Kuhle, Carol S. DO, MPH; Truitt, Frances MD, MPH; Steffen, Mark MD, MPH; Undavalli, Chaitanya MBBS; Wang, Zhen PhD; Montori, Victor M. MD, MSc; Murad, Mohammad Hassan MD, MPH
From the Divisions of Preventive, Occupational, and Aerospace Medicine (Drs Kuhle, Truitt, Steffen, and Murad) and Endocrinology, Diabetes, Metabolism, and Nutrition (Dr Montori), and Knowledge and Evaluation Research Unit (Drs Undavalli, Wang, Montori, and Murad), Mayo Clinic, Rochester, Minn.
Address correspondence to: Mohammad Hassan Murad, MD, MPH, Knowledge and Evaluation Research Unit, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (Murad.firstname.lastname@example.org).
Authors Kuhle, Truitt, Steffen, Murad, Montori, Undavalli, and Wang have no relationships/conditions/circumstances that present potential conflict of interest.
The JOEM editorial board and planners have no financial interest related to this research.
* Discuss the rationale for evaluating agenda-setting as an approach toward patient-centered care and improved patient satisfaction.
* Outline the process by which the authors developed their quality improvement project and the agenda-setting approach used in the study.
* Summarize the effects of agenda-setting on patient experience and satisfaction with occupational medicine visits.
Patient-centered care is an immutable component of high-quality health care.1 Patient-centered care requires that consultations deal fundamentally with the patient agenda in a satisfactory manner. Yet, many clinical visits end without clearly addressing patient needs and with patient dissatisfaction. More than 40% of patients present to primary care settings with more than one concern, and patients leave the consultation with 30% to 80% of their expectations unmet.2,3 Formal agenda-setting before patient–physician encounters has been suggested as a way to address patient concerns and, ultimately, improve patient satisfaction; particularly, the professional care component of the satisfaction questionnaires.4
Agenda-setting is a process by which clinicians initiate patient encounters by eliciting the full set of concerns from the patient perspective and using that information to work with the patient to prioritize and negotiate which clinical issues should most appropriately be dealt with and which (if any) should be deferred for a subsequent visit.5 Nevertheless, agenda-setting is not commonly or adequately performed. A cross-sectional survey using linguistic analysis of a convenience sample of 264 patient–physician interviews showed that physicians solicited patient concerns in 75% of the encounters but addressed only 28% of those concerns.6
The effectiveness of agenda-settings on patient satisfaction remains unclear. A systematic review of the literature found that many of the studies evaluating agenda-setting did not have an experimental design, were not well controlled, or did not yield generalizable conclusions.7 Furthermore, we found no studies evaluating the impact of agenda-setting in an occupational health setting, although these types of encounters often involve multiple patient complaints or concerns.8,9 Therefore, we initiated a quality improvement (QI) project to help improve patient–provider communication and enhance patient satisfaction in an outpatient occupational health clinic by promoting agenda-setting.
MATERIALS AND METHODS
The reporting of this study is consistent with the recommendations made in the Standards For Quality Improvement Reporting Excellence statement.10
This study has a quasi-experimental design in which we compare two samples, each was selected at random from the rosters of all patients presenting for appointments to an outpatient occupational health clinic practice in May 2011. We used a computer-generated random number list to select each sample, and investigators assigned one sample to the intervention and considered the other as the control group.
The practice is located within a tertiary referral center (Mayo Clinic, Rochester, MN). Patients were either employees of the medical center or were sponsored by their employers as part of an executive health program. We excluded certifying examinations intended for the Department of Transportation, the Federal Aviation Administration, and preemployment because of the administrative nature and established protocols and fixed agendas pertinent to these examinations. The institutional review board exempted this study as a quality improvement project required from trainees in graduate medical education.
Quality Improvement Framework
Fellows in a training program in preventive medicine and public health with mentorship from quality improvement experts followed standard quality improvement methods11 to execute this project. The basic steps for conducting a QI project are described (Fig. 1). We conducted a needs assessment (via interviewing clinicians and front desk staff asking about one problem they need to improve in their workday), stakeholders identification, QI project charter development, process mapping (observing a single patient to define and describe the clinical encounter process from check-in through check-out), and root-cause analysis (using a fish bone diagram to categorize the possible causes of possible communication failure in these office visits). The team brainstormed and developed several ideas for an intervention. Affinity mapping led to pursuing agenda-setting as the intervention of choice. Literature review was conducted to find the appropriate tools that could be used to test this intervention. We used a standard Plan–Do–Study–Act method (Fig. 2) to improve the implementation and evaluation procedures, with feedback from the clinicians and the patients. These modifications improved the clarity in the survey questions, honing on patient satisfaction with the agenda-setting form and their interest in using this form in future encounters.
Patients received the agenda-setting form (Fig. 3) on check-in and were instructed to complete it while waiting. Clinical assistants handed the completed form to clinicians before the encounter. The form was adapted from a previous trial that used a written tool to elicit patient concerns before outpatient visits.4 Patients in the control group received usual care, with no additional intervention before or during their visit.
