Member ratings of health care provided by 48 physician groups

Compassion in Spanish-speaking health care: A systematic review

Altought compassionate care is an important factor in health care, remains an unmet need in patients. The studies have been carried out in Anglo-Saxon countries with cultural environments and health systems that are very different from Spanish-speaking contexts. The aim of this study to understand the conceptual, evaluation and clinical application nuances of compassion and compassionate care in Spanish-speaking health care settings, through a systematic review. A search of the scientific literature was carried out following the PRISMA guidelines in ProQuest Central, PubMed and Web Of Science, resulting in 295 studies, of which 27 were selected, based on the following inclusion criteria: the article studied or analyzed the construct of compassion in healthcare setting and the participants were Spanish speakers or the authors spoke of the construct in Spanish. Two blinded evaluators performed the study selection process using the Covidence tool. The agreement between evaluators was in all cases satisfactory. Different definitions of the construct have been identified, that they generally share: the recognition of suffering and the attempt to alleviate it. There are few studies that focus solely on the analysis of compassion, since other concepts appear that are associated with it, such as empathy and self-compassion. Further research is needed to obtain a better and greater understanding of compassionate care adapted to the perceptions of patients and health professionals in different socio-cultural contexts. In this way, instruments that measure compassionate care can be better developed and adjusted, and interventions aimed at promoting compassion can be properly assessed.

Examining the Business Case for Patient Experience: A Systematic Review

EXECUTIVE SUMMARY

Hospitals, physician groups, and other healthcare providers are investing in improved patient care experiences. Prior reviews have concluded that better patient care experiences are associated with less healthcare utilization and better adherence to recommended prevention and treatment, clinical outcomes, and patient safety within hospitals. No comprehensive review has examined the business case for investing in patient experiences. This article reviews the literature on associations between patient experience-measured from the perspective of patients and families-and business outcomes, including patient allegiance and retention, complaints, lawsuits, provider job satisfaction, and profitability. We searched U.S. English-language peer-reviewed articles from January 1990 to July 2019. We followed the preferred reporting items for systematic reviews and meta-analyses guidelines and undertook a full-text review of 564 articles, yielding the inclusion of 40 articles. Our review found that patients with positive care experiences are more likely to return to the same hospital and ambulatory settings for future healthcare needs, retain their health plan, and voice fewer complaints. Associations between patient experiences and profitability or provider job satisfaction were limited/mixed. This suggests that providers can pursue better patient care experiences for the intrinsic value to patients, while also recognizing it is good for intermediate business outcomes: specifically increased recommendations, better patient retention, and fewer complaints. Nursing and physician care, broadly defined, are the only specific aspects of patient experience consistently associated with retention, with evidence pointing to communication and trust as parts of care linked to the intent to return. These aspects of patient experience are also the largest contributors to the overall ratings of a provider or facility.

Patient-Reported Experiences of Dialysis Care Within a National Pay-for-Performance System

IMPORTANCE

Medicare's End-Stage Renal Disease Quality Incentive Program incorporates measures of perceived value into reimbursement calculations. In 2016, patient experience became a clinical measure in the Quality Incentive Program scoring system. Dialysis facility performance in patient experience measures has not been studied at the national level to date.

OBJECTIVE

To examine associations among dialysis facility performance with patient experience measures and patient, facility, and geographic characteristics.

DESIGN

In this cross-sectional analysis, patients from a national end-stage renal disease registry receiving in-center hemodialysis in the United States on December 31, 2014, were linked with dialysis facility scores on the In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH-CAHPS) survey. Of 4977 US dialysis facilities, 2939 (59.1%) reported ICH-CAHPS scores from April 8, 2015, through January 11, 2016. Multivariable linear regression models with geographic random effects were used to examine associations of facility ICH-CAHPS scores with patient, dialysis facility, and geographic characteristics and to identify the amount of total between-facility variation in patient experience scores explained by these categories. Data were analyzed from September 15, 2017, through June 1, 2018.

EXPOSURES

Dialysis facility, geographic characteristic, and 10% change in patient characteristics.

MAIN OUTCOMES AND MEASURES

Dialysis facility ICH-CAHPS scores and the total between-facility variation explained by different categories of characteristics.

