Health plan effects on patient assessments of Medicaid managed care among racial/ethnic minorities

Trends and Race/Ethnic Disparities in Diabetes-Related Hospital Use in Medicaid Enrollees: Analyses of Serial Cross-sectional State Data, 2008-2017

BACKGROUND

Race/ethnic disparities in preventable diabetes-specific hospital care may exist among adults with diabetes who have Medicaid coverage.

OBJECTIVE

To examine race/ethnic disparities in utilization of preventable hospital care by adult Medicaid enrollees with diabetes across nine states over time.

DESIGN

Using serial cross-sectional state discharge records for emergency department (ED) visits and inpatient (IP) hospitalizations from the Healthcare Cost and Utilization Project, we quantified race/ethnicity-specific, state-year preventable diabetes-specific hospital utilization.

PARTICIPANTS

Non-Hispanic Black, non-Hispanic White, and Hispanic adult Medicaid enrollees aged 18-64 with a diabetes diagnosis (excluding gestational or secondary diabetes) who were discharged from hospital care in Arizona, Iowa, Kentucky, Florida, Maryland, New Jersey, New York, North Carolina, and Utah for the years 2008, 2011, 2014, and 2017.

MAIN MEASURES

Non-Hispanic Black-over-White and Hispanic-over-White rate ratios constructed using age- standardized state-year, race/ethnicity-specific ED, and IP diabetes-specific utilization rates.

KEY RESULTS

The ratio of Black-over-White ED utilization rates for preventable diabetes-specific hospital care increased across the 9 states in our sample from 1.4 (CI 95, 1.31-1.50) in 2008 to 1.73 (CI 95, 1.68-1.78) in 2017. The cross-year-state average non-Hispanic Black-over-White IP rate ratio was 1.46 (CI 95, 1.42-1.50), reflecting increases in some states and decreases in others. The across-state-year average Hispanic-over-White rate ratio for ED utilization was 0.67 (CI 95, 0.63-0.71). The across-state-year average Hispanic-over-White IP hospitalization rate ratio was 0.72 (CI 95, 0.69-0.75).

CONCLUSIONS

Hospital utilization by non-Hispanic Black Medicaid enrollees with diabetes was consistently greater and often increased relative to utilization by White enrollees within state programs between 2008 and 2017. Hispanic enrollee hospital utilization was either lower or indistinguishable relative to White enrollee hospital utilization in most states, but Hispanic utilization increased faster than White utilization in some states. Among broader patterns, there is heterogeneity in the magnitude of race/ethnic disparities in hospital utilization trends across states.

Healthcare satisfaction at the intersections of sexual orientation and race/ethnicity

OBJECTIVES

Existing scholarship has consistently demonstrated disparities in healthcare experience based on sexual identity. However, relatively little research has considered intersections with race/ethnicity, despite that intersection with other characteristics may complicate healthcare experiences and satisfaction among sexual minorities. This study aims to address such a gap by examining healthcare satisfaction across the intersections of sexual and racial/ethnic identity.

DESIGN

Utilizing data on U.S. adults included in the 2013-2018 Behavioral Risk Factor Surveillance System (BRFSS) (n = 372,766), we investigate levels of satisfaction with care among a range of groups simultaneously embodying two identities.

RESULTS

Findings from ordered logistic regression models show that among adults who identify as heterosexual, the odds of reporting high satisfaction with care are lower among Blacks, Asians, and Native Americans. Among sexual minority adults, the likelihood of reporting high satisfaction with care is consistently lower among Native American gay and lesbian adults compared to gays and lesbians of other race/ethnicity or Native American and White heterosexuals, indicating heightened vulnerability to poorer healthcare experience among this multiple minority group.

CONCLUSION

While levels of satisfaction with care tend to be generally high across groups, future research should endeavor to investigate the driving factors that lower the odds of high healthcare satisfaction among those with intersecting minority identities.

Racial and Ethnic Disparities in Health Care Access and Utilization among Medicaid Managed Care Beneficiaries

This quasi-experimental study examined the impact of a statewide integrated special needs program Health and Recovery Plan (HARP) for individuals with serious mental illness and identified racial and ethnic disparities in access to Medicaid services. Generalized estimating equation negative binomial models were used to estimate changes in service use, difference-in-differences, and difference-in-difference-in-differences in the pre- to post-HARP periods. Implementation of the special needs plan contributed to reductions in racial/ethnic disparities in access and utilization. Notable among those enrolled in the special needs plan was the declining Black-White disparities in emergency room (ER) visits and inpatient stays, but the disparity in non-behavioral health clinic visits remains. Also, the decline of Hispanic-White disparities in ER, inpatient, and clinic use was more evident for HARP-enrolled patients. Health equity policies are needed in the delivery of care to linguistically and culturally disadvantaged Medicaid beneficiaries.

Development of a Tool to Assess Medical Oral Language Proficiency

PURPOSE

To communicate with linguistically diverse patients, medical students and physicians often use their non-English-language skills. However, there is no standard protocol to determine whether those skills are adequate before patient care. This causes many physicians, institutions, educators, and learners to forgo non-English-language proficiency assessment altogether. The purpose of this study is to report on the development, refinement, and interrater reliability of the Physician Oral Language Observation Matrix (POLOM), a rater-based tool assessing 6 language skill categories observed during clinical interactions: comprehension, fluency/fluidity, vocabulary, pronunciation, grammar, and communication. This study focused on the use of the POLOM in Spanish interactions.

METHOD

The authors adapted an existing language observation tool for use in clinical settings, creating the preliminary POLOM. Next, they iteratively refined the tool from April to July 2021 using videorecorded medical student-standardized patient encounters from a U.S.-based medical Spanish program. In each refinement iteration, 4 bilingual raters (2 physicians and 2 linguists) independently rated 3 to 6 encounters and convened to discuss ratings with the goals of improving instrument instructions, descriptors, and subsequent rater agreement. Using the final POLOM, raters independently rated 50 videos in rotating interdisciplinary pairs. Generalizability theory was applied to estimate reliability via interrater agreement (dependability) coefficients (range 0-1) for each POLOM category and the total score.

RESULTS

POLOM total score dependability equaled 0.927 (single rater) and 0.962 (averaged across 2 raters). The highest mean score was observed for the comprehension category (4.15; range 1-5) while the lowest was for communication (3.01; range 1-5).

CONCLUSIONS

Raters achieved a high level of agreement on POLOM assessments of students' medical oral Spanish proficiency. The POLOM is the first assessment tool that provides examinees and instructors with both a holistic and detailed review of clinician non-English oral language skills as contextualized for patient care.

Patient Satisfaction With Breast Cancer Care Delivery at the National Cancer Institute of Sri Lanka: Does Language Play a Role?

PURPOSE

This study sought to examine whether there was an association between language barriers and patient satisfaction with breast cancer care in Sri Lanka.

METHODS

A telephone-based survey was conducted in the three official languages (Sinhala, Tamil, or English) among adult women (older than 18 years) who had been treated for breast cancer within 6-12 months of diagnosis at the National Cancer Institute of Sri Lanka. The European Organisation for Research and Treatment of Cancer Satisfaction with Cancer Care core questionnaire was adapted to assess three main domains (physicians, allied health care professionals, and the organization). All scores were linearly transformed to a 0-100 scale, and subscores for domains were summarized using means and standard deviations. These were also calculated for the Sinhalese and Tamil groups and compared.

RESULTS

The study included 72 participants (32 ethnically Tamil and 40 Sinhalese, with 100% concordance with preferred language). The most commonly reported best aspect of care (n = 25) involved affective behaviors of the physicians and nurses. Ease of access to the hospital performed poorest overall, with a mean satisfaction score of 54 (30.5). Clinic-related concerns were highlighted as the worst aspect of the care (n = 10), including long waiting times during clinic visits. Sixty-three percent of Tamil patients reported receiving none of their care in Tamil and 18% reported experiencing language barriers during their care. Tamil patients were less satisfied overall and reported lower satisfaction with care coordination (P = .005) and higher financial burden (P = 0.014).

CONCLUSION

Ethnically Tamil patients were significantly less satisfied than their Sinhalese counterparts and experienced more language barriers, suggesting there is a need to improve access to language-concordant care in Sri Lanka.

