Performance of the Physical Functioning Activities of Daily Living Scale in the 2020 Medicare Health Outcomes Survey

OBJECTIVE

Assessing functional limitations for adults at high risk of frailty yields valuable information for identifying those in need of therapy. We evaluate a self-report measure used to assess physical function among Medicare recipients in the United States.

DESIGN

Secondary analysis of the 2020 Medicare Health Outcomes Survey.

SETTING

A random sample of adult enrollees of 510 managed care plans.

PARTICIPANTS

287,476 adults (37% completion rate): 58% women; 16% were <65 years old (entitled via disability), 50% 65-74, and 34% 75 or older; 77% White, 14% Black, and 8% another race; 19% had

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

We evaluate item distributions, dimensionality, monotonicity of response options, reliability, and validity of the 8-item Physical Functioning Activities of Daily Living (PFADL) scale.

RESULTS

Most reported they could do 6 basic activities of daily living without difficulty. More limitations were reported for the other 2 PFADL items: 32% were not limited at all in climbing several flights of stairs and 40% in moderate activities. Product-moment correlations among the 8 items ranged from r=0.19 between the easiest-to-do (eating) and most difficult-to-do (climbing several flights of stairs) items to r=0.73 between bathing and dressing. The coefficient alpha and omega for the 8-item scale were both 0.86. Item slopes ranged from 2.6 (climbing several flights of stairs and eating) to 4.8 (dressing). Item characteristic curves revealed that response options were most likely to be selected in the appropriate order along the physical functioning continuum. The PFADL had at least 0.80 reliability between about -3 SDs below the mean to the mean. It was negatively correlated with comorbid condition count, disability days, problems with balance or walking, falling, and obesity.

CONCLUSIONS

The PFADL is useful for assessing average or below physical function in Medicare recipients.

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Key Words

• Aged
• Functional status
• Medicare
• Rehabilitation
• Self-assessment

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MESH Headings

• Adult
• Humans
• Female
• Aged
• United States
• Male
• Activities of Daily Living
• Reproducibility of Results
• Medicare
• Surveys and Questionnaires
• Outcome Assessment, Health Care
• Disability Evaluation

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Affiliation(s)

Ron D Hays UCLA Division of General Internal Medicine, Department of Medicine, Los Angeles, CA.
Marc N Elliott RAND Corporation, Santa Monica, CA

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Assessing the accuracy of race-and-ethnicity data in the Outcome and Assessment Information Set

BACKGROUND

Limitations in the quality of race-and-ethnicity information in Medicare's data systems constrain efforts to assess disparities in care among older Americans. Using demographic information from standardized patient assessments may be an efficient way to enhance the accuracy and completeness of race-and-ethnicity information in Medicare's data systems, but it is critical to first establish the accuracy of these data as they may be prone to inaccurate observer-reported or third-party-based information. This study evaluates the accuracy of patient-level race-and-ethnicity information included in the Outcome and Assessment Information Set (OASIS) submitted by home health agencies.

METHODS

We compared 2017-2022 OASIS-D race-and-ethnicity data to gold-standard self-reported information from the Medicare Consumer Assessment of Healthcare Providers and Systems® survey in a matched sample of 304,804 people with Medicare coverage. We also compared OASIS data to indirect estimates of race-and-ethnicity generated using the Medicare Bayesian Improved Surname and Geocoding (MBISG) 2.1.1 method and to existing Centers for Medicare & Medicaid Services (CMS) administrative records.

RESULTS

Compared with existing CMS administrative data, OASIS data are far more accurate for Hispanic, Asian American and Native Hawaiian or other Pacific Islander, and White race-and-ethnicity; slightly less accurate for American Indian or Alaska Native race-and-ethnicity; and similarly accurate for Black race-and-ethnicity. However, MBISG 2.1.1 accuracy exceeds that of both OASIS and CMS administrative data for every racial-and-ethnic category. Patterns of inconsistent reporting of racial-and-ethnic information among people for whom there were multiple observations in the OASIS and Consumer Assessment of Healthcare Providers and Systems (CAHPS) datasets suggest that some of the inaccuracies in OASIS data may result from observation-based reporting that lessens correspondence with self-reported data.

CONCLUSIONS

When health record data on race-and-ethnicity includes observer-reported information, it can be less accurate than both true self-report and a high-performing imputation approach. Efforts are needed to encourage collection of true self-reported data and explicit record-level data on the source of race-and-ethnicity information.

Narrative comments about pediatric inpatient experiences yield substantial information beyond answers to closed-ended CAHPS survey questions

PURPOSE

Adults' comments on patient experience surveys explain variation in provider ratings, with negative comments providing more actionable information than positive comments. We investigate if narrative comments on the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) survey of inpatient pediatric care (Child HCAHPS) account for global perceptions of the hospital beyond that explained by reports about specific aspects of care.

METHODS

We analyzed 545 comments from 927 Child HCAHPS surveys completed by parents and guardians of hospitalized children with at least a 24-h hospital stay from July 2017 to December 2020 at an urban children's hospital. Comments were coded for valence (positive/negative/mixed) and actionability and used to predict Overall Hospital Rating and Willingness to Recommend the Hospital along with Child HCAHPS composite scores.

RESULTS

Comments were provided more often by White and more educated respondents. Negative comments and greater actionability of comments were significantly associated with Child HCAHPS global rating measures, controlling for responses to closed-ended questions, and child and respondent characteristics. Each explained an additional 8% of the variance in respondents' overall hospital ratings and an additional 5% in their willingness to recommend the hospital.

CONCLUSIONS

Child HCAHPS narrative comment data provide significant additional information about what is important to parents and guardians during inpatient pediatric care beyond closed-ended composites.

PRACTICE IMPLICATIONS

Quality improvement efforts should include a review of narrative comments alongside closed-ended responses to help identify ways to improve inpatient care experiences. To promote health equity, comments should be encouraged for racial-and-ethnic minority patients and those with less educational attainment.

Survey Protocols, Response Rates, and Representation of Underserved Patients: A Randomized Clinical Trial

Importance

Surveys often underrepresent certain patients, such as underserved patients. Methods that improve their response rates (RRs) would help patient surveys better represent their experiences and assess equity and equity-targeted quality improvement efforts.

Objective

To estimate the effect of adding an initial web mode to existing Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey protocols and extending the fielding period on RR and representativeness of underserved patient groups.

Design, Setting, and Participants

This randomized clinical trial included 36 001 patients discharged from 46 US hospitals from May through December 2021. Data analysis was performed from May 2022 to September 2023.

Exposures

Patients were randomized to 1 of 6 survey protocols: 3 standard HCAHPS protocols (mail only, phone only, mail-phone) plus 3 web-enhanced protocols (web-mail, web-phone, web-mail-phone).

Main Outcomes and Measures

RR and number of respondents per 100 survey attempts (yield) were calculated and compared for each of the 6 survey protocols, overall, and by patient age, service line, sex, and race and ethnicity.

Results

A total of 34 335 patients (median age range, 55-59 years; 59.3% female individuals and 40.7% male individuals) were eligible and included in the study. Of the respondents, 6.9% were Asian American or Native Hawaiian or Other Pacific Islander, 0.7% were American Indian or Alaska Native, 11.5% were Black, 17.4% were Hispanic, 61.0% were White, and 2.6% were multiracial. Of the 6 protocols, RRs were highest in web-mail-phone (36.5%), intermediate for the 3 two-mode survey protocols (mail-phone, web-mail, web-phone, 30.3%-31.1%), and lowest for the 2 single-mode protocols (mail only, phone only, 22.1%-24.3%). Web-mail-phone resulted in the highest yield for 3 racial and ethnic groups (Black, Hispanic, and White patients) and second highest for another (multiracial patients). Otherwise, the highest or second highest yield was almost always a 2-mode protocol. Mail only was the lowest-yield protocol for Black, Hispanic, and multiracial patients and phone-only was the lowest-yield protocol for White patients; these 2 protocols tied for lowest-yield for Asian American or Native Hawaiian or Other Pacific Islander patients. Gains from multimode approaches were often 2 to 3 times as large for Asian American or Native Hawaiian or Other Pacific Islander, Black, Hispanic, and multiracial patients as for White patients. Web-mail-phone had the highest RR for 6 of 8 age groups and 4 of 5 combinations of service line and sex.

