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South Med J. Author manuscript; available in PMC 2016 June 01. Published in final edited form as: South Med J. 2015 June ; 108(6): 372–376. doi:10.14423/SMJ.0000000000000300.
Incorporating Patient Satisfaction Metrics in Assessing Multidisciplinary Breast Cancer Care Quality
Author Manuscript
Jennifer L. Harper, MD, Anna-Maria A. De Costa, MD, PhD, Elizabeth Garrett-Mayer, PhD, and Katherine R. Sterba, PhD Department of Radiation Oncology and the College of Medicine, Medical University of South Carolina, Charleston, and the Biostatistics Shared Resource and the Department of Public Health Sciences, Hollings Cancer Center, Charleston, South Carolina.
Abstract Objectives—The Medical University of South Carolina implemented a patient-centered multidisciplinary breast clinic program (MDBC) in August 2012. In this study, patient satisfaction with MDBC care delivery model and communication with healthcare providers was examined to inform the refinement of the MDBC program. Methods—During the first 10 months of the MDBC, patients were asked to complete a 14question postconsultation telephone survey. A statistical analysis was performed to explore potential associations between age, race, and stage with overall patient satisfaction scores.
Author Manuscript
Results—Overall, patients (N = 52, 56% white, 42% African American, 2% Hispanic; mean age 61 years) rated the quality of care highly (mean 4.7, range [1 = poor to 5 = excellent]) and felt comfortable with their plan of care (mean 1.63, range [1 = extremely comfortable to 5 = not at all comfortable]). No statistically significant differences in overall satisfaction were found by age, race, or stage; however, patient responses were commonly not optimal (ie, either “no” or “yes, but not as much as I would like”) when asked if the care team addressed the impact of their diagnosis on personal relationships (40.4%) or emotional health (28.9%). Conclusions—Patients were highly satisfied with the care they received in the MDBC program. Findings suggest that this model is well suited to a diverse patient population and have highlighted quality improvement targets such as increased emphasis on providers’ communication about psychosocial issues.
Author Manuscript
Keywords breast cancer; quality improvement; patient satisfaction The Institute of Medicine’s report on the quality of US cancer care asserts, “Cancer care is often not as patient-centered, accessible, coordinated, or evidence based as it could be,
Correspondence to Dr Jennifer L. Harper, 169 Ashley Ave, MSC 318, Charleston, SC 29425. [email protected]. To purchase a single copy of this article, visit sma.org/southern-medical-journal. To purchase larger reprint quantities, please contact [email protected]. The research was presented in poster form at the 2013 American Society of Clinical Oncology Quality Improvement Symposium, San Diego, California.
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detrimentally impacting patients.”1 This report defines six components of a high quality cancer care delivery system: engaged patients; an adequately staffed, trained, and coordinated workforce; evidence-based cancer care; a learning healthcare information technology system; translation of evidence into clinical practice, quality improvement, and performance improvement; and accessible, affordable cancer care.1
Author Manuscript
In an effort to incorporate these high quality cancer care elements, a new model for breast cancer care delivery was implemented at the Medical University of South Carolina (MUSC) in August 2012, based on the model examined and reviewed by Fennell et al.2 In the multidisciplinary breast clinic (MDBC) model, the MDBC team meets weekly for a morning tumor board to prospectively review all new patients being seen in clinic that day. The MDBC team includes representatives from the medical specialties of medical oncology, surgical oncology, radiation oncology, pathology, radiology, and psychology. The team also includes genetic counselors, nurse navigators, and patient navigators, and community health workers who help address logistic and sociocultural barriers to care.
Author Manuscript
In preparation for a patient consultation with the MDBC team, the nurse navigators facilitate the collection of all relevant imaging, pathology, and medical records. The nurse navigators contact patients to coordinate appointments and to introduce the MDBC model of care. All patients’ medical records are placed in the institutional electronic medical record system and are made available for all MDBC team members to review. All imaging and pathology collected outside MUSC undergo review by the MDBC’s radiologist and pathologist before the meeting of the tumor board. The tumor board moderator, typically the surgical oncologist, presents the patient to the group with a brief summary of the oncologic presentation and pertinent medical history. The MDBC’s radiologist and pathologist present their diagnostic findings.
