Family Practice Vol. 20, No. 5, 563-569
© Oxford University Press 2003
Information in practice |
The relationship between primary care physicians’ adherence to guidelines for the treatment of diabetes and patient satisfaction: findings from a pilot study
a JDC-Brookdale Institute, Jerusalem
b Bar-Ilan University, Ramat Gan
c Clalit Health Services
d Maccabi Healthcare Services, Tel Aviv, Israel.
Correspondence to Revital Gross, PhD, JDC-Brookdale Institute, POB 13087, Jerusalem 91130, Israel; E-mail: revital{at}jdc.org.il
Gross R, Tabenkin H, Porath A, Heymann A, Greenstein M, Porter B and Matzliach R. The relationship between primary care physicians’ adherence to guidelines for the treatment of diabetes and patient satisfaction: findings from a pilot study. Family Practice 2003; 20: 563–569.
Received 21 October 2002; Accepted 19 May 2003.
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Abstract |
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Background. Adherence to clinical guidelines improves health care outcomes, reduces expenditure and prevents the complication of unnecessary interventions. It is uncertain what effect the adherence to guidelines for treating diabetes has on patient satisfaction. Some authors have reported that the use of guidelines does not affect patient satisfaction with care, and have concluded that satisfaction is related to a physician’s interpersonal skills, rather than to the quality of care. Others have reported that structured intervention programmes improve patient satisfaction with care.
Objective. The purpose of our study was to explore the association between adherence to clinical guidelines and satisfaction with care among diabetics.
Methods. The study population included 135 randomly sampled diabetes patients listed with 12 primary care physicians at two health plans in Israel, which together insure >80% of the population. Telephone interviews were conducted with the patients between August and November 2000, using structured questionnaires. Patients were asked to report on the extent to which their primary care physician treated them as indicated by the clinical guidelines of these health plans. They were also asked to rate their satisfaction with their primary care physician and the treatment of their disease. Bi-variate analysis was conducted using the chi-square statistical significance test. Multivariate analysis was conducted using logistic regression models.
Results. Adherence to guidelines for diabetes was associated with patient satisfaction with care, independently of the patient’s ethnicity (first language), age, gender, education, medication (insulin versus other) and health plan affiliation.
Conclusion. Patients who report being treated as recommended in practice guidelines were more likely to be satisfied with their care. This finding may encourage primary care physicians to adhere to clinical practice guidelines.
Keywords. Adherence, diabetes, guidelines, patient satisfaction.
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Introduction |
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TopAbstractIntroductionMethodsResultsDiscussionAppendix 1References |
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A clinical guideline is a recommended approach to solving a clinical problem, which is presented in the form of a flow chart or text. Adherence to clinical guidelines has been shown to increase the efficiency of health services, constrain expenditures, improve the quality of health care and prevent inappropriate medication and referral.1,2 For managed care organizations, clinical guidelines have the additional advantage of standardizing treatment, facilitating the monitoring of individual physicians and serving as a risk management tool for coping with lawsuits.3–5 Yet several studies have indicated that health plans find it difficult to induce physicians to adopt clinical guidelines, in general,2,3,5,6 and specifically those for the treatment of diabetes in primary care.7,8
The two largest health maintenance organizations (HMOs) in Israel are Clalit Health Services and Maccabi Healthcare Services, which together insure >80% of the population. Both have adopted and distributed guidelines for diabetes care to all of their physicians and primary health care teams, similar to those of the American Diabetes Association. Preliminary data indicate that this has led to an improvement in the medical treatment of diabetes patients, as measured by average Hba1c levels.9,10
The objective of this study was to test the hypothesis that adherence to guidelines for treating diabetic patients would be positively associated with patient satisfaction with medical care. Patients were asked to report on the extent to which their primary care physician treated them as indicated by the clinical guidelines distributed by the Clalit and Maccabi health plans. They were also asked to rate their satisfaction with their primary care physician, and with the medical treatment of their disease.
Patient satisfaction with care is an important outcome measure in primary care.11 Furthermore, patient satisfaction can lead to compliance with the physician’s recommendations, and thus lead to improved health outcomes.12 Therefore, the findings of this study are of significance to both primary care physicians treating diabetes patients and to the health plan managers employing them, who wish to improve the quality of care and increase patient satisfaction.