Conclusions and Relevance

In this randomized clinical trial, web-first multimode survey protocols significantly improved the RR and representativeness of patient surveys. The best-performing protocol based on RR and representativeness was web-mail-phone. Web-phone performed well for young and diverse patient populations, and web-mail for older and less diverse patient populations. The US Centers for Medicare & Medicaid Services will allow hospitals to use the web-mail, web-phone, and web-mail-phone protocols for HCAHPS administration beginning in 2025.

Do Hospital Characteristics Predict Racial-and-Ethnic Disparities in Patient Experience? National Results From the HCAHPS Survey

OBJECTIVE

Assess whether hospital characteristics associated with better patient experiences overall are also associated with smaller racial-and-ethnic disparities in inpatient experience.

BACKGROUND

Hospitals that are smaller, non-profit, and serve high proportions of White patients tend to be high-performing overall, but it is not known whether these hospitals also have smaller racial-and-ethnic disparities in care.

RESEARCH DESIGN

We used linear mixed-effect regression models to predict a summary measure that averaged eight Hospital CAHPS (HCAHPS) measures (Nurse Communication, Doctor Communication, Staff Responsiveness, Communication about Medicines, Discharge Information, Care Coordination, Hospital Cleanliness, and Quietness) from patient race-and-ethnicity, hospital characteristics (size, ownership, racial-and-ethnic patient-mix), and interactions of race-and-ethnicity with hospital characteristics.

SUBJECTS

Inpatients discharged from 4,365 hospitals in 2021 who completed an HCAHPS survey ( N =2,288,862).

RESULTS

While hospitals serving larger proportions of Black and Hispanic patients scored lower on all measures, racial-and-ethnic disparities were generally smaller for Black and Hispanic patients who received care from hospitals serving higher proportions of patients in their racial-and-ethnic group. Experiences overall were better in smaller and non-profit hospitals, but racial-and-ethnic differences were slightly larger.

CONCLUSIONS

Large, for-profit hospitals and hospitals serving higher proportions of Black and Hispanic patients tend to be lower performing overall but have smaller disparities in patient experience. High-performing hospitals might look at low-performing hospitals for how to provide less disparate care whereas low-performing hospitals may look to high-performing hospitals for how to improve patient experience overall.

Understanding the social risk factor adjustment's effect on Star Ratings

OBJECTIVES

CMS implemented the Categorical Adjustment Index (CAI) to address measurement bias in the Medicare Advantage (MA) Star Ratings, as unadjusted scores may disadvantage MA contracts serving more enrollees at greater social risk. CAI values are added to a contract's Star Ratings to adjust for the mean within-contract performance disparity associated with its percentage of enrollees with low socioeconomic status (ie, receipt of a Part D low-income subsidy or dual eligibility for Medicare and Medicaid [LIS/DE]) and who are disabled. We examined the CAI's effect on Star Ratings and the type of contracts affected.

STUDY DESIGN

Observational study of MA contracts with health and prescription drug coverage.

METHODS

We compared adjusted and unadjusted 2017-2020 Star Ratings overall and by contracts' proportion of LIS/DE and disabled enrollees. We assessed the CAI's effect on qualifying for quality bonus payments (QBPs), eligibility for rebate payments, and high-performing and low-performing designations.

RESULTS

The CAI's impact was modest overall (3.2%-14.9% of contracts experienced one-half Star Rating changes). Upward changes were concentrated among contracts with high percentages of LIS/DE or disabled enrollees (7.7%-32.3% of these contracts saw increased Star Ratings). In 2020, 26.0% of contracts with a high proportion of LIS/DE or disabled enrollees that qualified for a QBP did so because of the CAI.

CONCLUSIONS

The CAI primarily affected contracts with high LIS/DE or disabled enrollment, which received higher Star Ratings because of the CAI. The adjustment helps ensure that such contracts' performance is not understated and reduces incentives for MA contracts to avoid patients at greater social risk.

Refining United States Sexual Minority Adult Population Estimates with the Inclusion of "Something Else" and "Don't Know" Survey Responses

Purpose: To refine estimates of the U.S. sexual minority population, we sought to characterize trends in the odds of respondents selecting "something else" or "don't know" when asked about sexual orientation on the National Health Interview Survey and to reclassify those respondents likely to be sexual minority adults. Methods: Logistic regression was conducted to test whether the odds of selecting "something else" or "don't know" increased over time. A previously established analytic approach was used to identify sexual minority adults among these respondents. Results: Between 2013 and 2018, the percentage of respondents selecting "something else" or "don't know" increased 2.7-fold, from 0.54% to 1.44%. Reclassifying respondents with >50% predicted probabilities of being sexual minorities increased sexual minority population estimates by as much as 20.2%. Conclusion: A growing proportion of adults are selecting "something else" or "don't know." Properly classifying these responses yields more accurate sexual minority population estimates.

Exploring Which Patients Use Their Closest Emergency Departments Using Geocoded Data

BACKGROUND

Each year, roughly 20% of U.S. adults visit an emergency department (ED), but little is known about patients' choice of ED.

OBJECTIVES

Examine the discretion patients have to choose among EDs, characteristics associated with ED choice, and relationship between ED choice and self-reported care experiences of ED patients.

METHODS

We surveyed adult patients discharged to the community (DTC) in January-March 2018 from 16 geographically dispersed hospital-based EDs, geocoded patient and hospital-based ED addresses within 100 miles of patient addresses, and calculated travel distances. We examined the likelihood of visiting the closest ED based on patient and ED characteristics. Linear regression models examined the association of choosing the closest ED with seven measures of patient experience of care (scaled 0-100), adjusting for patient characteristics.

RESULTS

43.6% of 4647 responding patients visited the ED nearest their home (on average, 5.7 miles away). Patients who chose a farther ED had more urgent conditions, were more educated, and were less likely to be non-Hispanic White. They were significantly more likely to have visited an ED in a higher-rated, metropolitan, network hospital with major teaching status, a cardiac intensive care unit, and a certified trauma center. Patients who chose a farther ED were more likely to recommend that ED, with "medium-to-large" differences in scores (+4.3% more selected "definitely yes", p < 0.05).

CONCLUSIONS

Fewer than half of patients visited the closest ED. Patients who chose a farther ED tended to seek higher-rated hospitals and report more favorable experiences.

A Formal Framework For Incorporating Equity Into Health Care Quality Measurement

Quality measurement is an important tool for incentivizing improvement in the quality of health care. Most quality measurement efforts do not explicitly target health equity. Although some measurement approaches may intend to realign incentives to focus quality improvement efforts on underserved groups, the extent to which they accomplish this goal is understudied. We posit that tying incentives to approaches on the basis of stratification or disparities may have unintended consequences or limited effects. Such approaches might not reduce existing disparities because addressing one aspect of equity may be in competition with addressing others. We propose equity weighting, a new measurement framework to advance equity on multiple fronts that addresses the shortcomings of existing approaches and explicitly calibrates incentives to align with equity goals. We use colorectal cancer screening data derived from 2017 Medicare claims to illustrate how equity weighting fixes unintended consequences in other methods and how it can be adapted to policy goals.

Changes in Patient Experiences of Hospital Care During the COVID-19 Pandemic

Importance

It is important to assess how the COVID-19 pandemic was adversely associated with patients' care experiences.

Objective

To describe differences in 2020 to 2021 patient experiences from what would have been expected from prepandemic (2018-2019) trends and assess correlates of changes across hospitals.

Design, Setting, and Participants

This cohort study compared 2020 to 2021 data with 2018 to 2019 data from 3 900 887 HCAHPS respondents discharged from 3381 HCAHPS-participating US hospitals. The data were analyzed from 2022 to 2023.

Main Outcomes and Measures

The primary outcome was an HCAHPS summary score (HCAHPS-SS), which averaged 10 HCAHPS measures. The primary analysis estimated whether HCAHPS scores from patients discharged from 2020 to 2021 differed from scores that would be expected based on quarterly and linear trends from 2018 to 2019 discharges. Secondary analyses stratified hospitals by prepandemic overall star ratings and staffing levels.

Results

Of the 3 900 887 HCAHPS 2020 to 2021 respondents, 59% were age 65 years or older, and 35% (11%) were in the surgical (maternity) service lines. Compared with trends expected based on prepandemic (2018-2019) data, HCAHPS-SS was 1.2 percentage points (pp) lower for quarter (Q) 2/2020 discharges and -1.9 to -2.0 pp for Q3/2020 to Q1/2021, which then declined to -3.6 pp by Q4/2021. The most affected measures (Q4/2021) were staff responsiveness (-5.6 pp) and cleanliness (-4.9 pp); the least affected were discharge information (-1.6 pp) and quietness (-1.8 pp). Overall rating and hospital recommendation measures initially exhibited smaller-than-average decreases, but then fell as much as the more specific experience measures by Q2/2021. Quietness did not decline until Q2/2021. The HCAHPS-SS fell most for hospitals with the lowest prepandemic staffing levels; hospitals with bottom-quartile staffing showed the largest decrements, whereas top-quartile hospitals showed smaller decrements in most quarters. Hospitals with better overall prepandemic quality showed consistently smaller HCAHPS-SS drops, with effects for 5-star hospitals about 25% smaller than for 1-star and 2-star hospitals.

