Beverly A. Weidmer

Translating the Cahps™ 1.0 Survey Instruments Into Spanish

OBJECTIVES Collecting accurate health data on the growing number of ethnic minorities in the United States has increased in policy relevance in recent years. Today, most general population sample surveys conducted in the United States, including the CAHPS 1.0 Surveys, require translation into Spanish and often other languages as well. This article discusses the process used to translate the CAHPS 1.0 survey instruments into Spanish and the techniques used to evaluate these instruments. METHODS The CAHPS team used a technique of translation-backtranslation to translate the survey instruments into Spanish and conducted cognitive testing and pretesting of preliminary versions of the 1.0 Survey Instruments in both English and Spanish. RESULTS The translation-backtranslation method produced Spanish-language versions of the survey instruments that were adequate for more educated respondents but were inadequate for less educated respondents and respondents who seemed to be less acculturated. CONCLUSION Adept translation of a survey instrument is an integral part of the instrument-development process, but it alone does not ensure that a culturally appropriate survey instrument will result. Producing a survey instrument that is culturally appropriate for Latinos in the United States may require modifying the English versions of instruments as well as subjecting Spanish-language instruments to more rigorous testing that includes cognitive testing, pretesting, and an evaluation of the reading level by a literacy expert.

Measuring the incremental cost of clinical cancer research.

PURPOSE To summarize evidence on the costs of treating patients in clinical trials and to describe the Cost of Cancer Treatment Study, an ongoing effort to produce generalizable estimates of the incremental costs of government-sponsored cancer trials. METHODS A retrospective study of costs will be conducted with 1,500 cancer patients recruited from a randomly selected sample of institutions in the United States. Patients accrued to either phase II or phase III National Cancer Institute-sponsored clinical trials during a 15-month period will be asked to participate in a study of their health care utilization (n = 750). Costs will be measured approximately 1 year after their trial enrollment from a combination of billing records, medical records, and an in-person survey questionnaire. Similar data will be collected for a comparable group of cancer patients not in trials (n = 750) to provide an estimate of the incremental cost. RESULTS Evidence suggests insurers limit access to trials because of cost concerns. Public and private efforts are underway to change these policies, but their permanent status is unclear. Previous studies found that treatment costs in clinical trials are similar to costs of standard therapy. However, it is difficult to generalize from these studies because of the unique practice settings, insufficient sample sizes, and the exclusion of potentially important costs. CONCLUSION Denials of coverage for treatment in a clinical trial limit patient access to trials and could impede clinical research. Preliminary estimates suggest changes to these policies would not be expensive, but these results are not generalizable. The Cost of Cancer Treatment Study is an ongoing effort to provide generalizable estimates of the incremental treatment cost of phase II and phase III cancer trials. The results should be of great interest to insurers and the research community as they consider permanent ways to finance cancer trials.

The Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Cultural Competence (CC) Item Set

Background:There is a need for reliable and valid measures of cultural competence (CC) from the patient’s perspective. Objective:This paper evaluates the reliability and validity of the Consumer Assessments of Healthcare Providers and Systems (CAHPS) CC item set. Research Design:Using 2008 survey data, we assessed the internal consistency of the CAHPS CC scales using the Cronbach &agr;’s and examined the validity of the measures using exploratory and confirmatory factor analysis, multitrait scaling analysis, and regression analysis. Subjects:A random stratified sample (based on race/ethnicity and language) of 991 enrollees, younger than 65 years, from 2 Medicaid managed care plans in California and New York. Measures:CAHPS CC item set after excluding screener items and ratings. Results:Confirmatory factor analysis (Comparative Fit Index=0.98, Tucker Lewis Index=0.98, and Root Mean Square Error or Approximation=0.06) provided support for a 7-factor structure: Doctor Communication—Positive Behaviors, Doctor Communication—Negative Behaviors, Doctor Communication—Health Promotion, Doctor Communication—Alternative Medicine, Shared Decision-Making, Equitable Treatment, and Trust. Item-total correlations (corrected for item overlap) for the 7 scales exceeded 0.40. Exploratory factor analysis showed support for 1 additional factor: Access to Interpreter Services. Internal consistency reliability estimates ranged from 0.58 (Alternative Medicine) to 0.92 (Positive Behaviors) and was 0.70 or higher for 4 of the 8 composites. All composites were positively and significantly associated with the overall doctor rating. Conclusions:The CAHPS CC 26-item set demonstrates adequate measurement properties and can be used as a supplemental item set to the CAHPS Clinician and Group Surveys in assessing culturally competent care from the patient’s perspective.

