Patients' preferences for technical versus interpersonal quality when selecting a primary care physician

Health Services Research, August, 2005 by Constance H. Fung, Marc N. Elliott, Ron D. Hays, Katherine L. Kahn, David E. Kanouse, Elizabeth A. McGlynn, Mark D. Spranca, Paul G. Shekelle

The release of performance data about health care providers to the public as a means of improving quality of care has been advocated by government agencies such as the Centers for Medicare and Medicaid Services (CMS), nonprofit accreditation organizations such as the National Committee for Quality Assurance (NCQA), and private sector organizations such as the Leapfrog Group (National Committee for Quality Assurance 2003; The Leapfrog Group Purchasers 2003, Centers for Medicare and Medicaid Services 2004). In theory, increased access to information about providers will produce better-informed consumers and set the stage for quality improvement (Marshall et al. 2000). These consumers who have information about the quality of prospective providers will tend to select providers who deliver care of higher quality, increasing the market share of high-quality providers and creating incentives for improving quality of care (Marshall et al. 2000). Convincing consumers that quality problems are real and improving the dissemination of quality information are among other important considerations in this conceptual framework (Shaller et al. 2003).

Report cards that summarize performance data are widely available for health plans (The Pacific Business Group on Health 2003; United States Office of Personnel Management 2003a; Centers for Medicare and Medicaid Services 2004) and hospitals (The Pacific Business Group on Health 2003; U.S. News and World Report 2003), but not individual providers. However, there is increasing interest in the use of physician performance measures. For example, CMS is developing physician-level performance measures as part of the Doctor's Office Quality project (Centers for Medicare and Medicaid Services 2003). The Consumer Assessment of Health Plans Survey (CAHPS[R]) investigators are also developing survey instruments to assess individual physicians and physician groups (Solomon et al. 2005; Hays et al. 2003; Agency for Healthcare Research and Quality 2004a). Because individual provider-level information is potentially more salient and directly applicable to patients (Schauffler and Mordavsky 2001; Gandhi et al. 2002), patients may use report cards of individual providers more extensively than they use existing report cards.

The effectiveness of physician-specific report cards will depend, in part, on their content and the relevance of the information to consumers (Shaller et al. 2003). In theory, report cards could contain information about technical and/or interpersonal quality, and this information could come from a variety of sources. Thus far, however, report cards on individual providers have been largely limited to reporting surgical mortality data (Damberg, Chung, and Steimle 2001; Pennsylvania Health Care Cost Containment Council 2002; New York State Department of Health 2003). These report cards are based on data collected from systems or records and emphasize patient outcomes that depend on technical aspects of care. Survey-based tools to evaluate patients' experiences with primary care physicians are another potential source information (Safran et al. 1998). Report cards that summarize patients' assessments for other consumers have been developed as part of CAHPS (Farley et al. 2002; CAHPS-SUN 2003). Although some Supplemental CAHPS questions clearly focus on technical aspects of care (e.g., Have you had a flu shot in the past 12 months?) (CAHPS-SUN 2003), CAHPS and other survey-based tools emphasize interpersonal over technical aspects of care. Focus groups and interviews conducted as part of CAHPS demonstrated early on that consumers were most interested in consumers' reports about aspects of care such as communication and respectful relationships (CAHPS-SUN 2003). Future report cards of individual providers may include measures of technical quality, measures of interpersonal quality, or a mixture of both types of measures. Greater understanding of patients' values for technical and interpersonal quality may improve the content and relevance of provider report cards and help providers improve the quality of their practice.

Previous studies have helped us understand the values patients place on technical and interpersonal quality in a primary care setting. Wensing et al. (1998) reviewed the literature on patient priorities for general practice care and found that both technical and interpersonal quality are important to patients. Studies that go beyond assessing attitudes to elicit patient choices are important, because "separate attitudes to two objects do not necessarily predict the outcome of a choice or direct comparison between them" (Kahneman, Ritov, and Schkade 2000). Few studies have examined how patients would set priorities, if forced to make choices or tradeoffs between technical and interpersonal quality in the primary care setting (Fletcher et al. 1983; Jung et al. 1998; Wensing et al. 1998). Without concrete information about technical quality, patients may perceive that they are receiving high-quality technical care if their provider has strong interpersonal skills (Ware and Williams 1975). No studies have assessed patient priorities in the context of report cards, which have the capability of providing patients with information about both the interpersonal and technical quality of a prospective physician.