House staff communication training and patient experience scores

Objective:

To assess whether communication training for house staff via role-playing exercises (1) is well received and (2) improves patient experience scores in house staff clinics.

Methods:

We conducted a pre–post study in which the house staff for 3 adult hospital departments participated in communication training led by trained faculty in small groups. Sessions centered on a published 5-step strategy for opening patient-centered interviews using department-specific role-playing exercises. House staff completed posttraining questionnaires. For 1 month prior to and 1 month following the training, patients in the house staff clinics completed surveys with Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) questions regarding physician communication, immediately following clinic visits. Preintervention and postintervention results for top-box scores were compared.

Results:

Forty-four of a possible 45 house staff (97.8%) participated, with 31 (70.5%) indicating that the role-playing exercise increased their perception of the 5-step strategy. No differences in patient responses to CG-CAHPS questions were seen when comparing 63 preintervention surveys to 77 postintervention surveys.

Conclusion:

Demonstrating an improvement in standard patient experience surveys in resident clinics may require ongoing communication coaching and investigation of the “hidden curriculum” of training.

Advice to Quit Smoking and Ratings of Health Care among Medicare Beneficiaries Aged 65

OBJECTIVE

To examine the relationship between physician advice to quit smoking and patient care experiences.

DATA SOURCE

The 2012 Medicare Consumer Assessment of Healthcare Providers and Systems (MCAHPS) surveys.

STUDY DESIGN

Fixed-effects linear regression models were used to analyze cross-sectional survey data, which included a nationally representative sample of 26,432 smokers aged 65+.

PRINCIPAL FINDINGS

Eleven of 12 patient experience measures were significantly more positive among smokers who were always advised to quit smoking than those advised to quit less frequently. There was an attenuated but still significant and positive association of advice to quit smoking with both physician rating and physician communication, after controlling for other measures of care experiences.

CONCLUSIONS

Physician-provided cessation advice was associated with more positive patient assessments of their physicians.

Evolving Concepts of Patient-Centered Care and the Assessment of Patient Care Experiences: Optimism and Opposition

In his seminal work on health care quality, Avedis Donabedian noted that patient satisfaction was a key indicator of health care quality, and in the 1970s and 1980s a great deal of research explored the determinants of patient satisfaction. Subsequently, attention shifted toward assessing care experiences, and there is now a large body of evidence related to the reliability and validity of survey-based assessments of care. As the use of such surveys has increased, so too have concerns about the validity and uses of such surveys. The available research, however, indicates that such surveys are reliable, valid, correlated across individuals and settings with other quality indicators, and predictive of better outcomes. Patient experiences are now routinely measured, and substantial effort is being devoted to providing high-quality patient-centered care. Providing patient-centered care need not divert resources away from other quality improvement efforts. Improving the infrastructure supporting certain aspects of care may have broad effects because system changes can influence multiple outcomes. Thus, rather than detract from general quality improvement efforts, making changes that facilitate patient-centered care may lead to broader improvements. There is good reason to be optimistic that our health care system will increasingly be "patient centered."

Methodological Considerations When Studying the Association between Patient-Reported Care Experiences and Mortality

OBJECTIVE

To illustrate methodological considerations when assessing the relationship between patient care experiences and mortality.

DATA SOURCE

Medical Expenditure Panel Survey data (2000-2005) linked to National Health Interview Survey and National Death Index mortality data through December 31, 2006.

STUDY DESIGN

We estimated Cox proportional hazards models with mortality as the dependent variable and patient experience measures as independent variables and assessed consistency of experiences over time.

DATA EXTRACTION METHODS

We used data from respondents age 18 or older with at least one doctor's office or clinic visit during the year prior to the round 2 interview. We excluded subjects who died in the baseline year.

PRINCIPAL FINDINGS

The association between overall care experiences and mortality was significant for deaths not amenable to medical care and all-cause mortality, but not for amenable deaths. More than half of respondents were in a different care experience quartile over a 1-year period. In the five individual experience questions we analyzed, only time spent with the patient was significantly associated with mortality.

CONCLUSIONS

Deaths not amenable to medical care and the time-varying and multifaceted nature of patient care experience are important issues to consider when assessing the relationship between care experience and mortality.

Accelerating Improvement and Narrowing Gaps: Trends in Patients' Experiences with Hospital Care Reflected in HCAHPS Public Reporting

OBJECTIVE

Measure HCAHPS improvement in hospitals participating in the second and fifth years of HCAHPS public reporting; determine whether change is greater for some hospital types.

DATA

Surveys from 4,822,960 adult inpatients discharged July 2007-June 2008 or July 2010-June 2011 from 3,541 U.S. hospitals.

STUDY DESIGN

Linear mixed-effect regression models with fixed effects for time, patient mix, and hospital characteristics (bedsize, ownership, Census division, teaching status, Critical Access status); random effects for hospitals and hospital-time interactions; fixed-effect interactions of hospital characteristics and patient characteristics (gender, health, education) with time predicted HCAHPS measures correcting for regression-to-the-mean biases.

DATA COLLECTION METHODS

National probability sample of adult inpatients in any of four approved survey modes.

PRINCIPAL FINDINGS

HCAHPS scores increased by 2.8 percentage points from 2008 to 2011 in the most positive response category. Among the middle 95 percent of hospitals, changes ranged from a 5.1 percent decrease to a 10.2 percent gain overall. The greatest improvement was in for-profit and larger (200 or more beds) hospitals.

CONCLUSIONS

Five years after HCAHPS public reporting began, meaningful improvement of patients' hospital care experiences continues, especially among initially low-scoring hospitals, reducing some gaps among hospitals.

Should health care providers be accountable for patients' care experiences?

Measures of patients' care experiences are increasingly used as quality measures in accountability initiatives. As the prominence and financial impact of patient experience measures have increased, so too have concerns about the relevance and fairness of including them as indicators of health care quality. Using evidence from the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) surveys, the most widely used patient experience measures in the United States, we address seven common critiques of patient experience measures: (1) consumers do not have the expertise needed to evaluate care quality; (2) patient "satisfaction" is subjective and thus not valid or actionable; (3) increasing emphasis on improving patient experiences encourages health care providers and plans to fulfill patient desires, leading to care that is inappropriate, ineffective, and/or inefficient; (4) there is a trade-off between providing good patient experiences and providing high-quality clinical care; (5) patient scores cannot be fairly compared across health care providers or plans due to factors beyond providers' control; (6) response rates to patient experience surveys are low, or responses reflect only patients with extreme experiences; and (7) there are faster, cheaper, and more customized ways to survey patients than the standardized approaches mandated by federal accountability initiatives.

Clinician advice to quit smoking among seniors

OBJECTIVE

Little smoking research in the past 20years includes persons 50 and older; herein we describe patterns of clinician cessation advice to US seniors, including variation by Medicare beneficiary characteristics.

METHOD

In 2012-4, we analyzed 2010 Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey data from Medicare beneficiaries over age 64 (n=346,674). We estimated smoking rates and the proportion of smokers whose clinicians encouraged cessation.

RESULTS

12% of male and 8% of female respondents aged 65 and older smoke. The rate decreases with age (14% of 65-69, 3% of 85+) and education (12-15% with no high school degree, 5-6% with BA+). Rates are highest among American Indian/Alaskan Native (16%), multiracial (14%), and African-American (13%) seniors, and in the Southeast (14%). Only 51% of smokers say they receive cessation advice "always" or "usually" at doctor visits, with advice more often given to the young, those in low-smoking regions, Asians, and women. For all results cited p<0.05.

CONCLUSIONS

Smoking cessation advice to seniors is variable. Providers may focus on groups or areas in which smoking is less common or when they are most comfortable giving advice. More consistent interventions are needed, including cessation advice from clinicians.

Examining the role of patient experience surveys in measuring health care quality

Patient care experience surveys evaluate the degree to which care is patient-centered. This article reviews the literature on the association between patient experiences and other measures of health care quality. Research indicates that better patient care experiences are associated with higher levels of adherence to recommended prevention and treatment processes, better clinical outcomes, better patient safety within hospitals, and less health care utilization. Patient experience measures that are collected using psychometrically sound instruments, employing recommended sample sizes and adjustment procedures, and implemented according to standard protocols are intrinsically meaningful and are appropriate complements for clinical process and outcome measures in public reporting and pay-for-performance programs.

Development and evaluation of the CAHPS (Consumer Assessment of Healthcare Providers and Systems) survey for in-center hemodialysis patients

BACKGROUND

The US Centers for Medicare & Medicaid Services assess patient experiences of care as part of the end-stage renal disease prospective payment system and Quality Incentive Program. This article describes the development and evaluation of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) In-Center Hemodialysis Survey.

STUDY DESIGN

We conducted formative research to generate survey questions and performed statistical analyses to evaluate the survey's measurement properties.

SETTING & PARTICIPANTS

Formative research included focus groups, cognitive interviews, and field testing the survey with dialysis patients.

MEASUREMENTS & OUTCOMES

We assessed internal consistency reliability (Cronbach alpha) and center-level reliability for 3 multi-item scales. We evaluated construct validity using correlations of the scales with global ratings of the kidney doctor, staff, and dialysis center.

RESULTS

Response rate was 46% (1,454 completed surveys). Analyses support 3 multi-item scales: Nephrologists' Communication and Caring (7 items, alpha=0.89), Quality of Dialysis Center Care and Operations (22 items, alpha=0.93), and Providing Information to Patients (11 items, alpha=0.75). The communication scale was correlated the most strongly with the global rating of the "kidney doctor" (r=0.78). The Dialysis Center Care and Operations scale was correlated most strongly with global ratings of staff (r=0.75) and the center (r=0.69). Providing Information to Patients was correlated most strongly with the global rating of the staff (r=0.41).

LIMITATIONS

A relatively small number of patients completed the survey in Spanish.

CONCLUSIONS

This study provides support for the reliability and validity of the CAHPS In-Center Hemodialysis Survey for assessing patient experiences of care at dialysis facilities. The survey can be used to compare care provided at different facilities.

Are comparisons of patient experiences across hospitals fair? A study in Veterans Health Administration hospitals

BACKGROUND

Surveys are increasingly used to assess patient experiences with health care. Comparisons of hospital scores based on patient experience surveys should be adjusted for patient characteristics that might affect survey results. Such characteristics are commonly drawn from patient surveys that collect little, if any, clinical information. Consequently some hospitals, especially those treating particularly complex patients, have been concerned that standard adjustment methods do not adequately reflect the challenges of treating their patients.

OBJECTIVES

To compare scores for different types of hospitals after making adjustments using only survey-reported patient characteristics and using more complete clinical and hospital information.

RESEARCH DESIGN

We used clinical and survey data from a national sample of 1858 veterans hospitalized for an initial acute myocardial infarction (AMI) in a Department of Veterans Affairs (VA) medical center during fiscal years 2003 and 2004. We used VA administrative data to characterize hospitals. The survey asked patients about their experiences with hospital care. The clinical data included 14 measures abstracted from medical records that are predictive of survival after an AMI.

RESULTS

Comparisons of scores across hospitals adjusted only for patient-reported health status and sociodemographic characteristics were similar to those that also adjusted for patient clinical characteristics; the Spearman rank-order correlations between the 2 sets of adjusted scores were >0.97 across 9 dimensions of inpatient experience.

CONCLUSIONS

This study did not support concerns that measures of patient care experiences are unfair because commonly used models do not adjust adequately for potentially confounding patient clinical characteristics.

The effect of response scale, administration mode, and format on responses to the CAHPS Clinician and Group survey

OBJECTIVE

To examine how different response scales, methods of survey administration, and survey format affect responses to the CAHPS (Consumer Assessment of Healthcare Providers and Systems) Clinician and Group (CG-CAHPS) survey.

STUDY DESIGN

A total of 6,500 patients from a university health center were randomly assigned to receive the following: standard 12-page mail surveys using 4-category or 6-category response scales (on CG-CAHPS composite items), telephone surveys using 4-category or 6-category response scales, or four-page mail surveys.

PRINCIPAL FINDINGS

A total of 3,538 patients completed surveys. Composite score means and provider-level reliabilities did not differ between respondents receiving 4-category or 6-category response scale surveys or between 12-page and four-page mail surveys. Telephone respondents gave more positive responses than mail respondents.

CONCLUSIONS

We recommend using 4-category response scales and the four-page mail CG-CAHPS survey.

Expanding the use of patient reports about patient-centered care

In an informative article on the assessment of patient care experiences, Zimlichman, Rozenblum, and Millenson describe the evolving use of surveys that elicit patient reports about medical care experiences in Israel, a trend that parallels developments in the U.S. This commentary summarizes some of experiences in the U.S. that might inform the development of more consistent and extensive strategies for assessing and promoting patient-centered care in Israel.

More comprehensive patient experience surveys, the results of which would be publicly available, as Zimlichman and colleagues advocate, would facilitate quality improvements, especially if users are provided with support for the use and interpretation of the data. Developing more efficient survey methods will facilitate the broader use of such surveys, although it is important to use methods that yield results that are as representative of the target population as possible and to account for survey mode effects when data are reported. Although the surveys need to be appropriate for the Israeli context, the use of standard questions used in other countries would facilitate comparisons that could help to identify best practices that can be adopted in different settings. Those who work on assessing patient-centered care in the U.S. look forward to learning from the work of their Israeli colleagues.

This is a commentary on http://www.ijhpr.org/content/2/1/35/.

Care experiences of managed care Medicare enrollees near the end of life

OBJECTIVES

To compare reports about care experiences of individuals who died within 1 year of survey with reports of those who did not.

DESIGN

Medicare Advantage (MA) Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys asked about care experiences. Survey completion dates were linked to Social Security Administration death records to identify enrollees dying within 1 year of survey completion. Propensity-score weighting combined with regression-based case-mix adjustment was used to compare these individuals' experiences with experiences of those who were alive 1 year later.

SETTING

Nationally representative sample of MA enrollees.

PARTICIPANTS

Four hundred two thousand five hundred ninety-three MA enrollees responding to 2008 and 2009 CAHPS Surveys.

MEASUREMENTS

Outcomes were five care ratings (plan, prescription drug coverage, doctor, specialists, care) and five composite measures of care (getting needed care, getting care quickly, doctor communication, getting drugs, getting drug information). Analyses were adjusted for age, sex, race and ethnicity, education, Medicaid status, geographic region, and several health status measures.

RESULTS

Twelve thousand one hundred two enrollees (3%) died within 1 year of survey completion (near-end-of-life group). Those enrollees reported slightly better experiences than other enrollees with respect to getting care quickly (+2%, P < .001) and gave slightly higher ratings for their plans (+1%, P = .02) and prescription drug coverage (+1%, P < .001). There were no measures of participant experience for which the near-end-of-life group reported worse experiences than other enrollees.

CONCLUSION

Contrary to analyses based on retrospective reports from surviving relatives after an individual's death, MA enrollees' reports about care within 1 year of death were as good as or better than reports of other MA enrollees. Future research might investigate whether results are similar in other Medicare populations.

Why pharmacists belong in the medical home

Pharmacists can affect the delivery of primary care by addressing the challenges of medication therapy management. Most office visits involve medications for chronic conditions and require assessment of medication effectiveness, the cost of therapies, and patients' adherence with medication regimens. Pharmacists are often underused in conducting these activities. They perform comprehensive therapy reviews of prescribed and self-care medications, resolve medication-related problems, optimize complex regimens, design adherence programs, and recommend cost-effective therapies. Pharmacists should play key roles as team members in medical homes, and their potential to serve effectively in this role should be evaluated as part of medical home demonstration projects.

Safety climate and medical errors in 62 US emergency departments

STUDY OBJECTIVE

We describe the incidence and types of medical errors in emergency departments (EDs) and assess the validity of a survey instrument that identifies systems factors contributing to errors in EDs.

METHODS

We conducted the National Emergency Department Safety Study in 62 urban EDs across 20 US states. We reviewed 9,821 medical records of ED patients with one of 3 conditions (myocardial infarction, asthma exacerbation, and joint dislocation) to evaluate medical errors. We also obtained surveys from 3,562 staff randomly selected from each ED; survey data were used to calculate average safety climate scores for each ED.

RESULTS

We identified 402 adverse events (incidence rate 4.1 per 100 patient visits; 95% confidence interval [CI] 3.7 to 4.5) and 532 near misses (incidence rate 5.4 per 100 patient visits; 95% CI 5.0 to 5.9). We judged 37% of the adverse events, and all of the near misses, to be preventable (errors); 33% of the near misses were intercepted. In multivariable models, better ED safety climate was not associated with fewer preventable adverse events (incidence rate ratio per 0.2-point increase in ED safety score 0.82; 95% CI 0.57 to 1.16) but was associated with more intercepted near misses (incidence rate ratio 1.79; 95% CI 1.06 to 3.03). We found no association between safety climate and violations of national treatment guidelines.

CONCLUSION

Among the 3 ED conditions studied, medical errors are relatively common, and one third of adverse events are preventable. Improved ED safety climate may increase the likelihood that near misses are intercepted.

Development of and field test results for the CAHPS PCMH Survey

OBJECTIVE

To develop and evaluate survey questions that assess processes of care relevant to Patient-Centered Medical Homes (PCMHs).

RESEARCH DESIGN

We convened expert panels, reviewed evidence on effective care practices and existing surveys, elicited broad public input, and conducted cognitive interviews and a field test to develop items relevant to PCMHs that could be added to the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Clinician & Group (CG-CAHPS) 1.0 Survey. Surveys were tested using a 2-contact mail protocol in 10 adults and 33 pediatric practices (both private and community health centers) in Massachusetts. A total of 4875 completed surveys were received (overall response rate of 25%).

ANALYSES

We calculated the rate of valid responses for each item. We conducted exploratory factor analyses and estimated item-to-total correlations, individual and site-level reliability, and correlations among proposed multi-item composites.

RESULTS

Ten items in 4 new domains (Comprehensiveness, Information, Self-Management Support, and Shared Decision-Making) and 4 items in 2 existing domains (Access and Coordination of Care) were selected to be supplemental items to be used in conjunction with the adult CG-CAHPS 1.0 Survey. For the child version, 4 items in each of 2 new domains (Information and Self-Management Support) and 5 items in existing domains (Access, Comprehensiveness-Prevention, Coordination of Care) were selected.

CONCLUSIONS

This study provides support for the reliability and validity of new items to supplement the CG-CAHPS 1.0 Survey to assess aspects of primary care that are important attributes of PCMHs.

Multilevel interventions: study design and analysis issues

Multilevel interventions, implemented at the individual, physician, clinic, health-care organization, and/or community level, increasingly are proposed and used in the belief that they will lead to more substantial and sustained changes in behaviors related to cancer prevention, detection, and treatment than would single-level interventions. It is important to understand how intervention components are related to patient outcomes and identify barriers to implementation. Designs that permit such assessments are uncommon, however. Thus, an important way of expanding our knowledge about multilevel interventions would be to assess the impact of interventions at different levels on patients as well as the independent and synergistic effects of influences from different levels. It also would be useful to assess the impact of interventions on outcomes at different levels. Multilevel interventions are much more expensive and complicated to implement and evaluate than are single-level interventions. Given how little evidence there is about the value of multilevel interventions, however, it is incumbent upon those arguing for this approach to do multilevel research that explicates the contributions that interventions at different levels make to the desired outcomes. Only then will we know whether multilevel interventions are better than more focused interventions and gain greater insights into the kinds of interventions that can be implemented effectively and efficiently to improve health and health care for individuals with cancer. This chapter reviews designs for assessing multilevel interventions and analytic ways of controlling for potentially confounding variables that can account for the complex structure of multilevel data.

Factors affecting the use of patient survey data for quality improvement in the Veterans Health Administration

Background

Little is known about how to use patient feedback to improve experiences of health care. The Veterans Health Administration (VA) conducts regular patient surveys that have indicated improved care experiences over the past decade. The goal of this study was to assess factors that were barriers to, or promoters of, efforts to improve care experiences in VA facilities.

Methods

We conducted case studies at two VA facilities, one with stable high scores on inpatient reports of emotional support between 2002 and 2006, and one with stable low scores over the same period. A semi-structured interview was used to gather information from staff who worked with patient survey data at the study facilities. Data were analyzed using a previously developed qualitative framework describing organizational, professional and data-related barriers and promoters to data use.

Results

Respondents reported more promoters than barriers to using survey data, and particularly support for improvement efforts. Themes included developing patient-centered cultures, quality improvement structures such as regular data review, and training staff in patient-centered behaviors. The influence of incentives, the role of nursing leadership, and triangulating survey data with other data on patients' views also emerged as important. It was easier to collect data on current organization and practice than those in the past and this made it difficult to deduce which factors might influence differing facility performance.

Conclusions

Interviews with VA staff provided promising examples of how systematic processes for using survey data can be implemented as part of wider quality improvement efforts. However, prospective studies are needed to identify the most effective strategies for using patient feedback to improve specific aspects of patient-centered care.

Market characteristics and awareness of managed care options among elderly beneficiaries enrolled in traditional Medicare

BACKGROUND

Medicare beneficiaries' awareness of Medicare managed care plans is critical for realizing the potential benefits of coverage choices.

OBJECTIVES

To assess the relationships of the number of Medicare risk plans, managed care penetration, and stability of plans in an area with traditional Medicare beneficiaries' awareness of the program.

RESEARCH DESIGN

Cross-sectional analysis of Medicare Current Beneficiary Survey data about beneficiaries' awareness and knowledge of Medicare managed care plan availability. Logistic regression models used to assess the relationships between awareness and market characteristics.

SUBJECTS

Traditional Medicare beneficiaries (n = 3,597) who had never been enrolled in Medicare managed care, but had at least one plan available in their area in 2002, and excluding beneficiaries under 65, receiving Medicaid, or with end stage renal disease.

MEASURES

Traditional Medicare beneficiaries' knowledge of Medicare managed care plans in general and in their area.

RESULTS

Having more Medicare risk plans available was significantly associated with greater awareness, and having an intermediate number of plans (2-4) was significantly associated with more accurate knowledge of Medicare risk plan availability than was having fewer or more plans.

CONCLUSIONS

Medicare may have more success engaging consumers in choice and capturing the benefits of plan competition by more actively selecting and managing the plan choice set.

How do the experiences of Medicare beneficiary subgroups differ between managed care and original Medicare?

OBJECTIVE

To examine whether disparities in health care experiences of Medicare beneficiaries differ between managed care (Medicare Advantage [MA]) and traditional fee-for-service (FFS) Medicare.

DATA SOURCES

132,937 MA and 201,444 FFS respondents to the 2007 Medicare Consumer Assessment of Health Care Providers and Systems (CAHPS) survey.

