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.

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.

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.

How responding in Spanish affects CAHPS results

BACKGROUND

The most widely used surveys for assessing patient health care experiences in the U.S. are the Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys. Studies examining the associations of language and ethnicity with responses to CAHPS surveys have yielded inconsistent findings. More research is needed to assess the effect of responding to CAHPS surveys in Spanish.

METHODS

Subjects were patients who had received care at a study community health center in Connecticut within 6 or 12 months of being sent a CAHPS survey that asks about care experiences. The survey included four multi-item measures of care plus an overall rating of the provider. Sampled patients were mailed dual language (English and Spanish) cover letters and questionnaires. Those who did not respond after follow-up mailings were contacted by bilingual interviewers to complete the survey by telephone. We tested three hypotheses for any observed differences by ethnicity and language: 1. Spanish speakers are more likely than others to choose extreme response options. 2. The semantic meaning of the Spanish translation is not the same as the English version of the questions, resulting in Spanish speakers giving different answers because of meaning differences. 3. Spanish speakers have different expectations regarding their health care than those who answer in English. Analyses compared the answers on the survey measures for three groups: non-Hispanics answering in English, Hispanics answering in English, and Hispanics answering in Spanish.

RESULTS

The overall response rate was 45%. After adjusting for differences in demographic characteristics and self-rated health, those answering in Spanish gave significantly more positive reports than the other two groups on three of the five measures, and higher than the non-Hispanic respondents on a fourth.

CONCLUSIONS

Those answering in Spanish gave more positive reports of their medical experiences than Hispanics and non-Hispanics answering in English. Whether these results reflect different response tendencies, different standards for care, or better care experiences is a key issue in whether CAHPS responses in Spanish need adjustment to make them comparable to responses in English.

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.

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.

Summary of the 2020 AHRQ research meeting on 'advancing methods of implementing and evaluating patient experience improvement using consumer assessment of healthcare providers and systems (CAHPS®) surveys'

BACKGROUND

The Agency for Healthcare Research and Quality held a research meeting on using Consumer Assessment of Healthcare Providers and Systems (CAHPS®) data for quality improvement (QI) and evaluating such efforts.

TOPICS COVERED.

Meeting addressed: 1)What has been learned about organizational factors/environment needed to improve patient experience? 2)How have organizations used data to improve patient experience? 3)What can evaluations using CAHPS data teach us about implementing successful programs to improve patient experience?

KEY THEMES

Providers and stakeholders need to be engaged early and often, standardize QI processes, complement CAHPS data with other data, and compile dashboards of CAHPS scores to identify and track improvement. Rigorous study designs are valuable, but much can be learned and accomplished through practical organization-level studies.

Is Patient-Physician Gender Concordance Related to the Quality of Patient Care Experiences?

BACKGROUND

There is great interest in identifying factors that are related to positive patient experiences such as physician communication style. Documented gender-specific physician communication and patient behavior differences raise the question of whether gender concordant relationships (i.e., both the provider and patient share the same gender) might affect patient experiences.

OBJECTIVE

Assess whether patient experiences are more positive in gender concordant primary care relationships.

DESIGN

Statewide telephone surveys. Linear mixed regression models to estimate the association of CAHPS scores with patient gender and gender concordance.

SUBJECTS

Two probability samples of primary care Medicaid patients in Connecticut in 2017 (5/17-7/17) and 2019 (7/19-10/19).

MAIN MEASURES

Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) survey augmented with questions about aspects of care most salient to PCMH-designated organizations and two questions to assess access to mental health services.

KEY RESULTS

There were no significant effects of gender concordance and differences in experiences by patient gender were modest.

CONCLUSIONS

This study did not support the suggestion that patient and physician gender and gender concordance have an important effect on patient experiences.

Comparing Web and Mail Protocols for Administering Hospital Consumer Assessment of Healthcare Providers and Systems Surveys

OBJECTIVE

The objective of this study was to compare results of using web-based and mail (postal) Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) data collection protocols.

RESEARCH DESIGN

Patients who had been hospitalized in a New England Hospital were surveyed about their hospital experience. Patients who provided email addresses were randomized to 1 of 3 data collection protocols: web-alone, web with postal mail follow-up, and postal mail only. Those who did not provide email addresses were surveyed using postal mail only. Analyses compared response rates, respondent characteristics, and patient-reported experiences.

SUBJECTS

For an 8-week period, patients were discharged from the study hospital to home.

MEASURES

Measures included response rates, characteristics of respondents, 6 composite measures of their patient experiences, and 2 ratings of the hospital.

