Prevalence and Sources of Patients' Unmet Expectations for Care

Patients' expectations for medical care are of increasing interest to clinicians, policymakers, and researchers. For clinicians, understanding and attempting to meet these expectations is an inherent responsibility [1] and may lead to increased patient satisfaction [2]. For policymakers, patients' expectations warrant attention because of their potential influence on health care utilization [3] and because fulfillment of expectations is one measure of the quality of health care systems [1, 4]. For researchers, patients' expectations can serve as both independent and dependent variables in studies of health care utilization, costs, quality, and satisfaction. Thus, further understanding of patients' expectations could improve the clinical process of care, health care delivery systems, and health services research. Although several studies [5] have highlighted the importance of patients' expectations, none has directly addressed the question of what influences the development and expression of these expectations. Obtaining a more thorough understanding of this process is important for two reasons. First, it may sensitize physicians to patients' concerns and facilitate more effective communication and clinical care; second, it could lead to strategies for helping patients form more consistently reasonable expectations in this era of limited medical resources. We sought to identify influences on the development of patients' expectations by interviewing patients whose expectations about an office visit were unmet. In doing this, we focused on three questions. First, what is the prevalence of patient-reported omissions of care after visits to internists? Second, what factors influence the development of patients' expectations and patients' perceptions of omissions in care? Third, how do patients come to articulate perceived omissions of care? After describing the methods by which our data were collected and analyzed, we present the characteristics of the patients who were interviewed and the prevalence of unfulfilled expectations reported by these patients. We then discuss the various sources of patients' expectations. Finally, we discuss the implications of our findings for clinical effectiveness and health policy. Methods Sampling of Practices and Patients Our study was done in three general internal-medicine practices in a mid-sized city in northern California. Two practices were branch offices of a large group-model health maintenance organization. Within these two practices, all patients were members of the health maintenance organization and received care on a capitated basis; the 10 physicians and three nurse practitioners were each paid a salary. The third practice consisted of 8 general internists (2 of whom had additional subspecialty training) and one nurse practitioner, all of whom worked in a single private office and received a combination of salary and productivity bonuses. Patients in this practice were insured under various prepaid and fee-for-service plans. All three practices attempted to schedule patients with their own regular practitioners when possible. We selected these practices to represent the dominant models of health care in northern California, an area heavily penetrated by managed care. Because managed care providers may have financial incentives to restrict medical care, managed care settings are potential sites of conflict between patients' expectations and the ability of clinicians to meet those expectations. During 36 half-day sessions (12 sessions per practice) scheduled between October and December 1994, trained research assistants approached patients in waiting rooms and encouraged them to complete a brief form that was designed to identify and thus exclude patients presenting for routine checkups. [In preliminary research, we had found that such patients were relatively unlikely to have unmet expectations. ] The form asked two questions: 1) Do you have a new or worsening problem that you wish to discuss with the doctor today [yes or no]? and 2) How concerned are you that you might have a serious disease or condition that has not yet been diagnosed (not-at-all to extremely)? Of the 1221 patients who completed the form, 804 had a new or worsening problem or were at least moderately concerned about an undiagnosed condition and thus were eligible for further study. Of the 804 eligible patients, 688 (86%) agreed to participate in the study and completed a post-visit questionnaire that asked about demographic characteristics, recent health care utilization, health status, satisfaction with the visit, and perceived omissions of care. The core of the written survey was eight questions about perceived omissions of care. Patients were given the following instructions: When people go to the doctor, they usually bring some thoughts about how he or she can be of the most help. Sometimes, however, the doctor may not be able or willing to do exactly what the patient wants These questions are about things you felt were necessary for the doctor to do today but which (for whatever reason) didn't happen These instructions were followed by questions about sets of possible omissions involving physician preparation for the visit; history taking; physical examination; laboratory testing or diagnostic imaging; prescription of medication; referral to specialists; information, counseling, or personal help; and anything else you felt was necessary or might be necessary for the doctor to do today but which didn't happen. The wording of the instructions reflected semantic concerns reviewed elsewhere [5] and was intended to convey a broad definition of patients' expectations, emphasizing expectations as things that patients value. Of the 688 respondents, 125 (18%) reported one or more omissions and 108 (86%) consented in writing to participate in a telephone interview within several days of the visit. Telephone Interviews Within 1 to 7 days of the visit, one investigator conducted telephone interviews with 90 of the 108 patients who had reported one or more omissions on their questionnaire and who had provided their home telephone numbers as part of the consent process. The interviewer identified himself as a researcher from UC Davis but not as a physician (he did say that he was a physician if specifically asked). The interviewing approach was modeled on the critical incident technique [6], which focuses on patients' accounts of events that have actually happened rather than on generalizations or opinions [7]. In this case, the critical incident was the perceived omission of care. Thus, the opening question was, You mentioned on your questionnaire that you were hoping that the doctor would [perform a particular intervention], but that didn't happen. Can you tell me more about that? Patient interviews averaged 15 minutes in length. Data Transformation Of the 90 interviews, 88 were successfully tape recorded and transcribed. To locate key themes related to the genesis of patients' expectations for care, we used an iterative process, which began with a careful reading by three investigators of approximately 20 randomly selected transcripts. In a series of meetings, the research team developed by consensus a preliminary coding scheme. Codes were developed inductively, consistent with the grounded theory approach used in sociology [8, 9]. We focused on the sources and the process of development of patient's expectations. Examples of codes and their definitions are shown in Table 1. Table 1. Selected Coding Categories Used To Examine Patients' Expectations for Care* In the second stage of the analysis, the lead investigator applied the coding scheme to 50% of the transcripts (n = 44) by using a qualitative research tool, the Ethnograph [10]. A health psychologist independently coded 20% of these transcripts. The coefficient for inter-rater reliability at the coded-segment level was 0.39, indicating moderate agreement beyond chance. The lead investigator then coded the remaining transcripts, and the study team as a whole reviewed the results and reached a consensus on major concepts and themes. Results Patient Characteristics The patients who completed the post-visit survey (n = 688) had a mean age of 51 years and a mean education level of 14.2 years; 63% were female and 83% were white. Six percent were visiting a physician for an initial, comprehensive evaluation; 49% were making follow-up visits with their own physicians; 38% were being seen on an urgent basis by someone other than their own physicians; and 7% were making other types of visits. In terms of sex, education level, and the percentage of patients who were making follow-up visits to their own physicians, the group of patients who reported at least one omission of care (n = 125) was similar to the group of patients who reported no omissions of care. However, patients with unmet expectations were younger (mean age, 47 years compared with 52 years; P = 0.001). The likelihood of reporting one or more omissions was lowest among the 188 patients aged 65 years and older (11% reported one or more omissions), highest for the 127 patients younger than 35 years of age (23% reported one or more omissions), and intermediate for the 365 middle-aged patients (20% reported one or more omissions) (P = 0.007). Patients who reported at least one omission were less likely than patients who did not report an omission to provide an excellent rating for the visit overall (35% compared with 75%; P < 0.001). Prevalence of Unmet Expectations A total of 125 patients (18.2%) reported at least one unfulfilled expectation within eight broad categories of care (Table 2). The prevalence of specific perceived omissions ranged from 2.8% (for failure to provide needed information, counseling, or personal help) to 5.5% (for omission of a component of the physical examination) (Table 2). Among patients who reported at least one perceived omission, the mean number of perceived omissions S