Racial And Ethnic Disparities In Patient Experience Of Care Among Nonelderly Medicaid Managed Care Enrollees

Medicaid managed care enrollees who are members of racial and ethnic minority groups have historically reported worse care experiences than White enrollees. Few recent studies have identified disparities within and between Medicaid managed care plans. Using 2014-18 data on 242,274 nonelderly Medicaid managed care enrollees in thirty-seven states, we examined racial and ethnic disparities in four patient experience metrics. Compared with White enrollees, minority enrollees reported significantly worse care experiences. Overall adjusted disparities for Black enrollees ranged between 1.5 and 4.5 percentage points; 1.6-3.9 percentage points for Hispanic or Latino enrollees; and 9.0-17.4 percentage points for Asian American, Native Hawaiian, or other Pacific Islander enrollees. Disparities were largely attributable to worse experiences by race or ethnicity within the same plan. For all outcomes, disparities were smaller in plans with the highest percentages of Hispanic or Latino enrollees, and for some outcomes, there were smaller disparities in plans with the highest percentages of Asian American, Native Hawaiian, or other Pacific Islander enrollees. Interventions to mitigate racial and ethnic inequities in care experiences include collection of comprehensive race and ethnicity data, adoption of health equity performance metrics, plan-level enrollee engagement, and multisectoral initiatives to dismantle structural racism.

Home Health Agencies With More Socially Vulnerable Patients Have Poorer Experience of Care Ratings

OBJECTIVES

Examine the relationships between dual eligibility and race/ethnicity characteristics of Medicare-Certified Home Health Agencies (CHHAs) and experience of care ratings.

METHODS

Analysis of 2017 national Consumer Assessment of Healthcare Providers and Systems and matched datasets of 10,906 CHHAs.

RESULTS

CHHAs with higher concentrations of dual-eligible patients were less likely to have high experience of care ratings for all three domains (e.g., for care delivery, quartile 4 vs. 1: odds ratio [OR] = 0.622, p < .001); CHHAs with higher concentrations of racial/ethnic minorities generally were less likely to have high experience of care ratings in care delivery (e.g., Black: quartile 4 vs. 1: OR = 0.418, p<0.001), communication (e.g., Black: quartile 4 vs. 1: OR = 0.316, p<0.001), and specific care issues (e.g., Hispanic: quartile 4 vs. 1: OR = 0.397, p < .001).

DISCUSSION

CHHAs with greater concentrations of dual-eligible patients and racial/ethnic minorities were more likely to have poor experience of care ratings.

Racial/Ethnic Disparities in Patient Experiences With Health Care in Association With Earlier Stage at Colorectal Cancer Diagnosis: Findings From the SEER-CAHPS Data

BACKGROUND

Racial/ethnic minorities are more likely to be diagnosed at a later stage of colorectal cancer (CRC). Therefore, our objective was to identify whether racial/ethnic differences in patient experiences (PE) with health care are associated with stage at CRC diagnosis.

METHODS

The authors used the National Cancer Institute Surveillance, Epidemiology and End Results registry data linked with the Consumer Assessment of Healthcare Providers and Systems to conduct a retrospective cohort analysis. They examined composite measures from surveys to assess 3 domains: patient-centeredness, timeliness, and realized access. Multivariable logistic regression was used to determine the association between PE with care and earlier stage at diagnosis.

RESULTS

Of the 9211 patients, 31.1% non-Hispanic White, 27.2% non-Hispanic Black (NHB), 32.3% Hispanic, and 36.4% Asian were diagnosed with early stage cancer. Compared with non-Hispanic White patients, for the timeliness domain, Hispanic [β=-2.82; 95% confidence interval (CI), -5.42 to -0.39] and Asian (β=-6.65; 95% CI, -9.44 to -3.87) patients had significant lower adjusted mean score for getting care quickly. For the realized access domain, Asian (β=-5.78; 95% CI, -8.51 to -3.05) and NHB patients (β=-3.18; 95% CI, -5.50 to -0.87) had significantly lower adjusted mean score for getting needed prescription drugs compared with non-Hispanic White patients. Among NHB patients, a 5-Unit increase in getting needed care quickly was associated with higher odds of earlier CRC stage at diagnosis (odds ratio, 1.06; 95% CI, 1.01-1.10).

CONCLUSION

There are racial/ethnic disparities in PE with timeliness and realized access to care preceding a CRC diagnosis. Among NHB patients, poor experiences with timeliness and realized access of care may be associated with later stage at diagnosis.

Perceptions of Patient-Provider Communication Across the Six Largest Asian Subgroups in the USA

BACKGROUND

Asians are the fastest-growing racial/ethnic minority group in the USA and many face communication barriers when seeking health care. Given that a high proportion of Asians are immigrants and have limited English proficiency, poor patient-provider communication may explain Asians' relatively low ratings of care. Though Asians are linguistically, economically, and culturally heterogeneous, research on health care disparities typically combines Asians into a single racial/ethnic category.

OBJECTIVES

To estimate racial/ethnic differences in perceptions of provider communication among the six largest Asian subgroups.

DESIGN AND PARTICIPANTS

Using a nationally representative sample of adults from the 2014-2017 Medical Expenditure Panel Survey (N = 136,836, round-specific response rates range from 72% to 98%), we estimate racial/ethnic differences in perceptions of provider communication, adjusted for English proficiency, immigration status, and sociodemographic characteristics.

MAIN MEASURES

The main dependent variable is a 4-item scale ranging from 0 to 100 measuring how positively patients view their health care providers' communication, adapted from the Consumer Assessment of Healthcare Providers and Systems (CAHPS©) program. Respondents report how often their providers explain things clearly, show respect, listen carefully, and spend enough time with them.

KEY RESULTS

Asians, overall, had less positive perceptions of their providers' communication than either Whites or Latinxs. However, only Chinese-White differences remained after differences in English proficiency and immigration status were controlled (difference = - 2.67, 95% CI - 4.83, - 0.51). No other Asian subgroup differed significantly from Whites.

CONCLUSIONS

Negative views of provider communication are not pervasive among all Asians but, rather, primarily reflect the perceptions of Chinese and, possibly, Vietnamese patients. Researchers, policymakers, health plan executives, and others who produce or use data on patients' experiences with health care should, if possible, avoid categorizing all Asians into a single group.

Adjustment of Patient Experience Surveys for How People Respond

BACKGROUND

Patient surveys are the primary tool to measure patient experiences of care. Caution must be taken when analyzing these data, as responses can be influenced by factors that do not reflect the quality of care received.

OBJECTIVES

To provide a practical overview of adjusting patient experience survey results to address bias related to patient case-mix, extreme response tendency, and mode of survey administration.

RESEARCH DESIGN

We discuss options for adjustment for biases in how people respond to patient experience surveys.

RESULTS

Case-mix adjustment (CMA) aims to compare provider performance that would have been observed if all providers had treated the same set of patients by removing the effects of patient characteristics that vary across providers. Extreme response tendency can bias the measurement of the disparities in patient experiences even after typical CMAs, since differences in patients' use of extreme response options may affect patient experience scores when they have a skewed distribution. Survey mode may affect scores for the provider entity being evaluated (eg, hospital) more than CMA if survey mode differs at the provider level.

CONCLUSIONS

It is best practice to evaluate known source of bias when analyzing patient experience surveys. Failure to adjust for patient case-mix, extreme response tendency, and survey mode in patient experience surveys may lead to erroneous comparisons of providers.

Hospital Consumer Assessment of Healthcare Providers and Systems: Do Patient Demographics Affect Outcomes in Total Hip Arthroplasty?

BACKGROUND

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) score is a nationally standardized measure of a patient's hospital experience. This study aims to assess whether HCAHPS scores vary by demographic or surgical factors in patients undergoing primary total hip arthroplasty.

METHODS

Patients who completed an HCAHPS survey after a primary total hip arthroplasty between October 2011 and November 2016 were included in this study. Patient demographics and surgical factors were evaluated for correlations with individual HCAHPS questions.

