Towards more patient centred healthcare: A new Consumer Quality Index instrument to assess patients’ experiences with breast care

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Abstract

Objective

To develop a Consumer Quality Index (CQ-index) Breast Care instrument that measures quality of care from the perspective of patients with (suspicion of) breast cancer.

Methods

To develop a pilot questionnaire, three focus group discussions with breast cancer patients were performed. The questionnaire was sent to 1197 patients. We performed psychometric and descriptive analyses to optimise the new instrument.

Results

Focus group discussions revealed nine main themes related to breast care quality. Psychometric analyses resulted in 15 reliable scales. The final instrument consisted of 152 items, of which 118 items regarded patients’ experiences. The aspect with the highest need for quality improvement was informing patients about a second opinion.

Conclusion

The CQ-index Breast Care (CQI-BC) instrument provides a good starting point for further research on the quality of breast care seen from the perspective of patients. The newly developed instrument can be used by different stakeholders for future quality monitoring.

Introduction

Healthcare systems in many countries are moving towards more patient centred care. In this process, transparency about healthcare quality is an issue of paramount importance. In addition to the release of clinical outcome data, which usually originate from medical professional groups, effort has been made to assemble and report patients’ own quality assessments. Patient and public involvement in defining and assessing healthcare quality has now been introduced in various countries.1, 2, 3

In the Netherlands, the assessment of patient experiences in healthcare is standardised using Consumer Quality Index (CQ-index or CQI) surveys.4, 5 The CQ-index is based on two families of instruments: (a) American CAHPS (Consumer Assessment of Healthcare Providers and Systems)6 and (b) Dutch QUOTE (QUality Of Care Through the patient’s Eyes) instruments.1 The strengths of both methods have been combined: the frequency with which quality criteria are met (CAHPS) and the importance of quality aspects (QUOTE) are integrated in patient surveys. A four-point answering structure of experience items (‘never’, ‘sometimes’, ‘usually’, ‘always’), and a four-point scale of importance items (‘not important’, ‘fairly important’, ‘important’, ‘extremely important’) are the questionnaires’ basis. In addition, global ratings of healthcare and healthcare professionals as well as items on problems concerning accessibility of care are standard elements.

Like CAHPS and QUOTE, CQI instruments assess patients’ experiences, rather than their satisfaction. Experience measures are known to be less subjective and to yield more detailed information for quality improvement than satisfaction measures.7 An advantage of standardised instruments is that healthcare performance can be compared over years8 and across healthcare sectors. Importantly, CQI information can fulfil different stakeholders’ information needs: (a) consumers on the healthcare market and health insurance market, who are more and more expected to act as informed and critical decision makers; (b) healthcare providers monitoring their provided healthcare; (c) health insurance companies on the health purchaser market; (d) patient organisations which represent patients’ interests and needs; (e) healthcare inspectorates supervising healthcare quality; and (f) governments monitoring general healthcare quality. Using the CQ-index is thus efficient; several parties, having their own needs, are provided with quality information through one single measurement. At present, a large amount of CQI information is assembled, using general,9 sector-specific10 and disease-specific4, 5 questionnaires. Particularly, disease-specific instruments are expected to play a major role for healthcare providers because these instruments provide detailed information about particular patient groups within specific healthcare settings. In addition, from the patient’s perspective, disease-specific quality aspects contribute to the (face) validity of the instruments.

Within the set of disease-specific CQI questionnaires, a breast care instrument was developed from December 2006 to October 2007: the CQI-BC. Since breast cancer generally brings about many emotional and psychosocial consequences,11, 12, 13, 14 and breast cancer care is rather complex and prolonged, it seems obvious that patients will search for a high quality treatment in a high quality hospital. Therefore, an important aim of the instrument is to develop public comparative information for future patients. Besides patients, medical care providers or professionals are important potential users of the instrument, since comparative information can enforce quality improvement initiatives through both internal and public hospital reports.15 Insight into patient’s experience allows professionals to compare the quality of care they provide with that of their colleagues in other hospitals, and might be a stimulus to improve public perception of their own hospital.

Our aim was to develop a CQI-BC instrument that is both scientifically grounded and manageable by several users. In this article, we describe the development of the CQI-BC, while focusing on the application of the instrument by one important group of potential users, namely, healthcare providers and professionals. In this context, aspects of care that need quality improvement were explored, and options to report CQI information are discussed.

Section snippets

Patients and methods

The construction of the new survey was based on CQI protocols.16 The CQI-BC was developed in close cooperation with key stakeholders (representatives of health insurance companies, a patient organisation, the Dutch Institute for Healthcare Improvement, a surgeon, a radiologist, a radiotherapist, a nurse practitioner and an oncologic psychologist) to ensure public support.

Focus groups

A total of 27 breast cancer patients participated in the focus group discussions (n = 11, n = 9 and n = 7). Participants’ mean age was 51 (SD = 11.5; minimum = 26; maximum = 73). Data analyses resulted in nine main themes related to breast care quality. These themes concerned general aspects, such as conduct of healthcare professionals, as well as more disease-specific aspects, such as options for an immediate breast conserving treatment and referrals to follow-up care. The nine main themes were (1)

Discussion

Our aim was to develop a CQI-BC instrument with good psychometric properties as well as with the capacity to be used by several stakeholders in the healthcare market. Several quality aspects important to patients were reliably measured. While we removed several items from the questionnaire, a substantial number of stable quality aspects remained in the instrument on which future information can be created. In short, the CQI-BC forms a good basis to investigate breast care quality from the

Conclusion

The CQI-BC instrument covers the most important aspects of quality of care according to patients. In the near future, hospitals and other users can use CQ-index information about the quality of breast care. Particularly in combination with other quality indicators, the instrument can contribute to a complete picture of breast care quality.

Conflict of interest statement

None declared.

Role of the funding sources

The supporting organisation ZonMw (The Netherlands Organisation for Health Research and Development) did not have any involvement in the study. Stichting Miletus (a concordance of Dutch health insurance companies) sponsored the data collection, and this organisation contributed to the project meetings, just like the other key stakeholders.

Acknowledgements

We would like to thank all breast cancer patients who participated in the focus groups, and the stakeholders participating in the project ‘CQ-index Breast Care’ for their contribution to the development of the instrument.

References (20)

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