Conclusions and Relevance

The results of this cohort study of HCAHPS-participating hospitals found that patient experience scores declined during 2020 to 2021. By Q4/2021, the HCAHPS-SS was 3.6 pp lower than would have been expected, a medium effect size. The most affected measures (staff responsiveness and cleanliness) showed large effect sizes, possibly reflecting high illness-associated hospital workforce absenteeism. Hospitals that were lower performing and less staffed prepandemic may have been less resilient to reduced staff availability and other pandemic-associated challenges. However, by Q4/2021, even prepandemic high-performing hospitals had similar declines.

Shadow Coaching Improves Patient Experience for English-Preferring Patients but not for Spanish-Preferring Patients

BACKGROUND

Shadow coaching, a type of one-on-one provider counseling by trained peers, is an effective strategy for improving provider behaviors and patient interactions, but its effects on improving patient experience for English- and Spanish-preferring patients is unknown.

OBJECTIVE

Assess effects of shadow coaching on patient experience for English- and for Spanish-preferring patients.

DESIGN

We analyzed 2012-2019 Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) data (n=46,089) from an urban Federally Qualified Health Center with 44 primary care practices and 320 providers. One-third (n=14,631) were Spanish-preferring patients. We fit mixed-effects regression models with random effects for provider (the level of treatment assignment) and fixed effects for time (a linear spline for time with a knot and "jump" at coaching date), patient characteristics, and site indicators, stratified by preferred language.

PARTICIPANTS

The 74 providers who had a 6-month average top-box score on the CAHPS overall provider rating below 90 (on a 100-point scale) were shadow coached. Similar percentages of English-preferring (45%) and Spanish-preferring patients (43%) were seen by coached providers.

INTERVENTION

Trained providers observed patient care by colleagues and provided suggestions for improvement. Verbal feedback was provided immediately after the observation and the participant received a written report summarizing the comments and recommendations from the coaching session.

MAIN MEASURES

CG-CAHPS Visit Survey 2.0 provider communication composite and overall provider rating (0-100 scoring).

KEY RESULTS

We found a statistically significant 2-point (small) jump in CAHPS provider communication and overall provider rating among English-preferring patients of coached providers. There was no evidence of a coaching effect on patient experience for Spanish-preferring patients.

CONCLUSIONS

Coaching improved care experiences for English-preferring patients but may not have improved patient experience for Spanish-preferring patients. Selection and training of providers to communicate effectively with Spanish-preferring patients is needed to extend the benefits of shadow coaching to Spanish-preferring patients.

Stress-induced changes in autonomic reactivity vary with adolescent violence exposure and resting-state functional connectivity

Exposure to violence during childhood can lead to functional changes in brain regions that are important for emotion expression and regulation, which may increase susceptibility to internalizing disorders in adulthood. Specifically, childhood violence exposure can disrupt the functional connectivity among brain regions that include the prefrontal cortex (PFC), hippocampus, and amygdala. Together, these regions are important for modulating autonomic responses to stress. However, it is unclear to what extent changes in brain connectivity relate to autonomic stress reactivity and how the relationship between brain connectivity and autonomic responses to stress varies with childhood violence exposure. Thus, the present study examined whether stress-induced changes in autonomic responses (e.g., heart rate, skin conductance level (SCL)) varied with amygdala-, hippocampus-, and ventromedial prefrontal cortex (vmPFC)-whole brain resting-state functional connectivity (rsFC) as a function of violence exposure. Two hundred and ninety-seven participants completed two resting-state functional magnetic resonance imaging scans prior to (pre-stress) and after (post-stress) a psychosocial stress task. Heart rate and SCL were recorded during each scan. Post-stress heart rate varied negatively with post-stress amygdala-inferior parietal lobule rsFC and positively with post-stress hippocampus-anterior cingulate cortex rsFC among those exposed to high, but not low, levels of violence. Results from the present study suggest that post-stress fronto-limbic and parieto-limbic rsFC modulates heart rate and may underlie differences in the stress response among those exposed to high levels of violence.

Association of Hospice Profit Status With Family Caregivers' Reported Care Experiences

Importance

Expansive growth in the US hospice market has been driven almost exclusively by an increase in for-profit hospices. Prior research found that, in contrast to not-for-profit hospices, for-profit hospices focus on delivering care to patients in nursing homes, provide fewer nursing visits, and use less skilled staff. However, prior studies have not reported on the associations of these differences in care patterns with hospice care quality. Patient- and family-centeredness is a core element of hospice care quality that is measured through surveys of care experiences.

Objective

To examine whether differences in profit status are associated with family caregivers' reports of hospice care experiences and assess factors that may be associated with observed differences in care experiences by profit status.

Design, Setting, and Participants

Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Survey data from 653 208 caregiver respondents, reflecting care received from 3107 hospices between April 2017 and March 2019, were used for a cross-sectional examination of hospice care experiences by profit status. Data analysis was performed from January 2020 to November 2022.

Main Outcomes and Measures

Outcomes were case-mix-adjusted and mode-adjusted top-box scores for 8 measures of hospice care experiences, including communication, timely care, symptom management, and emotional and religious support, as well as a summary score averaging across measures. Linear regression examined the association between profit status and hospice-level scores, adjusting for other organizational and structural hospice characteristics.

Results

There were 906 not-for-profit and 1761 for-profit hospices with mean (SD) time in operation of 25.7 (7.8) years and 13.8 (8.0) years, respectively. Mean (SD) decedent age at death was 82.8 (2.3) years, similar for not-for-profit and for-profit hospices. The mean proportion of patients who were Black, Hispanic, and White was 4.9%, 0.9%, and 91.4% for not-for-profit hospices and 9.0%, 2.2%, and 85.4% for for-profit hospices, respectively. Family caregivers reported worse care experiences at for-profit hospices than at not-for-profit hospices for all measures. Significant differences in average hospice performance by profit status remained after adjusting for hospice characteristics. However, for-profit hospice performance varied, with 548 of 1761 (31.1%) for-profit hospices scoring 3 or more points below the national hospice average of overall performance and 386 of 1761 (21.9%) scoring 3 or more points above the average. In contrast, only 113 of 906 (12.5%) not-for-profit hospices scored 3 or more points below the average, and 305 of 906 (33.7%) scored 3 or more points above the average.

Conclusions and Relevance

In this cross-sectional study of CAHPS Hospice Survey data, caregivers of patients receiving hospice care reported substantially worse care experiences in for-profit than in not-for-profit hospices; however, there was variation in reported experiences among both types of hospices. Public reporting of hospice quality is important.

Development of a Medicare plan dashboard to promote health equity

OBJECTIVE

To describe a multistage process of designing and evaluating a dashboard that presents data on how equitably health plans provide care for their members.

STUDY DESIGN

We designed a dashboard for presenting summative and finer-grained data to health plans for characterizing how well plans are serving individuals who belong to racial/ethnic minority groups and individuals with low income. The data presented in the dashboard were based on CMS' Health Equity Summary Score (HESS) for Medicare Advantage plans.

METHODS

Interviews and listening sessions were conducted with health plan representatives and other stakeholders to assess understanding, perceived usefulness, and interpretability of HESS data. Usability testing was conducted with individuals familiar with quality measurement and reporting to evaluate dashboard design efficiency.

RESULTS

Listening session participants understood the purpose of the HESS and expressed a desire for this type of information. Usability testing revealed a need to improve dashboard navigability and to streamline content.

CONCLUSIONS

The HESS dashboard is a potentially useful tool for presenting data on health equity to health plans. The multistage process of continual testing and improvement used to develop the dashboard could be a model for targeting and deciding upon quality improvement efforts in the domain of health equity.

Follow-Up Shadow Coaching Improves Primary Care Provider-Patient Interactions and Maintains Improvements When Conducted Regularly: A Spline Model Analysis

INTRODUCTION

Shadow coaching improves provider-patient interactions, as measured by CG-CAHPS® overall provider rating (OPR) and provider communication (PC). However, these improvements erode over time.