RESULTS

Of the 2939 facilities included in the analysis, adjusted mean ICH-CAHPS scores were 2.6 percentage points (95% CI, 1.5-3.7) lower in for-profit facilities, 1.6 percentage points (95% CI, 0.9-2.2) lower in facilities owned by large dialysis organizations, and 2.3 percentage points (95% CI, 0.5-4.2) lower in free-standing facilities compared with their counterparts. More nurses per patient was associated with 0.2 percentage points (95% CI, 0.03-0.3) higher scores; a privately insured patient population was associated with 1.2 percentage points (95% CI, 0.2-2.2) higher scores. Facilities with higher proportions of black patients had 0.95 percentage points (95% CI, 0.78-1.12) lower scores; more Native American patients, 1.00 percentage point (95% CI, 0.39-1.60) lower facility scores. Geographic location and dialysis facility characteristics explained larger proportions of the overall between-facility variation in ICH-CAHPS scores than did patient characteristics.

CONCLUSIONS AND RELEVANCE

This study suggests that for-profit operation, free-standing status, and large dialysis organization designation were associated with less favorable patient-reported experiences of care. Patient experience scores varied geographically, and black and Native American populations reported less favorable experiences. The study findings suggest that perceived quality of care delivered in these settings are of concern, and that there may be opportunities for improved implementation of patient experience surveys as is highlighted.

Quantifying Magnitude of Group-Level Differences in Patient Experiences with Health Care

OBJECTIVE

Review approaches assessing magnitude of differences in patient experience scores between different providers.

DATA SOURCES

1990-2016 literature.

STUDY DESIGN

Systematic literature review.

DATA EXTRACTION METHODS

Of 812 articles mentioning "CAHPS," "patient experience," "patient satisfaction," "important(ce)," "difference," or "significance," we identified 79 possible articles, yielding 35 for data abstraction. We included 22 articles measuring magnitude of differences in patient experiences.

PRINCIPAL FINDINGS

We identified three main ways of estimating magnitude of differences in patient experience scores: (1) by distribution/range of patient experience variable, (2) against external anchor, and (3) comparing a difference in patient experience on one covariate to differences in patient experience on other covariates.

CONCLUSIONS

We suggest routine estimation of magnitude in patient experience research. More work is needed documenting magnitude of differences between providers to make patient experience data more interpretable and usable.

Clinician ratings of interpreter mediated visits in underserved primary care settings with ad hoc, in-person professional, and video conferencing modes

Linguistic interpretation ameliorates health disparities disfavoring underserved limited English-proficient patients, yet few studies have compared clinician satisfaction with these services. Self-administered clinician post-visit surveys compared the quality of interpretation and communication, visit satisfaction, degree of patient engagement, and cultural competence of visits using untrained people acting as interpreters (ad hoc), in-person professional, or video conferencing professional interpretation for 283 visits. Adjusting for clinician and patient characteristics, the quality of interpretation of in-person and video conferencing modes were rated similarly (OR 1.79, 95% CI 0.74, 4.33). The quality of in-person (OR 5.55, 95% CI 1.50, 20.51) and video conferencing (OR 3.10, 95% CI 1.16, 8.31) were rated higher than ad hoc interpretation. Self-assessed cultural competence was better for in-person versus video conferencing interpretation (OR 2.32, 95% CI 1.11, 4.86). Video conferencing interpretation increases access without compromising quality, but cultural nuances may be better addressed by in-person interpreters. Professional interpretation is superior to ad hoc (OR 4.15, 95% CI 1.43, 12.09).

Associations of eye diseases and symptoms with self-reported physical and mental health

PURPOSE

To study the associations of eye diseases and visual symptoms with the most widely used health-related quality-of-life (HRQOL) generic profile measure.

DESIGN

HRQOL was assessed using the short form-36 (SF-36) version 1 survey administered to a sample of patients receiving care provided by a physician group practice association.

METHODS

Eye diseases, ocular symptoms, and general health were assessed in a sample of patients from 48 physician groups. A total of 18,480 surveys were mailed out and 7,093 returned; 5,021 of these had complete data. Multiple linear regression models were used to examine the decrements in self-reported physical and mental health associated with eye diseases and symptoms, including trouble seeing and blurred vision.

RESULTS

Nine percent of the respondents had cataracts, 2% had age-related macular degeneration, 2% glaucoma, 8% blurred vision, and 13% trouble seeing. Trouble seeing and blurred vision both had statistically unique associations with worse scores on the SF-36 mental health summary score. Only trouble seeing had a significant association with the SF-36 physical health summary score. While these ocular symptoms were significantly associated with SF-36 scores, having an eye disease (cataracts, glaucoma, and macular degeneration) was not, after adjusting for other variables in the model.