RESULTS

One thousand three hundred eighty-three HCAHPS questionnaires were reviewed for this study. Patients with a submitted HCAHPS response had an average age of 63.83 ± 10.17 years. Gender distribution was biased toward females at 57.27% (792 females) versus 42.73% (591 males). The average body mass index (BMI) was 28.68 ± 5.86 kg/m². Race distribution was predominantly Caucasian at 81.49% (1127 patients), followed by "unknown" at 8.60% (119 patients) and African-American at 8.46% (117 patients). Home discharge occurred for 93.06% (1287 patients) versus 6.94% for facility discharge (96 patients). Mean length of stay was 2.41 ± 1.17 days. Each 1-year increase in age was positively correlated with a 0.16% increase in top-box response rate (β = 0.0016 ± 0.0008; P < .05). Male gender was correlated with a 4.61% increase in top-box response rate when compared to female gender (β = 0.0461 ± 0.0118; P < .01). BMI was found to be correlated with a 0.20% increase in HCAHPS response rates for each 1 kg/m² increase (β = 0.0020 ± 0.0010; P < .05). For each day increase in length of stay, HCAHPS top-box response rates decrease by 3.41% (β = -0.0341 ± 0.0051; P < .0001). Race, marital status, smoking status, insurance type, and discharge disposition were not found to be significantly correlated with HCAHPS top-box response rate (P > .05).

CONCLUSION

The HCAHPS quality measurement metric affects physician reimbursement and may be biased by a number of variables including sex, length of stay, and BMI, rather than a true reflection of the quality of their hospital experience. Further research is warranted to determine whether HCAHPS scores are an appropriate measure of the quality of care received.

Differences in Patient Experience Between Hispanic and Non-Hispanic White Patients Across U.S. Hospitals

INTRODUCTION

Despite the increased emphasis on patient experience, little is known about whether there are meaningful differences in hospital satisfaction between Hispanic and non-Hispanic whites.

METHODS

To determine if satisfaction differs, we used Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey data (2009-2010) reported by hospitals to compare responses between Hispanic and non-Hispanic white patients. Clustered logistic regression models identified within-hospital and between-hospital differences in satisfaction.

RESULTS

Of the 3,864,938 respondents, 6.2% were Hispanics, who were more often younger and females and less likely to have graduated from high school. Hispanics were overall more likely to recommend their hospital (74.1% vs. 70.9%, p < .001) and to rate it 9 or 10 (72.5% vs. 65.9%, p < .001) than whites. Increased satisfaction among Hispanics was more pronounced when compared with whites within the same hospitals, with significantly higher ratings on all HCAHPS measures. However, hospitals serving a higher percentage of Hispanics had lower satisfaction scores for both Hispanic and white patients than other hospitals.

CONCLUSION

There were significant but only modest-sized differences in patient experience between Hispanic and white patients across U.S. hospitals. Hispanics tended to be more satisfied with their care but received care at lower-performing hospitals.

What is needed in culturally competent healthcare systems? A qualitative exploration of culturally diverse patients and professional interpreters in an Australian healthcare setting

Background

Culturally competent health care service delivery can improve health outcomes, increasing the efficiency of clinical staff, and greater patient satisfaction. We aimed to explore the experience of patients with limited English proficiency and professional interpreters in an acute hospital setting.

Methods

In-depth interviews explored the experiences of four culturally and linguistically diverse communities with regards to their recent hospitalisation and access to interpreters. We also conducted focus group with professional interpreters working. Data were analysed using an inductive thematic approach with constant comparison.

Results

Individual interviews were conducted with 12 patients from Greek, Chinese, Dari and Vietnamese backgrounds. Focus groups were conducted with 11 professional interpreters. Key themes emerged highlighting challenges to the delivery of health care due distress and lack of advocacy in patients. Interpreters struggled due to a reliance on family to act as interpreters and hospital staff proficiency in working with them.

Conclusions

In an era of growing ethnic diversity this study confirms the complexity of providing a therapeutic relationships in contemporary health practice. This can be enhanced by training towards the effective use of professional interpreters in a hospital setting. Such efforts should be multidisciplinary and collective in order to ensure patients don’t fall through the gaps with regards to the provision of culturally competent care.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7378-9) contains supplementary material, which is available to authorized users.

Hospital Consumer Assessment of Healthcare Providers and Systems: Do Patient Demographics Affect Outcomes in Total Knee Arthroplasty?

BACKGROUND

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a nationally standardized tool to assess patient experience between hospitals. The HCAHPS survey can affect hospital reimbursement. This study aims to determine if HCAHPS scores vary by a number of demographic variables in patients undergoing primary total knee arthroplasty (TKA).

METHODS

Patients who underwent primary TKA and returned a completed HCAHPS survey were included in this study. HCAHPS surveys were collected from our institution's Center for Quality and Patient Safety department, which was cross-referenced with our hospital's electronic data warehouse. Patient demographics, surgical factors, and quality outcomes were queried, and multivariable linear regression was performed.

RESULTS

In total, 1028 HCAHPS questionnaires after primary TKA were evaluated. The average age of patients was 65.9 ± 9.0 years and 67.9% (698 patients) were female. Average body mass index was 32.5 ± 6.9 kg/m². Sixty-nine percent of the patients (1287 patients) were discharged home versus 10.3% (106 patients) to another facility. Mean length of stay was 2.9 ± 1.4 days. Age was correlated with a 0.3% decrease in top-box response rate (P < .01) for each 1-year increase in age. Compared to Caucasian race, African American race was correlated with a 5.6% increased rate for top-box response (P < .01), while Asian race (P = .42) and unknown race (P = 1.00) demonstrated no significant difference. Marital status demonstrated that divorced/separated status resulted in a significant 5.4% decrease in top-box response rates (P < .05). Similarly, single (P = .12) and widowed (P = .09) statuses also demonstrated a trend toward lower top-box response rates when compared to married or partnered patients. For each day increase in length of stay, HCAHPS top-box response rates decrease by 1.6% (P < .01). Gender, body mass index, smoking status, insurance type, and discharge disposition were not found to be significantly correlated with HCHAPS top-box response rate (P > .05).

CONCLUSION

HCAHPS scores in patients undergoing primary TKA are influenced not just by hospital and surgeon factors such as length of stay but by demographic variables such as age, race, and marital status. As surgeons become more involved with the burden of improving patient experience, they should be aware that static demographic variables can have a significant effect on HCAHPS scores.

Racial Disparities in Readmission Rates among Patients Discharged to Skilled Nursing Facilities

OBJECTIVES

Prior studies have reported mixed findings about the existence of racial disparities in readmission rates among Medicare Advantage beneficiaries, but these studies used data from one state, focused on black-white disparities, and did not focus on patients discharged to skilled nursing facilities (SNFs). The objective of the study was to characterize racial and ethnic disparities in rates of 30-day rehospitalization directly from SNFs among fee-for-service and Medicare Advantage patients.

DESIGN

A cross-sectional study of admissions to SNFs in 2015 was conducted.

SETTING

SNFs across the United States.

PARTICIPANTS

The sample included 1 500 334 white, 213 848 African American, and 99 781 Hispanic Medicare patients who were admitted to 13 375 SNFs.

MEASUREMENTS

The main outcome of interest was readmission, identified as patients sent back to any hospital directly from the SNF within 30 days of admission, as indicated on the Minimum Data Set discharge assessment.

RESULTS

Overall readmission rates for fee-for-service patients were 16.7% (95% confidence interval [CI] = 16.7%-16.8%) for whites, 18.8% (95% CI = 18.7%-19.0%) for African Americans, and 17.4% (95% CI = 17.1%-17.7%) for Hispanics. Readmission rates in Medicare Advantage were 14.7% (95% CI = 14.5%-14.8%) for whites, 16.8% (95% CI = 16.6%-17.1%) for African Americans, and 15.3% (95% CI = 14.9%-15.6%) for Hispanics. We also found that African Americans had about 1% higher readmission rates than whites, even when they received care within the same SNF. No statistically significant differences were found in the magnitude of within-SNF racial disparities in Medicare Advantage compared with Medicare fee-for-service.

CONCLUSION

We found racial disparities in readmission rates even within the same facility for both Medicare Advantage and fee-for-service beneficiaries. Intervention to reduce disparities in readmission rates, as well as more comprehensive quality measures that incorporate outcomes for Medicare Advantage enrollees, are needed. J Am Geriatr Soc 67:1672-1679, 2019.

Revision Versus Primary Hospital Consumer Assessment of Healthcare Providers and Systems Scores in Total Joint Arthroplasty

BACKGROUND

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) score is a nationally standardized measure of a patient's inpatient experience. This study aims to assess whether HCAHPS scores differ between patients undergoing primary total joint arthroplasty (TJA) and patients undergoing revision TJA.

