ORIGINAL INVESTIGATION

Transcription

1 ORIGINAL INVESTIGATION Insight Into atient Dissatisfaction With Asthma Treatment Leona E. Markson, ScD; William M. Vollmer, hd; Leslye Fitterman, hd; Elizabeth O Connor, hd; Siva Narayanan, MHS; Marc Berger, MD; A. Sonia Buist, MD Background: Measures of patient satisfaction or dissatisfaction with treatment are increasingly being used as indicators of quality of care. As these measures become more widely used, it is important to know if patient dissatisfaction is associated with important processes or outcomes of medical care. Methods: Survey of patient-reported asthma management issues using the Asthma Therapy Assessment Questionnaire in a large health maintenance organization in the acific Northwest. Associations between patient dissatisfaction with asthma treatment and patient-reported measures of asthma control, patient-provider communication, and belief in asthma medications (selfefficacy) were examined. Results: Of the 5181 adult members with asthma enrolled in the health maintenance organization, 30% indicated dissatisfaction with current treatment. Dissatisfaction was higher among patients with a higher number of asthma control problems, patient-provider communication problems, or belief in medication problems (eg, failure to believe their medications are useful and inability to take asthma medications as directed). The odds of dissatisfaction with treatment were 2.8 (95% confidence interval [CI], ; ) for asthma control problems, 2.0 (95% CI, ; ) for communication problems, and 8.0 (95% CI, ; ) for belief in medication problems compared with patients without these perceived problems. Conclusion: atient dissatisfaction with treatment may be related to important asthma disease management issues. Arch Intern Med. 2001;161: From Merck & Co, Inc, West oint, a (Drs Markson, Fitterman, and Berger and Mr Narayanan), Kaiser ermanente Center for Health Research, ortland, Ore (Drs Vollmer and O Connor), and Oregon Health Sciences University, ortland (Dr Buist). WITH THE prevalence of asthma on the rise 1 and the annual cost associated with the disease exceeding $5.8 billion (in 1994 dollars), 2 providers and payers are interested in evaluating the outcomes of asthma care. 3 In the past, clinical and economic outcomes of asthma care received attention. 4-8 However, evaluation of patient care across a range of medical conditions increasingly includes measures of patient satisfaction Managed care organizations have started to incorporate patient satisfaction in their report cards to assess the performance of the plans and the quality of patient management programs. 17,19-21 Added importance of patient satisfaction measures may result from the work of the National Committee for Quality Assurance and the Foundation for Accountability, since these organizations have suggested that health plans use patient satisfaction to evaluate care In this context, the potential is large for measures of patient satisfaction or evidence of dissatisfaction to drive accountability and infer level of quality or value of health care. Most health care research on patient satisfaction has focused on satisfaction with generic aspects of patient care, such as office hours or helpfulness of the staff. It is also reasonable to ask patients with chronic diseases about their satisfaction with treatment, since it is the specific treatment that will likely have the greatest impact on patient outcomes. In addition, patients are generally asked about their overall level of satisfaction as opposed to whether they are dissatisfied with any part of their care. It is possible that the important improvements needed in health care may best be obtained by assessing whether there is evidence of dissatisfaction. This study extends the research on patient satisfaction 379

2 MATERIALS AND METHODS OULATION We studied factors associated with patient dissatisfaction with asthma treatment at Kaiser ermanente, Northwest Region, a large group-model health maintenance organization with approximately covered lives, centered in ortland, Ore. The study population was selected based on the following criteria: age of 18 years or older, 2 or more anti-asthma medication dispensings in 1996, and/or a hospital or emergency department visit in 1994, 1995, or In addition, all individuals needed to have current health plan coverage as of June The Asthma Therapy Assessment Questionnaire (ATAQ), a 2-page screening questionnaire designed to identify possible disease management problems for patients diagnosed as having asthma, was sent between August and September 1997 to members who met the selection criteria. Additional information about the sampling design can be found elsewhere. 