CONCLUSIONS

Our results suggest an important link between visual symptoms and general HRQOL. The study extends the findings of prior research to show that both trouble seeing and blurred vision have independent, measurable associations with HRQOL, while the presence of specific eye diseases may not.

Interpersonal processes of care and patient satisfaction: do associations differ by race, ethnicity, and language?

OBJECTIVE

Describe association of patient satisfaction with interpersonal processes of care (IPC) by race/ethnicity.

DATA SOURCES/STUDY SETTING

Interview with 1,664 patients (African Americans, English- and Spanish-speaking Latinos, and non-Latino Whites).

STUDY DESIGN/METHODS

Cross-sectional study of seven IPC measures (communication, patient-centered decision making, and interpersonal style) and three satisfaction measures (satisfaction with physicians, satisfaction with health care, and willingness to recommend physicians). Regression models explored associations, controlling for patient characteristics.

PRINCIPAL FINDINGS

In all groups: patient-centered decision making was positively associated with satisfaction with physicians (B=0.10, p<.0001) and health care (B=0.07, p<.001), and "recommend physicians" (OR=1.23, 95 percent CI 1.06, 1.43); discrimination was negatively associated with satisfaction with physicians (B=0.09, p<.05) and health care (B=0.17, p<.001). Unclear communication was associated with less satisfaction with physicians among Spanish-speaking Latinos. Explaining results was positively associated with all satisfaction outcomes for all groups with one exception (no association with satisfaction with physicians for Latino Spanish-speakers). Compassion/respect was positively associated with all outcomes for all groups with two exceptions (no association with satisfaction with health care among English-speaking Latinos and Whites).

CONCLUSIONS

All IPC measures were associated with at least one satisfaction outcome for all groups except for unclear communication.

Validation and reliability of 2 specialty care satisfaction scales

DrScore.com an online patient satisfaction survey, uses 2 patient satisfaction scales, namely, satisfaction with physician care and satisfaction with office policy and procedures, including accessibility to care, convenience of office and practice location, and staff friendliness. This study assesses the validity and reliability of the scales. The sample includes 11,212 specialty care visits, comprised of 64% women, 82% established patients, and 24% routine visits. A confirmatory factor analysis is used to test factor structure. Convergent validity also is examined. The goodness-of-fit index is 0.99, and standardized factor loadings are uniformly high, exceeding 0.90 for all but 2 items. Cronbach alpha is 0.99 for the physician scale and 0.94 for the office scale. Both scales discriminate other satisfaction indicators. Correlation between scales is high at 0.90. Both scales possess excellent psychometric properties but are not clearly differentiated. Results agree with the unidimensional view of patient satisfaction and confirm that online surveys can be reliable and valid.

Correlated physical and mental health summary scores for the SF-36 and SF-12 Health Survey, V.I

BACKGROUND

The SF-36 and SF-12 summary scores were derived using an uncorrelated (orthogonal) factor solution. We estimate SF-36 and SF-12 summary scores using a correlated (oblique) physical and mental health factor model.

METHODS

We administered the SF-36 to 7,093 patients who received medical care from an independent association of 48 physician groups in the western United States. Correlated physical health (PCSc) and mental health (MCSc) scores were constructed by multiplying each SF-36 scale z-score by its respective scoring coefficient from the obliquely rotated two factor solution. PCSc-12 and MCSc-12 scores were estimated using an approach similar to the one used to derive the original SF-12 summary scores.

RESULTS

The estimated correlation between SF-36 PCSc and MCSc scores was 0.62. There were far fewer negative factor scoring coefficients for the oblique factor solution compared to the factor scoring coefficients produced by the standard orthogonal factor solution. Similar results were found for PCSc-12, and MCSc-12 summary scores.

CONCLUSION

Correlated physical and mental health summary scores for the SF-36 and SF-12 derived from an obliquely rotated factor solution should be used along with the uncorrelated summary scores. The new scoring algorithm can reduce inconsistent results between the SF-36 scale scores and physical and mental health summary scores reported in some prior studies.(Subscripts C = correlated and UC = uncorrelated).

Initiation, choice and satisfaction of nursing appointments in general practice: a cross-sectional survey of patients and nurses

AIMS AND OBJECTIVES

To compare patients' and nurses' perceptions regarding the initiation of appointments, and to assess patients' satisfaction with appointment provision.