Psychometric Properties of the Spanish Consumer Assessment of Health Plans Survey (CAHPS)

This study describes the psychometric properties of the Consumer Assessments of Health Plans Survey (CAHPS) in 279 persons who completed it in Spanish and 439 persons who completed it in English. We found negatively skewed distributions of responses and significant ceiling effects in both English and Spanish surveys. Cronbach’s alphas for English and Spanish multiple-item composites were 0.69 or higher. Correlations between the CAHPS measures and willingness of individuals to recommend their doctor and health plan to family and friends were all moderately strong and statistically significant except for one global rating. There were significant differences in the patterns of correlations between global ratings and composites for English and Spanish surveys. This study suggests that the Spanish CAHPS 2.0 core survey has acceptable psychometric properties.

Development and Evaluation of CAHPS® Survey Items Assessing How Well Healthcare Providers Address Health Literacy

Background:The complexity of health information often exceeds patients’ skills to understand and use it. Objective:To develop survey items assessing how well healthcare providers communicate health information. Methods:Domains and items for the Consumer Assessment of Healthcare Providers and Systems (CAHPS)® Item Set for Addressing Health Literacy were identified through an environmental scan and input from stakeholders. The draft item set was translated into Spanish and pretested in both English and Spanish. The revised item set was field tested with a randomly selected sample of adult patients from 2 sites using mail and telephonic data collection. Item-scale correlations, confirmatory factor analysis, and internal consistency reliability estimates were estimated to assess how well the survey items performed and identify composite measures. Finally, we regressed the CAHPS global rating of the provider item on the CAHPS core communication composite and the new health literacy composites. Results:A total of 601 completed surveys were obtained (52% response rate). Two composite measures were identified: (1) Communication to Improve Health Literacy (16 items); and (2) How Well Providers Communicate About Medicines (6 items). These 2 composites were significantly uniquely associated with the global rating of the provider (communication to improve health literacy: P<0.001, b=0.28; and communication about medicines composite: P=0.02, b=0.04). The 2 composites and the CAHPS core communication composite accounted for 51% of the variance in the global rating of the provider. A 5-item subset of the Communication to Improve Health Literacy composite accounted for 90% of the variance of the original 16-item composite. Conclusions:This study provides support for reliability and validity of the CAHPS Item Set for Addressing Health Literacy. These items can serve to assess whether healthcare providers have communicated effectively with their patients and as a tool for quality improvement.

Development of Items to Assess Patients’ Health Literacy Experiences at Hospitals for the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Hospital Survey

Background:The complexity of health information frequently exceeds patients’ skills to understand and use it. Improvement in hospital communication has the potential to improve the quality of care. Objective:To develop a set of items to supplement the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospital Survey (HCAHPS) to assess how well hospitals communicate health information to inpatients. Methods:We conducted an environmental scan and obtained input from stakeholders to identify domains and survey items, and cognitively tested the item set in English and Spanish. We administered the items to a random sample of adult hospital patients using mail and telephone data collection. We estimate item-scale correlations for hypothesized multi-item composites, internal consistency reliability for composites, correlations among composites, and regressed global rating of the hospital and a would you recommend the hospital items on HCAHPS existing core and the new composites to evaluate the unique contribution of each to these “bottom-line” measures. Results:A total of 1013 surveys were obtained (55% response rate). With some exceptions, correlations between items and scales were consistent with the hypothesized item clusters. Three composites were identified: (1) communication about tests; (2) communication about how to care for self and medicines; and (3) communication about forms. Conclusions:This study provides support for the measurement properties of the HCAHPS Item Set for Addressing Health Literacy. It can serve as both a measure of whether healthcare providers in a hospital setting have communicated effectively with their patients and as a tool for quality improvement.