Literature review
Diabetes is a major and growing health care problem in Israel and worldwide. The increasing prevalence of type 1 and type 2 diabetes imposes a huge burden of morbidity and mortality through micro- and macro-vascular complications,13–15 and a large proportion of patients with diabetes are at high risk.16,17 Strict control of blood glucose, blood pressure and cholesterol can reduce the risk of diabetes-related complications.18–20 To achieve strict control, structured care is needed.21 Randomized trials have shown that this may provide a standard of primary care that is as good as or better than hospital out-patient care in the short term.22
Indeed, a wide range of interventions aimed at improving the provision of diabetes care and achieving better metabolic control for patients with diabetes has been implemented in primary care settings.23–34 These interventions are based on disease management models, which are defined as an organized, pro-active, multi-component approach to health care delivery to all members of a population affected by a specific disease. The disease management model emphasizes the importance of a high degree of patient involvement in his own care.35
A significant positive correlation was found between various structured intervention programmes and improvement in the control and treatment of diabetes.36–38 However, the effect of such programmes on patient satisfaction is uncertain. On one hand, it has been reported that a systematic approach to risk stratification and intervention according to a defined protocol improved diabetes outcomes, as well as patient satisfaction.36 A cluster visit model for poorly controlled diabetics, comprising a multi-disciplinary team led by a diabetes nurse educator, showed high levels of satisfaction with the programme in the treatment group, relative to the control group.37 A study examining the use and implementation of a quality improvement programme among diabetic patients found that the percentage of patients satisfied with their care was significantly greater among those whose care was being managed according to the disease management programme.38 Other interventions have also been found to increase patient satisfaction; these include an automated voice messaging system,39 as well as a programme that included patient counselling and shorter waiting times.40
On the other hand, some studies have shown that the use of guidelines for diabetic patients did not significantly influence patient satisfaction with care.41 Others have argued that patients satisfaction with care is influenced by physicians’ interpersonal skills, rather than by the quality of medical care they provide.42
Furthermore, studies of the relationship between quality of care and satisfaction among diabetes patients have not shown a clear trend. One such study found that, despite poor quality of life and poor control and monitoring, there was a high level of satisfaction among diabetic patients.43 Another claimed that satisfaction correlated significantly with the number of complications an individual experienced.44 Still others have reported that patients treated with insulin who were younger than patients treated by diet and oral medication had lower scores for well-being, but similar scores for satisfaction. No significant correlation was found between satisfaction and levels of Hba1c.45
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Methods |
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TopAbstractIntroductionMethodsResultsDiscussionAppendix 1References |
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The study population
Physicians employed in the Clalit and Maccabi health plans were selected randomly to represent various background characteristics, such as age, gender, specialty, location of clinic (central, northern or southern Israel) and employment contract (salaried or independent).
The study population included diabetes patients listed with these primary care physicians. The pilot study comprised six primary care physicians employed by Clalit Health Services and six primary care physicians employed by Maccabi Healthcare Services. We randomly sampled 
20 of the diabetes patients listed with each physician. Among physicians employed by Clalit Health Services, we conducted a random sample from the physician’s register of diabetes patients. Among physicians employed by Maccabi Healthcare Services, we sampled from a list of patients diagnosed with diabetes, whom the physician had seen between 1 January 1999 and 31 October 2000. (This method was chosen because physicians employed by Maccabi do not have a register of diabetic patients, as do the physicians employed by Clalit.) Some of these patients had since transferred to another physician (we interviewed them nevertheless). In all, we sampled 200 diabetes patients and conducted interviews with 135 patients (a 68% response rate).
Between August and November 2000, telephone interviews were conducted with the diabetes patients using structured questionnaires. The interviews lasted an average of 20 min, and were conducted by specially trained interviewers. The questionnaires were translated into Russian to adapt them for a significant segment of Israel’s population that does not speak Hebrew.
The questionnaire included a series of questions on the treatment for diabetes; special attention was given to follow-up, explanations about the disease and self-care, and non-pharmaceutical aspects of treatment (e.g. tests, examination of legs, referral to an ophthalmologist, referral to a nutritionist, etc.). These questions were meant to determine the degree of physicians’ adherence to the guidelines. Previous studies have shown that the patient is a valid source of information on such aspects of care.12 Other questions rated the patient’s satisfaction with the professional level and attitude of his primary care physician, and the patient’s perception of the quality of the treatment of his condition.