BACKGROUND

Appointment provision is changing in primary care and no research has assessed the initiation of nursing appointments.

DESIGN

Cross-sectional survey assessing patients' and nurses' perceptions of the same appointment.

METHODS

A survey distributed to a convenience sample of patients attending nursing appointments for a two-week period.

RESULTS

Patients are highly satisfied with appointment provision. There is little agreement between patients and nursing staff regarding the initiation of an appointment.

CONCLUSION

Patients are satisfied with appointment provision which can accommodate different perceptions regarding the initiation of an appointment.

RELEVANCE TO CLINICAL PRACTICE

It is important to acknowledge patients' perceptions regarding appointment management as the views of nursing staff differ regarding the initiation of the appointment.

A randomized trial of chiropractic and medical care for patients with low back pain: eighteen-month follow-up outcomes from the UCLA low back pain study

STUDY DESIGN

Randomized clinical trial.

OBJECTIVES

To compare the long-term effectiveness of medical and chiropractic care for low back pain in managed care and to assess the effectiveness of physical therapy and modalities among patients receiving medical or chiropractic care.

SUMMARY OF BACKGROUND DATA

Evidence comparing the long-term relative effectiveness of common treatment strategies offered to low back pain patients in managed care is lacking.

METHODS

A total of 681 low back pain patients presenting to a managed-care facility were randomized to chiropractic with or without physical modalities, or medical care with or without physical therapy, and followed for 18 months. The primary outcome variables are low back pain intensity, disability, and complete remission. The secondary outcome is participants' perception of improvement in low back symptoms.

RESULTS

Of the 681 patients, 610 (89.6%) were followed through 18 months. Among participants not assigned to receive physical therapy or modalities, the estimated improvements in pain and disability and 18-month risk of complete remission were a little greater in the chiropractic group than in the medical group (adjusted RR of remission = 1.29; 95% CI = 0.80-2.07). Among participants assigned to medical care, mean changes in pain and disability and risk of remission were larger in patients assigned to receive physical therapy (adjusted RR = 1.69; 95% CI = 1.08-2.66). Among those assigned to chiropractic care, however, assignment to methods was not associated with improvement or remission (adjusted RR = 0.98; 95% CI = 0.62-1.55). Compared with medical care only patients, chiropractic and physical therapy patients were much more likely to perceive improvement in their low back symptoms. However, less than 20% of all patients were pain-free at 18 months.

CONCLUSIONS

Differences in outcomes between medical and chiropractic care without physical therapy or modalities are not clinically meaningful, although chiropractic may result in a greater likelihood of perceived improvement, perhaps reflecting satisfaction or lack of blinding. Physical therapy may be more effective than medical care alone for some patients, while physical modalities appear to have no benefit in chiropractic care.

Satisfaction as a predictor of clinical outcomes among chiropractic and medical patients enrolled in the UCLA low back pain study

STUDY DESIGN

Observational study conducted within a randomized clinical trial.

OBJECTIVES

The objective of this study is to estimate the effects of patient satisfaction on subsequent changes in pain and disability among low back pain patients randomized to chiropractic or medical care in a managed-care practice setting.

SUMMARY OF BACKGROUND DATA

Recent studies of low back pain treatments have shown chiropractic patients to be more satisfied with their care than medical patients. However, little is known about the relation between patient satisfaction and clinical outcomes.

METHODS

A total of 681 low back pain patients presenting to three southern California healthcare clinics and screened for serious spinal pathology and contraindications were randomized to medical care with and without physical therapy, and chiropractic care with and without physical modalities, and followed for 18 months. Satisfaction with back care was measured on a 40-point scale and observed at 4 weeks following randomization. The primary outcome variables, observed between 6 weeks and 18 months of follow-up, are average and most severe low back pain intensity in the past week, assessed with 0 to 10 numerical rating scales, low back-related disability, assessed with the 24-item Roland-Morris Disability Questionnaire, and remission from clinically meaningful pain and disability. Perceived change in low back symptoms was a secondary outcome.