Author Manuscript
Recommendations for additional diagnostic studies are made and scheduled. Medical, surgical, and radiation oncologists have the opportunity to arrive at a consensus on treatment approaches before speaking with the patients, during consultation visits, which are held on the same day, in one location. Patients are screened for clinical trial eligibility and the need for genetic counseling, based on the National Comprehensive Cancer Network guidelines. If there are known barriers to compliance with care, the patient navigators are scheduled to meet with the patient during their MDBC visit. The tumor board also is a forum for the coordination of care as patients transition from one treatment modality to the next. For example, the MDBC team members review the pathologic findings for patients having recently completed surgery and make recommendations for adjuvant treatments based on those findings. The nurse navigators document the care plan decisions and the patient’s cancer stage in the electronic medical record. The nurse navigators ensure the patients are scheduled with the appropriate MDBC team members based on the tumor board’s recommended treatment plan. Patient consultations with the MBDC team begin immediately following tumor board. Patients are stationed in an examination room and all scheduled providers rotate in and out of each patient’s room. Patients have the opportunity to express their goals and desires for
South Med J. Author manuscript; available in PMC 2016 June 01.
Harper et al.
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Author Manuscript
their treatment during the consultation, and because of the physical proximity of the care team, this information is immediately conveyed to all members. To assess progress in improving the delivery of cancer care through the MDBC model, a 14question postconsultation telephone survey was developed to evaluate patient satisfaction with multiple aspects of their clinic experience. This study aimed to examine satisfaction with the MDBC model; identify any potential differences in satisfaction across age groups; cancer stages; or race; and to inform the future refinement of the MDBC program.
Methods
Author Manuscript
During the first 10 months of the MDBC, patients were asked to complete a postconsultation telephone survey assessing satisfaction with care quality, the clinical team, and various aspects of the MDBC model. Using five questions adapted from previous research, we assessed patients’ overall satisfaction with care, as well as satisfaction with various aspects of the MDBC model (eg, time, explanation of treatment options, communication about practical and psychosocial factors).3 Seven questions were used to evaluate how participants rated their interactions with the MDBC providers and to what extent the communication about practical and emotional factors met their needs. These questions focused on key elements of physician communication behavior in cancer care.4 One question was developed to examine how comfortable participants were with their plan of care after the MDBC visit, and one question was designed to rate patients’ perception of the overall quality of care received. Demographic and clinical data were abstracted from the medical record following MUSC institutional review board approval of the research proposal. Information was stored using REDCap (Research Electronic Data Capture, Vanderbilt University, Nashville, TN).5 Statistical analysis was performed using R version 3.0.2 (R Foundation, Vienna, Austria). Parameter estimates were estimated using summary statistics (means, proportion) and potential associations of age, race, and stage with overall patient satisfaction scores were evaluated using linear regression (age, stage) and Wilcoxon rank sum test (race).
Author Manuscript
Results A total of 52 patients completed the telephone survey. Of these, 29 (56%) were white, 22 (42%) were African American, and 1 (2%) was Hispanic. The age of patients ranged from 29 to 85 years, with a mean age of 61 years. The majority of these patients were diagnosed as having a stage II or less advanced cancer, with 13 (25%) having stage 0, 16 (31%) having stage I, 16 (31%) having stage II, 5 (10%) having stage III, and 1 (2%) having stage IV breast cancer.