26 Of the 62% of individuals who responded to the survey, we analyzed data for the 5181 individuals (60%) who reported that they had physiciandiagnosed asthma and had taken asthma medications within the past 12 months. Further analysis for this study is based on the results obtained from these 5181 respondents. INSTRUMENTS All data presented herein come from the ATAQ, which was developed as a disease management tool to identify individuals whose asthma management may be suboptimal. This brief, self-administered questionnaire assesses several asthma management domains and levels of asthma control. 26 It also includes several additional items, such as whether the patients have been told by a provider that they have asthma, whether they have been told they have chronic obstructive pulmonary disease(cod), andwhethertheywerecurrentlytakingmedication for asthma. For this study, we examined the relation betweenpatienttreatmentdissatisfactionand3patient-reported measures:(1)levelofasthmacontrol,(2)patient-providercommunication, and (3) belief in medication. atient dissatisfaction was assessed by the question, Are you dissatisfied with any part of your current asthma treatment? atients could respond yes, no, or unsure. We combined the yes and unsure response categories, so patients expressing no dissatisfaction with asthma treatment were distinguished from those who were or might be dissatisfied. To assess level of asthma control, the ATAQ asks about the following: (1) self-perception of asthma control; (2) missed work, school, or normal daily activities due to asthma; (3) nighttime waking due to asthma symptoms; and (4) use of quick relief inhaler medication (defined in terms of the number of puffs a day the patient took the inhaler). All items ask about control in the past 4 weeks. Respondents were assessed as either having or not having a control problem in each of these dimensions, and the number of control problems was then summed to provide an index ranging from 0 to 4. To assess patient-provider communication, the ATAQ asks about the following: (1) physician or medical provider review of medications, (2) physician or medical provider involvement of the patient in decision making, (3) physician or medical provider knowledge of patient medication preferences, (4) patient having an action plan for asthma attacks, and (5) patient having an action plan when not having an asthma attack. Respondents were assessed as either having or not having a patient-provider communication problem in each of these dimensions, and the number of problems was then summed to provide an index ranging from 0 to 5. To assess patients belief in medication, the ATAQ asks about the following: (1) patients belief in the usefulness of their asthma medications to control their asthma and (2) belief that they can take their medications as directed. Respondents were assessed as either having or not having a belief in medication problem in each of these dimensions, and the number of problems was then summed to provide an index ranging from 0 to 2. Most of the questions comprising the asthma control, patient-provider communication, and belief in medications domains had yes, no, and unsure response options. For some questions, a yes indicated a potential problem in asthma management, whereas for other questions the no response was an indicator of a potential asthma management problem. The unsure responses were grouped with the question-specific answer that indicated a potential problem in asthma disease management. STATISTICAL METHODS Bivariate associations were assessed between patient dissatisfaction with their current asthma treatment and each of the individualquestionsthatcomprisetheasthmacontrol, patientprovider communication, and belief in medication domains aswellasthecountofthenumberofproblemsobservedwithin each domain. 2 Tests with continuity corrections were used forthe2 2tables.Mantel-Haenszeltestsfortrendswereused to evaluate treatment dissatisfaction by the number of problems observed within each domain. Other bivariate associations were assessed with a general earson 2 test. Next, we ran a logistic regression analysis of patient dissatisfaction. The logistic model included variables for patient age (18-25, 26-45, 46-55, 56-65, and 65 years), sex, coexistence of COD andindicatorvariablesforthepresenceofasthmacontrolproblems, patient-provider communication problems, and belief in medication problems (one or more issues=1, no issues=0). Odds ratios (ORs) and 95% confidence intervals (CIs) are presented for the logistic regression. A separate logistic regression model was also analyzed to study the influence of theindividualquestionsoftheasthmacontrol, patient-provider communication, and belief in medication domains. by specifically studying whether there is evidence of dissatisfaction with asthma treatment and then identifying processes of care associated with treatment dissatisfaction. In addition, we examine whether dissatisfaction is associated with level of asthma control (an outcome of treatment). The findings from this study provide insights into potential areas that may be targets for quality improvement programs. RESULTS Sixty-seven percent of the respondents were female. The age distribution of the study population was as follows: 36% were 18 to 45 years, 40% were 46 to 65 years, and 24% were older than 65 years. The proportion of the population with both asthma and COD was 19.4%. Overall, 30% of the patients were dissatisfied with their asthma 380