RESULTS

Response rates were significantly lower for the web-only protocol than the mail or combined protocols, and those who had not provided email addresses had lower response rates. Those over 65 were more likely than others to respond to all protocols, especially for the mail-only protocols. Respondents without email addresses were older, less educated, and reported worse health than those who provided email addresses. After adjusting for respondent differences, those in the combined protocol differed significantly from the mail (postal) only respondents on 2 measures of patient experience; those in the web-only protocol differed on one. Those not providing an email address differed from those who did on one measure.

CONCLUSION

If web-based protocols are used for HCAHPS surveys, adjustments for a mode of data collection are needed to make results comparable.

The development and evaluation of an HIV implementation science network in New England: lessons learned

BACKGROUND

Describe and evaluate an implementation science network focused on HIV prevention and treatment in New England.

METHODS

In 2014, we established a partnership among university researchers and community stakeholders to stimulate and support HIV-related implementation research. We solicited information from Network members through surveys, interviews at Network events, and dialog with participants. In 2017, we conducted a sociocentric network assessment of collaborations on research projects, grants, manuscripts, and consultations.

RESULTS

We identified 988 connections made through the Network that resulted in 185 manuscripts published and 15 grants funded. Our experience indicated that eight factors were instrumental in building and sustaining the Network: (1) acknowledging different perspectives, (2) balancing content and expertise, (3) encouraging consistent engagement, (4) providing seed funding, (5) membership flexibility, (6) maintenance of Network interactions, (7) supporting local HIV prevention and treatment efforts, and (8) maintaining productive relationships with health departments and community-based organizations.

CONCLUSIONS

Developing and maintaining a regional network on implementation science for HIV prevention and treatment is feasible and can facilitate new and productive partnerships among researchers and community organizations and members.

A quasi-experiment assessing the six-months effects of a nurse care coordination program on patient care experiences and clinician teamwork in community health centers

Background

Recognition that coordination among healthcare providers is associated with better quality of care and lower costs has increased interest in interventions designed to improve care coordination. One intervention is to add care coordination to nurses’ role in a formal way. Little is known about effects of this approach, which tends to be pursued by small organizations and those in lower-resource settings. We assessed effects of this approach on care experiences of high-risk patients (those most in need of care coordination) and clinician teamwork during the first 6 months of use.

Methods

We conducted a quasi-experimental study using a clustered, controlled pre-post design. Changes in staff and patient experiences at six community health center practice locations that introduced the added-role approach for high-risk patients were compared to changes in six locations without the program in the same health system. In the pre-period (6 months before intervention training) and post-period (about 6 months after intervention launch, following 3 months of training), we surveyed clinical staff (N = 171) and program-qualifying patients (3007 pre-period; 2101 post-period, including 113 who were enrolled during the program’s first 6 months). Difference-in-differences models examined study outcomes: patient reports about care experiences and clinician-reported teamwork. We assessed frequency of patient office visits to validate access and implementation, and contextual factors (training, resources, and compatibility with other work) that might explain results.

Results

Patient care experiences across all high-risk patients did not improve significantly (p > 0.05). They improved somewhat for program enrollees, 5% above baseline reports (p = 0.07). Staff-perceived teamwork did not change significantly (p = 0.12). Office visits increased significantly for enrolled patients (p < 0.001), affirming program implementation (greater accessing of care). Contextual factors were not reported as problematic, except that 41% of nurses reported incompatibility between care coordination and other job demands. Over 75% of nurses reported adequate training and resources.

Conclusions

There were some positive effects of adding care coordination to nurses’ role within 6 months of implementation, suggesting value in this improvement strategy. Addressing compatibility between coordination and other job demands is important when implementing this approach to coordination.

The effects of survey version on patient experience scores and plan rankings

OBJECTIVE

To assess the effect of changing survey questions on plan-level patient experience measures and ratings.

DATA SOURCE

2015 Medicare Advantage CAHPS Survey respondents.

STUDY DESIGN

Ninety three randomly selected beneficiaries in each of 40 MA plans received a revised (5.0) CAHPS survey; 38 832 beneficiaries received version 4.0. Linear mixed-effect regression predicted CAHPS measures from fixed effects for survey version and beneficiary characteristics and random effects for plan and plan-by-version random slope.

PRINCIPAL FINDINGS

Response rates were 42 percent for both versions. Removal of "try to" from screeners increased the percentage of respondents eligible for follow-up questions. Version 5.0 caused a small increase (1-3 points on a 0-100 scale, P < 0.05) in the mean of three altered measures and a moderate increase (>3 points) in one. There was a small statistically significant increase in two unaltered measures. These changes were uniform across plans, so there would be no expected change compared to results using the legacy survey in the score distributions other than uniform mean shifts, and no expected effect on summary measures.