Author Manuscript
Overall, there was high satisfaction with care. In questions with answer choices ranging from 1 (not at all satisfied) to 4 (extremely satisfied), the MDBC team scored an average of 3.67 (95% confidence interval [CI] 3.50–3.84) in how they helped patients understand their medical condition, 3.67 (95% CI 3.49–3.85) in how they explained treatment options, 3.69 (95% CI 3.55–3.83) in time that patients were able to spend with clinical providers, 3.65 (95% CI 3.49–3.81) in caring for the patient as an individual, and 3.77 (95% CI 3.65–3.89) in overall satisfaction with the MDBC team (Fig. 1). In questions with answer choices of 0
South Med J. Author manuscript; available in PMC 2016 June 01.
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(no, not at all), 1 (yes, but not as much as I wanted), 2 (yes, almost as much as I wanted), and 3 (yes, as much as I wanted), patients reported an average score of 2.75 (95% CI 2.60– 2.90) in physicians’ understanding of patients’ needs, an average score of 2.88 (95% CI 2.78–2.98) in the belief that the treatment staff worked together toward the same goal, and an average score of 2.82 (95% CI 2.69–2.95) in the feeling that patients had enough time to talk to each of their physicians (Fig. 1). Regarding questions with the same answer choices, however, the MDBC team received somewhat lower mean scores in areas such as discussion into how health and treatment may affect normal work (mean 2.18; 95% CI 1.86–2.50), normal daily activities (mean 2.24; 95% CI 1.93–2.55), personal relationships (mean 1.71; 95% CI 1.34–2.08), and emotions (mean 2.10; 95% CI 1.75–2.45; Fig. 1). In the penultimate question with answer choices ranging from 1 (extremely comfortable) to 5 (not at all comfortable), patients reported a mean score of 1.63 (95% CI 1.41–1.85) in how comfortable they were with their plan of care (Fig. 1). In the final question with answer choices of 1 (poor) to 5 (excellent), patients reported a mean score of 4.67 (95% CI 4.50– 4.84) for the quality of care received during the initial MDBC consultation visit (Fig. 1).
Author Manuscript
Analysis of average scores for each question among patients of different race, stage, or age revealed no statistically significant differences in overall satisfaction. White women reported an average score of 4.79 out of 5 (95% CI 4.64–4.94), while African American women reported an average score of 4.5 out of 5 (95% CI 4.16–4.84; P = 0.17) for overall quality of care with the MDBC model (Fig. 2). For the same question, women with stage 0 cancer reported an average score of 4.77 (95% CI 4.44–5), women with stage 1 cancer reported an average score of 4.88 (95% CI 4.71–5), women with stage 2 cancer reported an average score of 4.5 (95% CI 4.10–4.90), and women with stage 3 cancer reported an average score of 4.20 (95% CI 3.81–4.59). Because only one woman with stage 4 cancer answered the survey, these results were not included in the analysis. The P value for a test of trend for the overall quality of care by stage was not significant (P = 0.17; Fig. 2). The correlation coefficient between age and quality of care score was 0.13, with a P value of 0.35 (Fig. 2).
Discussion
Author Manuscript
Overall, patients are highly satisfied with the care they receive at the MDBC, and findings suggest that this model is well suited to a diverse patient population; however, the results also revealed relatively lower satisfaction scores regarding the extent to which the care team addressed psychosocial issues, which may result from a number of factors. First, these issues may not be addressed at length during the initial consultation because of the volume of information pertaining to diagnosis and treatment that must be conveyed in the first visit. Because some patients require further diagnostic studies, the clinicians may not always have the information required to counsel these patients at the initial visit about how the treatment may affect their health-related quality of life. Whatever the cause, these data identify providers’ communication about psychosocial issues as an area for improvement in the care model. In response to the findings of this analysis, measures have been undertaken to improve the communication regarding psychosocial issues by implementing universal screening with the Distress Thermometer.6 The Distress Thermometer is a widely used single-item validated
South Med J. Author manuscript; available in PMC 2016 June 01.
Harper et al.
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Author Manuscript
instrument in which patients report on a scale of 0 to 10 the level of distress they have been experiencing during the past week.7 Scores on the Distress Thermometer ≥4 are reflective of clinically significant distress. Patient with scores
South Med J. Author manuscript; available in PMC 2016 June 01. Published in final edited form as: South Med J. 2015 June ; 108(6): 372–376. doi:10.14423/SMJ.0000000000000300.