Data analysis
The dependent variables were defined dichotomously. Satisfaction with the professional level and attitude of the primary care physician were defined as follows: 1 = very satisfied, 0 = other. Satisfaction with the treatment of diabetes ("to what extent do you agree with the sentence ‘my diabetes could have been treated better’?") was defined as follows: 1 = agree, 0 = disagree somewhat or disagree. Independent variables were divided into four groups: (i) personal demographic characteristics (age, gender, language of the interview, education); (ii) health plan membership; (iii) duration of the illness, prevalence of complications, use of medications (insulin pills and injections); and (iv) physician’s adherence to guidelines as measured by the patient’s self-reports, based on a measure of explanations and a measure of treatment.
The measure of explanations counted the number of explanations a respondent received regarding a list of topics that physicians are required to explain according to the clinical guidelines (see Appendix 1). The measure’s range was from 0 = did not receive an explanation about anything, to 13 = the physician explained everything.
The measure of treatment counted the number of referrals and tests the physician ordered, out of a list of symptoms that physicians are required to test according to the clinical guidelines (see Appendix 1). The measure’s range was from 0 = the physician did not make any referrals or order any tests, to 9 = the physician provided all necessary referrals and tests.
Bi-variate analysis was conducted using the chi-square statistical significance test. Multivariate analysis was conducted using logistic regression models. Analysis of the data was conducted using the SPSS computer package. The characteristics of the study population are presented in Table 1
.
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Results |
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TopAbstractIntroductionMethodsResultsDiscussionAppendix 1References |
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Bi-variate analysis was conducted to examine the relationship between the three independent variables and patients’ background variables (Table 2
). The findings indicate that younger people, Russian speakers and members of Maccabi Healthcare Services are more satisfied with their physician’s professional level. Younger people and Russian speakers were also more satisfied with their physician’s attitude. Finally, a smaller proportion of members of Maccabi Healthcare Services than members of Clalit Health Services believed it was possible to provide better treatment for diabetes. No other statistically significant relationships were found between the independent variables and the other background characteristics examined.
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In order to examine the independent effect of physician’s adherence to guidelines on satisfaction with the physician and with treatment, we conducted three multivariate analyses using logistic regression models (see Table 3
).
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Table 3
indicates that the measure of explanations and health plan membership have an independent positive correlation with satisfaction with the physician’s professional level. Patients who receive more recommended explanations and members of Maccabi Healthcare Services were more satisfied with the professional level of their primary care physician. The measure of treatment, and level of education (marginally), had an independent positive influence on satisfaction with the physician’s attitude. Patients who received more recommended treatments, and those with secondary or post-secondary education, were more satisfied with their physician’s attitude.
Finally, the measure of treatment (marginally) and membership of Maccabi Healthcare Services had an independent negative influence on agreement that it is possible to better treat diabetes. In other words, members of Maccabi Healthcare Services and patients who received more recommended treatments tended to be more satisfied with the way in which their illness was being treated.
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionAppendix 1References |
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There are two main findings from this pilot study of diabetes treatment and patient satisfaction. First, in the two health plans participating in this study, a positive association was found between diabetes patients’ satisfaction with care and the degree to which physicians implement clinical guidelines regarding diabetes care. Secondly, a difference was found in the satisfaction rates of members of the two health plans.
The first finding supports the argument that providing better health care and maintaining constant communication with the patient improve patient satisfaction. Our finding supports previous studies that have noted a similar association when implementing structured interventions for diabetes care,36–38 or programmes for improving communication with diabetes patients.39,40 Our finding corroborates the cumulative research evidence that patients want an expanded role in their medical care, as well as more information from their physician.12 The guidelines for care of diabetic patients indeed include providing explanations about the disease and information about a healthy life style and self-care, both of which empower the diabetic patient and hence increase satisfaction with care.