CONCLUSIONS

These analyses illustrate how to assess the impact of seemingly minor survey modifications for other national surveys considering changes and highlight the importance of screeners in instrument design.

The effect of different sampling and recall periods in the CAHPS Clinician & Group (CG-CAHPS) survey

OBJECTIVE

To examine the effect of changing the sampling and reference periods for the CAHPS^® Clinician & Group Survey from 12 to 6 months.

DATA SOURCES/STUDY SETTING

Adult patients with a visit in the last 12 months to New England community health centers.

STUDY DESIGN

We randomly assigned patients to receive a survey with either a 12- or 6-month recall period.

DATA COLLECTION/EXTRACTION METHODS

Questionnaires were mailed to patients, with a second questionnaire mailed to nonrespondents, followed by six attempts to complete a telephone interview.

PRINCIPAL FINDINGS

If the sampling criterion was a visit in the last 6 months, 9 percent of those with a visit in the last 12 months would not have been surveyed. A total of 1837 patients completed 6-month surveys (44.9 percent response rate); 588 completed 12-month surveys (46.0 percent response rate). Shortening the reference from 12 to 6 months reduced the proportion of respondents reporting a blood test, X-ray, or other tests. Adjusting for respondent characteristics, the most positive response was selected more often on the 6-month survey for 12 out of 13 questions, and three of these differences were statistically significant (P < 0.05).

CONCLUSIONS

Surveys using a 6-month recall period may yield slightly higher scores than surveys with a 12-month recall period.

The effect of administration mode on CAHPS survey response rates and results: A comparison of mail and web-based approaches

OBJECTIVE

The objective of this study was to compare response rates, respondents' characteristics, and substantive results for CAHPS surveys administered using web and mail protocols.

DATA SOURCES

Patients who had one or more primary care visits in the preceding 6 months.

STUDY DESIGN/DATA COLLECTION METHODS

Patients for whom primary care practices had email addresses were randomized to one of four survey administration protocols: web via a portal invitation; web via an email invitation; combination of web and mail; and mail only. Another sample of patients without known email addresses was surveyed by mail. Samples of nonrespondents to the Internet and mail protocols were surveyed by telephone.

PRINCIPAL FINDINGS

Response rates to surveys administered using the Internet protocols were lower than for the surveys administered by mail (20 percent vs over 40 percent). However, characteristics of respondents and survey answers were very similar across protocols. Respondents without email addresses were older, less educated, and more likely to be male than those with email addresses, and there were a few differences in their responses. There was little evidence of nonresponse bias in either the mail or web protocols.

CONCLUSION

In this well-educated patient population, web protocols had lower response rates, but substantive results very similar to those from mail protocols.

Hospital quality indicators are not unidimensional: A reanalysis of Lieberthal and Comer

OBJECTIVE

To evaluate the dimensionality of hospital quality indicators treated as unidimensional in a prior publication.

DATA SOURCE/STUDY DESIGN

Pooled cross-sectional 2010-2011 Hospital Compare data (10/1/10 and 10/1/11 archives) and the 2012 American Hospital Association Annual Survey.

DATA EXTRACTION

We used 71 indicators of structure, process, and outcomes of hospital care in a principal component analysis of Ridit scores to evaluate the dimensionality of the indicators. We conducted an exploratory factor analysis using only the indicators in the Centers for Medicare & Medicaid Services' Hospital Value-Based Purchasing.

PRINCIPAL FINDINGS

There were four underlying dimensions of hospital quality: patient experience, mortality, and two clinical process dimensions.

CONCLUSIONS

Hospital quality should be measured using a variety of indicators reflecting different dimensions of quality. Treating hospital quality as unidimensional leads to erroneous conclusions about the performance of different hospitals.

Understanding the determinants of public trust in the health care system in China: an analysis of a cross-sectional survey

OBJECTIVES

Despite increasing research attention on public trust in health care systems, empirical evidence on this topic in the developing world is limited and inconclusive. This paper examines the level and determinants of public trust in the health care system in China.

METHODS

We used data from a survey conducted with a sample of 5347 adults in all Chinese provincial areas between January and February 2016. Trust in the health care system was assessed with a question used by the 2011-2013 International Social Survey Programme (ISSP) to assess public trust in the health care systems of 29 industrialized countries and regions ('In general, how much confidence do you have in the health care system in your country?').

RESULTS

Only 28% of respondents reported that they had a great deal or complete trust in China's health care system. Respondents who reported to have more trust in other people in society, more trust in the local government and who were more satisfied with their most recent health care system experience and their health insurance were significantly more likely to trust the country's health care system. Furthermore, respondents who reported a higher level of happiness, better health status and positive attitudes towards social equity were more likely to trust the health care system in China.