RESULTS

Greater satisfaction increased the odds of remission from clinically meaningful pain and disability at 6 weeks (adjusted odds ratio [OR] for 10-point increase in satisfaction = 1.61, 95% confidence interval [CI] = 0.99, 2.68), but not at 6, 12, or 18 months (6 months: adjusted OR = 1.05, 95% CI = 0.73, 1.52; 12 months: adjusted OR = 0.94, 95% CI = 0.67, 1.32; 18 months: adjusted OR = 1.07; 95% CI = 0.76, 1.50). Perception of improvement was greater among highly satisfied than less satisfied patients throughout the 18-month follow-up period. The estimated effects of satisfaction on clinical outcomes were similar for medical and chiropractic patients.

CONCLUSIONS

Patient satisfaction may confer small short-term clinical benefits for low back pain patients. Long-term perceived improvement may reflect, in part, perceived past improvement as measured by satisfaction.

Effects of recreational physical activity and back exercises on low back pain and psychological distress: findings from the UCLA Low Back Pain Study

OBJECTIVES

We sought to estimate the effects of recreational physical activity and back exercises on low back pain, related disability, and psychological distress among patients randomized to chiropractic or medical care in a managed care setting.

METHODS

Low back pain patients (n=681) were randomized and followed for 18 months. Participation in recreational physical activities, use of back exercises, and low back pain, related disability, and psychological distress were measured at baseline, at 6 weeks, and at 6, 12, and 18 months. Multivariate logistic regression modeling was used to estimate adjusted associations of physical activity and back exercises with concurrent and subsequent pain, disability, and psychological distress.

RESULTS

Participation in recreational physical activities was inversely associated--both cross-sectionally and longitudinally--with low back pain, related disability, and psychological distress. By contrast, back exercise was positively associated--both cross-sectionally and longitudinally--with low back pain and related disability.

CONCLUSIONS

These results suggest that individuals with low back pain should refrain from specific back exercises and instead focus on nonspecific physical activities to reduce pain and improve psychological health.

Application of structural equation modeling to health outcomes research

This article provides an overview of the basic underlying principles of structural equation modeling (SEM). SEM models have two basic elements: a measurement model and a structural model. The measurement model describes the associations between the indicators (observed measures) of the latent variables, whereas the structural model delineates the direct and indirect substantive effects among latent variables and between measured and latent variables. The application of SEM to health outcomes research is illustrated using two examples: (a) assessing the equivalence of the SF-36 and patient evaluations of care for English- and Spanish-language respondents and (b) evaluating a theoretical model of health in myocardial infarction patients. The results of SEM studies can contribute to better understanding of the validity of health outcome measures and of relationships between physiologic, clinical, and health outcome variables.

Surveying Minorities with Limited-English Proficiency

BACKGROUND

Little is known about how modes of survey administration affect response rates and data quality among populations with limited-English proficiency (LEP). Asian Americans are a rapidly growing minority group with large numbers of LEP immigrants.

OBJECTIVE

We sought to compare the response rates and data quality of interviewer-administered telephone and self-administered mail surveys among LEP Asian Americans.

DESIGN

This was a randomized, cross-sectional study using a 78-item survey about quality of medical care that was given to Vietnamese, Mandarin, or Cantonese Chinese patients in their native language.

MEASURES

We examined response rates and missing data by mode of survey and language groups. To examine nonresponse bias, we compared the sociodemographic characteristics of respondents and nonrespondents. To assess response patterns, we compared the internal-consistency reliability coefficients across modes and language groups.

RESULTS

We achieved an overall response rate of 67% (322 responses of 479 patients surveyed). A higher response rate was achieved by phone interviews (75%) as compared with mail surveys with telephone reminder calls (59%). There were no significant differences in response rates by language group. The mean number of missing item for the mail mode was 4.14 versus 1.67 for the phone mode (P< or =0.000). There were no significant differences in missing data among the language groups and no significant differences in scale reliability coefficients by modes or language groups.

CONCLUSIONS

Telephone interviews and mail surveys with phone reminder calls are feasible options to survey LEP Chinese and Vietnamese Americans. These methods may be less costly and labor-intensive ways to include LEP minorities in research.

Psychometric properties of the Consumer Assessment of Health Plans Study (CAHPS) 2.0 adult core survey

OBJECTIVE

To estimate the reliability and validity of survey measures used to evaluate health plans and providers from the consumer's perspective.

DATA SOURCES

Members (166,074) of 306 U.S. health plans obtained from the National CAHPS Benchmarking Database 2.0, a voluntary effort in which sponsors of CAHPS surveys contribute data to a common repository.

