. Using data from the Hispanic Chronic Renal Insufficiency Cohort study, they show that lower patient experience scores in various domains of the ACES are associated with more hospitalizations, including cardiovascular and noncardiovascular hospitalizations, as well as a trend toward more hospitalizations for ambulatory-sensitive conditions, hospitalizations that have been deemed to be preventable with high-quality primary care by the Agency for Healthcare Research and Quality (AHRQ). In particular, lower scores in the “communication quality,” “health promotion,” “interpersonal treatment,” and “trust” domains were independently associated with higher rate ratios for hospitalizations, independent of sociodemographic and clinic factors. Scores in the “whole-person” domain were not associated with differing hospitalization rates. Also, patient experience scores in any of the domains were not associated with differences in incident ESKD or death over a follow-up of nearly 5 years.

The study population was relatively small (n=252), was recruited mainly from one city in the United States, and only included individuals who self-identified as Hispanic, thus limiting generalizability of results to a broader CKD population. However, these data are consistent with studies that have shown lower hospital readmission rates for acute myocardial infarction, pneumonia, and heart failure among hospitalized patients with higher patient experience scores (3).

Is this believable? What might be the mechanism by which patient experience influences outcomes? A recent systematic review of 34 studies across the health care spectrum noted that higher patient experience scores in the ambulatory setting were associated with increased patient adherence to physician advice, greater medication adherence, and higher participation in health prevention activities, all of which have been independently associated with fewer hospitalizations (4). Other studies have documented that patient experience is positively correlated with completion of important process of care measures, including LDL cholesterol, glycosylated hemoglobin, albuminuria testing, and retinopathy screening among individuals with diabetes (4,5). Although entirely speculative, it is not hard to imagine that better patient experience encourages patients to communicate with their health care team about new or concerning symptoms and more openly discuss facilitators/barriers to chronic disease management, potentially obviating the need for emergency department visits and subsequent hospitalization.

It is important to note that patient experience and quality of clinical care delivery are not always correlated and that many studies have been unable to show a clear link between the two entities in either direction (positive or negative) (4). Importantly, however, no inherent tradeoff or competing risk between patient experience and quality of care delivery has been identified either.

The results from the study by Cedillo-Couvert et al. (2) challenge us to develop strategies to further improve the ambulatory patient experience for individuals with CKD, not just in primary care (the focus of this study) but also, in other clinics where nephrologists are providers. Over the past decade, many initiatives have been tested in primary care, with mixed success. To disseminate best practices across the United States and help spur further innovation in this field, the AHRQ has developed a comprehensive toolkit for providers and health systems to use and adapt to improve patient experience in ambulatory care: https://www.ahrq.gov/cahps/quality-improvement/improvement-guide/improvement-guide.html (accessed September 3, 2018). Although not specific to CKD care, the toolkit highlights strategies that are universal to chronic disease management, including ways to improve health-related communication and enhance patient engagement. Some of these strategies are already being tested in nephrology practices, such as patient navigator (6) and health coach (7) programs, mobile applications to enhance patient engagement (8), communication training for physicians (9), and enhanced primary care-specialty care coordination in the form of electronic consultations or coordination agreements within medical neighborhoods (10) (Table 1). There has been less experience in nephrology clinics with other strategies, such as patient advisory councils and consistent use of patient experience surveys.

Table 1.

Strategies that are being tested to enhance patient experience of ambulatory nephrology care and the patient-centered domain that they affect

Strategies to Improve Patient Experience with CKD Care	Institute of Medicine Domain of Patient-Centered Care
	Respect for Patients’ Preferences and Needs	Information, Communication, and Education	Coordination of Care	Physical Comfort	Emotional Support	Engagement of Family
Physician training in communication	X	X		X	X	X
Navigators		X	X
Peer health coaches	X	X	X		X
Mobile health applications	X	X				X
Electronic consultations			X
Multidisciplinary care clinics		X	X	X	X	X
Workforce diversity	X				X
Multimedia educational tools	X				X	X

Patient-centered care is widely accepted as a critical component of care quality. In addition to the intrinsic value inherent to maximizing patient experience, data, such as those published in this volume of the CJASN, provide evidence that better patient care experiences are also associated with less health care utilization and provide a step toward the overarching goal of achieving the quadruple aim: high-quality and cost-effective care delivery that improves population health and achieves high satisfaction among providers, care team members, and patients (11).

Disclosures

None.