Carol A. Edwards

Components of Care Vary in Importance for Overall Patient-Reported Experience By Type of Hospitalization

Background:Patients are hospitalized for disparate conditions and procedures. Patient experiences with care may depend on hospitalization type (HT). Objectives:Determine whether the contributions of patient experience composite measures to overall hospital ratings on the Hospital Consumer Assessment of Healthcare Providers and Systems Survey vary by HT. Research Design:In cross-sectional observational data, we defined 24 HTs using major diagnostic category and service line (medical, surgical, or obstetrical). To assess the importance of each composite for each HT, we calculated the simultaneous partial correlations of 7 composite scores with an overall hospital rating, controlling for patient demographics. Subjects:Nineteen thousand seven hundred twenty English- or Spanish-speaking adults with nonpsychiatric primary diagnoses discharged home 12/02-1/03 after an overnight inpatient stay in any of 132 general acute care hospitals in 3 states. Measures:Patient-reported doctor communication, nurse communication, staff responsiveness, physical environment, new medicines explained, pain control, and postdischarge information; overall 0 to 10 rating of care. Results:Nurse communication was most important overall, with a 0.34 average partial correlation (range: 0.17-0.49; P < 0.05 and among the 3 most important composites for all HTs). Discharge information was least important (0.05 average partial correlation; P < 0.05 for 10 of 24 HTs). Interactions demonstrated significant (P < 0.05) variation in partial correlations by HT for 5 of 7 composites (all but responsiveness and environment), with nurse communication, doctor communication, and pain control showing the most variation (F > 2, P < 0.05). Conclusions:The importance of patient experience dimensions differs substantially and varies by HT. Quality improvement efforts should target those aspects of patient experience that matter most for each HT.

Understanding Nonresponse to the 2007 Medicare CAHPS Survey

PURPOSE The Medicare Consumer Assessments of Healthcare Providers and Systems (MCAHPS) survey, a primarily English-language mail survey with English and Spanish telephone follow-up, is the primary means of assessing the health care experiences of American seniors. We examine unit (whole survey) and item nonresponse for this survey to explore issues regarding surveying seniors about their health care. DESIGN AND METHODS We describe overall rates and analyze predictors of unit and item nonresponse for the 695,197 Medicare beneficiaries selected for the 2007 MCAHPS survey (335,249 unit respondents, 49% overall response rate). RESULTS Asians, African Americans, and Hispanics responded at adjusted response rates 7-17 percentage points lower than non-Hispanic Whites (p < .001 for each). Among seniors, response rates dropped beyond age 75. Asians and older beneficiaries were especially likely to respond by mail, and African Americans and Hispanics by phone. Breakoff from telephone surveys was most common among African Americans and older respondents. Among respondents, older age was the strongest predictor of item missingness (e.g., those 85 years and older failed to answer items at twice the rate of those aged 65-74 years, p < .001). Non-Hispanic Whites had lower rates of item missingness than other racial/ethnic groups (p < .001 for each; one-third lower than African Americans). IMPLICATIONS Survey research on older adults, especially regarding racial/ethnic disparities in health care, could benefit from improved response rates. These results suggest that targeted prenotification materials and campaigns, tailored follow-up, targeted Spanish mailings, Chinese translations/calls, and adjustments to telephone protocols may improve representation and response.

Can Additional Patient Experience Items Improve the Reliability of and Add New Domains to the CAHPS® Hospital Survey?

CONTEXT The Centers for Medicare and Medicaid Services will introduce the reporting of patient surveys in 2008. The Consumer Assessment of Health Care Providers and Systems (CAHPS) Hospital Survey contains 18 questions about hospital care. Internal consistency reliability of the discharge information scale is relatively low and some important domains of care are not represented. OBJECTIVE To determine whether adding questions increases the reliability and validity of the survey. DATA SOURCES AND STUDY SETTING Surveys of patients at 181 hospitals participating in the California Hospitals Assessment and Reporting Taskforce (CHART), an initiative for voluntary public reporting of hospital performance in California. STUDY DESIGN CHART added nine questions to the CAHPS Hospital Survey; two to improve reliability of the discharge information domain, five to create a coordination of care domain, and two relating to interpreter services. DATA COLLECTION Surveys were sent to randomly selected patients from each CHART hospital. PRINCIPAL FINDINGS A total of 40,172 surveys were included. Adding the new discharge information questions improved the internal consistency reliability from 0.45 to 0.72 and the hospital-level reliability from 0.75 to 0.81. New coordination of care composites had good internal consistency reliabilities ranging from 0.58 to 0.70 and hospital-level reliabilities ranging from 0.84 to 0.87. The new coordination of care composites were more closely correlated with overall hospital ratings and willingness to recommend than six of the seven original domains. CONCLUSIONS The additional discharge information questions and the new coordination of care questions significantly improved the psychometric properties of the CAHPS Hospital Survey.

Care Experiences of Managed Care Medicare Enrollees Near the End of Life

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

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

OBJECTIVE To examine how similar racial/ethnic disparities in clinical quality (Healthcare Effectiveness Data and Information Set [HEDIS]) and patient experience (Consumer Assessment of Healthcare Providers and Systems [CAHPS]) measures are for different measures within Medicare Advantage (MA) plans. DATA SOURCES/STUDY SETTING 5.7 million/492,495 MA beneficiaries with 2008-2009 HEDIS/CAHPS data. STUDY DESIGN Binomial (HEDIS) and linear (CAHPS) hierarchical mixed models generated contract estimates for HEDIS/CAHPS measures for Hispanics, blacks, Asian-Pacific Islanders, and whites. We examine the correlation of within-plan disparities for HEDIS and CAHPS measures across measures. PRINCIPAL FINDINGS Plans with disparities for a given minority group (vs. whites) for a particular measure have a moderate tendency for similar disparities for other measures of the same type (mean r = 0.51/.21 and 53/34 percent positive and statistically significant for CAHPS/HEDIS). This pattern holds to a lesser extent for correlations of CAHPS disparities and HEDIS disparities (mean r = 0.05/0.14/0.23 and 4.4/5.6/4.4 percent) positive and statistically significant for blacks/Hispanics/API. CONCLUSIONS Similarities in CAHPS and HEDIS disparities across measures might reflect common structural factors, such as language services or provider incentives, affecting several measures simultaneously. Health plan structural changes might reduce disparities across multiple measures.

How Much Do Additional Mailings and Telephone Calls Contribute to Response Rates in a Survey of Medicare Beneficiaries

Surveys often spend substantial money on multiple mailings and telephone calls to ensure high overall response rates and adequate representation of hard-to-reach demographic subgroups. We examine the extent to which an additional mailing and additional sets of telephone calls are effective in attaining these goals across a variety of subgroups in a large, national multimode survey of Medicare beneficiaries. We also examine the relative data quality of the responses that come with each level of extra effort. We find that additional mailings appear more effective in some groups, while additional telephone calls appear more effective in others. Tailoring the fielding strategy differently by subgroup may improve response rates at a lower cost per complete than using the same fielding protocol for all potential respondents, although data quality is likely to decline with additional efforts in either mode.