Elsevier

Journal of Surgical Research

Volume 228, August 2018, Pages 290-298
Journal of Surgical Research

Gastrointestinal
Patient-provider relationships and health outcomes among hepatopancreatobiliary patients

https://doi.org/10.1016/j.jss.2018.03.026Get rights and content

Abstract

Background

The patient-provider relationship (PPR) is an important element of health care delivery and may influence patient outcomes. The objective of the present study was to identify clinical predictors of PPR among patients with hepatopancreatobiliary (HPB) diseases and assess the association of PPR and health care utilization.

Materials and Methods

The Medical Expenditure Panel Survey database from 2008-2014 was used to identify adult patients with HPB diagnoses. A PPR score of “poor,” “average,” and “optimal” was calculated from the Consumer Assessment of Healthcare Providers and Systems Survey. Predictors of poor PPR and the association of PPR and health care utilization were assessed.

Results

Among 592 patients, PPR was optimal (210, 35.4%), average (270, 45.5%), or poor (114, 19.2%). Patients without insurance (36.3%) or with Medicaid (28.8%) were more likely to report poor PPR versus patients with private insurance (14.0%) or Medicare (15.4%) (P = 0.03). Poor (24.3%)- and low (21.5%)-income patients were more likely to report poor PPR versus middle (12.8%)- or high-income (14.0%) patients (P = 0.03). Poor mental health was also more common among patients with poor PPR (13.4%) versus average (5.4%) or optimal (3.7%) PPR (P = 0.02), and this association between poor PPR and poor mental health remained significant on multivariable analysis (odds ratio [OR] 2.43, 95% confidence interval [CI] 1.20-4.92). Poor PPR was associated with increased emergency room utilization on univariate (OR 2.50, 95% CI 1.21-5.14), but not multivariate (OR 2.18, 95% CI 0.92-5.15) analysis.

Conclusions

Among patients with HPB diseases, PPR was associated with insurance type, socioeconomic status, and mental health scores. Patients reporting poor PPR were more likely to be high utilizers of the emergency room. Efforts to improve the PPR are needed and should be focused on these high-risk populations.

Introduction

A strong patient-provider relationship (PPR) is critical to the effective prevention, diagnosis, and treatment of disease. Historically, this relationship could be described as benevolent paternalism, in which information and advice was delivered from physician to patient.1 With cultural shifts toward patient empowerment and autonomy, as well as increasing access to medical information on the internet, the PPR has evolved such that many patients now exercise primary authority over health care decisions.1, 2 More recently, a shared decision-making model in which informed patients make decisions in conjunction with their health care providers has been popularized.1, 3 The PPR has both emotional and cognitive components. The emotional factors focus on mutual respect, trust, support, and empathy, whereas cognitive factors include information gathering, patient education, and counseling.4 Both domains are important, and several observational studies have noted a correlation between the quality of the PPR and health care outcomes.5, 6, 7 Indeed, interventions focused on improving the PPR have consistently demonstrated a small but significant effect on health care outcomes.8

There are few studies examining the association between the PPR and health care outcomes among patients with hepatopancreatobiliary (HPB) diseases. HPB diseases represent a heterogeneous group of infectious, inflammatory, autoimmune, and neoplastic disorders that require consultation with specialized providers.9 Management of HPB diseases often require multiple visits with providers, potentially invasive tests and therapeutic procedures, as well as frequent strict adherence to medications.9 In addition, the direct and indirect costs of diagnosing and treating HPB diseases can be high for patients and the health care system.10, 11 Surgery for HPB diseases can also be associated with higher than average risk of complications, as well as prolonged hospitalization and/or readmission.12, 13, 14 Given the large resource needs of patients with HPB conditions, the quality of the PPR may be a particularly important determinant of health care outcomes. In addition, a better understanding of predictors of poor PPR and the association of the PPR and health care outcomes might help identify appropriate patient populations for targeted interventions.

The Medical Expenditure Panel Survey (MEPS) database is a prospectively maintained collection of surveys completed by patients and medical providers that is the most comprehensive source of data covering health care cost and utilization in the United States.15 Using this database, the objective of the present study was to identify clinical predictors of poor PPR among patients with HPB diseases. In particular, we sought to define the relationship between PPR quality and health care outcomes, including emergency room (ER) utilization, inpatient hospital admissions, and health care expenditures.

Section snippets

Study design and patient population

Institutional Review Board consent was waived for this study given the use of publically available deidentified data. The MEPS database from 2008-2014 was queried to identify all patients with HPB conditions based on the following diagnosis codes: 006 hepatitis; 016 cancer of liver and intrahepatic bile duct; 017 cancer of pancreas; 149 biliary tract diseases; 151 benign liver diseases including cirrhosis; and 152 pancreatic disorders. Surveys of patients younger than 18 y, individuals with a

Results

A total of 592 participants, representing six million noninstitutionalized US adults with an HPB diagnosis, met inclusion criteria. Underlying diagnoses included cholelithiasis and other diseases of the biliary tract (n = 302, 51%), benign liver diseases including cirrhosis (n = 121, 20%), pancreatic disorders (n = 81, 14%), hepatitis (n = 75, 13%), cancer of liver and intrahepatic bile duct (n = 10, 2%), and cancer of pancreas (n = 3, 1%). The proportion of respondents with self-rated poor PPR

Discussion

The PPR is important to patient satisfaction, as well as the key component of successful therapeutic relationships between patients and caregivers. Among patients with HPB diseases, which can be complex and involve multiple different providers and multiple different treatment modalities, a robust PPR may be particularly important. Despite the importance of PPR, data on factors associated with PPR and health care outcomes is scarce. The present study was therefore important as we utilized the

Acknowledgment

E.C., E.W.B., J.C., Q.C., A.P., S.S., J.M.C., and T.M.P. participated in the design of this project, interpretation of data, drafting and critical revision of the article, and provided final approval of the version to be submitted. Q.C. completed the data collection and analysis.

Presented at the 14th Annual Academic Surgical Congress, Jacksonville, FL, February 2018.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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