3 Table 2. Association of atient-rovider Communication Issues With Treatment Dissatisfaction* atients, % Asthma Control roblems atient-rovider Communication roblems Belief in Medication roblems Treatment dissatisfaction among patients with asthma disease management problems (asthma control, patient-provider communication, and belief in medication). Asthma control is scored 0 (no problems) to 4 (maximum number of problems assessed). atient-provider communication is scored 0 (no problems) to 5 (maximum number of problems assessed). Belief in medications is scored 0 (no problems) to 2 (maximum number of problems assessed). Data show percentage dissatisfied within each level of disease mangement construct. For example, among patients with 2 belief in medication problems, 79.2% were dissatisfied. Elements of Communication Sample Size Dissatisfied With Treatment, % hysician or medical provider has gone over how to take medications in past year Yes No or unsure hysician or medical provider involves patient in decision making Yes No or unsure hysician or medical provider knows medication preferences Yes No or unsure atient has written treatment plan for asthma attacks Yes No or unsure atient has written treatment plan when not having attack Yes No or unsure Table 1. Association of Asthma Control Issues With Treatment Dissatisfaction* Elements of Asthma Control in ast 4 wk Sample Size Dissatisfied With Treatment, % Felt asthma was controlled Yes No or unsure Missed activities due to asthma Yes or unsure No Woke up at night due to asthma Yes or unsure No Overused quick relief medication Yes No *Boldface responses represent a possible disease management problem. values are based on continuity-adjusted 2 tests. Defined as more than 8 puffs per day for patients with asthma and more than 12 puffs per day for patients with both asthma and chronic obstructive pulmonary disease. *Boldface responses represent a possible disease management problem. values are based on continuity-adjusted 2 tests. Table 3. Association of atient Belief in Medications (Self-efficacy) Issues With Treatment Dissatisfaction* Elements of Self-efficacy Sample Size Dissatisfied With Treatment, % atient believes he/she is able to take medications as directed Yes No or unsure atient believes his/her medication is useful in controlling asthma Yes No or unsure *Boldface responses represent a possible disease management problem. values are based on continuity-adjusted 2 tests. treatment as indicated by a yes or unsure response to the question. The percentage dissatisfied did not vary significantly by patient age (=.10). Men were somewhat more dissatisfied than women (32.1% vs 29.3%, respectively; =.05). A greater percentage of patients with asthma and COD were dissatisfied compared with those without COD (33.5% vs 29.2%, respectively; =.02). The Figure shows the association between the number of asthma disease management problems and patient dissatisfaction with treatment. The proportion of respondents who reported dissatisfaction with their asthma treatment was directly related to increasing numbers of control problems. For example, among those who had no (0) control problems, 16% were dissatisfied, whereas among patients with 4 control problems, 70% were dissatisfied. Similarly, the proportion of patients who reported dissatisfaction increased with increase in communication and belief in medication problems. All 3 associations were significant (=). Tables 1, 2, 3, and 4 explore these associations in greater detail by looking at the association of dissatisfaction with each component of these 3 indices. Analysis of individual asthma control problems (Table 1) revealed more than half of the patients being dissatisfied with their asthma treatment if they thought in the past 4 weeks their asthma was not controlled (58.5%), they missed activities due to asthma (50.5%), or they were high users of quick relief medication (53.9%). Interestingly, only 41.8% of patients waking up at night because of their asthma were dissatisfied with their treatment. In contrast, between 18% and 29% of the patients 381

