In this paper, we describe our rationale and methods for an RCT to test the efficacy of a patient navigator intervention for increasing the impact of publicly reported quality of care data on the choice of a pediatric care provider. The potential impact of this study is great. With more than 73 million children under the age of 18 residing in the US [34
], the quality of ambulatory pediatric care can have an enormous impact on population health.
The impact of publicly reported quality data on patients’ choice has been disappointing, due in part to challenges in communicating the information to patients in a meaningful way [14
]. Our study takes a novel approach to making the science of public reporting available and understandable to a population known to be at greatest risk for limited capacity to use these data. Two elements of this study design enhance the potential for success: use of patient navigators and engagement of participants while they are receiving prenatal care. Although patient navigators have been used to assist patients in obtaining preventive care and treatment for complex medical conditions [22
], we are unaware of studies in which they have been used to enhance informed decision-making about choice of providers for a low income population. Navigators have demonstrated the greatest effectiveness among populations with lower socioeconomic status and low health literacy [25
]; thus, targeting a population with these characteristics may offer the greatest potential for effectiveness of the intervention. Pregnancy is also a time when women may be more engaged in their health and healthcare than at other times [35
]. This motivation, coupled with sufficient lead time between knowing they need to select a pediatrician and selecting one, makes this an opportune time to test navigator efficacy.
If successful, this model has important ramifications. Team approaches to care are increasingly used in the ambulatory setting [36
]. Although it is unlikely that a single practice can sponsor a dedicated patient navigator, it seems reasonable that case managers and ancillary staff can be trained to provide information about care quality to patients as part of a global effort to engage patients in health care decision-making. Should this efficacy trial favor use of navigators, this may have important implications for design and scope of responsibilities for care team members.
This study has limitations. First, women who already have children may be less likely to change pediatricians, even if quality scores for the current pediatrician are low. We have attempted to account for this by stratifying randomization to multiparous and nulliparous women and by asking mothers to rate the level of importance of a range of factors that may impact choice of pediatrician. Second, because the website is only available in English, we are not enrolling patients who are not comfortable with the English language. Few organizations have the resources to make websites available in multiple languages, but this continues to limit access to these data. Third, there is debate about how meaningful these types of quality measures are, with questions about the quality of the data used to develop them and the paucity of data linking them to improved patient outcomes. However, the MHQP website has been recognized for the soundness of the MHQP methods of compiling the performance scores, and there is growing use of these measures for assessment of care quality. Fourth, although we do not include a cost analysis for this intervention, it is possible that it may be prohibitively expensive to undertake outside of the study setting. If the intervention is successful, we plan to explore mechanisms of delivering the intervention in an affordable manner, such as using existing staff in obstetricians’ offices. Additionally, while the study was designed with power to detect differences within strata defined by parity, we may be underpowered to detect differences in secondary outcomes, or within subgroups of patients defined by literacy or ethnicity. It may be possible that as websites improve and become more usable for patients with limited health literacy, the need for a navigator may become less important.
In this paper, we have given a brief description of the rationale for a patient navigator intervention to increase access and understanding of publicly reported pediatric quality data for low-income pregnant women. This study will help determine whether removing barriers to use of quality-of-care data impacts women’s choice of pediatrician. If navigators are found to be effective in this study, patient navigator effectiveness in settings with other vulnerable populations may be warranted.