Incorporating Patient Satisfaction Metrics in Assessing Multidisciplinary Breast Cancer Care Quality
Author Manuscript
Jennifer L. Harper, MD, Anna-Maria A. De Costa, MD, PhD, Elizabeth Garrett-Mayer, PhD, and Katherine R. Sterba, PhD Department of Radiation Oncology and the College of Medicine, Medical University of South Carolina, Charleston, and the Biostatistics Shared Resource and the Department of Public Health Sciences, Hollings Cancer Center, Charleston, South Carolina.
Abstract Objectives—The Medical University of South Carolina implemented a patient-centered multidisciplinary breast clinic program (MDBC) in August 2012. In this study, patient satisfaction with MDBC care delivery model and communication with healthcare providers was examined to inform the refinement of the MDBC program. Methods—During the first 10 months of the MDBC, patients were asked to complete a 14question postconsultation telephone survey. A statistical analysis was performed to explore potential associations between age, race, and stage with overall patient satisfaction scores.
Author Manuscript
Results—Overall, patients (N = 52, 56% white, 42% African American, 2% Hispanic; mean age 61 years) rated the quality of care highly (mean 4.7, range [1 = poor to 5 = excellent]) and felt comfortable with their plan of care (mean 1.63, range [1 = extremely comfortable to 5 = not at all comfortable]). No statistically significant differences in overall satisfaction were found by age, race, or stage; however, patient responses were commonly not optimal (ie, either “no” or “yes, but not as much as I would like”) when asked if the care team addressed the impact of their diagnosis on personal relationships (40.4%) or emotional health (28.9%). Conclusions—Patients were highly satisfied with the care they received in the MDBC program. Findings suggest that this model is well suited to a diverse patient population and have highlighted quality improvement targets such as increased emphasis on providers’ communication about psychosocial issues.
Author Manuscript
Keywords breast cancer; quality improvement; patient satisfaction The Institute of Medicine’s report on the quality of US cancer care asserts, “Cancer care is often not as patient-centered, accessible, coordinated, or evidence based as it could be,
Correspondence to Dr Jennifer L. Harper, 169 Ashley Ave, MSC 318, Charleston, SC 29425. [email protected]. To purchase a single copy of this article, visit sma.org/southern-medical-journal. To purchase larger reprint quantities, please contact [email protected]. The research was presented in poster form at the 2013 American Society of Clinical Oncology Quality Improvement Symposium, San Diego, California.
Harper et al.
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Author Manuscript
detrimentally impacting patients.”1 This report defines six components of a high quality cancer care delivery system: engaged patients; an adequately staffed, trained, and coordinated workforce; evidence-based cancer care; a learning healthcare information technology system; translation of evidence into clinical practice, quality improvement, and performance improvement; and accessible, affordable cancer care.1
Author Manuscript
In an effort to incorporate these high quality cancer care elements, a new model for breast cancer care delivery was implemented at the Medical University of South Carolina (MUSC) in August 2012, based on the model examined and reviewed by Fennell et al.2 In the multidisciplinary breast clinic (MDBC) model, the MDBC team meets weekly for a morning tumor board to prospectively review all new patients being seen in clinic that day. The MDBC team includes representatives from the medical specialties of medical oncology, surgical oncology, radiation oncology, pathology, radiology, and psychology. The team also includes genetic counselors, nurse navigators, and patient navigators, and community health workers who help address logistic and sociocultural barriers to care.
Author Manuscript
In preparation for a patient consultation with the MDBC team, the nurse navigators facilitate the collection of all relevant imaging, pathology, and medical records. The nurse navigators contact patients to coordinate appointments and to introduce the MDBC model of care. All patients’ medical records are placed in the institutional electronic medical record system and are made available for all MDBC team members to review. All imaging and pathology collected outside MUSC undergo review by the MDBC’s radiologist and pathologist before the meeting of the tumor board. The tumor board moderator, typically the surgical oncologist, presents the patient to the group with a brief summary of the oncologic presentation and pertinent medical history. The MDBC’s radiologist and pathologist present their diagnostic findings.