The outcomes of this study included patient satisfaction with the visit assessed by the question, “I felt this provider addressed my important issues,” rated using a five-point Likert scale anchored in the following phrases: very dissatisfied, 1; dissatisfied, 2; neutral, 3; satisfied, 4; or very satisfied, 5. This question was adapted from a larger questionnaire used to evaluate patient satisfaction with consultations in general practices.12 We also evaluated patient satisfaction with the agenda-setting form and their interest in using the form in future visits. All patients were given an anonymous postvisit evaluation form (Fig. 4) to assess the outcomes and were asked to turn it in at the end of their appointment.
No identifiable patient data were collected during the whole period of this study. The study was deemed a minimal-risk quality improvement project and approved by the Mayo Clinic institutional review board.
We selected a convenience sample without formal sample size calculation. Analyses were conducted after all of the questionnaires were returned, including only those participants who completed and returned the questionnaires. We compared patient questionnaire responses by using frequency distributions and descriptive statistics, including measures of central tendency and dispersion, and estimated the odds ratio and 95% confidence interval of the rate of maximum satisfaction in the intervention and control groups. We also used the Mann-Whitney U Test to compare the difference between the intervention group and the control group and the two clinical settings (medical center employees vs patients of the executive health program). All statistical tests were two-sided, with significance set at P < 0.05, and conducted using Data Analysis and Statistical Software version 12.1 (StataCorp LP, College Station, TX).
A total of 113 patients (77 patients in the intervention group and 36 patients in the control group) completed the postvisit questionnaire. Table 1 shows the results of postvisit questionnaire. In both the groups, most of the patients strongly agreed that physicians addressed their concerns (n = 66, 85.7% in the invention group; vs n = 35, 97.2% in the control group). No patient responded “disagree” or “strongly disagree.” The difference on this question was not significant between the two groups (odds ratio, 0.17; 95% confidence interval, 0.21 to 1.38; P = 0.06). Regarding the agenda-setting form, 54 of 74 patients (73%) in the intervention group found the form helpful and 14 of 19 patients (74%) wanted to continue using this form in future visits.
Among the 77 patients in the intervention group, 31 were of the executive health program and the remaining patients were medical center employees. There were no significant differences between the two practices in patient satisfaction (P = 0.34), helpfulness of the agenda-setting form (P = 0.93), or interest in using the form in the future (P = 0.91).
In this quality improvement project, we evaluated the impact of agenda-settings in an occupational and executive health practice. We did not find a statistically significant difference in satisfaction among patients who received the agenda-setting form, though the level of patient satisfaction in both the groups was high. Patients also felt that the agenda-setting form was helpful and had interest in using it again in future encounters.
Previously, Middleton et al13 found no significant change in patient satisfaction when an agenda-setting form was used before patient visits. Our findings suggest decreased patient satisfaction but cannot rule out some benefit. A possible explanation for a reduction in patient satisfaction may arise from the process by which patients clarify their needs and make them explicit. This creates the expectation that clinicians will address these issues. If not, negotiation or reprioritization takes place and few issues get addressed. The result is dissatisfaction. This process may not occur consistently among patients who remain unclear about their needs and do not go through the process of listing these in a form. Other studies of agenda-setting that used a written form showed possible benefits in terms of improving the professional care component of the satisfaction questionnaires, with the only downside of extending the duration of the visit by 1 minute.4
On the contrary, Brock et al14 demonstrated increased patient satisfaction when physicians were trained in agenda-setting.15 In their study, physicians participated in 2 hours of training followed by 2 hours of coaching per week for 4 consecutive weeks. Trained physicians were more likely to make additional elicitations, and their patients were more likely to indicate agenda completion, and patients and physicians raised fewer concerns in the late encounter phase. There were no significant differences in visit length, total concerns addressed, patient or provider satisfaction, or patient trust and functional status. Therefore, formal physician training in agenda-setting seems to be somewhat effective, although more resource intensive than the passive approach that depends on written communication tools without prior training.
In this study, a large proportion of patients found the agenda-setting form helpful and most of them thought that the use of the form should be continued. This may indicate an unmet need of the patients and the desire for tools that support prioritization and listing of their concerns and enhances planning of their upcoming visits.
The trade-offs between rigor, applicability, and feasibility are well recognized in quality improvement studies.16–18 Such projects value expediency and derive processes from local resources and intuition, while de-emphasizing the mitigation of the risk of bias. In this study, we sought greater rigor in avoiding selection bias by randomly selecting participants from the pool of available patients. We also adhered to a recommended formal quality improvement methodology and framework. This methodology allowed us to modify our questionnaire to make it both easier to understand and to hone in on the outcomes of interest. In addition, patient feedback was obtained anonymously, perhaps enhancing the sincerity of their responses.
The main limitations of this study include the small number of responses, our inability to directly observe the clinical encounter to obtain a measure of the extent to which the agenda-setting was used as expected, and we did not measure clinician satisfaction. The small study size led to an imprecise estimate of effect, as witnessed by the broad confidence interval around the odds ratio estimate. We did not perform formal power analysis, considering the exploratory nature and the intention to use these data in a QI project in which the interventions varied several times (rapid Plan–Do–Study–Act cycles). Also, nonresponse has likely affected the validity of our findings, because not all the patients who were invited to participate completed the postvisit questionnaire.