AIM

Examine whether a second coaching session (re-coaching) improves and sustains patient experience.

SETTING

Large, urban Federally Qualified Health Center PROGRAM: Trained providers observed patient care by colleagues and provided suggestions for improvement. Providers with OPRs<90 (0-100-point scale) were eligible.

EVALUATION

We used stratified randomization based on provider type and OPR to assign half of the 40 eligible providers to re-coaching. For OPR and PC, we fit mixed-effects regression models with random-effects for provider (level of treatment assignment) and fixed-effects for time (linear spline with knots and possible "jump" at initial coaching and re-coaching), previous OPR, patient characteristics, and sites. We observed a statistically significant medium jump among re-coached providers after re-coaching on OPR (3.7 points) and PC (3.5 points); differences of 1, 3, and ≥5-points for CAHPS measures are considered small, medium, and large. Improvements from re-coaching persisted for 12 months for OPR and 8 months for PC.

DISCUSSION

Re-coaching improved patient experience more than initial coaching, suggesting the reactivation of knowledge from initial coaching. However, re-coaching gains also eroded. Coaching should occur every 6 to 12 months to maintain behaviors and scores.

Income-related disparities in Medicare advantage behavioral health care quality

OBJECTIVE

To inform efforts to improve equity in the quality of behavioral health care by examining income-related differences in performance on HEDIS behavioral health measures in Medicare Advantage (MA) plans.

DATA SOURCES AND STUDY SETTING

Reporting Year 2019 MA HEDIS data were obtained and analyzed.

STUDY DESIGN

Logistic regression models were used to estimate differences in performance related to enrollee income, adjusting for sex, age, and race-and-ethnicity. Low-income enrollees were identified by Dual Eligibility for Medicare and Medicaid or receipt of the Low-Income Subsidy (DE/LIS). Models without and with random effects for plans were used to estimate overall and within-plan differences in measure performance. Heterogeneity by race-and-ethnicity in the associations of low-income with behavioral health quality were examined using models with interaction terms.

DATA COLLECTION/EXTRACTION METHODS

Data were included for all MA contracts in the 50 states and the District of Columbia that collect HEDIS data.

PRINCIPAL FINDINGS

For six of the eight measures, enrollees with DE/LIS coverage were more likely to have behavioral health conditions that qualify for HEDIS measures than higher income enrollees. In mixed-effects logistic regression models, DE/LIS coverage was associated with statistically significantly worse overall performance on five measures, with four large (>5 percentage point) differences (-7.5 to -11.1 percentage points) related to follow-up after hospitalization and avoidance of drug-disease interactions. Where the differences were large, they were primarily within-plan rather than between-plan. Interactions between DE/LIS and race-and-ethnicity were statistically significant (p < 0.05) for all measures; income-based quality gaps were larger for White enrollees than for Black or Hispanic enrollees.

CONCLUSIONS

Low income is associated with lower performance on behavioral health HEDIS measures in MA, but these associations differ across racial-and-ethnic groups. Improving care integration and addressing barriers to care for low-income enrollees may improve equity across income levels in behavioral health care.

Patient Experience for Hispanic Older Adults Varies by Language Preference

BACKGROUND

Hispanic people with Medicare report worse patient experiences than non-Hispanic White counterparts. However, little research examines how these disparities may vary by language preference (English/Spanish).

OBJECTIVES

Using Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey data, assess whether 2014-2018 disparities in patient experiences for Hispanic people with Medicare vary by language preference.

RESEARCH DESIGN

We fit a series of linear, case-mix adjusted models predicting Medicare CAHPS measures by race/ethnicity/language preference (Hispanic Spanish-respondents; Hispanic Spanish-preferring English-respondents; Hispanic English-preferring respondents; and non-Hispanic White English-respondents).

SUBJECTS

A total of 1,006,543 Hispanic and non-Hispanic White respondents to the Medicare 2014-2018 CAHPS surveys.

RESULTS

There were disparities for all Hispanic groups relative to non-Hispanic White English-respondents. Hispanic Spanish-preferring English-respondents reported worse experience than Hispanic Spanish-respondents for getting care quickly (-8 points), getting needed care (-5 points), doctor communication (-2 points), and customer service (-1 point), but better experiences for flu immunization (+2 points). Similarly, Hispanic Spanish-preferring English-respondents reported worse experience than Hispanic English-preferring respondents for getting care quickly (-4 points) and getting needed care (-2 points). Hispanic English-preferring respondents reported worse experience than Hispanic Spanish-respondents for getting care quickly (-4 points), getting needed care (-3 points), doctor communication and customer service (-2 points each), but better experience for flu immunization (+2 points).

CONCLUSIONS

Regardless of language preference, Hispanic people with Medicare experience disparities in patient care relative to non-Hispanic White English-preferring counterparts. Hispanic Spanish-preferring English-respondents report the worse experiences, followed by Hispanic English-preferring respondents. Hispanic Spanish-respondents experienced the least disparities of the three Hispanic language subgroups.

Sex-related differences in violence exposure, neural reactivity to threat, and mental health

The prefrontal cortex (PFC), hippocampus, and amygdala play an important role in emotional health. However, adverse life events (e.g., violence exposure) affect the function of these brain regions, which may lead to disorders such as depression and anxiety. Depression and anxiety disproportionately affect women compared to men, and this disparity may reflect sex differences in the neural processes that underlie emotion expression and regulation. The present study investigated sex differences in the relationship between violence exposure and the neural processes that underlie emotion regulation. In the present study, 200 participants completed a Pavlovian fear conditioning procedure in which cued and non-cued threats (i.e., unconditioned stimuli) were presented during functional magnetic resonance imaging. Violence exposure was previously assessed at four separate time points when participants were 11-19 years of age. Significant threat type (cued versus non-cued) × sex and sex × violence exposure interactions were observed. Specifically, women and men differed in amygdala and parahippocampal gyrus reactivity to cued versus non-cued threat. Further, dorsolateral PFC (dlPFC) and inferior parietal lobule (IPL) reactivity to threat varied positively with violence exposure among women, but not men. Similarly, threat-elicited skin conductance responses varied positively with violence exposure among women. Finally, women reported greater depression and anxiety symptoms than men. These findings suggest that sex differences in threat-related brain and psychophysiological activity may have implications for mental health.

Implications of missingness in self-reported data for estimating racial and ethnic disparities in Medicaid quality measures

OBJECTIVE

To assess the feasibility and implications of imputing race and ethnicity for quality and utilization measurement in Medicaid.

DATA SOURCES AND STUDY SETTING

2017 Oregon Medicaid claims from the Oregon Health Authority and electronic health records (EHR) from OCHIN, a clinical data research network, were used.

STUDY DESIGN

We cross-sectionally assessed Hispanic-White, Black-White, and Asian-White disparities in 22 quality and utilization measures, comparing self-reported race and ethnicity to imputed values from the Bayesian Improved Surname Geocoding (BISG) algorithm.

DATA COLLECTION

Race and ethnicity were obtained from self-reported data and imputed using BISG.

PRINCIPAL FINDINGS

42.5%/4.9% of claims/EHR were missing self-reported data; BISG estimates were available for >99% of each and had good concordance (0.87-0.95) with Asian, Black, Hispanic, and White self-report. All estimated racial and ethnic disparities were statistically similar in self-reported and imputed EHR-based measures. However, within claims, BISG estimates and incomplete self-reported data yielded substantially different disparities in almost half of the measures, with BISG-based Black-White disparities generally larger than self-reported race and ethnicity data.

CONCLUSIONS

BISG imputation methods are feasible for Medicaid claims data and reduced missingness to <1%. Disparities may be larger than what is estimated using self-reported data with high rates of missingness.

A Systematic Review of Strategies to Enhance Response Rates and Representativeness of Patient Experience Surveys

BACKGROUND

Data from surveys of patient care experiences are a cornerstone of public reporting and pay-for-performance initiatives. Recently, increasing concerns have been raised about survey response rates and how to promote equity by ensuring that responses represent the perspectives of all patients.

OBJECTIVE

Review evidence on survey administration strategies to improve response rates and representativeness of patient surveys.

RESEARCH DESIGN

Systematic review adhering to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines.

STUDY SELECTION

Forty peer-reviewed randomized experiments of administration protocols for patient experience surveys.