METHODS

Patients who underwent primary or revision total hip or total knee arthroplasty (THA or TKA) and returned a completed HCAHPS survey were included in this study. HCAHPS scores were collected from our institution's Center for Quality and Patient Safety department, which was cross-referenced with our hospital's electronic data warehouse. Patient demographics, surgical factors, and quality outcomes were queried. Appropriate statistical analyses were performed using MatLab 2017a and P-values less than .05 were deemed significant.

RESULTS

In total, 523 primary and 59 revision THA recipients completed HCAHPS surveys at our institution between October 2011 and November 2016. During this same period, 507 primary TKA recipients and 40 revision TKA recipients completed HCAHPS surveys. Compared to revision THA, primary THA patients had a significantly higher top box for overall hospital ratings (58.46% vs 41.38%), felt that nurses listened to them carefully (84.3% vs 72.88%), and felt that they clearly understood the role of each medication (69.48% vs 56.90%). Moreover, 18 of 20 HCAHPS question responses favored primary THA despite not reaching significance for the majority of HCAHPS questions. Patients with revision TKA demonstrated a significantly higher incidence of "top box" choices for quieter rooms and a trend favoring better HCAHPS scores in revision TKA in a further 12 of 20 HCAHPS responses.

CONCLUSION

Patients undergoing primary THA report higher HCAHPS scores than those undergoing revision THA, while revision TKA demonstrated a general trend toward higher scores when compared to primary TKA patients. This publicly reported quality measurement metric which factors into physician reimbursement may be biased by the patient's health status, the complexity of the surgical procedure, and length of stay in hospital rather than a true reflection of the quality of their hospital experience.

National racial/ethnic and geographic disparities in experiences with health care among adult Medicaid beneficiaries

OBJECTIVES

To investigate whether health care experiences of adult Medicaid beneficiaries differ by race/ethnicity and rural/urban status.

DATA SOURCES

A total of 270 243 respondents to the 2014-2015 Nationwide Adult Medicaid Consumer Assessment of Healthcare Providers and Systems Survey.

STUDY DESIGN

Linear regression was used to estimate case mix adjusted differences in patient experience between racial/ethnic minority and non-Hispanic white Medicaid beneficiaries, and between beneficiaries residing in small urban areas, small towns, and rural areas vs large urban areas. Dependent measures included getting needed care, getting care quickly, doctor communication, and customer service.

PRINCIPAL FINDINGS

Compared with white beneficiaries, American Indian/Alaska Native (AIAN) and Asian/Pacific Islander (API) beneficiaries reported worse experiences, while black beneficiaries reported better experiences. Deficits for AIAN beneficiaries were 6-8 points on a 0-100 scale; deficits for API beneficiaries were 13-22 points (P's < 0.001); advantages for black beneficiaries were 3-5 points (P's < 0.001). Hispanic white differences were mixed. Beneficiaries in small urban areas, small towns, and isolated rural areas reported significantly better experiences (2-3 points) than beneficiaries in large urban areas (P's < 0.05), particularly regarding access to care. Racial/ethnic differences typically did not vary by geography.

CONCLUSIONS

Improving experiences for racial/ethnic minorities and individuals living in large urban areas should be high priorities for policy makers exploring approaches to improve the value and delivery of care to Medicaid beneficiaries.

Inpatient care experiences differ by preferred language within racial/ethnic groups

Objective

To describe differences in patient experiences of hospital care by preferred language within racial/ethnic groups.

Data Source

2014‐2015 HCAHPS survey data.

Study Design

We compared six composite measures for seven languages (English, Spanish, Russian, Portuguese, Chinese, Vietnamese, and Other) within applicable subsets of five racial/ethnic groups (Hispanics, Asian/Pacific Islanders, American Indian/Alaska Natives, Blacks, and Whites). We measured patient‐mix adjusted overall, between‐ and within‐hospital differences in patient experience by language, using linear regression.

Data Collection Methods

Surveys from 5 480 308 patients discharged from 4517 hospitals 2014‐2015.

Principal Findings

Within each racial/ethnic group, mean reported experiences for non‐English‐preferring patients were almost always worse than their English‐preferring counterparts. Language differences were largest and most consistent for Care Coordination. Within‐hospital differences by language were often larger than between‐hospital differences and were largest for Care Coordination. Where between‐hospital differences existed, non‐English‐preferring patients usually attended hospitals whose average patient experience scores for all patients were lower than the average scores for the hospitals of their English‐preferring counterparts.

Conclusions

Efforts should be made to increase access to better hospitals for language minorities and improve care coordination and other facets of patient experience in hospitals with high proportions of non‐English‐preferring patients, focusing on cultural competence and language‐appropriate services.

The experience of interpreter access and language discordant clinical encounters in Australian health care: a mixed methods exploration

BACKGROUND

Current evidence highlights that language discordant clinical encounters seriously compromise patient quality of care and health outcomes. We aimed to characterise patterns of interpreter service use in medical inpatient wards use and explore clinician experience of language discordance.

METHODS

Participants included medical students, residents, attending physicians, nursing and allied health professionals working in General Internal Medicine wards across two tertiary referral hospitals servicing a large Australian health care area. This study involved a retrospective electronic medical record audit of interpreter use. Six focus groups were conducted with 32 participants. Data were analysed using an inductive thematic approach with constant comparison.

RESULTS

Allied health professionals were identified as the largest users of interpreter services, followed by medical doctors. Distinct themes emerged regarding clinician experiences of language discordant encounters including: (1) Negotiating care when unable to get an accurate assessment; (2) Over servicing to fill in the gaps; (3) Using family members instead of professional interpreters: a vexed solution; (4) Disparities in care provision; and (5) Communication drought: broken by a flood.

CONCLUSIONS

Patients with low English proficiency are at risk of being less informed of care processes, and having a very large volume of information given in a shorter period of time when an interpreter is present. There is a need for systematic and transformative change that addresses utilisation of professional interpreters as well as embedded healthcare culture and practices leading to less interaction with patients with limited English proficiency and reliance on family members as informal interpreters.

Sociodemographic Characteristics as Predictors of Satisfaction in Public and Private Dental Clinics

Objective:

This study aimed to investigate influence of multiple sociodemographic characteristics on the patient satisfaction levels in outpatient public and private dental practices of Riyadh, Saudi Arabia.

Methods:

Questionnaire-based survey data were collected from 500 patients, 250 each from the public and private dental clinics of Riyadh, Saudi Arabia from September to December, 2017. Questions related to demographic factors and service attributes were included. A Likert scale of 5-points was used to measure satisfaction levels. Data was analyzed to calculate the descriptive and inferential statistics (analysis of variance and multiple regression analysis) to find the statistical difference (p < 0.01).

Results:

Satisfaction level differed significantly by education level (P< 0.001) and the type of clinic (P<0.001). The multiple regression analysis suggest that all variables influenced satisfaction, except age and marital status. The satisfaction score was higher by 27% for private clinics compared to public clinics.

Conclusion:

This study was exploratory and revealed an effect of individual variables on overall satisfaction score of the services attributes. Future plans for patient care could be developed with the help of this research.

"Improving Native American elder access to and use of health care through effective health system navigation"

BACKGROUND

Public insurance reforms of the past two decades have failed to substantively address the healthcare needs of American Indians in general, let alone the particular needs of American Indian elders, ages 55 years and older. Historically, this population is more likely to be uninsured and to suffer from greater morbidities, poorer health outcomes and quality of life, and lower life expectancies compared to all other United States aging populations, representing a neglected group within the healthcare system. Despite the pervasive belief that the Indian Health Service will address all their health-related needs, American Indian elders are negatively affected by gaps in insurance and lack of access to health care. While the 2010 Patient Protection and Affordable Care Act included provisions to ameliorate disparities for American Indians, its future is uncertain. In this context, American Indian elders with variable health literacy must navigate a complex and unstable healthcare system, regardless of where they seek care.

METHODS

This community-driven study features a mixed-method, participatory design to examine help-seeking behavior and healthcare experiences of American Indian elders in New Mexico, in order to develop and evaluate a tailored intervention to enhance knowledge of, access to, and use of insurance and available services to reduce healthcare disparities. This study includes qualitative and quantitative interviews combined with concept mapping and focus groups with American Indian elders and other key stakeholders.