Author Manuscript
Recommendations for additional diagnostic studies are made and scheduled. Medical, surgical, and radiation oncologists have the opportunity to arrive at a consensus on treatment approaches before speaking with the patients, during consultation visits, which are held on the same day, in one location. Patients are screened for clinical trial eligibility and the need for genetic counseling, based on the National Comprehensive Cancer Network guidelines. If there are known barriers to compliance with care, the patient navigators are scheduled to meet with the patient during their MDBC visit. The tumor board also is a forum for the coordination of care as patients transition from one treatment modality to the next. For example, the MDBC team members review the pathologic findings for patients having recently completed surgery and make recommendations for adjuvant treatments based on those findings. The nurse navigators document the care plan decisions and the patient’s cancer stage in the electronic medical record. The nurse navigators ensure the patients are scheduled with the appropriate MDBC team members based on the tumor board’s recommended treatment plan. Patient consultations with the MBDC team begin immediately following tumor board. Patients are stationed in an examination room and all scheduled providers rotate in and out of each patient’s room. Patients have the opportunity to express their goals and desires for
South Med J. Author manuscript; available in PMC 2016 June 01.
Harper et al.
Page 3
Author Manuscript
their treatment during the consultation, and because of the physical proximity of the care team, this information is immediately conveyed to all members. To assess progress in improving the delivery of cancer care through the MDBC model, a 14question postconsultation telephone survey was developed to evaluate patient satisfaction with multiple aspects of their clinic experience. This study aimed to examine satisfaction with the MDBC model; identify any potential differences in satisfaction across age groups; cancer stages; or race; and to inform the future refinement of the MDBC program.
Methods
Author Manuscript
During the first 10 months of the MDBC, patients were asked to complete a postconsultation telephone survey assessing satisfaction with care quality, the clinical team, and various aspects of the MDBC model. Using five questions adapted from previous research, we assessed patients’ overall satisfaction with care, as well as satisfaction with various aspects of the MDBC model (eg, time, explanation of treatment options, communication about practical and psychosocial factors).3 Seven questions were used to evaluate how participants rated their interactions with the MDBC providers and to what extent the communication about practical and emotional factors met their needs. These questions focused on key elements of physician communication behavior in cancer care.4 One question was developed to examine how comfortable participants were with their plan of care after the MDBC visit, and one question was designed to rate patients’ perception of the overall quality of care received. Demographic and clinical data were abstracted from the medical record following MUSC institutional review board approval of the research proposal. Information was stored using REDCap (Research Electronic Data Capture, Vanderbilt University, Nashville, TN).5 Statistical analysis was performed using R version 3.0.2 (R Foundation, Vienna, Austria). Parameter estimates were estimated using summary statistics (means, proportion) and potential associations of age, race, and stage with overall patient satisfaction scores were evaluated using linear regression (age, stage) and Wilcoxon rank sum test (race).
Author Manuscript
Results A total of 52 patients completed the telephone survey. Of these, 29 (56%) were white, 22 (42%) were African American, and 1 (2%) was Hispanic. The age of patients ranged from 29 to 85 years, with a mean age of 61 years. The majority of these patients were diagnosed as having a stage II or less advanced cancer, with 13 (25%) having stage 0, 16 (31%) having stage I, 16 (31%) having stage II, 5 (10%) having stage III, and 1 (2%) having stage IV breast cancer.