The assumption that correct treatment, as reflected in quality guidelines, can improve patient satisfaction recently has received significant reinforcement from the American National Council for Quality Assurance (NCQA). When HMO performance, based on Health Plan Employer Data and Information Set (HEDIS) criteria, was cross-matched with patient satisfaction measures, as reflected in the Consumer Assessment of Health Plans Study (CHAPS) 2.0 Survey Measures, a clear link was found between the two. Members of health plans in the top 25% CHAPS scores had a 47.6% rate of performance of eye examinations during the past year, compared with a 38.9% rate for HMO members in the bottom 75% CHAPS scores. Similar results were observed for other performance criteria, such as treatment with ß-blockers after myocardial infarction, breast cancer screening and counselling on smoking cessation. These findings led the NCQA to state that "health plans that deliver the best clinical care also have the most satisfied members."46
However, we should distinguish between patient satisfaction with care and clinical benefits arising from adherence to guidelines. In order for a patient to receive clinical benefit from adherence to guidelines, the guidelines must be medically correct and clear to the physician, who must consent to their content and be willing to integrate them into his daily practice. The guidelines must also be feasible, within the limited time frame of the patient–physician encounter. Furthermore, it should be remembered that patient satisfaction is influenced by a number of complex factors of which the standard of clinical care is only one—and not necessarily the principal one.12,47
Our second finding was that satisfaction with the primary care physician was greater among Maccabi health plan diabetes patients than among Clalit health plan diabetes patients. This finding corroborates findings from another study of patients’ satisfaction with their primary care physician which surveyed all health plan members, and not only those with diabetes.48
What might explain the difference in satisfaction between the two health plans? Clalit is the largest health plan in Israel, insuring 60% of the population. It is organized based on the staff model, and employs staff physicians who work solely for it. In comparison, Maccabi, Israel’s second largest health plan, insuring 23% of the population, is based predominantly on an independent physician model. According to this model, the health plan contracts with independent physicians who are reimbursed according to the number of visiting patients on their list. Many studies have established a relationship among reimbursement method, physician behaviour and patient satisfaction.49 In general, salaried physicians do not have a special incentive to attract patients, since their salary level is fixed. In contrast, physicians whose salary level is dependent on the number of patients they see do have an incentive to attract patients and make an effort to keep them satisfied. We can therefore hypothesize that the basic difference in how physicians are employed by Clalit and Maccabi, respectively, could affect the physician–patient relationship, and that this would find expression in patient satisfaction. Support for this hypothesis can be found in the literature on HMOs. For reasons that are not entirely clear, patients in closed-model practice settings (such as a staff-model HMO) behave and assess their care differently than do patients in open-model practice settings, such as an independent physician association model HMO.50 This difference may be related to some extent to practice characteristics, such as the quality of physician– patient communication, the trust that the patient has in his physician and the organization of the HMO.
In summary, this preliminary study reinforces the argument that patients recognize the improved performance characteristics that accompany the implementation of guidelines for diabetes care. This is reflected in patient satisfaction with the quality of care. If distributed to primary care physicians, these findings may encourage them to implement clinical guidelines as a means not only of improving clinical care, but also of improving their patients’ satisfaction. In addition (although it was not a stated goal of this study), our findings indicate that the characteristics of the provider organization (particularly contractual arrangements with physicians) have a general influence on the perceived satisfaction of their members. Specifically, staff model health plans may wish to reconsider the nature of their contract with physicians, and introduce incentives for improving the quality of care and patient satisfaction.
Clearly, the findings of this pilot study will need to be reinforced by expanding the study to additional populations. Also, further research is needed to determine whether the conclusions of this study are applicable to guidelines in other areas, and in other health care settings.
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Appendix 1 |
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TopAbstractIntroductionMethodsResultsDiscussionAppendix 1References |
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The following items were included in the measure of recommended explanations: someone from the primary care team (a physician or nurse), or the primary care physician, recommended stopping smoking; a physician or nurse explained the dangers and complications of diabetes, proper nutrition for diabetics, how to care for the feet, the importance of regular examinations of the cornea, what to do when the sugar level becomes elevated or drops suddenly, the importance of self-tests (urine or blood) of sugar level, how to test one’s sugar level, and the importance of carrying a medic alert card that indicates that one is a diabetic; a physician informed the patient of his sugar level; a physician or nurse recommended a guidance manual.
The following items were included in the measure of recommended treatment: the physician referred the patient for a test of his blood sugar level during the past 3 months; the physician referred the patient for a haemoglobin test during the past 6 months; the physician gave the patient a full physical examination during the past year; the physician examined the patient’s legs and feet during the past year; the physician referred the patient to a nutritionist during the past year; the physician referred the patient for an ophthalmic examination during the past year; the physician referred the patient for an ECG during the past year; the patient’s cholesterol was examined during the past 3 months; the patient’s heart and pulse were checked by a health plan physician or nurse during the past 3 months.
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Acknowledgments |
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The authors wish to thank Professor Jochanan Benbassat for his helpful comments, and Marsha Weinstein for editing the paper. The study was funded by a grant from the Israeli National Institute for Health Services and Health Policy Research.
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References |
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