Fremont AM, Cleary PD, Ayanian JZ, Hargraves JL, Rowe RM, Jacobsen NB; Association for Health Services Research. Meeting.
Abstr Book Assoc Health Serv Res Meet. 1999; 16: 319.
Brigham and Women's Hospital, Department of Health Care Policy, Harvard Medical School, Boston, MA 02115, USA.
RESEARCH OBJECTIVE: Most research on quality of care for acute myocardial infarction (AMI) focuses exclusively on technical aspects of care. Little is known about the extent to which non-technical aspects of care that are highly salient to patients and their families - such as providing information and education, emotional support, and preparation for discharge - affect recovery from AMI and long-term health outcomes. This paper assesses the impact of patients' reported quality of their hospital care on health outcomes during the year following their AMI. STUDY DESIGN: Data were collected from a prospectively defined cohort of AMI patients discharged from 20 New Hampshire hospitals participating in the Foundation for Healthy Communities initiative during 1996. Picker Institute surveys that ask patients about their care and health were mailed to patients 1, 3, and 12 months after discharge with 758 (58.4%), 609 (47.2%), and 548 (42.5%) of study participants responding, respectively. Response rates did not differ by age, sex, race, or the number or times of comorbidities (all P>0.05). Discharge abstracts were used to compute a validated comorbidity index and determine treatment type (medical, PTCA, or CABG). Patients' 1-month responses to questions about 7 dimensions of their AMI hospital care (e.g., coordination of care, emotional support, continuity and transition) were used to compute a problem score (0-100 with increasing score indicating more problems). Medical Outcomes Study questions were used to assess physical health status, mental health status, and self-rated health; angina and dyspnea were measured using 2 scales based on London School of Hygiene measures (all measures 0-100 with increasing score indicating better health). Multivariate regression analysis was used to assess the impact of patients' problem scores on their health status adjusting for sociodemographic factors, comorbidities, treatment type, hospital size, transfers, and 1-month health status. Separate regressions were run for each of the 3-month and 12-month health status measures, respectively. PRINCIPAL FINDINGS: Patients' problem scores ranged from 0 to 85 (mean=15). Compared to other patients, those reporting the most problems with care (top quartile, >21) had worse unadjusted health status at 1, 3, and 12 months for all 5 measures: self-rated health (1 month: 56 vs 42, 3 month: 54 vs 43, 12 month: 54 vs 44), physical health (61 vs 46, 68 vs 56, 70 vs 52), mental health (72 vs 59, 71 vs 59, 72 vs 65), angina (82 vs 65, 84 vs 76, 90 vs 71), and dyspnea (77 vs 54, 78 vs 69, 80 vs 63)(all P<.02). Adjusting for confounders and 1-month health status revealed that having more problems with care was associated with small but significant decreases in self-rated health (problem score regression coefficient b=-.15, p=.01), and mental health (b=-.14, P=.01) between 1 and 3 months, while physical health, angina, and dyspnea showed non-significant decreases. The effect of having more problems with care on changes in self-rated health (b=-.18, P=.01) at 12 months was similar to that in the 3-month model. However, in the 12-month model there were significant and more substantial negative effects of problems with care on changes in physical health (b=-.32, P=.001) and angina (b=-.27, P=.004); but not mental health or dyspnea. For example, each 10 point increase in problems was associated with a 3.2 oint decrease in physical health between 1 and 12 month post-MI. CONCLUSIONS: Patients' experience with their hospital care and discharge to home have both short and long-term effects on their post-MI course over the ensuing year, and the effects appear to increase the farther one gets from the MI. Precisely how negative experiences translate into worse health outcomes has yet to be determined. Potential explanations include decreased compliance with medications, life-style changes, cardiac rehabilitation, symptom reporting, and increased psychological distress. IMPLICATIONS FOR POLICY, DELIVERY OR PRACTICE: Although there is increasing use of patients' reports about their care, such information has generally been viewed as an indicator of patient satisfaction rather than a meaningful predictor of outcomes. This study suggests that patients' reports about non-technical aspects of care may be important indicators of the quality of AMI care and predictors of subsequent outcomes. Thus providers and policy makers may be able to improve post-MI outcomes by enhancing non-technical aspects of care such as coordination of care, emotional support, and discharge planning and continuity. This study also suggests that further research examining links between non-technical aspects of care and clinical outcomes should examine both short and longer-term effects because clinically important outcomes may not become manifest until many months after AMI care is provided.
Publication Types:
Keywords:
- Angina Pectoris
- Comorbidity
- Coronary Artery Bypass
- Coronary Disease
- Health Status
- Health Status Indicators
- Hospitalization
- Hospitals
- Humans
- London
- Mental Health
- Myocardial Infarction
- New Hampshire
- Patient Discharge
- Patient Satisfaction
- Patient-Centered Care
- surgery
- hsrmtgs
Other ID:
UI: 102194675
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