Improving the overall patient care experience is an essential focus for organizations as healthcare delivery continues to evolve. The US Department of Health & Human Services Agency for Healthcare Research and Quality (AHRQ) notes patient experience as an integral component of healthcare quality, which includes “several aspects of healthcare delivery that patients value highly when they seek and receive care, such as getting timely appointments, easy access to information, and good communication with healthcare providers.” A recent Medical Care article by Collins, Haas, Haviland, and Elliott reviewed data from Medicare beneficiaries 65 and older to evaluate how five major domains of patient experience vary by race, ethnicity, and language. The five domains include doctor communication, getting needed care, getting care quickly, customer service, and care coordination. The authors created measures of race, ethnicity, and language using self-reported race, Hispanic ethnicity, and language of survey response. The study concludes that “quality improvement efforts will need to pay attention to diversity… [and] that policies to improve patient experience may be more effective if tailored to the patient population at a given practice or hospital.” Of note, getting needed care and getting care quickly are the domains with the strongest associations for quality care among all subgroups.
According to Collins and colleagues, the “greatest improvement for the broadest set of patients is likely to be achieved by addressing access issues.” There are many reasons access continues to be a problem for many people. A recent study commissioned by the Association of American Medical Colleges (AAMC) notes an estimated shortage of between 8,700 and 43,100 primary care physicians by 2030, potentially exacerbating low supply of providers in many areas. As a primary care physician from Appalachia, access to care for persons in rural America is a particularly poignant concern for me. As part of the Rural Primary Care Track in medical school, I had the opportunity to learn medicine in areas where healthcare access was often insufficient. Most notably, access to mental healthcare in rural Appalachia is limited. A patient case that I’ll always remember . . . It was Friday afternoon, and the last clinic patient of the day was a middle-aged man from rural Appalachia who had long struggled with major depressive disorder. He presented to the clinic severely depressed and with passive suicidal ideation. His daughter had died by suicide the month prior, and he had also made multiple suicide attempts in the past. He desperately wanted (and needed) a psychologist and an acute care facility that could care for his mental health concerns. However, he had no health insurance, limited access to transportation, and there were no mental health providers in the region. Left with very few options, my supervising physician increased the patient’s antidepressant medication dose and sent him home. As seen in this scenario, when access is limited and uninsured rates are high, communities suffer.
Collins and colleagues note that innovative solutions, such as telehealth visits, may improve access to healthcare. This is of particular importance in rural areas. The middle-aged man with depression in the case noted previously could likely have greatly benefited from telehealth visits with a therapist–care that is otherwise not available in his region. Furthermore, while much has been written about the use of telehealth for certain conditions, such as stroke, cardiac care, and behavioral health[PDF], less has been written about its potential to improve access to reproductive healthcare. Increasing numbers of states are attempting to enact TRAP (Targeted Regulation of Abortion Providers) laws that ultimately “increase the cost and scarcity of abortion services. . . [and] jeopardize women’s access to safe, legal, high-quality reproductive healthcare.” Thus, access to abortion care is of critical concern. Grossman and Grindlay recently published research that notes “adverse events are rare with medical abortion, and telemedicine provision is not inferior to in-person provision with regard to clinically significant adverse events.” Clearly, healthcare access is vital, and telemedicine is an innovative solution that can be used to address quality.
Additionally, Collins and colleagues note that different groups of persons have varying thoughts about what constitutes good quality of care. For example, for Caucasians and Latinos surveyed in English, skilled physician communication is critical. For Asian/Pacific Islander patient populations and Latinos with a Spanish language preference, access to healthcare is of primary importance. For African-Americans, skilled physician communication, access to care, and coordination of care play nearly equal roles. As a primary care physician who now works primarily with immigrant populations in Boston, I agree that access to care is of fundamental importance. However, I would also note that the ability to communicate with patients in their preferred language is vital. Excellent healthcare requires that providers communicate with their patients and vice versa. Thus, supportive services, such as interpreter services, must be considered when discussing access to care.
Ultimately, quality improvement efforts in healthcare will need to pay attention to diversity and be tailored to the patient populations that are served at given clinics or hospital systems. Access to care is key for all patient populations, but myriads of other factors also play a role in quality measures.