STUDY DESIGN

Members of privately insured health plans serving public and private employers across the United States were surveyed by mail and telephone. Interitem correlations and correlations of items with the composite scores were estimated. Plan-level and internal consistency reliability are estimated. Multivariate associations of composite measures with global ratings are also examined to assess construct validity. Confirmatory factor analysis is used to examine the factor structure of the measure.

FINDINGS

Plan-level reliability of all CAHPS 2.0 reporting composites is high with the given sample sizes. Fewer than 170 responses per plan would achieve plan-level reliability of .70 for the five composites. Two of the composites display high internal consistency (Cronbach's alpha > or = .75), while responses to items in the other three composites were not as internally consistent (Cronbach's alpha from .58 to .62). A five-factor model representing the CAHPS 2.0 composites fits the data better than alternative two- and three-factor models.

CONCLUSION

Two of the five CAHPS 2.0 reporting composites have high internal consistency and plan-level reliability. The other three summary measures were reliable at the plan level and approach acceptable levels of internal consistency. Some of the items that form the CAHPS 2.0 adult core survey, such as the measure of waiting times in the doctor's office, could be improved. The five-dimension model of consumer assessments best fits the data among the privately insured; therefore, consumer reports using CAHPS surveys should provide feedback using five composites.

Do differences in methods for constructing SF-36 physical and mental health summary measures change their associations with chronic medical conditions and utilization?

BACKGROUND AND OBJECTIVE

Various approaches have been employed to derive physical health and mental health summary scores for the SF-36 and the RAND-36, but head-to-head comparisons of alternative scoring algorithms are rare. We determined whether the associations of the physical and mental health summary scores with chronic medical conditions and utilization would differ depending on the scoring algorithm used.

METHODS

We examined 5701 patients receiving medical care from an independent association of 48 physician groups located primarily in the western United States and compared SF-36 and RAND-36 scoring of physical health and mental health summary scores. Associations with the presence of diabetes, heart disease, and kidney disease, as well as with utilization of medical care and mental health care were compared using bivariate and multivariate analysis. To examine the relationship between SF-36 and RAND-36 scores, we regressed the SF-36 physical and mental health composite scores on the RAND-36 physical and mental health summary measures and vice versa.

RESULTS

We found that the SF-36 and RAND-36 summary scores generally yielded results similar to one another across measures of heart disease, diabetes, and kidney disease, as well as measures of utilization. However, for each chronic medical condition, the RAND-36 showed a slightly larger decrement in mental health than did the SF-36.

CONCLUSIONS

Differences between the two sets of summary scores were consistent with their respective conceptual and analytic approaches. Where comparisons of results between the SF-36 and RAND-36 summary scores are desirable in future studies, they can be estimated using the regression equations derived in this study.

The effect of capitation on switching primary care physicians

OBJECTIVE

To examine the relationship between patient case-mix, utilization, primary care physician (PCP) payment method, and the probability that patients switch their PCPs.

DATA SOURCES/STUDY SETTING

Administrative enrollment and claims/encounter data for 1994-1995 from four physician organizations.

STUDY DESIGN

We developed a conceptual model of patient switching behavior, which we used to guide the specification of multivariate logistic analyses focusing on interactions between patient case-mix, utilization, and PCP reimbursement methods.

DATA COLLECTION/EXTRACTION METHODS

Claims data were aggregated to the encounter level; a switch was defined as a change in PCP since the previous encounter. The PCPs were reimbursed on either a capitated or fee-for-service (FFS) basis.

PRINCIPAL FINDINGS

Patients with stable chronic conditions (Ambulatory Diagnostic Groups [ADG] 10) and capitated PCPs were 36 percent more likely to switch PCPs than similar patients with FFS PCPs, controlling for patient age and sex and physician fixed effects. When the number of previous encounters was included in the model this relationship was no longer significant. Instead high utilizers with capitated PCPs were significantly more likely to switch PCPs than were similar patients with FFS PCPs.

CONCLUSIONS

A patient's demographics and utilization are associated with the probability that the patient will switch PCPs. Capitated PCP payment was associated with higher rates of switching among high utilizers of health care resources. These findings raise concerns about the continuity and quality of care experienced by vulnerable patients in an era of changing financial incentives.

Patients using chiropractors in North America: who are they, and why are they in chiropractic care?

SUMMARY OF BACKGROUND DATA AND OBJECTIVES

Alternative health care was used by an estimated 42% of the U.S. population in 1997, and chiropractors accounted for 31% of the total estimated number of visits. Despite this high level of use, there is little empirical information about who uses chiropractic care or why.