DISCUSSION

The information gathered will generate new practical knowledge, grounded in actual perspectives of American Indian elders and other relevant stakeholders, to improve healthcare practices and policies for a population that has been largely excluded from national and state discussions of healthcare reform. Study data will inform development and evaluation of culturally tailored programming to enhance understanding and facilitate negotiation of the changing landscape of health care by American Indian elders. This work will fill a gap in research on public insurance initiatives, which do not typically focus on this population, and will offer a replicable model for enhancing the effects of such initiatives on other underserved groups affected by healthcare inequities.

TRIAL REGISTRATION

This protocol does not include the collection of health outcome data. Clinicaltrials.gov, NCT03550404 . Registered June 6, 2018.

Through the Veil of Language: Exploring the Hidden Curriculum for the Care of Patients With Limited English Proficiency

PURPOSE

Patients with limited English proficiency (LEP) experience lower-quality health care and are at higher risk of experiencing adverse events than fluent English speakers. Despite some formal training for health professions students on caring for patients with LEP, the hidden curriculum may have a greater influence on learning. The authors designed this study to characterize the hidden curriculum that medical and nursing students experience regarding the care of patients with LEP.

METHOD

In 2014, the authors invited students from one medical school and one nursing school, who had completed an interprofessional pilot curriculum on caring for patients with LEP 6 to 10 months earlier, to participate in semistructured interviews about their clinical training experiences with LEP patients. The authors independently coded the interview transcripts, compared them for agreement, and performed content analysis to identify major themes.

RESULTS

Thirteen students (7 medical and 6 nursing students) participated. Four major themes emerged: role modeling, systems factors, learning environment, and organizational culture. All 13 students described negative role modeling experiences, and most described role modeling that the authors coded as "indifferent." Students felt that the current system and learning environment did not support or emphasize high-quality care for patients with LEP.

CONCLUSIONS

The hidden curriculum that health professional students experience regarding the care of patients with LEP is influenced by systems limitations and a learning environment and organizational culture that value efficiency over effective communication. Role modeling seems strongly linked to these factors as supervisors struggle with these same challenges.

Across US Hospitals, Black Patients Report Comparable Or Better Experiences Than White Patients

Patient-reported experience is a critical part of measuring health care quality. There are limited data on racial differences in patient experience. Using patient-level data for 2009-10 from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), we compared blacks' and whites' responses on measures of overall hospital rating, communication, clinical processes, and hospital environment. In unadjusted results, there were no substantive differences between blacks' and whites' ratings of hospitals. Blacks were less likely to recommend hospitals but reported more positive experiences, compared to whites. Higher educational attainment and self-reported worse health status were associated with more negative evaluations in both races. Additionally, blacks rated minority-serving hospitals worse than other hospitals on all HCAHPS measures. Taken together, there were surprisingly few meaningful differences in patient experience between blacks and whites across US hospitals. Although blacks tend to receive care at worse-performing hospitals, compared to whites, within any given hospital black patients tend to report better experience than whites do.

Comparison of Data Quality for Reports and Ratings of Ambulatory Care by African American and White Medicare Managed Care Enrollees

Objective: Compare missing data and reliability of health care evaluations between African Americans and Whites in Medicare managed care health plans. Method: Consumer Assessment of Healthcare Providers and Systems (CAHPS) 3.0 health plan survey data collected from 109,980 Medicare managed care enrollees (101,189 Whites, 8,791 African Americans) in 321 plans. Participants self-administered the survey and four single-item global ratings of care. Results: Missing data rates were significantly higher for African Americans than Whites on all CAHPS items ( p < .0001). Internal consistency reliability estimates for the CAHPS scales did not differ significantly between African Americans and Whites, but plan-level reliability estimates for the scales and global rating items were significantly lower for African Americans than Whites. Discussion: Higher missing data rates and lower plan-level reliability estimates for African American Medicare managed care enrollees suggest caution in making race/ethnicity comparisons. Future efforts are needed to enhance the quality of data collected from older African Americans.

Less Use of Extreme Response Options by Asians to Standardized Care Scenarios May Explain Some Racial/Ethnic Differences in CAHPS Scores

BACKGROUND

Asian Americans (hereafter "Asians") generally report worse experiences with care than non-Latino whites (hereafter "whites"), which may reflect differential use of response scales. Past studies indicate that Asians exhibit lower Extreme Response Tendency (ERT)-they less frequently use responses at extreme ends of the scale than whites.

OBJECTIVE

To explore whether lower ERT is observed for Asians than whites in response to standardized vignettes depicting patient experiences of care and whether ERT might in part explain Asians reporting worse care than whites.

PROCEDURE

A representative US sample (n=575 Asian; n=505 white) was presented with 5 written vignettes describing doctor-patient encounters with differing levels of physician responsiveness. Respondents evaluated the encounters using modified CAHPS communication questions.

RESULTS

Case-mix-adjusted repeated-measures multivariate models show that Asians provided more positive responses than whites to several vignettes with less-responsive physicians but less positive responses than whites for the vignette with the most physician responsiveness (P<0.01 for each). While all respondents provided more positive ratings for vignettes with greater physician responsiveness, the increase was 15% less for Asian than white respondents.

CONCLUSIONS

Asians exhibit lower ERT than whites in response to standardized scenarios. Because CAHPS reponses are predominantly near the positive end of the scale and the most responsive scenario is most typical of the score observed in real-world settings, lower ERT in Asians may partially explain observations of lower observed mean CAHPS scores for Asians in real-world settings. Case-mix adjustment for Asian race/ethnicity or its correlates may improve quality of care measurement.

Racial and Ethnic Disparities in Patients' Experience With Skilled Home Health Care Services

Racial and ethnic disparities are found in many health care settings; however, there is little prior research on such disparities among patients receiving home health care services. This study used 2012 Home Health Care CAHPS(®) data to identify any overall patient-level disparities in self-reported experience of care and to decompose these disparities according to whether they result from within-agency versus between-agency differences. Although patient experience of care ratings were high across all groups, the study identified consistently lower ratings for all minority groups on two of three Home Health Care CAHPS measures, with Asians reporting the greatest disparities. Three quarters of disparities were found to be within-agency disparities, which were primarily related to care processes and provider/patient communications rather than to specific health care services received. Despite high ratings in general, home health agencies may need to focus on cultural competency initiatives to address racial and ethnic disparities within their agencies.

Drivers of Inpatient Hospital Experience Using the HCAHPS Survey in a Canadian Setting

OBJECTIVE

To identify factors associated with patients' overall rating of inpatient hospital care.

DATA SOURCES

Two years of patient interview data (April 1, 2011 to March 31, 2013), linked to inpatient administrative records.

STUDY DESIGN

Patients rated their overall health on a scale of 0 (worst care) to 10 (best care) using the HCAHPS instrument administered via telephone, up to 42 days postdischarge. Logistic regression was used to generate odds ratios for each independent predictor.

DATA EXTRACTION

HCAHPS data were linked to inpatient records based on health care numbers and dates of service. The outcome (overall health experience) was collapsed into two groups (10 vs. 0-9).

PRINCIPAL FINDINGS

Overall hospital experience of 0-9 was associated with younger age, male gender, higher level of education, being born in Canada, urgent admission, not having a family practitioner as the most responsible provider service, and not being discharged home. A length of stay of less than 3 days was protective. The c-statistic for the multivariate model was 0.635.

CONCLUSIONS

Our results are novel in the Canadian population. Several questions for future research have been generated, in addition to opportunities for quality improvement within our own organization.

Does Race/Ethnicity or Socioeconomic Status Influence Patient Satisfaction in Pediatric Surgical Care?

OBJECTIVE

To evaluate patient satisfaction in outpatient pediatric surgical care and assess differences in scores by race/ethnicity and socioeconomic status (SES).

STUDY DESIGN

Observational, cross-sectional analysis.

SETTING

Outpatient pediatric surgical specialty clinics at a tertiary academic center.

SUBJECT AND METHODS

Families of patients received a patient satisfaction survey following their initial care visit in 2012. Mean scores were calculated and compared by child race/ethnicity and insurance type, where insurance with medical assistance (MA) served as a proxy for low SES. Kruskal-Wallis tests were used to compare scores between groups. Surveys were dichotomized to low and high scorers, and multivariate logistic regression was used to calculate the likelihood of high satisfaction.