RESULTS

Mail administration with telephone follow-up provides a median response rate benefit of 13% compared with mail-only or telephone-only. While surveys administered only by web typically result in lower response rates than those administered by mail or telephone (median difference in response rate: -21%, range: -44%, 0%), the limited evidence for a sequential web-mail-telephone mode suggests a potential response rate benefit over sequential mail-telephone (median: 4%, range: 2%, 5%). Telephone-only and sequential mixed modes including telephone may yield better representation across patient subgroups by age, insurance type, and race/ethnicity. Monetary incentives are associated with large increases in response rates (median increase: 12%, range: 7%, 20%).

CONCLUSIONS

Sequential mixed-mode administration yields higher patient survey response rates than a single mode. Including telephone in sequential mixed-mode administration improves response among those with historically lower response rates; including web in mixed-mode administration may increase response at lower cost. Other promising strategies to improve response rates include in-person survey administration during hospital discharge, incentives, minimizing survey language complexity, and prenotification before survey administration.

The hospital care experiences of older patients compared to younger patients

BACKGROUND

Hospitals may provide less positive patient experiences for older than younger patients.

METHODS

We used 2019 HCAHPS data from 4358 hospitals to compare patient-mix adjusted HCAHPS Survey scores for 19 experience of care items for patients ages 75+ versus 55-74 years and tested for interactions of age group with patient and hospital characteristics. We contrasted the age patterns observed for inpatient experiences with those among respondents to the 2019 Medicare CAHPS (MCAHPS) Survey of overall experience.

RESULTS

Patients 75+ years (31% of all HCAHPS respondents) reported less-positive experiences than those 55-74 (46% of respondents) for 18 of 19 substantive HCAHPS items (mean difference -3.3% points). Age differences in HCAHPS top-box scores were large (>5 points) for 1 of 3 Nurse Communication items, 1 of 3 Doctor Communication, 2 of 2 Communication about Medication items, 1 of 2 Discharge Information items, and 2 of 3 Care Transition items. In contrast, for MCAHPS, those 75+ reported similar experiences to younger adults. The magnitude of age differences varied considerably across hospitals; some hospitals had very large age disparities for older patients (age 75+ vs. ages 55-74), while others had none. These age differences were generally smaller for patients in government and non-profit than in for-profit hospitals, and in the Pacific region than in other parts of the United States. This variation in age disparities across hospitals may help to identify best practices.

CONCLUSIONS

Patients ages 75+ reported less-positive experiences than patients ages 55-74, especially for measures of communication. These differences may be specific to inpatient care. Further study should investigate the effectiveness of hospital staffs' communication with older patients. Hospital protocols designed for younger patients may need to be adjusted to meet the needs of older patients. There may also be opportunities to learn from outpatient interactions with older patients.

Poor self-rated mental health and Medicare beneficiaries' routine care-seeking

OBJECTIVES

To assess the relationship between self-rated mental health (SRMH) and infrequent routine care among Medicare beneficiaries and to investigate the roles of managed care and having a personal doctor.

STUDY DESIGN

Cross-sectional analysis of data from the 2018 Medicare Consumer Assessment of Healthcare Providers and Systems survey.

METHODS

Logistic regression was used to predict infrequent routine care (having not made an appointment for routine care in the last 6 months) from SRMH, Medicare coverage type (fee-for-service [FFS] vs Medicare Advantage [MA], the managed care version of Medicare), and the interaction of these variables. Models that did and did not include having a personal doctor were compared. All models controlled for demographics and physical health.

RESULTS

Overall, 14.9% of beneficiaries did not make a routine care appointment in the last 6 months, with rates adjusted for demographics and physical health ranging from 14.5% for those with "excellent" SRMH to 19.2% for those with "poor" SRMH. Beneficiaries with poor SRMH were less likely to make a routine care appointment in FFS than in MA (20.1% vs 16.4%, respectively, had not done so in the last 6 months; P < .05). Accounting for having a personal doctor reduced the association between SRMH and infrequent routine care by about a third.

CONCLUSIONS

Extra efforts are needed to ensure receipt of routine care by beneficiaries with poor mental health-particularly in FFS, where more should be done to ensure that beneficiaries have a personal doctor.

Imputation of Race and Ethnicity in Health Insurance Marketplace Enrollment Data, 2015-2022 Open Enrollment Periods

Information on the race and ethnicity of individuals enrolled through the HealthCare.gov Health Insurance Marketplace is critical for assessing past enrollment efforts and determining whether outreach campaigns should be modified or tailored moving forward. However, approximately one-third of insurance applicants do not complete the race and Hispanic ethnicity questions on the Marketplace application. When self-reported race and ethnicity information is missing, other information about an individual can be used to infer race and ethnicity, such as surnames, first names, and addresses, with each characteristic contributing meaningfully to the identification of six mutually exclusive racial and ethnic groups: American Indian (AI)/Alaskan Native (AN); Asian American, Native Hawaiian, and Pacific Islander (AANHPI); Black; Hispanic; Multiracial; and White. Surnames are particularly useful for distinguishing people who identify as Hispanic and AANHPI from other racial and ethnic groups. Geocoded address information is particularly useful in distinguishing Black and White individuals who frequently reside in racially segregated neighborhoods. This article presents the results of imputing race and ethnicity for Marketplace enrollees from 2015 through 2022 using the modified Bayesian Improved First Name Surname and Geocoding (BIFSG) method, developed by the RAND Corporation, which uses surnames, first names, and residential addresses to indirectly estimate race and ethnicity.

Improving HPV Vaccination Rates in a Racially and Ethnically Diverse Pediatric Population

BACKGROUND AND OBJECTIVES

Nationally, 54.2% of youth are fully vaccinated for human papilloma virus (HPV) with persistent gender and racial/ethnic disparities. We used a quality improvement approach to improve completion of the HPV vaccine series by age 13 years. As a secondary aim, we examined racial/ethnic and gender differences in vaccine uptake.

METHODS

The study setting included 2 pediatric, academic, primary care practices in Massachusetts. We designed a multilevel patient-, provider-, and systems-level intervention addressing parental hesitancy, provider communication, and clinical operations. Rates of HPV series completion by age 13 were monitored using a control p chart. Bivariate and multivariate analyses evaluated vaccine completion differences on the basis of clinic size, gender, and race/ethnicity.

RESULTS

Between July 1, 2014, and September 30, 2021, control p charts showed special cause variation with HPV vaccine initiation by age 9 years, increasing from 1% to 52%, and vaccine completion by 13 years, increasing from 37% to 77%. Compared with White and Black children, Hispanic children were more likely to initiate the HPV vaccine at age 9 (adjusted odds ratio [95% confidence interval] = (1.4-2.6)] and complete the series by age 13 (adjusted odds ratio [95% confidence interval] = 2.3 (1.7-3.0).

CONCLUSIONS

A multilevel intervention was associated with sustained HPV vaccine series completion by age 13 years. Hispanic children were more likely to be vaccinated. Qualitative family input was critical to intervention design. Provider communication training addressed vaccine hesitancy. Initiation of the vaccine at age 9 and clinicwide vaccine protocols were key to sustaining improvements.

Rural disparities in the quality of clinical care are notable and larger for males

PURPOSE

To investigate whether rural-urban differences in quality of care for Medicare Advantage (MA) enrollees vary between females and males.

METHODS

Data for this study came from the 2019 Healthcare Effectiveness Data and Information Set. Linear regression was used to investigate urban-rural differences in individual MA enrollee scores on 34 clinical care measures grouped into 7 categories, and how those differences varied by sex (through evaluation of statistical interactions).

FINDINGS

Across all 7 categories of measures, scores for rural residents were worse than scores for urban residents. For 4 categories-care for patients with (suspected) chronic obstructive pulmonary disease, avoiding prescription misuse, behavioral health, and diabetes care-the average difference across measures in the category was greater than 3 percentage points. Across all 34 measures, there were 15 statistically significant rural-by-sex interactions that exceeded 1 percentage point. In 11 of those cases, the deficit associated with living in a rural area was greater for males than for females. In 3 cases, the deficit associated with living in a rural area was larger for females than for males. In 1 case involving Follow-up After Hospitalization for Mental Illness, rural residents had an advantage, and it was larger for males than for females.

CONCLUSIONS

Interventions may help address patient- (eg, health literacy and patient activation), provider- (eg, workforce recruitment and retention), and structural-level issues contributing to these disparities, especially for rural males.

Sex differences in Medicare beneficiaries' experiences by low-income status

OBJECTIVES

Medicare beneficiaries dually eligible for Medicaid are a low-income group who are often in poor health. Little research has examined sex differences in patient experience by dual/low-income subsidy (LIS) status.

