Table B-1Messages for improving quality for the patient/consumer/caregiver perspective

TopicTake-Home Messages Motivating Potential Actions
Bundled PaymentThe impact of bundled payment on quality of care is unknown. Implementing bundled payment programs generally showed small changes in quality measures, but the direction and magnitude of those effects varied within and across studies. Thus, it is unknown which aspects of care might be improved through bundled payments and which might experience a detrimental change. There was no evidence about whether bundled payment programs lead to providers avoiding high-risk patients.
Patient-Centered Medical HomeSmall positive effects on patient experience were associated with PCMH. The PCMH model holds promise for improving the experiences of patients, and potentially for improving care processes. The review found evidence of moderate strength indicating that interventions meeting PCMH criteria were associated with small improvements in patient experiences, both on overall measures of patient satisfaction and on measures of patient-reported/patient-perceived level of care coordination.
DisparitiesVery little research has focused on quality improvement strategies to reduce health care disparities. Further advocacy may be needed to encourage progress in this area.
Medication AdherenceReducing out-of-pocket medication costs improved adherence. One of the most robust conclusions from this series underscores the important role that out-of-pocket costs play in medication adherence. This suggests the importance of assessing adequacy of pharmacy benefits in connection with adherence behaviors.
Public ReportingSlight improvements in quality were associated with public reporting. Most studies of hospital-level public reporting found a decrease in mortality (19 studies, moderate strength of evidence), and studies of public reporting for health plans or long-term care facilities generally found improvements in outcomes such as pain, pressure ulcers, and satisfaction with care.
It is unclear whether public reporting limits patient access. Evidence about the potential for health care providers to cherry-pick patients (thereby limiting access for sicker patients) was of low quality and yielded mixed results. One study found greater disparities between whites and blacks or Hispanics in receipt of coronary artery bypass graft surgery that persisted for 9 years following public reporting, but another study found that high-risk patients were more likely to see high-quality surgeons, contradicting the hypothesis that physicians might refuse to treat the highest risk patients to improve their performance on mortality and other patient outcomes measures.
Public reporting had little impact on patient choice. Results across studies and settings consistently showed that patients and their families or representatives did not use public reports when selecting hospitals, clinicians, health plans, or nursing homes. The few studies reporting evidence for an effect of public reporting on patient choice did so only for a subgroup of patients. Evidence from 12 qualitative studies suggested that patients were often unaware that quality information was available through public reporting (4 studies); considered other factors such as travel distance; recommendations by family, friends, or doctors; and financial considerations to be more important in choosing a provider (7 studies); or did not find the quality measures included in the reports to be relevant or understandable (2 studies).
Healthcare-Associated InfectionsLittle evidence is available about patients' roles in reducing HAI. Patients and their caregivers may be able to encourage adherence to some preventive interventions if educated about good practices and empowered to voice concerns when their providers deviate from those practices. Yet this review found just 2 studies that examined patient education as a quality improvement strategy aimed at reducing HAI. Advocacy on behalf of patients may be needed to spur research in this area and further explore how the actions of patients and their caregivers may impact HAI rates or adherence to preventive interventions.
Disability OutcomesThere is a need to advocate for more inclusive research and engage in consensus efforts. Much of the literature included in this review views disability as the main health concern rather than as a complicating condition. None of the studies reviewed included a mixed population of people with and without disabilities. Advocacy from the community of people with disabilities may help encourage more inclusion of disabled people in research studies, further a view of disability as a complicating condition, and broaden the scope of outcomes measures used in disability research. Efforts to develop consensus-based core measure sets should incorporate input from individuals with disabilities.
Palliative CareInterventions targeting continuity, coordination, and transitions of care improved patient and caregiver satisfaction. Although these interventions did not improve quality of life or symptoms, or decrease health care utilization (low strength of evidence), patients and their caregivers reported higher satisfaction with care for interventions focused on providing continuity of care, well-coordinated care, and facilitated transitions (moderate strength of evidence).
Interventions targeting communication and decisionmaking did not improve patient satisfaction. Although these interventions decreased health care utilization (moderate strength of evidence), they did not improve patient or caregiver satisfaction (low strength of evidence), suggesting that this aspect of care may be less relevant to patients and their families.
Little is known about interventions to decrease patient distress. There was only low strength of evidence that interventions targeting patient distress were effective: 2 of 7 RCTs showed significant improvement.

Note: HAI = healthcare-associated infections; PCMH = patient-centered medical home; RCT = randomized controlled trial.

From: Appendix B, Focus on Action: Key Messages for Improving Quality

Cover of Through the Quality Kaleidoscope: Reflections on the Science and Practice of Improving Health Care Quality
Through the Quality Kaleidoscope: Reflections on the Science and Practice of Improving Health Care Quality: Closing the Quality Gap: Revisiting the State of the Science [Internet].
McDonald KM, Chang C, Schultz E.

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