Patients’ and caregivers’ experiences of the impact of Parkinson’s disease on health status

Background: Parkinson’s disease (PD) is a neurodegenerative disease that significantly affects patients’ quality of life. The myriad complexities of the disease, including its nonmotor manifestations, are beginning to be more fully appreciated, particularly in regard to the emotional and social effects of PD. Considering that both motor and nonmotor manifestations of PD significantly influence the health outcomes and conditions of patients, and their health-related quality of life (HRQOL), we collected qualitative data from patients with PD, as well as caregivers of persons with PD having cognitive impairment, to assess their perceptions of the impact of PD on HRQOL. Methods: We conducted eight focus groups and five one-on-one interviews in English and in Spanish between March 2007 and February 2008. Three of the focus groups were conducted with a total of 15 caregivers; the remaining focus groups and all interviews were conducted with 48 PD patients. Study participants were asked about the challenges that PD patients may experience, particularly pertaining to physical functioning, the impact of PD on their emotional status, and social functioning. Results: Based on analysis of the transcripts, we identified seven overarching domains or themes that reflect patients’ perspectives on living with PD, ie, physical functioning, social and role functioning, emotional impact, fears and uncertainty about the future, stigma and other feelings about PD, coping mechanisms, and benefits of having PD. Conclusion: We underscore the salient aspects regarding the physical effects of PD along with its nonphysical ramifications, offering perspectives into the experience of PD and suggestions on how PD patients and their caregivers may cope with the disease.

Implementation of Medical Homes in Federally Qualified Health Centers

BACKGROUND From 2011 through 2014, the Federally Qualified Health Center Advanced Primary Care Practice Demonstration provided care management fees and technical assistance to a nationwide sample of 503 federally qualified health centers to help them achieve the highest (level 3) medical‐home recognition by the National Committee for Quality Assurance, a designation that requires the implementation of processes to improve access, continuity, and coordination. METHODS We examined the achievement of medical‐home recognition and used Medicare claims and beneficiary surveys to measure utilization of services, quality of care, patients’ experiences, and Medicare expenditures in demonstration sites versus comparison sites. Using difference‐in‐differences analyses, we compared changes in outcomes in the two groups of sites during a 3‐year period. RESULTS Level 3 medical‐home recognition was awarded to 70% of demonstration sites and to 11% of comparison sites. Although the number of visits to federally qualified health centers decreased in the two groups, smaller reductions among demonstration sites than among comparison sites led to a relative increase of 83 visits per 1000 beneficiaries per year at demonstration sites (P<0.001). Similar trends explained the higher performance of demonstration sites with respect to annual eye examinations and nephropathy tests (P<0.001 for both comparisons); there were no significant differences with respect to three other process measures. Demonstration sites had larger increases than comparison sites in emergency department visits (30.3 more per 1000 beneficiaries per year, P<0.001), inpatient admissions (5.7 more per 1000 beneficiaries per year, P=0.02), and Medicare Part B expenditures (

Evaluation of CMS' FQHC APCP Demonstration: Final First Annual Report

37 more per beneficiary per year, P=0.02). Demonstration‐site participation was not associated with relative improvements in most measures of patients’ experiences. CONCLUSIONS Demonstration sites had higher rates of medical‐home recognition and smaller decreases in the number of patients’ visits to federally qualified health centers than did comparison sites, findings that may reflect better access to primary care relative to comparison sites. Demonstration sites had larger increases in emergency department visits, inpatient admissions, and Medicare Part B expenditures. (Funded by the Centers for Medicare and Medicaid Services.)

Federally Qualified Health Center Clinicians And Staff Increasingly Dissatisfied With Workplace Conditions

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