CONCLUSIONS

Our findings suggest that low public trust in China's health care system is a potential problem. Improving health care experiences may be the most practical and effective way of improving trust in the health care system in China.

An Adaptive Approach to Locating Mobile HIV Testing Services

BACKGROUND

Public health agencies suggest targeting "hotspots" to identify individuals with undetected HIV infection. However, definitions of hotspots vary. Little is known about how best to target mobile HIV testing resources.

METHODS

We conducted a computer-based tournament to compare the yield of 4 algorithms for mobile HIV testing. Over 180 rounds of play, the algorithms selected 1 of 3 hypothetical zones, each with unknown prevalence of undiagnosed HIV, in which to conduct a fixed number of HIV tests. The algorithms were: 1) Thompson Sampling, an adaptive Bayesian search strategy; 2) Explore-then-Exploit, a strategy that initially draws comparable samples from all zones and then devotes all remaining rounds of play to HIV testing in whichever zone produced the highest observed yield; 3) Retrospection, a strategy using only base prevalence information; and; 4) Clairvoyance, a benchmarking strategy that employs perfect information about HIV prevalence in each zone.

RESULTS

Over 250 tournament runs, Thompson Sampling outperformed Explore-then-Exploit 66% of the time, identifying 15% more cases. Thompson Sampling's superiority persisted in a variety of circumstances examined in the sensitivity analysis. Case detection rates using Thompson Sampling were, on average, within 90% of the benchmark established by Clairvoyance. Retrospection was consistently the poorest performer.

LIMITATIONS

We did not consider either selection bias (i.e., the correlation between infection status and the decision to obtain an HIV test) or the costs of relocation to another zone from one round of play to the next.

CONCLUSIONS

Adaptive methods like Thompson Sampling for mobile HIV testing are practical and effective, and may have advantages over other commonly used strategies.

Association of State Access Standards With Accessibility to Specialists for Medicaid Managed Care Enrollees

Importance

Medicaid recipients have consistently reported less timely access to specialists than patients with other types of coverage. By 2018, state Medicaid agencies will be required by the Center for Medicare and Medicaid Services (CMS) to enact time and distance standards for managed care organizations to ensure an adequate supply of specialist physicians for enrollees; however, there have been no published studies of whether these policies have significant effects on access to specialty care.

Objective

To compare ratings of access to specialists for adult Medicaid and commercial enrollees before and after the implementation of specialty access standards.

Design, Setting, and Participants

We used Consumer Assessment of Healthcare Providers and Systems survey data to conduct a quasiexperimental difference-in-differences (DID) analysis of 20 163 nonelderly adult Medicaid managed care (MMC) enrollees and 54 465 commercially insured enrollees in 5 states adopting access standards, and 37 290 MMC enrollees in 5 matched states that previously adopted access standards.

Main Outcomes and Measures

Reported access to specialty care in the previous 6 months.

Results

Seven thousand six hundred ninety-eight (69%) Medicaid enrollees and 28 423 (75%) commercial enrollees reported that it was always or usually easy to get an appointment with a specialist before the policy implementation (or at baseline) compared with 11 889 (67%) of Medicaid enrollees in states that had previously implemented access standards. Overall, there was no significant improvement in timely access to specialty services for MMC enrollees in the period following implementation of standard(s) (adjusted difference-in-differences, -1.2 percentage points; 95% CI, -2.7 to 0.1), nor was there any impact of access standards on insurance-based disparities in access (0.6 percentage points; 95% CI, -4.3 to 5.4). There was heterogeneity across states, with 1 state that implemented both time and distance standards demonstrating significant improvements in access and reductions in disparities.

Conclusions and Relevance

Specialty access standards did not lead to widespread improvements in access to specialist physicians. Meaningful improvements in access to specialty care for Medicaid recipients may require additional interventions.

Chronic Obstructive Pulmonary Disease Readmissions and Other Measures of Hospital Quality

RATIONALE

The Centers for Medicare and Medicaid Services recently implemented financial penalties to reduce hospital readmissions for select conditions, including chronic obstructive pulmonary disease (COPD). Despite growing pressure to reduce COPD readmissions, it is unclear how COPD readmission rates are related to other measures of quality, which could inform efforts on common organizational factors that affect high-quality care.

OBJECTIVES

To examine the association between COPD readmissions and other quality measures.