STUDY DESIGN

Cross-sectional comparison by sex and low-income status.

METHODS

We used linear regression to compare 6 case mix-adjusted patient experience measures (on a 0-100 scale) by sex within non-dual/LIS and dual/LIS beneficiary groups among 549,603 respondents 65 years and older to the 2016-2017 Medicare Consumer Assessment of Healthcare Providers and Systems surveys of beneficiary experience with Medicare (mail with telephone follow-up of nonrespondents, 42% response rate).

RESULTS

Dual/LIS male beneficiaries reported worse patient experiences on all 6 measures than female beneficiaries, with scores 1 to 2 percentage points lower for 3 measures and less than 1 percentage point lower for the other 3 measures. For 4 of the 6 measures, sex differences among dual/LIS beneficiaries were significantly larger than those among non-dual/LIS beneficiaries. In all 4 instances, the gaps between men and women among dual/LIS beneficiaries favored women; P < .05 for all differences discussed.

CONCLUSIONS

Low-income male Medicare beneficiaries are more likely to report poor patient experiences, possibly because of lower health literacy, less patient activation, and smaller social networks, along with provider responses to these characteristics. Efforts to address these patient-level factors should happen in parallel with structural-level approaches to train and prepare providers to ensure attentive, respectful patient-centered care for all patients. Additionally, targeted use of ombudsmen and interventions may help reduce inequities.

Association of Medicare Advantage Premiums With Measures of Quality and Patient Experience

Importance

Quality of care varies substantially across Medicare Advantage plans. The price information that Medicare Advantage enrollees are most likely to consider when selecting a Medicare Advantage plan is the monthly premium. Enrollees may select plans to minimize premium or, alternatively, use premium as a proxy for quality and select plans with higher premiums; however, quality implications of these choices are unknown.

Objective

To determine the extent to which the quality of care offered by Medicare Advantage plans varies within vs across premium levels.

Design, Setting, and Participants

This was a retrospective cross-sectional study of the population enrolled in Medicare Advantage plans in 2016 to 2017 using clinical quality measures from the Healthcare Effectiveness Data and Information Set (HEDIS), patient experience measures from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys, and administrative data. Data were analyzed from March 2021 to March 2022.

Exposures

Medicare Advantage monthly premium.

Main Outcomes and Measures

Ten publicly reported 2017 HEDIS measures and 5 publicly reported 2017 CAHPS measures linearly transformed to a 0 to 100 scale.

Results

The 168 968 Medicare Advantage CAHPS respondents were representative of the enrollee population (14% were <65 years old and eligible through disability; 24% ≥80 years old; sex and race/ethnicity data were not considered); 40% were in 591 plans with no monthly premiums and less than 6% were in 144 plans with monthly premiums of $120 or more. There were from 77 054 to 2 139 422 enrollees by HEDIS measure. Among all Medicare Advantage enrollees, 79% were in plans with either a $0 premium or a low monthly premium (≤$60); patient experience and clinical quality were generally similar in these 2 categories of plans. To a small extent, enrollees in moderately high ($60-$120) and high (≥$120) premium plans reported better patient experience (+1.4 [95% CI, 0.7-2.1] and 2.2 [95% CI, 1.5-2.9] points) and received better clinical care (1.4 [95% CI, 0.3-2.5] to 3.3 [5% CI, 2.1-4.5] percentage points on most measures than those with $0 and low-premium plans. Quality differences within each premium level category were substantial; the within-premium category plan-level SDs were 6.5 points and 7.2 percentage points for patient experience and clinical quality, respectively. A plan at the 50th percentile of clinical quality and patient experience in the high premium category would fall in the 65th and 62nd percentile within the $0-premium category, respectively.

Conclusions and Relevance

This population-based cross-sectional study found that although quality of care and patient experience were slightly higher with higher-premium plans, quality varied widely within each premium category. High-quality care and patient experience were found in each price category. Thus, paying higher premiums is not necessary for higher quality care in Medicare Advantage plans. Greater engagement of enrollees and advocates with quality of care and patient experience information for Medicare Advantage plan selection is recommended.

Longitudinal associations of parent-child communication, dating behaviors, decision-making processes, and sex initiation among United States Latina/o adolescents

Objective

This study examined differences and identified developmental predictors of oral, vaginal, and anal intercourse initiation across generational status among Latina/o adolescents of both genders. More specifically, we compare generational status and gender differences in the longitudinal predictions from parent-child sex communication and dating behaviors to sex initiation 5 years later, and how these associations may be mediated by perceived peer norms, intentions, and attitudes regarding sex among Latina/o adolescents.

Methods

Using prospective longitudinal data from the Healthy Passages™ project collected in Houston and Los Angeles, Latina/o girls (n = 879) and boys (n = 885) who were identified as 1st- (18%), 2nd- (58%), or 3rd (24%)-immigrant generational status reported on their dating behaviors and parent-child communication about sex at 5th grade (M age = 11.12 years), their perceived peer norms and attitudes regarding sex at 7th grade (M age = 13.11 years), and if they had initiated oral, vaginal, or anal sexual intercourse by 10th grade (M age = 16.06 years).

Results

Third-generation Latina girls were more likely than 1st- and 2nd-generation Latinas to have initiated sexual intercourse by 10th grade. More advanced dating behaviors in 5th grade had a positive association with sex initiation for all generational status groups among Latino boys, but only among 1st-generation Latina girls. Moreover, mediating decision-making processes of peer norms and attitudes differed for each group.

Conclusion

Pre-adolescent dating behaviors are associated with long-term differences in adolescents' sexual behaviors, which may point to targets for prevention efforts. Acculturation differences may contribute to different ways in which adolescents decide to engage in sexual intercourse based on the previous dating experiences.

Predicting Race And Ethnicity To Ensure Equitable Algorithms For Health Care Decision Making

Algorithms are currently used to assist in a wide array of health care decisions. Despite the general utility of these health care algorithms, there is growing recognition that they may lead to unintended racially discriminatory practices, raising concerns about the potential for algorithmic bias. An intuitive precaution against such bias is to remove race and ethnicity information as an input to health care algorithms, mimicking the idea of "race-blind" decisions. However, we argue that this approach is misguided. Knowledge, not ignorance, of race and ethnicity is necessary to combat algorithmic bias. When race and ethnicity are observed, many methodological approaches can be used to enforce equitable algorithmic performance. When race and ethnicity information is unavailable, which is often the case, imputing them can expand opportunities to not only identify and assess algorithmic bias but also combat it in both clinical and nonclinical settings. A valid imputation method, such as Bayesian Improved Surname Geocoding, can be applied to standard data collected by public and private payers and provider entities. We describe two applications in which imputation of race and ethnicity can help mitigate potential algorithmic biases: equitable disease screening algorithms using machine learning and equitable pay-for-performance incentives.

The Contribution of First-name Information to the Accuracy of Racial-and-Ethnic Imputations Varies by Sex and Race-and-Ethnicity Among Medicare Beneficiaries

BACKGROUND

Data on race-and-ethnicity that are needed to measure health equity are often limited or missing. The importance of first name and sex in predicting race-and-ethnicity is not well understood.

OBJECTIVE

The objective of this study was to compare the contribution of first-name information to the accuracy of basic and more complex racial-and-ethnic imputations that incorporate surname information.

RESEARCH DESIGN

We imputed race-and-ethnicity in a sample of Medicare beneficiaries under 2 scenarios: (1) with only sparse predictors (name, address, sex) and (2) with a rich set (adding limited administrative race-and-ethnicity, demographics, and insurance).

SUBJECTS

A total of 284,627 Medicare beneficiaries who completed the 2014 Medicare Consumer Assessment of Healthcare Providers and Systems survey and reported race-and-ethnicity were included.

RESULTS

Hispanic, non-Hispanic Asian/Pacific Islander, and non-Hispanic White racial-and-ethnic imputations are more accurate for males than females under both sparse-predictor and rich-predictor scenarios; adding first-name information increases accuracy more for females than males. In contrast, imputations of non-Hispanic Black race-and-ethnicity are similarly accurate for females and males, and first names increase accuracy equally for each sex in both sparse-predictor and rich-predictor scenarios. For all 4 racial-and-ethnic groups, incorporating first-name information improves prediction accuracy more under the sparse-predictor scenario than under the rich-predictor scenario.

CONCLUSION

First-name information contributes more to the accuracy of racial-and-ethnic imputations in a sparse-predictor scenario than in a rich-predictor scenario and generally narrows sex gaps in accuracy of imputations.