RESULTS

Of 527 surveys completed, 132 (25%) were for children with MA and 143 (27%) were for racial/ethnic minority children. The overall satisfaction score for all specialties was 84.8, which did not significantly differ by SES (P = .98) or minority status (P = .52). The survey item with the highest score in both SES groups was "degree to which provider talked with you using words you could understand" (overall mean 91.94, P = .23). Multivariate analysis showed that patient age, sex, race/ethnicity, insurance type, neighborhood SES, neighborhood diversity, or surgical department did not significantly influence satisfaction.

CONCLUSION

This is the first study to evaluate the relationship between SES and race/ethnicity with patient satisfaction in outpatient pediatric surgical specialty care. In this analysis, no disparities were identified in the patient experience by individual- or community-level factors. Although the survey methodologies may be limited, these findings suggest that provision of care in pediatric surgical specialties can be simultaneously equitable, culturally competent, and family centered.

Prevalence and associations of general practice nurses' involvement in consultations of general practitioner registrars: a cross-sectional analysis

OBJECTIVE

To establish prevalence and associations of general practice nurses' (GPNs) involvement in general practitioner (GP) registrars' consultations.

METHODS

A cross-sectional analysis from an ongoing cohort study of registrars' clinical consultations in five Australian states. Registrars recorded detailed data from 60 consecutive consultations per 6-month training term. Problems and diagnoses encountered, including chronic disease classification, were coded using the International Classification of Primary Care, second edition duplication system (ICPC-2plus) classification system. The outcome factor in our analysis was GPN involvement in management of individual problems and diagnoses. Independent variables were a range of patient, registrar, practice, consultation and educational factors.

RESULTS

We analysed 108 759 consultations of 856 registrars including 169 307 problems or diagnoses. Of the problems/diagnoses, 5.1% (95% confidence interval (CI) 5.0-5.2) involved a GPN. Follow-up with a GPN was organised for 1.5% (95% CI 1.4-1.5) of all problems/diagnoses. Significant associations of GPN involvement included patient age, male sex, Aboriginal or Torres Strait Islander status, non-English-speaking background (NESB) and the patient being new to the practice. Larger practice size, the particular training organisation, and the problem/diagnosis being new and not a chronic disease were other associations.

CONCLUSIONS

Associations with Aboriginal or Torres Strait Islander status and NESB status suggest GPNs are addressing healthcare needs of these under-serviced groups. But GPNs may be underutilised in chronic disease care.

Racial/Ethnic disparities in patient experience with communication in hospitals: real differences or measurement errors?

BACKGROUND

An important aspect of medical care is clear and effective communication, which can be particularly challenging for individuals based on race/ethnicity. Quality of communication is measured systematically in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, and analyzed frequently such as in the National Healthcare Disparities Report. Caution is needed to discern differences in communication quality from racial/ethnic differences in perceptions about concepts or expectations about their fulfillment.

OBJECTIVES

To examine assumptions about the degree of commonality across racial/ethnic groups in their perceptions and expectations, and to investigate the validity of conclusions regarding racial/ethnic differences in communication quality.

METHODS

We used 2007 HCAHPS data from the National CAHPS Benchmarking Database to construct racial/ethnic samples that controlled for other patient characteristics (828 per group). Using multiple-groups confirmatory factor analyses, we tested whether the factor structure and model parameters (ie, factor loadings, intercepts) differed across groups.

RESULTS

We identified support for basic tests of equivalence across 7 racial/ethnic groups in terms of equivalent factor structure and loadings. Even stronger support was found for Communication with Doctors and Nurses. However, potentially important nonequivalence was found for Communication about Medicines, including instances of statistically significant differences between non-Hispanic whites and non-Hispanic blacks, Asians, and Native Hawaiian/other Pacific Islanders.

CONCLUSIONS

Our results provide strongest support for racial/ethnic comparisons on Communication with Nurses and Doctors, and reason to caution against comparisons on Communication about Medicines due to significant differences in model parameters across groups; that is, a lack of invariance in the intercept.

Do Racial/Ethnic Disparities in Quality and Patient Experience within Medicare Plans Generalize across Measures and Racial/Ethnic Groups?

OBJECTIVE

To examine how similar racial/ethnic disparities in clinical quality (Healthcare Effectiveness Data and Information Set [HEDIS]) and patient experience (Consumer Assessment of Healthcare Providers and Systems [CAHPS]) measures are for different measures within Medicare Advantage (MA) plans.

DATA SOURCES/STUDY SETTING

5.7 million/492,495 MA beneficiaries with 2008-2009 HEDIS/CAHPS data.

STUDY DESIGN

Binomial (HEDIS) and linear (CAHPS) hierarchical mixed models generated contract estimates for HEDIS/CAHPS measures for Hispanics, blacks, Asian-Pacific Islanders, and whites. We examine the correlation of within-plan disparities for HEDIS and CAHPS measures across measures.

PRINCIPAL FINDINGS

Plans with disparities for a given minority group (vs. whites) for a particular measure have a moderate tendency for similar disparities for other measures of the same type (mean r = 0.51/.21 and 53/34 percent positive and statistically significant for CAHPS/HEDIS). This pattern holds to a lesser extent for correlations of CAHPS disparities and HEDIS disparities (mean r = 0.05/0.14/0.23 and 4.4/5.6/4.4 percent) positive and statistically significant for blacks/Hispanics/API.

CONCLUSIONS

Similarities in CAHPS and HEDIS disparities across measures might reflect common structural factors, such as language services or provider incentives, affecting several measures simultaneously. Health plan structural changes might reduce disparities across multiple measures.

Do Experiences with Medicare Managed Care Vary According to the Proportion of Same-Race/Ethnicity/Language Individuals Enrolled in One's Contract?

OBJECTIVE

To examine whether care experiences and immunization for racial/ethnic/language minority Medicare beneficiaries vary with the proportion of same-group beneficiaries in Medicare Advantage (MA) contracts.

DATA SOURCES/STUDY SETTING

Exactly 492,495 Medicare beneficiaries responding to the 2008-2009 MA Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey.

DATA COLLECTION/EXTRACTION METHODS

Mixed-effect regression models predicted eight CAHPS patient experience measures from self-reported race/ethnicity/language preference at individual and contract levels, beneficiary-level case-mix adjustors, along with contract and geographic random effects.

PRINCIPAL FINDINGS

As a contract's proportion of a given minority group increased, overall and non-Hispanic, white patient experiences were poorer on average; for the minority group in question, however, high-minority plans may score as well as low-minority plans. Spanish-preferring Hispanic beneficiaries also experience smaller disparities relative to non-Hispanic whites in plans with higher Spanish-preferring proportions.

CONCLUSIONS

The tendency for high-minority contracts to provide less positive patient experiences for others in the contract, but similar or even more positive patient experiences for concentrated minority group beneficiaries, may reflect cultural competency, particularly language services, that partially or fully counterbalance the poorer overall quality of these contracts. For some beneficiaries, experiences may be just as positive in some high-minority plans with low overall scores as in plans with higher overall scores.

Beyond black and white: race/ethnicity and health status among older adults

OBJECTIVES

This study examined physical and mental health, health symptoms, sensory and functional limitations, risk factors, and multimorbidity among older Medicare managed care members to assess disparities associated with race/ethnicity.

STUDY DESIGN AND METHODS

We used data on 236,289 older adults from 208 Medicare plans who completed the 2012 Medicare Health Outcomes Survey to compare 14 health indicators across non-Hispanic whites, blacks, American Indians/Alaskan Natives, Asians, Native Hawaiians/Pacific Islanders, multiracial individuals, and Hispanics. Logistic regression models that clustered on the plan estimated the risk of indicators of adverse health and functional status.

RESULTS

Even after controlling for key patient sociodemographic factors, race/ethnicity was significantly associated with most adverse health indicators. Except for Asians, all racial/ethnic minority groups were significantly more likely than whites to report poor mental health status, presence of most health symptoms, sensory limitations, and activities-of-daily-living disability. Important differences were observed across racial and ethnic groups.

CONCLUSIONS

Despite some exceptions, elders of racial/ethnic minority background are generally at higher risk than non-Hispanic whites for a broad range of adverse health and functional outcomes that are not routinely assessed. Limitations include bias related to self-reported data and respondent recall. Future research should consider ethnic subgroup variations; employing newer techniques to improve estimates for smaller groups; and prioritizing and identifying opportunities for care improvement of diverse enrollee groups by considering specific needs. To improve the health status of the elderly, service delivery targeting the needs of specific population groups, coupled with culturally appropriate care for racial/ ethnic minorities, should also be considered.

