Evidence Based Medicine and Patient Centered Care: Coexistence or Conflict
Mark M. Meterko PhD
VA Boston Healthcare System Jamaica Plain Campus, Jamaica Plain, MA
Boston, MA
Funding Period: April 2010 - March 2013

BACKGROUND/RATIONALE:
In its groundbreaking critique of the US medical system, the Institute of Medicine (IOM) endorsed patient-centered care (PCC) as one of the Six Aims of ideal health care. For over 12 years, the VA has assessed patients' perceptions of their health care using the patient-centered care surveys developed by the Picker Institute. Concurrently, another major force has been the movement toward evidence-based practice (EBP), treatment guidelines, and the collection and release of standardized outcome and performance measures. Here too the VA has been in the forefront, implementing a sophisticated performance measurement system using standardized metrics that make comparison with the private sector possible. There can be tension between these two movements. Is it possible to provide high quality medical care that is both consistently evidence-based and patient-centered? When evidence-based patient-centered care is delivered, what are the organizational factors that support such a potentially powerful combination?

OBJECTIVE(S):
The overall objectives of the proposed study are:
1. To identify the key hospital organizational characteristics that support the delivery of high quality, patient-centered inpatient care
2. To then understand in detail the behavioral, policy and process mechanisms whereby those organizational characteristics exert their influence.

METHODS:
The proposed study involves a mixed methods design including both the analysis of various secondary quantitative data and qualitative primary data collection by means of interviews at selected facilities and systematic content analysis of the interview notes. For the quantitative study, we will assemble an individual-level working database for the cohort of patients hospitalized during FY04 who were (a) selected to contribute to a VA clinical performance measure through the external peer review (EPRP) chart review program, and who also (b) completed a patient satisfaction (SHEP) survey regarding their experiences during the index EPRP hospitalization. To these individual records we will append aggregate organizational culture and employee satisfaction scores based on AES respondents from inpatient medical units at each facility. Descriptive statistics, bivariate analyses, and hierarchical linear modeling will be used to examine the relationships between culture, clinical processes, and patient-centered care. The hierarchical (mixed) modeling will allow us to account for the use of data at both the individual and facility levels. For the qualitative phase, notes of interviews with the leadership and staff at 12 VA facilities will be analyzed using qualitative analytic software. To establish inter-rater reliability, multiple members of the research team will code interviews from multiple sites, using an a priori list of thematic codes developed based on the organizational culture literature. Coding categories will be elaborated and expanded in an iterative fashion to capture new issues as the coding proceeds.

FINDINGS/RESULTS:
There are no findings at this time as the project is currently in the data collection and analysis phase.

IMPACT:
As the more highly educated baby boom generation ages, demand for patient-centered care is likely to grow in the population at large. Within VA, a similar pressure toward patient-centeredness will likely be experienced as veterans returning from Iraq and Afghanistan combine with Vietnam-era veterans to become the predominant cohort of patients. The research underway in this project will provide evidence about organizational characteristics that can be deployed or strengthened to facilitate patient-centered care models.

PUBLICATIONS:
None at this time.

DRA: Health Systems
DRE: none
Keywords: Models of Care, Organizational Structure, Outcomes, Outcomes - System, Quality Improvement, Research method, Satisfaction (patient), System Performance Measures
MeSH Terms: none