4 Table 4. Odds Ratios for Dissatisfaction With Asthma Treatment From Multiple Logistic Regression Model Variable Odds Ratio (95% Confidence Interval) atient age, y (Referent) ( ) ( ) ( ) ( ).16 Sex Male 1.00 (Referent) Female 0.82 ( ).009 Coexistence of chronic obstructive pulmonary disease No 1.00 (Referent) Yes 0.84 ( ).12 Asthma control problems (Referent) ( ) atient-provider communication problems (Referent) ( ) Self-efficacy problems (Referent) ( ) were dissatisfied with their treatment when they did not have one of these asthma control problems. Table 2 shows the distribution of patient-provider communication problems. Among all the patientprovider communication issues studied, the highest percentage of treatment dissatisfaction was observed among patients who reported that their physician or medical provider did not involve them in treatment decisions (49.8%) and among patients who reported that their physician or medical provider did not know their medication preferences (46.7%). Table 3 summarizes the association of dissatisfaction with the 2 beliefs in medication issues: ability to take medications as directed and belief that medication is useful in controlling asthma. These 2 problems exhibited the strongest associations with dissatisfaction, with 64.6% and 74.9% of the patients who reported these problems, respectively, indicating dissatisfaction with their current asthma treatment. The presence of asthma control problems, patientprovider communication problems, and belief in medication problems was significantly associated with treatment dissatisfaction in logistic regression analysis that adjusted for patient age, sex, and coexistence of asthma and COD (Table 4). The odds of dissatisfaction with asthma treatment were almost 3 times higher for patients with asthma control issues (OR, 2.8; 95% CI, ; ) and 2 times higher for patients with patientprovider communication issues (OR, 2.0; 95% CI, ; ) compared with patients without these perceived problems. atients with belief in medication issues had an odds of dissatisfaction that was 8 times higher (95% CI, ; ) than patients without these medication problems. The C statistic 27 for the logistic regression model was 0.77, indicating a good fit of the model to the study population. Not shown, a separate logistic regression model was used to analyze the influence of individual components of the asthma control, patient-provider communication, and belief in medication domains. Three items in the patient-provider communication domain were not significantly associated with treatment dissatisfaction: (1) if the physician or medical provider had reviewed medications with the patient in the last year, (2) if the patient had a written treatment plan for asthma attacks, and (3) if the patient had a written treatment plan when not having an asthma attack. All other questions comprising the patient-provider communication domain and all questions of the asthma control and belief in medications domains were significantly associated with treatment dissatisfaction in the direction anticipated. COMMENT Thirty percent of the adult patients with asthma in our study population were dissatisfied with their current asthma treatment. Dissatisfaction was significantly associated with asthma control problems, patient-provider communication problems, and issues with the patients belief in their medication. The findings of this study suggest that important aspects of care are associated with patient dissatisfaction with asthma treatment, implying that evidence of patient dissatisfaction may warrant serious consideration in quality improvement programs. Insufficient knowledge and inappropriate beliefs about asthma are considered major barriers to selfmanagement of asthma. 28,29 Our study suggests that patient confidence in their medications and their ability to take the medications as directed have a profound influence on dissatisfaction with treatment. The odds of treatment dissatisfaction were 8 times higher among patients who reported uncertainty about the efficacy of their asthma medication or their ability to take the medication as directed than those without these disease management problems. Given the current state of asthma treatment, it should be possible to identify regimens that patients believe will control their disease and that they can follow as directed by their providers. The way physicians or medical providers interact with patients appears to have an important influence on patient dissatisfaction. Among patients who believed that they were not involved in decision making, half were dissatisfied with their current treatment. This could be partly because of restriction in time that physicians spend with their patients during a regular visit and current pressure to improve the efficiency of health care provision In another study, assessing the effectiveness of a one-onone nurse education program, Forshee at al 33 found that better patient education and improved communication between patient and provider were associated with decreased urgent care utilization and hospital admission rates. If there is a link between lack of patient-provider communication, dissatisfaction with treatment, and resource use, approaches to improving communication should be explored. Interestingly, lack of written treat- 382