This study is the first to evaluate the impact of agenda-setting in occupational health. Nonoccupational health conditions are commonly detected in occupational health clinic visits; therefore, agenda-setting is likely important in this setting. One study demonstrated that worker screening programs can lead to diagnosing multiple conditions such as anemia, thyroid disease, hypertension, and hyperlipidemia with the prevalence of 6.2%, 8.9%, 20%, and 31%, respectively.9 In another study of employer-sponsored executive exams, the rate of new diagnoses per single episode of care was 0.9 diagnoses per patient, with 29% of these new diagnoses resulting from patient complaints.19
Agenda-setting tools like the one used in this study may have mixed effects on patient satisfaction, depending on how the tool is used. It is clear from the literature and our results that patients find agenda-setting useful and desirable. Perhaps the best approach may result from combining patient elicitation methods (in simple forms, patient portals, or portable apps) with adequate clinician training in a collaborative process to prioritize the agenda items, using shared decision-making. Such processes may lead to a patient-centered visit, a key component of high-quality health care.
Agenda-setting forms can improve patient experience of care before the visit but do not necessarily improve postvisit satisfaction. Agenda-setting forms may create expectations that when unmet may worsen satisfaction. Agenda-setting interventions may require clinician-training, improvements in patient–clinician communication, and patient participation in decision-making to prioritize needs and calibrate expectations.
1. Committee on Quality of Health Care in America, The Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001.
2. Heritage J, Robinson JD, Elliott MN, Beckett M, Wilkes M. Reducing patients' unmet concerns in primary care: the difference one word can make. J Gen Intern Med. 2007;22:1429–1433.
3. Epstein RM, Mauksch L, Carroll J, Jaen CR. Have you really addressed your patient's concerns? Fam Pract Manag. 2008;15:35–40.
4. McLean M, Armstrong D. Eliciting patients' concerns: a randomised controlled trial of different approaches by the doctor. Br J Gen Pract. 2004;54:663–666.
5. Rodriguez HP, Anastario MP, Frankel RM, et al. Can teaching agenda-setting skills to physicians improve clinical interaction quality? A controlled intervention. BMC Med Educ. 2008;8:3.
6. Marvel MK, Epstein RM, Flowers K, Beckman HB. Soliciting the patient's agenda: have we improved? JAMA. 1999;281:283–287.
7. Mauksch LB, Dugdale DC, Dodson S, Epstein R. Relationship, communication, and efficiency in the medical encounter: creating a clinical model from a literature review. Arch Intern Med. 2008;168:1387–1395.
8. Yarnall KS, Ostbye T, Krause KM, Pollak KI, Gradison M, Michener JL. Family physicians as team leaders: “time” to share the care. Prev Chronic Dis. 2009;6:A59. Paper presented at: APHA 139th Annual Meeting, Washington, DC; Oct 29–Nov 2, 2011. Available at: http://www.apha.org/meetings/AnnualMeeting/
10. Davidoff F, Batalden P, Stevens D, Ogrinc G, Mooney SE. Publication guidelines for quality improvement studies in health care: evolution of the SQUIRE project. BMJ. 2009;338:a3152.
11. Varkey P, Reller MK, Resar RK. Basics of quality improvement in health care. Mayo Clin Proc. 2007;82:735–739.
12. Baker R. Development of a questionnaire to assess patients' satisfaction with consultations in general practice. Br J Gen Pract. 1990;40:487–490.
13. Middleton JF, McKinley RK, Gillies CL. Effect of patient completed agenda forms and doctors' education about the agenda on the outcome of consultations: randomised controlled trial. BMJ. 2006;332:1238–1242.
14. Brock DM, Mauksch LB, Witteborn S, Hummel J, Nagasawa P, Robins LS. Effectiveness of intensive physician training in upfront agenda-setting. J Gen Intern Med. 2011;26:1317–1323.
15. Mauksch L, Hillenburg L, Robins L. The Establishing Focus protocol: training for collaborative agenda-setting and time management in the medical interview. Families Systems Health. 2001;19:147–157.
16. Glasziou P, Ogrinc G, Goodman S. Can evidence-based medicine and clinical quality improvement learn from each other? BMJ Qual Saf. 2011;20(suppl 1):i13–i17.
17. Shojania KG, Grimshaw JM. Evidence based quality improvement: the state of the science. Health Aff. 2005;24:138–150.
18. Nabhan M, Elraiyah T, Murad M. Teaching the contrasting paradigms of evidence-based medicine and quality improvement in residency. Int Soc Evidence-Based Health Care Newsl. 2011;4:5–6.
19. Kermott CA, Kuhle CS, Faubion SS, Johnson RE, Hensrud DD, Murad MH. The diagnostic yield of the first episode of a periodic health evaluation: a descriptive epidemiology study. BMC Health Serv Res. 2012;12:137.