Does a higher frequency of difficult patient encounters lead to lower quality care?

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Original Research

Does a higher frequency of difficult patient encounters lead to lower quality care?

J Fam Pract. 2013 January;62(1):24-29

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References

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Here we report on outcomes for those patients with diabetes and hypertension.

Measures
When we initially conducted the study, physicians completed an 8-item Burden of Difficult Encounters measure designed to approximate the frequency of difficult encounters experienced. Latent cluster analyses of this survey measure defined 3 distinct groups of physicians: those who estimated a high, medium, and low frequency of difficult encounters in their practices. Via chart audits, we determined quality of care and errors related to guideline-recommended management and preventive care for hypertension and diabetes. Details of these audits are found elsewhere.⁴

We defined quality care for hypertension as successful blood pressure control (<140/90), and for diabetes, successful control of hemoglobin A1c (≤7.5) and blood pressure (<135/80). One quality point was awarded for each of these 3 measures if achieved for at least 50% of recorded visits over an 18-month period. We calculated the quality score as the proportion of total possible quality points (with 100%=best).

We defined errors as guideline non-adherence and missed opportunities for prevention or management, tailored to each patient’s age, sex, and diagnoses. We calculated the error score as the proportion of total applicable error points (maximum=15; 0%=best). We assigned an error point for each missing process of care, including missed treatment opportunities, inattention to behavioral factors, guideline nonadherence, lack of tobacco use documentation, and missed prevention activities, such as mammograms, cervical cancer screening, colon cancer screening, and depression assessment.

We normalized scores to a range of 0 to 100 by dividing the number of quality or error points by the number of applicable items and multiplying by 100. We calculated quality and error scores for hypertension or diabetes for each patient and averaged them to determine total scores per physician.

Data analysis
Latent cluster analyses identified 3 distinct clusters of physicians based on their reported frequency of difficult encounters.¹ We used a 2-level hierarchical linear model of patients nested under physicians to assess if a higher number of perceived difficult patients was associated with poorer patient care, as measured by quality of care and medical errors, controlling for physician age, sex, and racial/ethnic minority status. To further adjust for negatively biased standard errors (physicians recruited from the same clinics, for example), we applied the Huber-White sandwich estimator.^15,16

We analyzed the association between levels of difficult patients and patient outcomes following a conceptual model. Using Cluster 3 (low frequency of difficult encounters) as the reference group, we tested the direct association of Cluster 1 (high frequency of difficult encounters) and Cluster 2 (medium frequency of encounters) with patient outcomes (eg, errors in diabetes and hypertension management, missed prevention activities, quality benchmarks met). We also tested the adjusted influence of Clusters 1 and 2 on patient outcomes, controlling for the mediators of burnout and satisfaction. Finally, we examined the direct influence of Clusters 1 and 2 on the mediators of burnout and satisfaction.

RESULTS

A total of 449 physicians from 119 clinics consented to participate in MEMO (59.8% of those approached), and 94% of these (n=422) completed the survey.⁴ Compared with participants, nonparticipants did not differ significantly by specialty or sex. Physicians were evenly divided between general internists (51.9%) and family physicians (48.1%). The mean age was 43 (range, 29-89), 44.4% were women, most (83.3%) worked full-time, and 22.0% were from a racial or ethnic minority group. Specific results of the Burden of Encounters measure, depicted in TABLE 1, have been reported previously.¹

TABLE 1
Burden of Difficult Encounters measure¹
Latent cluster analyses of this survey measure were used to assign physicians to one of 3 clusters: those who estimated a low, medium, or high frequency of difficult encounters in their practice.

How often do the following interactions occur? (1=never; 4=often)
Patients who:	No. of physicians providing ratings of 3 or 4 (%); n=422
Visit regularly, but ignore medical advice	155 (37)
Have expectations for care that are unrealistic	68 (16)
Insist on being prescribed an unnecessary drug	58 (14)
Insist on an unnecessary test	54 (13)
Persistently complain, although you have done everything possible to help	50 (12)
Do not express appropriate respect	16 (4)
Show dissatisfaction with your care	4 (1)
Are verbally abusive	1 (0.2)

Physicians were more likely to sort into the high (n=113) and medium (n=268) frequency of difficult encounter clusters as opposed to the low-frequency cluster (n=41) (TABLE 2). Of the 1384 patients whose records were audited, 359 were cared for by high-cluster physicians, 871 by medium-cluster physicians, and 154 by low-cluster physicians. Patients had a mean age of 59.6, 65.6% were women, and they had an average of 4.5 chronic medical conditions. A greater percentage of patients with physicians in the high-frequency cluster had a diagnosis of hypertension, compared with the medium cluster (92.4% vs 87.7%; P<.05). Patients did not differ across physician clusters by age, sex, prevalence of diabetes, or number of chronic diagnoses.