Understanding racial and ethnic differences in patient experiences with outpatient health care in Veterans Affairs Medical Centers

BACKGROUND

Racial and ethnic differences in patient health care experiences have not been well examined in the Veterans Affairs (VA) Healthcare System.

OBJECTIVES

To examine racial/ethnic differences in outpatient health care experiences within and between VA medical facilities.

RESEARCH DESIGN

We assessed within-facility and between-facility racial/ethnic differences in responses to the 2010 VA Survey of Healthcare Experiences of Patients using mixed-effects multinomial regression.

SUBJECTS

A total of 211,459 respondents (53.2%) to a random survey of outpatients from 910 VA medical facilities (71.9% non-Hispanic white, 15.1% non-Hispanic black, 6.4% Hispanic, and 6.7% Other race/ethnicity).

MEASURES

Negative and positive patient-reported experiences in 8 domains of health care.

RESULTS

Between-facility effects for black race were higher for 7 domains of negative experiences [risk differences (RDs): 0.37% to 1.64%] and lower for 6 domains of positive experiences (RDs: -0.69% to -2.54%). Between-facility effects for Hispanic ethnicity were higher for 5 domains of negative experiences (RDs: 0.60%-1.34%) and lower for 5 domains of positive experiences (RDs: -1.00% to -1.88%). Hispanic ethnicity was also associated with higher within-facility rates of positive experiences for 5 domains of care (RDs: 2.97%-4.08%). Other race/ethnicity was associated with significantly higher within-facility rates of negative experiences (RDs: 2.04%-3.95%) and lower rates of positive experiences for all 8 domains (RDs: -2.05% to -4.70%).

CONCLUSIONS

In a national random sample of Veterans managed in the VA Healthcare System, we demonstrated significant within-facility and between-facility racial and ethnic differences in outpatient health care experiences, with differing patterns for each minority group.

Working with interpreters in health care: a systematic review and meta-ethnography of qualitative studies

OBJECTIVE

To identify relational issues involved in working with interpreters in healthcare settings and to make recommendations for future research.

METHODS

A systematic literature search in French and English was conducted. The matrix method and a meta-ethnographic analysis were used to organize and synthesize the data.

RESULTS

Three themes emerged. Interpreters'roles: Interpreters fill a wide variety of roles. Based on Habermas's concepts, these roles vary between agent of the Lifeworld and agent of the System. This diversity and oscillation are sources of both tension and relational opportunities.

DIFFICULTIES

The difficulties encountered by practitioners, interpreters and patients are related to issues of trust, control and power. There is a clear need for balance between the three, and institutional recognition of interpreters' roles is crucial. COMMUNICATION CHARACTERISTICS: Non-literal translation appears to be a prerequisite for effective and accurate communication.

CONCLUSION

The recognition of community interpreting as a profession would appear to be the next step. Without this recognition, it is unlikely that communication difficulties will be resolved.

PRACTICE IMPLICATIONS

The healthcare (and scientific) community must pay more attention to the complex nature of interpreted interactions. Researchers need to investigate how relational issues in interpreted interactions affect patient care and health.

Analysis & commentary. Measuring patient experience as a strategy for improving primary care

Patients value the interpersonal aspects of their health care experiences. However, faced with multiple resource demands, primary care practices may question the value of collecting and acting upon survey data that measure patients' experiences of care. The Consumer Assessment of Healthcare Providers and Systems (CAHPS) suite of surveys and quality improvement tools supports the systematic collection of data on patient experience. Collecting and reporting CAHPS data can improve patients' experiences, along with producing tangible benefits to primary care practices and the health care system. We also argue that the use of patient experience information can be an important strategy for transforming practices as well as to drive overall system transformation.

Racial/ethnic disparities in Medicare Part D experiences

OBJECTIVE

To examine racial/ethnic differences in Medicare beneficiary experiences with Medicare Part D prescription drug (PD) coverage.

DATA SOURCES/STUDY SETTING

2008 Consumer Assessment of Health Care Providers and Systems survey of U.S. Medicare beneficiaries.

STUDY DESIGN

Surveys were administered by mail with phone follow-up to a nationally representative sample (61% response rate). This study examines 201,496 beneficiaries of age 65 and older with PD coverage [6% Hispanic, 7% non-Hispanic Black, 3% non-Hispanic Asian or Pacific Islander (API)]. Key variables are self-reported race/ethnicity and Consumer Assessment of Health Care Providers and Systems getting information and needed PDs measures.

DATA COLLECTION/EXTRACTION METHODS

We generated weighted case-mix adjusted means for 4 racial/ethnic groups and for Hispanics separately by English-language or Spanish-language preference status. We calculated within-plan disparities using a linear mixed-effect model, with fixed effects for race/ethnicity, coverage type and case-mix variables, and random effects for contract and contract by race/ethnicity interactions.

PRINCIPAL FINDINGS

Disparities for Hispanic, Black, and API beneficiaries on obtaining needed PDs and information regarding coverage range from -2 to -11 points (0-100 scale) relative to non-Hispanic Whites, with the greatest disparities observed for Spanish-preferring Hispanics and API beneficiaries, especially those with low income. There is wide variation in disparities across contracts, and contracts with the largest disparities for Hispanics have higher proportions of beneficiaries with lower education and income.

CONCLUSIONS

Quality improvement efforts may be needed to reduce racial/ethnic disparities in beneficiary experience with PD coverage. Cultural, language, and health literacy barriers in navigating Medicare's Part D program may partially explain the observed disparities.

Factors impacting career satisfaction of hospitalists

A study was undertaken to examine various factors that impact career satisfaction of hospitality. This study used data collected by the Center for Studying Health System Change's 2008 Health Tracking Physician survey. The 2008 HTP data set consisted of 4720 physicians belonging to the American Medical Association, of which 206 identified themselves as hospitalists. Results suggested that 41% of hospitalists were very satisfied with their careers in medicine. More than 26% of the hospitalists were 53 years or older. Seven of 10 hospitalists were men, whereas more than 55% were white. In addition, an average respondent earned between $150 000 and $200 000. Nearly 36% of the hospitalists in the study specialized in internal medicine. Regression analysis indicates that high-quality care had a highly significant impact on career satisfaction of hospitalists (P ≤ .00). In addition, formal written guidelines (P ≤ .07), gender (P ≤ .06), and white race (P ≤ .07) also had a significant impact on career satisfaction of hospitalists. It was concluded that perceived quality of care, presence of formal written guidelines, gender, and race were major predictors of career satisfaction of hospitalists.

The relationship between perceived discrimination and patient experiences with health care

BACKGROUND

Prior studies have shown that racial/ethnic minorities have lower Consumer Assessments of Healthcare Providers and Systems (CAHPS) scores. Perceived discrimination may mediate the relationship between race/ethnicity and patient experiences with care.

OBJECTIVE

To examine the relationship between perceived discrimination based on race/ethnicity and Medicaid insurance and CAHPS reports and ratings of care.

METHODS

The study analyzed 2007 survey data from 1509 Florida Medicaid beneficiaries. CAHPS reports (getting needed care, timeliness of care, communication with doctor, and health plan customer service) and ratings (personal doctor, specialist care, overall health care, and health plan) of care were the primary outcome variables. Patient perceptions of discrimination based on their race/ethnicity and having Medicaid insurance were the primary independent variables. Regression analysis modeled the effect of perceptions of discrimination on CAHPS reports and ratings controlling for age, sex, education, self-rated health status, race/ethnicity, survey language, and fee-for-service enrollment. SEs were corrected for correlation within plans.

RESULTS

Medicaid beneficiaries reporting discrimination based on race/ethnicity had lower CAHPS scores, ranging from 15 points lower (on a 0-100 scale) for getting needed care to 6 points lower for specialist rating, compared with those who never experienced discrimination. Similar results were obtained for perceived discrimination based on Medicaid insurance.

CONCLUSIONS

Perceptions of discrimination based on race/ethnicity and Medicaid insurance are prevalent and are associated with substantially lower CAHPS reports and ratings of care. Practices must develop and implement strategies to reduce perceived discrimination among patients.