5 ment plans was not associated with treatment dissatisfaction in our multiple logistic regression models. Lieu and colleagues 4 showed that having a written treatment plan is associated with reduced health care utilization. These findings raise the possibility that the verbal communication between the patient and provider that accompanies the treatment plan may be as important as the written document. rovider education and availability of office-based tools such as templates for treatment plans could foster communication and possibly decrease patient dissatisfaction, particularly if actual communication is fostered by having these office-based tools. 15,32 Although patient-provider communication and belief in medications are measures of process of care, level of asthma control is a measure of the outcome of care. In this study, patients with worse clinical outcomes, as measured by asthma control problems, were more dissatisfied with their treatment than patients with better clinical outcomes. A study by Vollmer et al 26 demonstrated the cross-sectional association of asthma control issues with quality of life and self-reported health care utilization. Although the relation between satisfaction and resource use was not assessed in that study, Druss et al, 34 found patient dissatisfaction (in terms of low level of satisfaction) to be associated with health care utilization. The results from these 2 studies indicate the potential for the measures of dissatisfaction to be associated with other important outcomes of care. The findings from this study raise concern about whether or not patients are reluctant to express dissatisfaction with treatment. Not all patients with disease management problems were dissatisfied. For example, about half of the patients with nocturnal asthma did not report dissatisfaction, indicating that perhaps patients with asthma may accept a lower level of functioning than possible. A study by Osman 35 suggests that patients are not always able to raise to their providers all the asthmarelated issues that are important to them. In addition, past studies 9,11 suggest that patients want more information on the nature of their disease and medication use and seek better relationships with their physicians. In this context, a disease management tool such as the ATAQ may be useful to evaluate asthma management problems that may influence treatment dissatisfaction and that can be verified and followed up by a health care provider. The results of this study only represent the perspective and disease management problems experienced by the responders of the survey. Whether the nonresponders are more or less dissatisfied with their current asthma treatment is unknown. Also, the outcome measure (patient dissatisfaction with asthma treatment) and the tools for measuring the 3 disease management constructs are both subjective measures and subject to the same limitations associated with patient-reported data. Although the study results have depicted a distinctive relation between patient dissatisfaction and the 3 asthma disease management constructs, only future research can quantify whether positive steps contributing to improvement in each of these 3 disease management domains can decrease patient dissatisfaction. In addition, disease management constructs (such as patient concern with involvement in decision making) may be another measure of dissatisfaction. There is not a clear conceptual framework for the factors that influence patient dissatisfaction with asthma treatment. It is possible that other important factors associated with treatment dissatisfaction were not measured in this study. Apart from marketing research, patient satisfaction is increasingly being used as an outcome measure for clinical trials and disease management programs, 36 and further consideration should be given to the distinctions between measures of satisfaction and evidence of dissatisfaction. This study has highlighted the fact that patient dissatisfaction can reflect poor disease outcome (ie, poor asthma control), problems with the process of care (in terms of communication issues such as physician understanding of patient preference), and problems related to the patients belief in their medication. The findings further support the idea that concentrating on more personal care would result in better communication and more patient involvement, resulting in better quality of care and hence decreased patient dissatisfaction. 37 Overall, our findings suggest that when patients express dissatisfaction with current asthma treatment, there may be disease management problems that can be rectified to potentially improve patient outcomes. Accepted for publication August 31, Corresponding author and reprints: Leona E. Markson, ScD, Outcomes Research and Management, Merck & Co, Inc, O Box 4, W39-164, West oint, A REFERENCES 1. Mannino DM, Homa DM, ertowski CA, et al. Surveillance for asthma: United States, MMWR Morb Mortal Wkly Rep. 1998;47(No. SS-1):1. 2. Smith DH, Malone DC, Lawson KA, Okamoto LJ, Battista C, Saunders WB. A national estimate of the economic costs of asthma. Am J Respir Crit Care Med. 1997;156: Sullivan S, Elixhauser A, Buist AS, Luce BR, Eisenberg J, Weiss KB. National Asthma Education and revention rogram Working Group report on the cost effectiveness of asthma care. Am J Respir Crit Care Med. 1996;154:S84-S Lieu TA, Quesenberry C Jr, Capra AM, Sorel ME, Martin KE, Mendoza GR. Outpatient management practices associated with reduced risk of pediatric asthma hospitalization and emergency department visits. ediatrics. 