STUDY DESIGN

We defined seven subgroup characteristics: low-income subsidy eligible, no high school degree, poor or fair self-rated health, age 85 and older, female, Hispanic, and black. We estimated disparities in CAHPS experience of care scores between each of these groups and beneficiaries without those characteristics within MA and FFS for 11 CAHPS measures and assessed differences between MA and FFS disparities in linear models.

PRINCIPAL FINDINGS

The seven subgroup characteristics had significant (p<.05) negative interactions with MA (larger disparities in MA) in 27 of 77 instances, with only four significant positive interactions.

CONCLUSION

Managed care may provide less uniform care than FFS for patients; specifically there may be larger disparities in MA than FFS between beneficiaries who have low incomes, are less healthy, older, female, and who did not complete high school, compared with their counterparts. There may be potential for MA quality improvement targeted at the care provided to particular subgroups.

Concurrent sexual partnerships and human immunodeficiency virus risk among South African youth

BACKGROUND

To estimate the prevalence of concurrency (more than 1 sex partner overlapping in time), the attitudes/behaviors of those engaged in concurrency, length of relationship overlap, and the association between concurrency and human immunodeficiency virus (HIV) among South Africans aged 15 to 24 years.

METHODS

A cross-sectional, nationally representative, household survey of HIV infection, and sexual attitudes and behaviors was conducted among 11,904 15 to 24 year old South Africans in 2003. Analyses were conducted among sexually experienced youth.

RESULTS

Men were more likely to report having concurrent (24.7%) than serial partners (5.7%) in the past 12 months, but concurrency was not associated with HIV. Among women, concurrency and serial monogamy were equally common (4.7%), and concurrency, defined by respondent reports of multiple ongoing partners, was associated with HIV in multivariate analysis (odds ratio, 3.4; 95% confidence interval, 1.8-6.5). Median length of relationship overlap was approximately 4 months for women and 3 months for men. Compared to serial monogamists, concurrents reported less consistent condom use, and female concurrents were more likely to report transactional sex and problems negotiating condoms and refusing intercourse.

CONCLUSIONS

Concurrency is a common partnership pattern among those youth with multiple partners, especially men. For women, having concurrent relationships may be associated with relationship power imbalances and less ability to protect against HIV. Given the prevalence and likely significance of concurrency in the spread of HIV throughout a sexual network, our findings underscore the need for prevention efforts targeting fidelity.

Parents' roles in decision making for children with cancer in the first year of cancer treatment

PURPOSE

To evaluate the extent to which parents of children with cancer are involved in decision making in the ways they prefer during the first year of treatment.

METHODS

We conducted a cross-sectional survey of 194 parents of children with cancer (response rate, 70%) in their first year of cancer treatment at the Dana-Farber Cancer Institute and Children's Hospital (Boston, MA) and the children's physicians. We measured parents' preferred and actual roles in decision making and physician perceptions of parents' preferred roles.

RESULTS

Most parents (127 of 192; 66%) wanted to share responsibility for decision making with their children's physician. Although most parents (122 of 192; 64%) reported that they had their preferred role in decision making, those who did not tended to have more passive roles than they wished (47 of 70; 67%; P < .001). Parents were no more likely to hold their ideal roles in decision making when the physician accurately identified the parents' preferred role (odds ratio [OR], 1.04; P = .92). Parents were less likely to hold more passive roles than they wished in decision making when they felt that physician communication (OR, 0.39; P = .04) and information received (OR, 0.45; P = .04) had been of high quality. Parents who held more passive roles than they wished in decision making were less likely to trust their physicians' judgments (OR, 0.46; P = .03).

CONCLUSION

Most parents of children in their first year of cancer treatment participate in decision making to the extent that they wish; although, nearly one fourth hold more passive roles than desired. High-quality physician communication is associated with attainment of one's preferred role.