Enhancing the quality of care in the ambulatory setting includes assuring the delivery of clinically effective care in a patient-centered manner.26,27
In this statewide evaluation, we found that measures of patient experiences were positively, but modestly correlated with process measures of clinical quality at both the practice site and individual physician level, with only one-third of these correlations achieving statistical significance. There were no significant correlations between patient experiences of care and clinical outcomes among practice sites and individual physicians.
Our study is consistent with prior research on the association of clinical performance and patient experience measures at the level of health plans, which demonstrated that better performance on some, but not all, patient reports of care experiences were associated with higher scores on clinical HEDIS measures.28
The magnitude of the correlations we observed were generally modest and similar in magnitude to previously reported correlations at the health plan level, which ranged from 0.24 to 0.38.28
The absence of overwhelmingly strong correlations in our study suggests that clinical care delivery and patient experience represent sufficiently distinct activities that ongoing quality measurement programs should include independent measurement of both domains in order to obtain a comprehensive evaluation of care. Patients using such data to select a primary care physician may need to make trade-offs between technical performance and interpersonal performance.29
Similarly, pay for performance programs will likely need to incorporate both aspects of health-care delivery to achieve broad-based improvements in care.
The modest correlations we observed suggest that improvements in clinical quality will not automatically produce improvements in patient experiences and vice versa.4,30
Monitoring both patient experience and clinical quality can ensure that efforts to improve patient experiences of care do not come at the expense of assuring the highest possible clinical performance.15
Importantly, the majority of all of the correlations examined were positive, with no evidence to support the notion that delivering high quality clinical processes is somehow in conflict with positive patient experiences in the primary care setting.
We found no association between patient experiences of care and clinical outcomes. Earlier research suggests that better patient experiences may improve patient outcomes through improved adherence.31–35
Our null findings may reflect aspects of our study design, such as the cross-sectional nature or the limited sample sizes for the outcomes measures. However, the absence of correlations between patient experiences of care and clinical outcomes parallels findings from recent studies demonstrating the lack of a consistent relationship between improvements in clinical process measures and clinical outcomes.3,21,36
Rather than reflecting a limitation of measures of patient experiences, our findings reinforce the inherent difficulty of linking process to outcome and that existing measures of process, including patient experiences of care, may not represent the full spectrum of factors that contribute to improved outcomes.
Our findings are strengthened by several aspects of the study design. Our data focused on care delivered by doctor’s offices and individual clinicians, including a statewide sample of practice sites and a large number of individual physicians across eastern Massachusetts. We were also able to include a wide range of measures of clinical quality and outcomes and patient experiences that were similar at both the practice site and individual physician level. However, our findings should be interpreted in the context of study design limitations as well. The availability of a large number of quality measures necessitated multiple testing, increasing the probability of detecting significant correlations by chance alone. However, our study goal was focused more on overall patterns rather than the importance of any single correlation.
While we included practice sites throughout Massachusetts, our sample was dependent on enrollment in one of five major commercial health plans and so may not generalize to other populations, particularly those lacking health insurance or the elderly. At the individual physician level, we were only able to include data from a single multispecialty practice group, though it is important to note that this is the largest ambulatory practice group in the state, providing care for over 300,000 patients and employing over 100 primary care physicians across 14 health centers in a mix of urban and distant suburban settings. In addition, while actual performance on HEDIS and ACES measures may not generalize across different health settings, there is no evidence to suggest that the relationship between these two domains of care differs across settings.
We are unable to draw conclusions regarding the mediators of the correlations we identified. In particular, we do not have information regarding structural characteristics of the practices, as well as individual characteristics of the physicians and patients in our study. It is very likely that specific attributes of a practice or physician mediate the strength of correlations between patient experiences of care and clinical measures of quality, and future research will be needed to explore this important question.
The definition and collection of patient experience measures were identical at the practice site and individual physician level; however, the collection of the clinical HEDIS measures differed between the two levels. At the practice site level, we relied mainly on health plan administrative data supplemented in some cases by chart review, while at the individual physician level we used mainly electronic medical record data. This resulted in a limited number of practice sites available for analysis of clinical outcomes, which are reliant on medical chart review. However, since our analyses were focused on determining correlations within these two levels (practice site and individual physician) and not between these two levels, the analyses are internally consistent at each level and are not substantially affected by differences in data collection for the clinical HEDIS measures. Finally, we were unable to correlate HEDIS chronic disease measures to patient experience measures for patients with those specific conditions, a technique that may have identified stronger associations.
In conclusion, we found that patient experiences of care were modestly correlated with clinical process measures and not correlated with clinical outcomes. Improving both patient experiences of care and clinical process measures should remain high priorities for health-care providers; however, the limited strength of the associations implies that distinct efforts in these areas are required to both monitor and improve these two domains of quality.