1997;100: Rupp MT, McCallian DJ, Sheth KK. Developing and marketing a community pharmacy-based asthma management program. J Am harm Assoc (Wash). 1997; NS37: Greineder DK, Loane K, arks. Outcomes for control patients referred to a pediatric asthma outreach program: an example of the Hawthorne effect. Am J Managed Care. 1998;4: Kravitz RL, Zwanziger J, Hosek S, olich S, Sloss E, McCaffrey D. Effect of a large managed care program on emergency department use: results from the CHAM- US reform initiative evaluation. Ann Emerg Med. 1998;31: Stout JW, White LC, Rogers LT, et al. The Asthma Outreach roject: a promising approach to comprehensive asthma management. J Asthma. 1998;35: Koning CJ, Maille AR, Stevens I, Dekker FW. atients opinions on respiratory care: do doctors fulfill their needs? J Asthma. 1995;32: Blaiss MS. Outcomes analysis in asthma. JAMA. 1997;278: Clark NM, Nothwehr F. Self-management of asthma by adult patients. atient Educ Counseling. 1997;32(1 suppl):s5-s Knoell DL, ierson JF, Marsh CB, Allen JN, athak DS. Measurement of outcomes in adults receiving pharmaceutical care in a comprehensive asthma outpatient clinic. harmacotherapy. 1998;18: Druss BG, Rosenheck RA, Stolar M. atient satisfaction and administrative measures as indicators of the quality of mental health care. sychiatr Serv. 1999; 50:

6 14. Mayer T, Cates RJ. Service excellence in health care. JAMA. 1999;282: Raper J, Davis BA, Scott L. atient satisfaction with emergency department triage nursing care: a multicenter study. J Nurs Care Qual. 1999;13: Rydman RJ, Roberts RR, Albrecht GL, Zalenski RJ, McDermott M. atient satisfaction with an emergency department asthma observation unit. Acad Emerg Med. 1999;6: Schlesinger M, Druss B, Thomas T. No exit? the effect of health status on dissatisfaction and disenrollment from health plans. Health Serv Res. 1999;34: Tomlin Z, Humphrey C, Rogers S. General practitioners perceptions of effective health care. BMJ. 1999;318: Dalzell MD. Health care report cards: are you paying attention? Managed Care. 1999;8:27-28, 30-32, Grumbach K, Selby JV, Schmittdiel JA, Quesenberry C Jr. Quality of primary care practice in a large HMO according to physician specialty. Health Serv Res. 1999;34: Simon L, Belman MJ, Tom E, Rideout J. rovider group characteristics and quality report card performance: a cross-sectional study in a managed care setting. Am J Med Qual. 1999;14: Foundation for Accountability. HEDIS outcomes may not be the only ones you need to benchmark. Healthcare Benchmarks. 1997;4(6): Graham J. FACCT (Foundation for Accountability): a large measure of quality. J AHIMA. 1997;68: Kippen LS, Strasser S, Joshi M. Improving the quality of the NCQA (National Committee for Quality Assurance) annual member health care survey version 1.0. Am J Managed Care. 1997;3: Buchner DA, robst LY. The member satisfaction survey as a measure of health plan accountability. Qual Managed Health Care. 1999;7: Vollmer WM, Markson LE, O Connor E, et al. Association of asthma control with health care utilization and quality of life. Am J Respir Crit Care Med. 1999;160: Hanley JA, McNeil BJ. The meaning and use of area under a receiver operating characteristic (ROC) curve. Radiology. 1982;143: Bauman AE, Craig AR, Dunsmore J, Browne G, Allen DH, Vandenberg R. Removing barriers to effective self-management of asthma. atient Educ Counseling. 1989;14: Katz, Yelin EH, Smith S, Blanc D. erceived control of asthma: development and validation of a questionnaire. Am J Respir Crit Care Med. 1997;155: Hornberger JC, Habrake H, Bloch DA. Minimum data needed on patient preferences for accurate, efficient medical decision making. Med Care. 1995;33: Kaplan SH, Gandek B, Greenfield S, Rogers W, Ware JE. atient and visit characteristics related to physicians participatory decision-making style: results from the Medical Outcomes Study. Med Care. 1995;33: Stewart M, Brown JB, Boon H, Galajda J, Meredith L, Sangster M. Evidence on patient-doctor communication. Cancer rev Control. 1999;3: Forshee JD, Whalen EB, Hackel R, et al. The effectiveness of one-on-one nurse education on the outcomes of high-risk adult and pediatric patients with asthma. Managed Care Interface. 1998;11: Druss BG, Rosenheck RA, Stolar M. atient satisfaction and administrative measures as indicators of the quality of mental health care. sychiatr Serv. 1999; 50: Osman L. The patient perspective: what should a new anti-asthma agent provide? Drugs. 1996;52(suppl 6): Weaver M, atrick DL, Markson LE, Martin D, Frederic I, Berger M. Issues in the measurement of satisfaction with treatment. Am J Managed Care. 1997;3: Cleary D, McNeil BJ. atient satisfaction as an indicator of quality care. Inquiry. 1988;25: