Julie A. Brown

Are Latinos less satisfied with communication by health care providers

AbstractOBJECTIVE: To examine associations of patient ratings of communication by health care providers with patient language (English vs Spanish) and ethnicity (Latino vs white). METHODS: A random sample of patients receiving medical care from a physician group association concentrated on the West Coast was studied. A total of 7,093 English and Spanish language questionnaires were returned for an overall response rate of 59%. Five questions asking patients to rate communication by their health care providers were examined in this study. All five questions were administered with a 7-point response scale. MAIN RESULTS: We estimated the associations of satisfaction ratings with language (English vs Spanish) and ethnicity (white vs Latino) using ordinal logistic models, controlling for age and gender. Latinos responding in Spanish (Latino/Spanish) were significantly more dissatisfied compared with Latinos responding in English (Latino/English) and non-Latino whites responding in English (white) when asked about: (1) the medical staff listened to what they say (29% vs 17% vs 13% rated this “very poor,” “poor,” or “fair”; p<.01); (2) answers to their questions (27% vs 16% vs 12%; p<.01); (3) explanations about prescribed medications (22% vs 19% vs 14%; p<.01); (4) explanations about medical procedures and test results (36% vs 21% vs 17%; p<.01); and (5) reassurance and support from their doctors and the office staff (37% vs 23% vs 18%; p<.01). CONCLUSION: This study documents that Latino/Spanish respondents are significantly more dissatisfied with provider communication than Latino/English and white respondents. These results suggest Spanish-speaking Latinos may be at increased risk of lower quality of care and poor health outcomes. Efforts to improve the quality of communication with Spanish-speaking Latino patients in outpatient health care settings are needed.

National estimates of HIV-related symptom prevalence from the HIV Cost and Services Utilization Study.

OBJECTIVES The objectives of this study were (1) to estimate the prevalence, bothersomeness, and variation of HIV-related symptoms in a nationally representative sample of HIV-infected adults receiving medical care and (2) to evaluate new aggregate measures of symptom frequency and bothersomeness. METHODS Beginning in January 1996, 76% of a multistage national probability sample of 4,042 HIV-infected adults receiving medical care were interviewed. Participants endorsed the presence and degree of bothersomeness of 14 HIV-related symptoms during the preceding 6 months. Sex-standardized symptom number and bothersomeness indices were constructed. After sampling weights were incorporated, symptom distributions were compared according to selected characteristics by analysis of variance and multiple linear regression modeling. RESULTS Prevalence of specific symptoms in the reference population was as follows: fever/night sweats, 51.1%; diarrhea, 51%; nausea/anorexia, 49.8%; dysesthesias, 48.9%; severe headache, 39.3%; weight loss, 37.1%; vaginal symptoms, 35.6% of women; sinus symptoms, 34.8%; eye trouble, 32.4%; cough/dyspnea, 30.4%; thrush, 27.3%; rash, 24.3%; oral pain, 24.1%; and Kaposis sarcoma, 4%. Aggregate measures were reliable (Cronbachs alpha > or =0.75) and demonstrated construct validity when compared with other measures of disease severity. After adjustment for CD4 count, both symptom number and bothersomeness varied significantly (P <0.05) by teaching status of care setting, exposure/risk group, educational achievement, sex, annual income, employment, and insurance category. However, the magnitude of variation was small. Symptoms were greatest in women and injection drug users, as well as in persons with lower educational levels, lower income, and Medicare enrollment or those who were followed up at teaching hospitals. CONCLUSIONS The prevalence and bothersomeness of HIV-related symptoms are substantial and vary by setting of care and patient characteristics.

Do patient consent procedures affect participation rates in health services research

Background. Few studies have examined the effects of Institutional Review Board (IRB) requirements to contact potential research participants. Objective. To examine the association between requirements to contact potential research subjects and participation rates in a multisite health services research study. Research Design, Subjects. Prospective observational study of survey participation by 2673 individuals with diabetes and 1974 individuals with congestive heart failure treated at 15 clinical sites in the United States that had implemented a quality improvement intervention. Main Outcome Measures. Telephone survey response rates. Results. Of 15 IRBs, seven required sites to obtain authorization from participants to release contact information to the study team. Five required oral and two required written advance permission. The response rate was 58% (913/1571) at sites where no advance permission was required, 39% (989/2530) from sites that required oral advance permission and 27% (145/546, P <0.001) at sites requiring written advance permission. Although 85% of eligible participants contacted directly by the study team consented to complete the survey, only 43% of individuals at sites requiring written advance permission allowed the release of contact information to the study team. Conclusions. Many potential participants did not grant advance permission to be contacted by the study team. Requiring advance permission reduced participation rates, especially at sites requiring written authorization.

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.

Patient reports and ratings of individual physicians: an evaluation of the DoctorGuide and Consumer Assessment of Health Plans Study provider-level surveys.

The objective of this study was to compare physician-level survey instruments and estimate the number of patients needed per physician to provide reliable estimates of health care. The setting consisted of 3 health plans and 1 large physician group in the greater Cincinnati metro area. Surveys were mailed to patients of 100 primary care physicians. Patients were mailed either the Consumer Assessment of Health Plans Study(r) (CAHPS) or DoctorGuide survey instrument. A total of 4245 CAHPS surveys and 5519 DoctorGuide surveys were returned. Internal consistency reliability estimates for the multi-item scales (access to care, communication, and preventive care) for both surveys were adequate. The number of patient responses needed to obtain a reliability of 0.70 at the physician level for the access to care, communication, and preventive care scales were 32, 43, and 38, respectively, for the CAHPS survey and 26, 25, and 47, respectively, for the DoctorGuide survey. These results indicate similar and parallel psychometric performance for the DoctorGuide and CAHPS survey instruments.

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.

Classical test theory and item response theory analyses of multi-item scales assessing parents' perceptions of their children's dental care.

Background:Classical test theory and item response theory methods can provide useful and potentially different insights into the performance of items in a survey designed to elicit parental perceptions of dental care delivered to children in publicly funded programs. Objectives:We sought to illustrate the use of both classical test theory and item response theory to evaluate survey instruments. Methods:Using 2 years of cross-sectional data collected from enrollees in dental plans in 2001 and 2002, we studied families with children between ages 4 to 18 who were enrolled in 1 of 5 dental plans for 12 months or longer. The 2001 survey yielded a total of 2536 usable surveys and the 2002 survey yielded 2232 useable surveys (50% and 46% response rate, respectively) for a total sample size of 4036 children who used the plan for most or all of their care. Measures:The beta version of the CAHPS® dental care survey instrument includes 2 global rating items (dental care, dental plan) and multi-item scales assessing getting needed care, getting care quickly, communication with dental providers, office staff, and customer service. Results:Item missing data rates were low. Item-scale correlations for hypothesized scales (corrected for overlap) tended to exceed correlations of items with other scales. Classical test theory analyses identified 5 of 10 communication items that did not perform well. Internal consistency reliability estimates for the scales ranged from 0.73 to 0.86. Item response theory painted a more promising picture than classical test theory for the 2 communication items that assessed access to an interpreter when needed. Conclusions:The beta CAHPS® dental survey performed well and the revised instrument is recommended for future studies. Classical test theory and item response theory can provide complementary information about survey items.

Comparison of Mail and Telephone in Assessing Patient Experiences in Receiving Care from Medical Group Practices

The medical group survey from the CAHPS® (formerly Consumer Assessment of Health Plans Study) project, G-CAHPS, focuses on patient experiences in receiving care from their medical group practice. We compared mail and telephone responses to the GCAHPS survey in a sample of 880 patients fromfour physician groups. Patients were randomly assigned to mode. Analyses included comparison of response rates, missing data, internal consistency reliability of six multiitem scales, and mean scores. A total of 537 phone completes and 343 mail completes were obtained (54% response rate). There were no significant differences in internal consistency by mode. In addition, there was only one significant mode difference in item and composite means by mode of administration after adjusting for case-mix differences. This study indicates that mail and telephone modes of data collection for the G-CAHPS survey produce similar results.

Cultural competency assessment tool for hospitals: Evaluating hospitals' adherence to the culturally and linguistically appropriate services standards

BACKGROUND The U.S. national standards for culturally and linguistically appropriate services (CLAS) in health care provide guidelines on policies and practices aimed at developing culturally competent systems of care. The Cultural Competency Assessment Tool for Hospitals (CCATH) was developed as an organizational tool to assess adherence to the CLAS standards. PURPOSES First, we describe the development of the CCATH and estimate the reliability and validity of the CCATH measures. Second, we discuss the managerial implications of the CCATH as an organizational tool to assess cultural competency. METHODOLOGY/APPROACH We pilot tested an initial draft of the CCATH, revised it based on a focus group and cognitive interviews, and then administered it in a field test with a sample of California hospitals. The reliability and validity of the CCATH were evaluated using factor analysis, analysis of variance, and Cronbachs alphas. FINDINGS Exploratory and confirmatory factor analyses identified 12 CCATH composites: leadership and strategic planning, data collection on inpatient population, data collection on service area, performance management systems and quality improvement, human resources practices, diversity training, community representation, availability of interpreter services, interpreter services policies, quality of interpreter services, translation of written materials, and clinical cultural competency practices. All the CCATH scales had internal consistency reliability of .65 or above, and the reliability was .70 or above for 9 of the 12 scales. Analysis of variance results showed that not-for-profit hospitals have higher CCATH scores than for-profit hospitals in five CCATH scales and higher CCATH scores than government hospitals in two CCATH scales. PRACTICE IMPLICATIONS The CCATH showed adequate psychometric properties. Managers and policy makers can use the CCATH as a tool to evaluate hospital performance in cultural competency and identify and target improvements in hospital policies and practices that undergird the provision of CLAS.

From well-being to positive mental health: conceptualization and qualitative development of an instrument in Singapore

PurposeThere is no global definition of well-being. Cultural differences in the perception of well-being and the social and behavioral contexts further limit its measurement. Existing instruments are developed in Western societies that differ in their conceptualization of well-being from Asian populations. Moreover, very few instruments address the multidimensional construct of well-being.MethodsLiterature was reviewed to develop a priori conceptual framework of mental health and well-being. Concepts were identified based on specific criteria to guide the qualitative investigations. Finally, focus group discussions were conducted among adults belonging to the three major ethnicities in Singapore to identify salient domains of mental health and well-being.ResultsMental well-being is a multidimensional construct constituting of positive affect, satisfaction, and psychological functioning. While well-being explains the functional and psychological components, positive mental health is a combination of these and the skills required to achieve them. Although there is an overlap between the concepts identified from the literature and those identified in Singapore, certain differences existed, particularly with the relevance attributed to family interactions and religiosity or spirituality. Similar findings were observed across the three ethnic groups.ConclusionDomains identified can be used to develop a culturally relevant instrument in Singapore.