Adjusting for Patient Characteristics to Compare Quality of Care Provided by Serious Illness Programs

Background: To compare serious illness programs (SIPs) using recently developed patient experience measures, adjustment must be made for patient characteristics not under control of the programs. Objectives: To develop a case-mix adjustment model to enable fair comparison of patient experience between SIPs by investigating the roles of patient characteristics, proxy response, and mode of survey administration (mail-only vs. mail with telephone follow-up) in survey responses. Methods: Using survey data from 2263 patients from 32 home-based SIPs across the United States, we fit regression models to assess the association between patient-level variables and scores for seven quality measures (Communication, Care Coordination, Help for Symptoms, Planning for Care, Support for Family and Friends, and two global assessments of care). Characteristics that are not consequences of the care the program delivered were considered as adjustors. Results: Final recommended case-mix adjustors are age, education, primary diagnosis, self-reported functional status, self-rated physical health, self-rated mental health, proxy respondent use, and response percentile (a measure of how soon a person responded compared with others in the same program and mode). Age, primary diagnosis, self-rated mental health, and proxy respondent use had the most impact on program-level scores. We also recommend adjusting for mode of survey administration. We find that up to 12 percent of pairs of programs would have their rankings reversed by adjustment. Conclusions: To ensure fair comparison of programs, scores should be case-mix adjusted for variables that influence patients' reports about care quality, but are not under the control of the program administering care.

Trends in Missing Race and Ethnicity Information After Imputation in HealthCare.gov Marketplace Enrollment Data, 2015-2021

This cross-sectional study examines patterns of missing information on race and ethnicity after an imputation of HealthCare.gov enrollment data between 2015 and 2021.

Reliable and Valid Survey-Based Measures to Assess Quality of Care in Home-Based Serious Illness Programs

Background: There is a pressing need for standardized measures to assess the quality of home-based serious illness care. Currently, there are no validated quality measures that are specific to home-based serious illness programs (SIPs) and the unique needs of their patients. Objective: To develop and evaluate standardized survey-based measures of serious illness care experiences for assessing and comparing quality of home-based serious illness care programs. Methods: From October 2019 through January 2020, we administered a survey to patients who received care from 32 home-based SIPs across the United States. Using the 2263 survey responses, we assessed item performance and constructed composite measures via factor analysis, evaluated item-scale correlations, estimated reliability, and examined validity by regressing overall ratings and willingness to recommend care on each composite. Results: The overall survey response rate was 36%. Confirmatory factor analyses supported five composite quality measures: Communication, Care Coordination, Help for Symptoms, Planning for Care, and Support for Family and Friends. Cronbach's alpha estimates for the composite measures ranged from 0.69 to 0.85, indicating adequate internal consistency in assessing their underlying constructs. Interprogram reliability ranged from 0.67 to 0.80 at 100 completed surveys per measure, meeting common standards for distinguishing between programs' performance. Together, the composites explained 45% of the variance in patients' overall care ratings. Communication, Care Coordination, and Planning for Care were the strongest predictors of overall ratings. Conclusion: Our analyses provide evidence of the feasibility, reliability, and validity of proposed survey-based measures to assess the quality of home-based serious illness care from the perspective of patients and their families.

Measuring Inconsistency in Quality Across Patient Groups to Target Quality Improvement

BACKGROUND

Quality improvement (QI) may be aimed at improving care for all patients, or it may be targeted at only certain patient groups. Health care providers have little guidance when determining when targeted QI may be preferred.

OBJECTIVES

The aim was to develop a method for quantifying performance inconsistency and guidelines for when inconsistency indicates targeted QI, which we apply to the performance of health plans for different patient groups.

RESEARCH DESIGN AND MEASURES

Retrospective analysis of 7 Health Care Effectiveness Data and Information Set (HEDIS) measures of clinical care quality.

SUBJECTS

All Medicare Advantage (MA) beneficiaries eligible for any of 7 HEDIS measures 2015-2018.

RESULTS

MA plans with higher overall performance tended to be less inconsistent in their performance (r=-0.2) across groups defined by race-and-ethnicity and low-income status (ie, dual eligibility for Medicaid or receipt of Low-Income Subsidy). Plan characteristics were usually associated with only small differences in inconsistency. The characteristics associated with differences in consistency [eg, size, Health Maintenance Organization (HMO) status] were also associated with differences in overall performance. We identified 9 (of 363) plans that had large inconsistency in performance across groups (>0.8 SD) and investigated the reasons for inconsistency for 2 example plans.

CONCLUSIONS

This newly developed inconsistency metric may help those designing and evaluating QI efforts to appropriately determine when targeted QI is preferred. It can be used in settings where performance varies across groups, which can be defined by patient characteristics, geographic areas, hospital wards, etc. Effectively targeting QI efforts is essential in today's resource-constrained health care environment.

Disparities In The Quality Of Clinical Care Delivered To American Indian/Alaska Native Medicare Advantage Enrollees

This study used data from the 2019 Healthcare Effectiveness Data and Information Set (HEDIS) to examine differences in the quality of care received by American Indian/Alaska Native beneficiaries versus care received by non-Hispanic White beneficiaries enrolled in Medicare Advantage (managed care) plans. American Indian/Alaska Native beneficiaries were more likely than White beneficiaries to receive care that meets clinical standards for eight of twenty-six HEDIS measures and were less likely than White beneficiaries to receive care that meets clinical standards for five of twenty-six measures. Measures for which American Indian/Alaska Native beneficiaries were less likely to receive care meeting clinical standards were mainly ones pertaining to appropriate treatment of diagnosed conditions. In all cases, differences in care for American Indian/Alaska Native and White beneficiaries were largely within-plan differences. These findings indicate the need for improved clinical care for all beneficiaries. For American Indian/Alaska Native beneficiaries, there is a particular need for improvement in the treatment of diagnosed conditions, including diabetes, chronic obstructive pulmonary disease, and alcohol and other forms of substance abuse.

National travel distances for emergency care

Background

Most emergency department (ED) patients arrive by their own transport and, for various reasons, may not choose the nearest ED. How far patients travel for ED treatment may reflect both patients’ access to care and severity of illness. In this study, we aimed to examine the travel distance and travel time between a patient’s home and ED they visited and investigate how these distances/times vary by patient and hospital characteristics.

Methods

We randomly sampled and collected data from 14,812 patients discharged to the community (DTC) between January and March 2016 from 50 hospital-based EDs nationwide. We geocoded and calculated the distance and travel time between patient and hospital-based ED addresses, examined the travel distances/ times between patients’ home and the ED they visited, and used mixed-effects regression models to investigate how these distances/times vary by patient and hospital characteristics.

Results

Patients travelled an average of 8.0 (SD = 10.9) miles and 17.3 (SD = 18.0) driving minutes to the ED. Patients travelled significantly farther to avoid EDs in lower performing hospitals (p < 0.01) and in the West (p < 0.05) and Midwest (p < 0.05). Patients travelled farther when visiting EDs in rural areas. Younger patients travelled farther than older patients.

Conclusions

Understanding how far patients are willing to travel is indicative of whether patient populations have adequate access to ED services. By showing that patients travel farther to avoid a low-performing hospital, we provide evidence that DTC patients likely do exercise some choice among EDs, indicating some market incentives for higher-quality care, even for some ED admissions. Understanding these issues will help policymakers better define access to ED care and assist in directing quality improvement efforts. To our knowledge, our study is the most comprehensive nationwide characterization of patient travel for ED treatment to date.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07743-7.

Development and validation of a patient experience of care survey for emergency departments

OBJECTIVES

To (1) develop a survey to assess the patient experience of care in hospital-based emergency departments (ED) and (2) evaluate the reliability and validity of composite measures of patient experience using data collected through the experimental implementation of the newly developed Emergency Department Patient Experience of Care (EDPEC) Discharged to Community (DTC) Survey.

DATA SOURCE

4893 adult patients were treated in the ED of 16 hospitals across the United States in 2018.

STUDY DESIGN

The study utilized a cross-sectional survey.

DATA COLLECTION

Survey development activities included a literature review, focus groups, and cognitive interviews with recently discharged ED patients, technical expert panels, and multiple field experiments. Survey development resulted in a 34-item instrument; the analysis reported here focuses on 18 items on patient experience of care. Using data from the EDPEC DTC Survey in the 2018 Feasibility Test, we performed confirmatory factor analysis to group 15 evaluative survey items into composite measures. We examined internal consistency reliability, interunit reliability, and associations between each composite measure and patients' overall rating and willingness to recommend the ED.

