Mediación en los conflictos

These study findings have significant policy implications regarding the

conceptualization and measurement of patient centeredness, patient-doctor relationship, patient-doctor communication, and cultural competency. As presented in Chapter I, the National Healthcare Disparities and Quality Reports (NHDR, 2003, 2004, 2005, 2006, 2007; NHQR, 2003, 2004, 2005, 2006, 2007) use these terms and define the concepts patient centeredness, patient-doctor relationship, patient-doctor communication, and cultural competency interchangeably and conceptualize that these are four distinct but related

domains of patient experience of care. However, such use and conceptualization is devoid of theoretical underpinnings. Furthermore, the reports monitor and present data on measures of these concepts either as individual items (NHDR, 2003, 2004; NHQR, 2003, 2004) or as composite measures calculated using a subset of items and use these measures

interchangeably (NHDR, 2005, 2006, 2007; NHQR, 2005, 2006, 2007). However, the relationships among these measures of patient centeredness, patient-doctor relationship, patient-doctor communication, and cultural competency and the psychometric properties of these items have not been empirically examined. This is the first study to theorize about and

empirically examine the validity of and interrelationships among measures of the four domains -- patient centeredness, patient-doctor relationship, patient-doctor communication, and cultural competency -- of patient experience of care as conceptualized by the National Healthcare Disparities and Quality Reports.

Findings should be of particular relevance and interest to the Agency for Healthcare Quality and Research which is the federal agency charged by the United States Congress to annually compile, report, and disseminate valid, reliable, and scientifically sound data on the four domains -- patient centeredness, patient-doctor relationship, patient-doctor

communication, and cultural competency -- of patient experience of care in order to monitor nation‘s progress in eliminating health care and health disparities and improving the quality of health care for all Americans. Stakeholders across federal, state and local governmental agencies including the Department of Health and Human Services that are responsible for undertaking efforts to monitor and improve patient experience of care will also find these findings of particular interest and relevance to guide and modify their conceptualization and measurement of patient centeredness, patient-doctor relationship, patient-doctor

communication, and cultural competency.

Study findings highlight the universality of what patients, irrespective of their gender and racial and ethnic groups, experience during their interaction with the doctor. Patient experience of care comprises of patient‘s confidence and trust in the doctor and the extent to which the doctor (a) listened, (b) treated the patient with dignity and respect, (c) involved the patient in decision- making, (d) allowed the patient to discuss questions about care or

treatment, (e) explained things carefully, (f) understood patient background and values, (g) looked down on the patient, (h) disrespected or treated the patient unfairly due to any reason,

and (h) spent enough time with the patient. Furthermore, findings support the notion that during their interaction with the doctor, patients experience these aspects not in isolation of each other but in a highly interrelated manner. One key implication of the study finding is that it not only demonstrates that the four-domain conceptualization lacks empirical and theoretical support, but that interchangeable use of terms and concept might hinder desired progress in reducing health and health care disparities and improving quality of care by unintentionally creating ambiguity in stakeholders‘ understanding of these terms and concepts.

Based on the strong and consistent evidence supporting one-domain

conceptualization underlying measures of patient centeredness, patient-doctor relationship, patient-doctor communication, and cultural competency, a key policy recommendation is that the patient experience of care should be meaningfully conceptualized and comprehensively measured using ten items retained in the PRIAC scale. The study highlights the lack of validity of NHDR and NHQR approach of monitoring and reporting on single or a subset of items as measures of four domains of patient experience of care since such use fails to

comprehensively, reliably, and adequately measure patient experience of care. It is important to note that the review of individual items might help identify specific areas of patient

experience of care where patients report less than optimal experience and suggest areas to target specific interventions. However, it is recommended that AHRQ should calculate and report a composite score using all 10 items rather than individual score or a composite score using a subset of items in order to provide valid and reliable information on patient

Findings also indicate that some items used to measure patient centeredness, patient- doctor relationship, patient-doctor communication, and cultural competency in the NHDR and NHQR need further validation before their inclusion in future reports and their use to guide policy decisions and monitor improvements in quality of care and health and health care disparities. Specifically, three items, individual‘s response to: ―Do you think there was ever a time when you would have gotten better medical care if you had belonged to a different race or ethnic group?,‖ ―Do you think there was ever a time when you would have gotten better medical care if you were a woman/man?,‖ and ―I feel that my doctor

understands my background and values‖ had a high proportion of respondents who did not respond. Nonrespondents were predominantly non-English speaking/Limited English-

proficient individuals and/or belonged to a racial/ethnic minority group. Furthermore, among respondents, a very small proportion endorsed these items. It is recommended that these items need further validation before continuing their use as measures of patient experience of care in future NHDR and NHQR.

The National Healthcare Disparities and Quality Reports present data on patient centeredness, patient-doctor relationship, patient-doctor communication, and cultural

competency by racial/ethnic and income groups and not by individual‘s English-proficiency. In so doing, these reports do not offer insight into or monitor patient experience of care by individual‘s English-proficiency. In this study, a vast majority of the nationally

representative English-proficient adults reported experiencing high level of interpersonal relations with their doctor as measured by the ten items retained in the PRIAC scale compared to the non-English speaking/Limited English proficient adults. This finding is similar to prior evidence showing that a lack of English-proficiency negatively affects patient

experience of care in the domains of patient centeredness, patient-doctor relationship, patient-doctor communication, and cultural competency (Weech-Maldonado et al., 2001; Morales et al., 1999; Crane, 1997; David & Rhee, 1998; Carrasquillo et al., 1999; Tucker et al., 2003). Findings from this study strongly suggest that it is crucial to gain insight into disparities in patient experience of the interpersonal aspects of care between English- proficient population and Limited English proficient/non-English speaking population. A policy recommendation is that future National Healthcare Disparities and Quality Reports monitor, analyze, and report patient experience of the interpersonal aspects of care by separately for English-proficienct and non-English speaking/Limited English-proficient populations.

Findings of positive and significant association between measures of access to care and patient experience of the interpersonal aspects of care suggest policy recommendation on how patient experience of the interpersonal aspects of care can be impro ved. These findings suggest that system- level efforts to ensure that patients have a usual source of care, to improve continuity of usual source of care and with health insurance coverage, and to offer choice to patients regarding the place where they seek care will likely result in improvements in patient experience of interpersonal aspects of care. Similarly, findings of positive and significant association between measures of patient experience of the interpersonal aspect of care and health care outcomes suggest that efforts to improve patient experience of the interpersonal aspects of care will likely result in improvements in patient satisfaction with overall quality of care, compliance with recommended care, confidence in seeking care in the future and timely utilization of services.