Author Manuscript
Overall, there was high satisfaction with care. In questions with answer choices ranging from 1 (not at all satisfied) to 4 (extremely satisfied), the MDBC team scored an average of 3.67 (95% confidence interval [CI] 3.50–3.84) in how they helped patients understand their medical condition, 3.67 (95% CI 3.49–3.85) in how they explained treatment options, 3.69 (95% CI 3.55–3.83) in time that patients were able to spend with clinical providers, 3.65 (95% CI 3.49–3.81) in caring for the patient as an individual, and 3.77 (95% CI 3.65–3.89) in overall satisfaction with the MDBC team (Fig. 1). In questions with answer choices of 0
South Med J. Author manuscript; available in PMC 2016 June 01.
Harper et al.
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(no, not at all), 1 (yes, but not as much as I wanted), 2 (yes, almost as much as I wanted), and 3 (yes, as much as I wanted), patients reported an average score of 2.75 (95% CI 2.60– 2.90) in physicians’ understanding of patients’ needs, an average score of 2.88 (95% CI 2.78–2.98) in the belief that the treatment staff worked together toward the same goal, and an average score of 2.82 (95% CI 2.69–2.95) in the feeling that patients had enough time to talk to each of their physicians (Fig. 1). Regarding questions with the same answer choices, however, the MDBC team received somewhat lower mean scores in areas such as discussion into how health and treatment may affect normal work (mean 2.18; 95% CI 1.86–2.50), normal daily activities (mean 2.24; 95% CI 1.93–2.55), personal relationships (mean 1.71; 95% CI 1.34–2.08), and emotions (mean 2.10; 95% CI 1.75–2.45; Fig. 1). In the penultimate question with answer choices ranging from 1 (extremely comfortable) to 5 (not at all comfortable), patients reported a mean score of 1.63 (95% CI 1.41–1.85) in how comfortable they were with their plan of care (Fig. 1). In the final question with answer choices of 1 (poor) to 5 (excellent), patients reported a mean score of 4.67 (95% CI 4.50– 4.84) for the quality of care received during the initial MDBC consultation visit (Fig. 1).
Author Manuscript
Analysis of average scores for each question among patients of different race, stage, or age revealed no statistically significant differences in overall satisfaction. White women reported an average score of 4.79 out of 5 (95% CI 4.64–4.94), while African American women reported an average score of 4.5 out of 5 (95% CI 4.16–4.84; P = 0.17) for overall quality of care with the MDBC model (Fig. 2). For the same question, women with stage 0 cancer reported an average score of 4.77 (95% CI 4.44–5), women with stage 1 cancer reported an average score of 4.88 (95% CI 4.71–5), women with stage 2 cancer reported an average score of 4.5 (95% CI 4.10–4.90), and women with stage 3 cancer reported an average score of 4.20 (95% CI 3.81–4.59). Because only one woman with stage 4 cancer answered the survey, these results were not included in the analysis. The P value for a test of trend for the overall quality of care by stage was not significant (P = 0.17; Fig. 2). The correlation coefficient between age and quality of care score was 0.13, with a P value of 0.35 (Fig. 2).
Discussion
Author Manuscript
Overall, patients are highly satisfied with the care they receive at the MDBC, and findings suggest that this model is well suited to a diverse patient population; however, the results also revealed relatively lower satisfaction scores regarding the extent to which the care team addressed psychosocial issues, which may result from a number of factors. First, these issues may not be addressed at length during the initial consultation because of the volume of information pertaining to diagnosis and treatment that must be conveyed in the first visit. Because some patients require further diagnostic studies, the clinicians may not always have the information required to counsel these patients at the initial visit about how the treatment may affect their health-related quality of life. Whatever the cause, these data identify providers’ communication about psychosocial issues as an area for improvement in the care model. In response to the findings of this analysis, measures have been undertaken to improve the communication regarding psychosocial issues by implementing universal screening with the Distress Thermometer.6 The Distress Thermometer is a widely used single-item validated
South Med J. Author manuscript; available in PMC 2016 June 01.
Harper et al.
Page 5
Author Manuscript
instrument in which patients report on a scale of 0 to 10 the level of distress they have been experiencing during the past week.7 Scores on the Distress Thermometer ≥4 are reflective of clinically significant distress. Patient with scores