PRINCIPAL FINDINGS

Analyses of 15 evaluative items identified four composite measures: Getting Timely Care, How Well Doctors and Nurses Communicate, Communication about Medications, and Communication about Follow-up. Patient-level internal consistency reliability exceeded 0.75 for two of four composites; ED-level internal consistency reliability exceeded 0.83 for all four composites. Interunit reliability estimates indicated that 450 survey completes per ED results in at least 0.70 reliability for all composites. Higher scores on each composite were associated with higher overall ratings and willingness to recommend the ED.

CONCLUSIONS

The composite measures derived from the EDPEC DTC Survey are statistically reliable and valid. These results provide guidance for EDPEC DTC Survey adopters on how to construct meaningful and psychometrically-sound composite measures for monitoring the quality of care they provide.

Community-dwelling adults with functional limitations are at greater risk for sleep disturbances

OBJECTIVE

To evaluate whether sleep disturbances vary along a continuum of functional limitations in a large nationally representative sample of US adults.

METHODS

Using 2014-2015 National Health Interview Survey data (n = 33,424), we considered associations between each of 5 sleep disturbance measures (duration, trouble falling asleep, trouble staying asleep, use of sleep medications, waking rested) and Functional Limitations Index score, which distinguishes among adults with little-or-no (least-limited), moderate (somewhat-limited), and high functional limitations (most-limited).

RESULTS

Somewhat-limited and most-limited respondents reported significantly worse sleep health for all sleep disturbance measures than people with little-or-no limitations, even controlling for body mass index, psychological distress, and 14 health indicators.

CONCLUSIONS

People with significant self-reported limitations in physical functioning, independent of specific disabilities or disabling condition, report more sleep disturbances. Clinicians may want to evaluate the sleep health of patients with functional limitations.

The underlying structure of the English Cancer Patient Experience Survey: Factor analysis to support survey reporting and design

BACKGROUND

The English Cancer Patient Experience Survey (CPES) is a regularly conducted survey measuring the experience of cancer patients. We studied the survey's underlying structure using factor analysis to identify potential for improvements in reporting or questionnaire design.

METHODS

Cancer Patient Experience Survey 2015 respondents (n = 71,186, response rate 66%) were split into two random subgroups. Using exploratory factor analysis (EFA) on the first subgroup, we identified the survey's latent structure. EFA was then applied to 12 sets of items. A first ("core") set was formed by questions that applied to all participants. The subsequent sets contained the "core set" plus questions corresponding to specific care pathways/patient groups. We used confirmatory factor analysis (CFA) on the second data subgroup for cross-validation.

RESULTS

The EFA suggested that five latent factors underlie the survey's core questions. Analysis on the remaining 11 care pathway/patient group items also indicated the same five latent factors, although additional factors were present for questions applicable to patients with an overnight stay or those accessing specialist nursing. The five factors models had an excellent fit (comparative fit index = 0.95, root mean square error of approximation = 0.045 for core set of questions). Items loading on each factor generally corresponded to a specific section or subsection of the questionnaire. CFA findings were concordant with the EFA patterns.

CONCLUSION

The findings suggest five coherent underlying sub-constructs relating to different aspects of cancer health care. The findings support the construction of evidence-based composite indicators for different domains of experience and provide options for survey re-design.

Disparities in Care Experienced by Older Hispanic Medicare Beneficiaries in Urban and Rural Areas

BACKGROUND

Hispanic older adults face substantial health disparities compared with non-Hispanic-White (hereafter "White") older adults. To the extent that these disparities stem from cultural and language barriers faced by Hispanic people, they may be compounded by residence in rural areas.

OBJECTIVE

The objective of this study was to investigate possible interactions between Hispanic ethnicity and rural residence in predicting the health care experiences of older adults in the United States, and whether disparities in care for rural Hispanic older adults differ in Medicare Advantage versus Medicare Fee-for-Service.

SUBJECTS

Medicare beneficiaries age 65 years and older who responded to the 2017-2018 nationally representative Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys.

METHODS

We fit a series of linear, case-mix-adjusted models predicting Medicare CAHPS measures of patient experience (rescaled to a 0-100 scale) from ethnicity, place of residence, and Medicare coverage type.

RESULTS

In all residential areas, Hispanic beneficiaries reported worse experiences with getting needed care (-3 points), getting care quickly (-4 points), and care coordination (-1 point) than White beneficiaries (all P's<0.001). In rural areas only, Hispanic beneficiaries reported significantly worse experiences than White beneficiaries on doctor communication and customer services (-3 and -9 points, respectively, P<0.05). Tests of a 3-way interaction between ethnicity, rural residence, and coverage type were nonsignificant.

CONCLUSIONS

There is a need to improve access to care and care coordination for Hispanic beneficiaries overall and doctor-patient communication and customer service for rural Hispanic beneficiaries. Strategies for addressing deficits faced by rural Hispanics may involve cultural competency training and provision of language-appropriate services for beneficiaries (perhaps as telehealth services).

Racial/Ethnic Differences in Emergency Department Utilization and Experience

BACKGROUND

Previous work has demonstrated racial/ethnic differences in emergency department (ED) utilization, but less is known about racial/ethnic differences in the experience of care received during an ED visit.

OBJECTIVE

To examine differences in self-reported healthcare utilization and experiences with ED care by patients' race/ethnicity.

DESIGN

Adult ED patients discharged to community (DTC) were surveyed (response rate: 20.25%) using the Emergency Department Patient Experience of Care (EDPEC) DTC Survey. Linear regression was used to estimate case-mix-adjusted differences in patient experience between racial/ethnic groups.

PARTICIPANTS

3122 survey respondents who were discharged from the EDs of 50 hospitals nationwide January-March 2016.

MAIN MEASURES

Six measures: getting timely care, doctor and nurse communication, communication about medications, receipt of sufficient information about test results, whether hospital staff discussed the patient's ability to receive follow-up care, and willingness to recommend the ED.

KEY RESULTS

Black and Hispanic patients were significantly more likely than White patients to report visiting the ED for an ongoing health condition (40% Black, 30% Hispanic, 28% White, p<0.001), report having visited an ED 3+ times in the last 6 months (26% Black, 25% Hispanic, 19% White, p<0.001), and report not having a usual source of care (19% Black, 19% Hispanic, 8% White, p<0.001). Compared with White patients, Hispanic patients more often reported that hospital staff talked with them about their ability to receive needed follow-up care (+7.2 percentile points, p=0.038) and recommended the ED (+7.2 points, p=0.037); Hispanic and Black patients reported better doctor and nurse communication (+6.4 points, p=0.008; +4 points, p=0.036, respectively).

CONCLUSIONS

Hispanic and Black ED patients reported higher ED utilization, lacked a usual source of care, and reported better experience with ED care than White patients. Results may reflect differences in care delivery by staff and/or different expectations of ED care among Hispanic and Black patients.

Sexual Minority Adults in England Have Greater Odds of Chronic Mental Health Problems: Variation by Sexual Orientation, Age, Ethnicity, and Socioeconomic Status

Purpose: Sexual minority adults report worse mental health than heterosexual peers, although few empirical studies are large enough to measure variation in these disparities by sexual orientation, age, ethnicity, and socioeconomic status (SES). We investigate chronic mental health problems among sexual minority adults. Methods: Sex-disaggregated logistic regressions examined associations between self-reported chronic mental health problems and sexual orientation, age, ethnicity, and SES in a 2015-2017 dataset from the nationally representative English General Practice Patient Survey data (n = 1,341,339). Results: Bisexual adults, especially young bisexual females, reported the highest rates of chronic mental health problems. Sexual minority females 18-24 years of age had five times the odds of reporting chronic mental health problems of their heterosexual peers, with 32% of sexual minority females 18-24 years of age reporting the outcome. Sexual minority identity was also strongly associated with chronic mental health problems for adults who were White and lived in more affluent areas. Conclusion: The very high odds of chronic mental health problems among bisexual adults, especially younger bisexual females, may reflect simultaneous isolation from sexual minority and heterosexual communities. Elevated odds at younger ages may reflect disproportionate social media use and bullying. It is plausible that those who are subject to minority stress associated with SES and ethnicity may develop resilience strategies that they then apply to sexual minority stress. The results suggest that sexual minority identity is a source of minority stress, even for those who are affluent. Clinicians should be alert to the need to support the specific mental health concerns of their sexual minority patients.