This study of a national sample of veterans hospitalized for an initial AMI in FY 2003 and FY 2004 at VA medical centers provided a unique opportunity to assess the long-term impact of PCC. In addition to including a measure of such care, we also had a measure of the technical quality of care and detailed information about the clinical characteristics of patients. There was a relatively high level of adherence to technical care guidelines in our sample. This may have resulted in a ceiling effect and may account for the absence of a stronger relationship in this study between technical quality and survival. This result is broadly consistent with Bradley and colleagues, who found that seven core process measures of AMI care measured and reported by the Centers for Medicare & Medicaid Services and the Joint Commission on Accreditation of Healthcare Organizations individually explained between 0.1 and 3.3 percent, and collectively only 6 percent, of the hospital-level variation in 30-day risk-standardized mortality (Bradley et al. 2006
). Using 1-year postadmission survival data, however, PCC was significantly related to survival, even after controlling for patient sociodemographic characteristics, clinical condition and history, technical quality of care, and admission process characteristics. This is consistent with the findings of Fremont et al. (2001)
that postdischarge symptoms of angina and dyspnea and global health ratings were better in patients that reported better PCC during their hospitalization.
Increasingly, eliciting patient reports about their care experiences is seen as an important part of care quality assessment (Cleary and Edgman-Levitan 1997
; Cleary 1999
; Goldstein et al. 2001
; Hargraves et al. 2003
; Landon et al. 2004
; Keenan et al. 2009
;). This study suggests that in addition to providing information about aspects of care that patients think are important, there may be important clinical consequences associated with the interpersonal and information needs of patients. Thus, efforts to improve PCC (Cleary et al. 1993
; Goldstein et al. 2001
; Davies et al. 2008
;) by enhancing aspects of care such as coordination of care, attention to patient preferences, emotional support, and physical comfort might result not only in better patient experiences but also better clinical outcomes. Although studies examining the relationship between PCC and technical quality of care have had mixed results, the results of the present study argue for the desirability of continuing to assess the relationship between PCC and outcomes until the nature and degree of the impact of PCC is more clearly established.
We do not know the mechanism(s) whereby PCC during hospitalization could result in better health outcomes. Research has demonstrated that communication and other aspects of PCC can have a positive effect on important patient behaviors, such as adherence (Lowes 1998
), that are related to illness management and outcomes (Bartlett et al. 1984
; Greenfield et al. 1985
; Brody et al. 1989
; Horwitz et al. 1990
; Horwitz and Horwitz 1993
; Safran et al. 1998
). Some recent research suggests that supportive interactions between clinicians and patients may lead to enhanced patient trust in their providers (Keating et al. 2002
); such trust may in turn lead patients to assume greater personal responsibility for their health (Becker and Gerhart 1996
). The results of this study are consistent with earlier studies showing that patient reports about their hospital care are associated with better outcomes (Covinsky et al. 2000
; Fremont et al. 2001
;) but addresses some of their methodological weaknesses, including better measures of technical quality of care, better measures of health status, and independent assessments of PCC and outcomes.
This study has several potential limitations. The sample was predominately male and consisted of veterans seeking care within the VA system. Whether the same findings would have been obtained in a more representative sample of AMI patients is not clear. Further, our sample was about 2 years younger on average than the AMI patients who were not included because they lacked SHEP survey data on which to base a PCC index score. Given our finding that higher age at admission was associated with a significantly higher hazard for 1-year posthospitalization mortality, and that in general age has also been found to be associated with perceptions of more PCC, this nonresponse bias may have affected the observed results. Had more, older patients with high PCC index scores been included, and had they contributed to an increased 1-year mortality rate as indicated by the observed hazard ratio for age (1.03), this would have attenuated the findings regarding the protective effect of PCC. The observed relationship between age and perceptions of PCC in our sample was weak, however, with a maximum correlation of 0.06 (between age and the Picker family involvement dimension). This suggests that the inclusion of more patients who were somewhat older would not have greatly elevated PCC scores, even though their mortality rate may have been higher. Nonetheless, caution should be exercised in generalizing the reported findings to older patients until they can be confirmed by future research.
An additional limitation concerns the noncomparability of two of the clinical condition and history variables in the EPRP database across FY. Analyses using the data available for FY 2004 cases indicate that neither history of stroke nor initial troponin level was related to mortality at 1 year. However, the results may have been different had comparable data for these two variables been available for all cases.
The estimated positive effect of PCC was modest, and we attribute this in part to the use of mortality as an outcome variable. Although the extensive VA data made it possible to control for the technical quality of care and thereby close an important gap in previous research, relying on secondary data limited our selection of outcome measures. Mortality over the course of a year is likely to be an insensitive measure of the impact of technical quality or PCC, and this may account in part for the small size of the observed effect. A better design would be to prospectively include more sensitive measures such as symptoms and functional status (Wilson and Cleary 1995
). Indeed, the lack of measures of symptoms or quality of life at the time of discharge is a weakness of the present study as compared with that of Fremont and colleagues, inasmuch as overall health at the time of discharge could lead patients to subsequently view their hospital experience more favorably and to be associated with longer survival. Thus, the design of the present study does leave open the possibility that some other factor such as overall health status at discharge might explain the higher levels of PCC among those who were living 1 year after their index hospitalization. Finally, there may be limitations in the technical quality of care measures used in the present study. Although there is consensus around many of these indicators, the 14 measures used in this study do not entirely overlap with other proposed sets of quality of care indicators (Tu et al. 2008
). Thus, a different result may have been obtained regarding the impact of technical quality if additional measures had been included, such as those related to postdischarge out-of-hospital care.
Finally, patients who either died in the hospital or within the 4–6 weeks after discharge before the patient survey sample was identified would have been excluded from the SHEP survey and this study. This is an important limitation that could have biased the results of this study depending on the profile of technical quality and PCC among that group of patients. If, for example, this group of patients had both high technical quality and high PCC, their mortality may have attenuated the reported findings.
In spite of these potential limitations, the finding that PCC is related to survival in a nationally representative sample of hospitalized veterans who were treated for an AMI suggests that future research should investigate the impact of patients' experiences as well as the quality of technical care on outcomes.