METHODS

The authors surveyed randomly sampled chiropractors (n = 131) at six study sites and systematically sampled chiropractic patients seeking care from participating chiropractors on 1 day (n = 1275). Surveys collected data about the patient's reason for seeking chiropractic care, health status, health attitude and beliefs, and satisfaction. In addition to descriptive statistics, the authors compared data between patients and chiropractors, and between patients and previously published data on health status from other populations, corrected for the clustering of patients within chiropractors.

RESULTS

More than 70% of patients specified back and neck problems as their health problem for which they sought chiropractic care. Chiropractic patients had significantly worse health status on all SF-36 scales than an age- and gender-matched general population sample. Compared with medical back pain patients, chiropractic back pain patients had significantly worse mental health (6-8 point decrement). Roland-Morris scores for chiropractic back pain patients were similar to values reported for medical back pain patients. The health attitudes and beliefs of chiropractors and their patients were similar. Patients were very satisfied with their care.

CONCLUSION

These data support the theory that patients seek chiropractic care almost exclusively for musculoskeletal symptoms and that chiropractors and their patients share a similar belief system.

Item response theory and health outcomes measurement in the 21st century

Item response theory (IRT) has a number of potential advantages over classical test theory in assessing self-reported health outcomes. IRT models yield invariant item and latent trait estimates (within a linear transformation), standard errors conditional on trait level, and trait estimates anchored to item content. IRT also facilitates evaluation of differential item functioning, inclusion of items with different response formats in the same scale, and assessment of person fit and is ideally suited for implementing computer adaptive testing. Finally, IRT methods can be helpful in developing better health outcome measures and in assessing change over time. These issues are reviewed, along with a discussion of some of the methodological and practical challenges in applying IRT methods.

Health-related quality of life in patients with human immunodeficiency virus infection in the United States: results from the HIV Cost and Services Utilization Study

PURPOSE

To measure health-related quality of life among adult patients with human immunodeficiency virus (HIV) disease; to compare the health-related quality of life of adults with HIV with that of the general population and with patients with other chronic conditions; and to determine the associations of demographic variables and disease severity with health-related quality of life.

SUBJECTS AND METHODS

We studied 2,864 HIV-infected adults participating in the HIV Cost and Services Utilization Study, a probability sample of adults with HIV receiving health care in the contiguous United States (excluding military hospitals, prisons, or emergency rooms). A battery of 28 items covering eight domains of health (physical functioning, emotional well-being, role functioning, pain, general health perceptions, social functioning, energy, disability days) was administered. The eight domains were combined into physical and mental health summary scores. SF-36 physical functioning and emotional well-being scales were compared with the US general population and patients with other chronic diseases on a 0 to 100 scale.

RESULTS

Physical functioning was about the same for adults with asymptomatic HIV disease as for the US population [mean (+/- SD) of 92+/-16 versus 90+/-17) but was much worse for those with symptomatic HIV disease (76+/-28) or who met criteria for the acquired immunodeficiency syndrome (AIDS; 58+/-31). Patients with AIDS had worse physical functioning than those with other chronic diseases (epilepsy, gastroesophageal reflux disease, clinically localized prostate cancer, clinical depression, diabetes) for which comparable data were available. Emotional well-being was comparable among patients with various stages of HIV disease (asymptomatic, 62+/-9; symptomatic, 59+/-11; AIDS, 59+/-11), but was significantly worse than the general population and patients with other chronic diseases except depression. In multivariate analyses, HIV-related symptoms were strongly associated with physical and mental health, whereas race, sex, health insurance status, disease stage, and CD4 count were at most weakly associated with physical and mental health.

CONCLUSIONS

There is substantial morbidity associated with HIV disease in adults. The variability in health-related quality of life according to disease progression is relevant for health policy and allocation of resources, and merits the attention of clinicians who treat patients with HIV disease.

Access to medical care reported by Asians and Pacific Islanders in a West Coast physician group association

This study examines access to medical care for Asians and Pacific Islanders in the United States, using a survey of patients receiving care provided by a physician group practice association concentrated on the West Coast. Asians and Pacific Islanders who had used their health plan in the past year had worse access to health care than whites, blacks, Hispanics, and Native American or other ethnicities. The odds that Asians reported that they had adequate access ranged from about one quarter to three quarters that of whites, depending on the measure. Cultural differences and associated communication problems may explain the access problems experienced by Asians. Interventions need to be developed to address the problems with access to services, and better translation services may play an important role in improving access to care for Asians. Future studies need to clarify why Asians were more vulnerable to the access problems examined than other ethnic groups that might experience similar barriers.