METHODS

We analyzed data from the 2015 Centers for Medicare and Medicaid Services annual files, downloaded from the Hospital Compare website. We included 3,705 hospitals nationwide that had publically reported data on COPD readmissions. We compared COPD readmission rates to other risk-adjusted measures of quality, including readmission and mortality rates for other conditions, and patient reports about care experiences.

MEASUREMENTS AND MAIN RESULTS

There were modest correlations between COPD readmission rates and readmission rates for other medical conditions, including heart failure (r = 0.39; P < 0.01), acute myocardial infarction (r = 0.30; P < 0.01), pneumonia (r = 0.38; P < 0.01), and stroke (r = 0.29; P < 0.01). In contrast, we found low correlations between COPD readmission rates and readmission rates for surgical conditions, as well as mortality rates for all measured conditions. There were significant correlations between COPD readmission rates and all patient experience measures.

CONCLUSIONS

These findings suggest there may be common organizational factors that influence multiple disease-specific outcomes. As pay-for-performance programs focus attention on individual disease outcomes, hospitals may benefit from in-depth assessments of organizational factors that affect multiple aspects of hospital quality.

Medicare Prescription Drug Plan Enrollees Report Less Positive Experiences Than Their Medicare Advantage Counterparts

Since 2006, Medicare beneficiaries have been able to obtain prescription drug coverage through standalone prescription drug plans or their Medicare Advantage (MA) health plan, options exercised in 2015 by 72 percent of beneficiaries. Using data from community-dwelling Medicare beneficiaries older than age sixty-four in 700 plans surveyed from 2007 to 2014, we compared beneficiaries' assessments of Medicare prescription drug coverage when provided by standalone plans or integrated into an MA plan. Beneficiaries in standalone plans consistently reported less positive experiences with prescription drug plans (ease of getting medications, getting coverage information, and getting cost information) than their MA counterparts. Because MA plans are responsible for overall health care costs, they might have more integrated systems and greater incentives than standalone prescription drug plans to provide enrollees medications and information effectively, including, since 2010, quality bonus payments to these MA plans under provisions of the Affordable Care Act.

House staff communication training and patient experience scores

Objective:

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

Methods:

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

Results:

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

Conclusion:

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

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

OBJECTIVE

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

DATA SOURCE

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

STUDY DESIGN

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

PRINCIPAL FINDINGS

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

CONCLUSIONS

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

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

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

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

OBJECTIVE

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

DATA SOURCE

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

STUDY DESIGN

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

DATA EXTRACTION METHODS

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

PRINCIPAL FINDINGS

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

CONCLUSIONS

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

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

OBJECTIVE

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

DATA

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

STUDY DESIGN

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

DATA COLLECTION METHODS

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

PRINCIPAL FINDINGS

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

CONCLUSIONS

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

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

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

Clinician advice to quit smoking among seniors

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

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

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

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

BACKGROUND

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

STUDY DESIGN

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

SETTING & PARTICIPANTS

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

MEASUREMENTS & OUTCOMES

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

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

BACKGROUND

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

OBJECTIVES

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

RESEARCH DESIGN

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE

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

STUDY DESIGN

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

PRINCIPAL FINDINGS

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

CONCLUSIONS

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

Expanding the use of patient reports about patient-centered care

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

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

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

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

OBJECTIVES

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

DESIGN

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

SETTING

Nationally representative sample of MA enrollees.

PARTICIPANTS

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

MEASUREMENTS

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

RESULTS

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

CONCLUSION

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

Why pharmacists belong in the medical home

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

Safety climate and medical errors in 62 US emergency departments

STUDY OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Development of and field test results for the CAHPS PCMH Survey

OBJECTIVE

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

RESEARCH DESIGN

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

ANALYSES

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

RESULTS

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

CONCLUSIONS

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

Multilevel interventions: study design and analysis issues

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

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

Background

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

Methods

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

Results

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

Conclusions

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

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

BACKGROUND

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

OBJECTIVES

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

RESEARCH DESIGN

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

SUBJECTS

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

MEASURES

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE

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

DATA SOURCES

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

STUDY DESIGN

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

PRINCIPAL FINDINGS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Hospital survey shows improvements in patient experience

Hospitals are improving the inpatient care experience. A government survey that measures patients' experiences with a range of issues from staff responsiveness to hospital cleanliness-the Hospital Consumer Assessment of Healthcare Providers and Systems survey-is showing modest but meaningful gains. Using data from the surveys reported in March 2008 and March 2009, we present the first comprehensive national assessment of changes in patients' experiences with inpatient care since public reporting of the results began. We found improvements in all measures of patient experience, except doctors' communication. These improvements were fairly uniform across hospitals. The largest increases were in measures related to staff responsiveness and the discharge information that patients received.