The Consumer Assessment of Healthcare Providers and Systems (CAHPS) cultural competence (CC) item set

BACKGROUND

There is a need for reliable and valid measures of cultural competence (CC) from the patient's perspective.

OBJECTIVE

This paper evaluates the reliability and validity of the Consumer Assessments of Healthcare Providers and Systems (CAHPS) CC item set.

RESEARCH DESIGN

Using 2008 survey data, we assessed the internal consistency of the CAHPS CC scales using the Cronbach α's and examined the validity of the measures using exploratory and confirmatory factor analysis, multitrait scaling analysis, and regression analysis.

SUBJECTS

A random stratified sample (based on race/ethnicity and language) of 991 enrollees, younger than 65 years, from 2 Medicaid managed care plans in California and New York.

MEASURES

CAHPS CC item set after excluding screener items and ratings.

RESULTS

Confirmatory factor analysis (Comparative Fit Index=0.98, Tucker Lewis Index=0.98, and Root Mean Square Error or Approximation=0.06) provided support for a 7-factor structure: Doctor Communication--Positive Behaviors, Doctor Communication--Negative Behaviors, Doctor Communication--Health Promotion, Doctor Communication--Alternative Medicine, Shared Decision-Making, Equitable Treatment, and Trust. Item-total correlations (corrected for item overlap) for the 7 scales exceeded 0.40. Exploratory factor analysis showed support for 1 additional factor: Access to Interpreter Services. Internal consistency reliability estimates ranged from 0.58 (Alternative Medicine) to 0.92 (Positive Behaviors) and was 0.70 or higher for 4 of the 8 composites. All composites were positively and significantly associated with the overall doctor rating.

CONCLUSIONS

The CAHPS CC 26-item set demonstrates adequate measurement properties and can be used as a supplemental item set to the CAHPS Clinician and Group Surveys in assessing culturally competent care from the patient's perspective.

Reporting CAHPS and HEDIS data by race/ethnicity for Medicare beneficiaries

OBJECTIVE

To produce reliable and informative health plan performance data by race/ethnicity for the Medicare beneficiary population and to consider appropriate presentation strategies.

DATA SOURCES

Patient experience data from the 2008-2009 Medicare Advantage (MA) and fee-for-service (FFS) CAHPS surveys and 2008-2009 HEDIS data (MA beneficiaries only).

STUDY DESIGN

Mixed effects linear (and binomial) regression models estimated the reliability and statistical informativeness of CAHPS (HEDIS) measures.

PRINCIPAL FINDINGS

Seven CAHPS and seven HEDIS measures were reliable and informative for four racial/ethnic subgroups-Whites, Blacks, Hispanics, and Asian/Pacific Islanders-at sample sizes of 100 beneficiaries (200 for prescription drug plans). Although many plans lacked adequate sample size for reporting group-specific data, reportable plans contained a large majority of beneficiaries from each of the four racial/ethnic groups.

CONCLUSIONS

Statistically reliable and valid information on health plan performance can be reported by race/ethnicity. Many beneficiaries may have difficulty understanding such reports, however, even with careful guidance. Thus, it is recommended that health plan performance data by subgroups be reported as supplemental data and only for plans meeting sample size requirements.

Assessing cultural perspectives on healthcare quality

This study explores cultural differences in perceptions of quality of care and examines whether existing surveys, such as the Consumer Assessment of Healthcare Providers and Systems (CAHPS(®)) questionnaires, adequately capture conceptions of healthcare quality among members of racial/ethnic minority groups. Eight focus groups with African Americans, Asian Indians, Latinos, and whites were organized into two 45-minute segments. In one segment, participants rated the quality of care depicted in a video; in the other they discussed the concept of "healthcare quality." We found that members of racial/ethnic minority groups are more likely than whites to identify cultural competency and providing a holistic approach to care as important to healthcare quality. Neither of these concepts is currently included in the core CAHPS(®) questionnaire. The CAHPS(®) and other quality surveys may not accurately capture concepts of healthcare quality that members of racial/ethnic minority groups deem most important.

Are there differences in the Medicare experiences of beneficiaries in Puerto Rico compared with those in the U.S. mainland?

BACKGROUND

Little is known about the healthcare experiences of Medicare beneficiaries in Puerto Rico.

OBJECTIVES

We compare the experiences of elderly Medicare beneficiaries in Puerto Rico with their English-preferring and Spanish-preferring Medicare counterparts in the U.S. mainland.

RESEARCH DESIGN

Linear regression models compared mean Consumer Assessment of Healthcare Providers and Systems scores for these groups, using cross-sectional data from the 2008 Medicare Consumer Assessment of Healthcare Providers and Systems survey.

SUBJECTS

Medicare beneficiaries aged 65 years and older (6733 in Puerto Rico, 282,654 in the U.S. mainland) who completed the 2008 Medicare Consumer Assessment of Healthcare Providers and Systems survey.

MEASURES

Six composite measures of beneficiary reports and two measures of beneficiary-reported immunization.

RESULTS

Beneficiaries in Puerto Rico reported less positive experiences than both English-preferring and Spanish-preferring U.S. mainland beneficiaries for getting needed care, getting care quickly, and immunization (P<0.05 in all cases). Beneficiaries in Puerto Rico reported better customer service than Spanish-preferring U.S. mainland beneficiaries and better doctor communication experiences than English-preferring U.S. mainland beneficiaries. Additional analyses find little variation in care experiences within Puerto Rico by region, plan type, or specific plan.

CONCLUSIONS

Medicare beneficiaries in Puerto Rico report generally worse healthcare experiences than beneficiaries in the U.S. mainland for several Consumer Assessment of Healthcare Providers and Systems outcomes and lower immunization rates. Lower funding of healthcare services in Puerto Rico relative to the U.S. mainland may affect healthcare. Strategies such as patient and provider education, provider financial incentives, and increased use of information technologies may improve adherence to the recommended preventive care practices.

Understanding variations in Medicare Consumer Assessment of Health Care Providers and Systems scores: California as an example

OBJECTIVE

To understand reasons why California has lower Consumer Assessment of Healthcare Providers and Systems (CAHPS) scores than the rest of the country, including differing patterns of CAHPS scores between Medicare Advantage (MA) and fee-for-service, effects of additional demographic characteristics of beneficiaries, and variation across MA plans within California.

STUDY DESIGN/DATA COLLECTION

Using 2008 CAHPS survey data for fee-for-service Medicare beneficiaries and MA members, we compared mean case mix adjusted Medicare CAHPS scores for California and the remainder of the nation.

PRINCIPAL FINDINGS

California fee-for-service Medicare had lower scores than non-California fee-for-service on 11 of 14 CAHPS measures; California MA had lower scores only for physician services measures and higher scores for other measures. Adding race/ethnicity and urbanity to risk adjustment improved California standing for all measures in both MA and fee-for-service. Within the MA plans, one large plan accounted for the positive performance in California MA; other California plans performed below national averages.

CONCLUSIONS

This study shows that the mix of fee-for-service and MA enrollees, demographic characteristics of populations, and plan-specific factors can all play a role in observed regional variations. Anticipating value-based payments, further study of successful MA plans could generate lessons for enhancing patient experience for the Medicare population.

Examining multiple sources of differential item functioning on the Clinician & Group CAHPS® survey

OBJECTIVE

To evaluate psychometric properties of a widely used patient experience survey.

DATA SOURCES

English-language responses to the Clinician & Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS®) survey (n = 12,244) from a 2008 quality improvement initiative involving eight southern California medical groups.

METHODS

We used an iterative hybrid ordinal logistic regression/item response theory differential item functioning (DIF) algorithm to identify items with DIF related to patient sociodemographic characteristics, duration of the physician-patient relationship, number of physician visits, and self-rated physical and mental health. We accounted for all sources of DIF and determined its cumulative impact.

PRINCIPAL FINDINGS

The upper end of the CG-CAHPS® performance range is measured with low precision. With sensitive settings, some items were found to have DIF. However, overall DIF impact was negligible, as 0.14 percent of participants had salient DIF impact. Latinos who spoke predominantly English at home had the highest prevalence of salient DIF impact at 0.26 percent.

CONCLUSIONS

The CG-CAHPS® functions similarly across commercially insured respondents from diverse backgrounds. Consequently, previously documented racial and ethnic group differences likely reflect true differences rather than measurement bias. The impact of low precision at the upper end of the scale should be clarified.