Evaluating the equivalence of health care ratings by whites and Hispanics

PURPOSE

This study was designed to assess the equivalence of a health care ratings scale administered to non-Hispanic white and Hispanic survey respondents.

METHODS

We sent 18,840 questionnaires to a random sample of patients receiving medical care from a physician group association concentrated in the western United States; 7,093 were returned (59% adjusted response rate). Approximately 90% of survey respondents self-identified as white/Caucasian (n = 5,508) or Hispanic/Latino (n = 713). Interpersonal and technical aspects of medical care were assessed with 9 items, all administered with a 7-point response format: the best, excellent, very good, good, fair, poor, and very poor, with a "not applicable" option. Item response theory procedures were used to test for differential item functioning between white and Hispanic respondents.

RESULTS

Hispanics were found to be significantly more dissatisfied with care than whites (effect size=0.27; P <0.05). Of the 9 test items, 2 had statistically significant differential item functioning (P <0.05): reassurance and support offered by your doctors and staff and quality of examinations received. However, summative scale scores and test characteristic curves for whites and Hispanics were similar whether or not these items were included in the scale.

CONCLUSIONS

Despite some differences in item functioning, valid satisfaction-with-care comparisons between whites and Hispanics are possible. Thus, disparities in satisfaction ratings between whites and Hispanics should not be ascribed to measurement bias but should be viewed as arising from actual differences in experiences with care.

Patient satisfaction with care in programs for low income individuals

Although a variety of public and private programs provide care for low-income individuals, little is known about patient satisfaction across these programs. The objective of this study was to examine patient satisfaction across a variety of health insurance programs. A survey was conducted of randomly selected adults in Kentucky who had an outpatient visit in the past 12 months (616 with private insurance, 683 Medicaid recipients, 287 in private sector charity program for uninsured indigents). Patient satisfaction with multiple dimensions of their most recent outpatient visit was assessed. All insurance groups were generally satisfied with the care received in their most recent visit. For all 8 dimensions of patient satisfaction, the private insurance group was significantly higher than the other groups. In a model controlling for standard demographic and health status variables, higher overall satisfaction with the visit was positively related to higher income and higher mental health functional status. The insurance category variable had no significant relationship to overall satisfaction with the visit. Although patients receiving care through health insurance programs for low-income individuals are generally satisfied with the services, there is an indication that low-income individuals, regardless of insurance type, are less satisfied with the care they receive.

Are Latinos less satisfied with communication by health care providers?

OBJECTIVE

To examine associations of patient ratings of communication by health care providers with patient language (English vs Spanish) and ethnicity (Latino vs white).

METHODS

A random sample of patients receiving medical care from a physician group association concentrated on the West Coast was studied. A total of 7,093 English and Spanish language questionnaires were returned for an overall response rate of 59%. Five questions asking patients to rate communication by their health care providers were examined in this study. All five questions were administered with a 7-point response scale.

MAIN RESULTS

We estimated the associations of satisfaction ratings with language (English vs Spanish) and ethnicity (white vs Latino) using ordinal logistic models, controlling for age and gender. Latinos responding in Spanish (Latino/Spanish) were significantly more dissatisfied compared with Latinos responding in English (Latino/English) and non-Latino whites responding in English (white) when asked about: (1) the medical staff listened to what they say (29% vs 17% vs 13% rated this "very poor," "poor," or "fair"; p <.01); (2) answers to their questions (27% vs 16% vs 12%; p <.01); (3) explanations about prescribed medications (22% vs 19% vs 14%; p <.01); (4) explanations about medical procedures and test results (36% vs 21% vs 17%; p <.01); and (5) reassurance and support from their doctors and the office staff (37% vs 23% vs 18%; p <.01).

CONCLUSION

This study documents that Latino/Spanish respondents are significantly more dissatisfied with provider communication than Latino/English and white respondents. These results suggest Spanish-speaking Latinos may be at increased risk of lower quality of care and poor health outcomes. Efforts to improve the quality of communication with Spanish-speaking Latino patients in outpatient health care settings are needed.