Katrin Hambarsoomian

Racial/Ethnic Differences in Patients’ Perceptions of Inpatient Care Using the HCAHPS Survey:

Using HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems, also known as the CAHPS Hospital Survey) data from 2,684 hospitals, the authors compare the experiences of Hispanic, African American, Asian/Pacific Islander, American Indian/Alaska Native, and multiracial inpatients with those of non-Hispanic White inpatients to understand the roles of between- and within-hospital differences in patients’ perspectives of hospital care. The study finds that, on average, non-Hispanic White inpatients receive care at hospitals that provide better experiences for all patients than the hospitals more often used by minority patients. Within hospitals, patient experiences are more similar by race/ethnicity, though some disparities do exist, especially for Asians. This research suggests that targeting hospitals that serve predominantly minority patients, improving the access of minority patients to better hospitals, and targeting the experiences of Asians within hospitals may be promising means of reducing disparities in patient experience.

The Relationship Between Spanish Language Use and Substance Use Behaviors Among Latino Youth: A Social Network Approach

PURPOSE Greater acculturation is associated with higher rates of substance use among Latino adolescents, but the reasons are poorly understood. One potential explanation is that social networks change with acculturation, leading to decreased protection and increased risk. Our objective was to identify Spanish language-sensitive individual and social network attributes associated with substance use in Latino adolescents. METHODS Latino eighth-grade students in a Los Angeles public middle school completed a computerized, self-administered survey about tobacco, alcohol, drug use, and parental monitoring; and description of 30 social network members. Regression analyses were used to estimate the independent associations of network-level Spanish language use and other factors with a substance use behavior scale. Mediation analysis identified Spanish language-sensitive attributes. RESULTS Network-level Spanish language use was associated with a substance use scale in bivariate but not multivariate models. Protective Spanish language-sensitive attributes included greater numbers of extended family members in the network, less substance use among network members, and greater perceived parental monitoring. Risky Spanish language-insensitive attributes include more high school aged network members. CONCLUSIONS These results suggest that parental monitoring and some characteristics of social networks account for the relationship between Spanish language use and substance use among Latino adolescents. Clinic- or community-based interventions that enhance protective characteristics of social networks in Latino adolescents may be effective.

Do hospitals rank differently on HCAHPS for different patient subgroups

Prior research documents differences in patient-reported experiences by patient characteristics. Using nine measures of patient experience from 1,203,229 patients discharged in 2006-2007 from 2,684 acute and critical access hospitals, the authors find that adjusted hospital scores measure distinctions in quality for the average patient with high reliability. The authors also find that hospital “ranks” (the relative scores of hospitals for patients of a given type) vary substantially by patient health status and race/ ethnicity/language, and moderately by patient education and age (p < .05 for almost all measures). Quality improvement efforts should examine hospital performance with both sicker and healthier patients, because many hospitals that do well with one group (relative to other hospitals) may not do well with another. The experiences of American Indians/Alaska Natives should also receive particular attention. As HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) data accumulate, reports that drill down to hospital performance for patient subtypes (especially by health status) may be valuable.

Prevalence of Posttraumatic Stress Disorder and Major Depression After Trauma Center Hospitalization

BACKGROUND Individuals hospitalized after physical trauma are at heightened risk for mental disorders. We examined prevalence rates of both posttraumatic stress disorder (PTSD) and major depression at 6 and 12 months in a sample of 677 individuals experiencing different types of trauma who were representative of physical trauma survivors hospitalized in Los Angeles County trauma centers. Demographic and injury-related risk factors for these disorders were also evaluated. METHODS Bivariate logistic regressions estimated risk for PTSD and depression at either 6 or 12 months associated with baseline risk factors. RESULTS At 6 months, 31% of participants met screening criteria for probable PTSD and 31% met criteria for probable depression. At 12 months, 28% and 29% met criteria for PTSD and depression, respectively. There were also high rates of comorbidity; depression and PTSD co-occurred in 21% of individuals at 6 months and in 19% of patients at 12 months. Bivariate logistic regressions indicated that preexisting disability and lower education were associated with higher odds of PTSD at either 6 or 12 months. African Americans and Hispanics had higher odds of PTSD compared with non-Hispanic Caucasians. Assault-related injury (versus accident), more severe injury, and longer hospitalizations were also associated with greater odds of PTSD. By contrast, higher odds of depression at 6 or 12 months were only associated with preexisting disability, losing consciousness, more severe injury, and longer hospitalizations. CONCLUSIONS Key demographic and injury characteristics may enhance identification of at-risk trauma survivors who would benefit from targeted screening, patient education, and early intervention efforts.

Gender differences in patients' perceptions of inpatient care.

OBJECTIVE To examine gender differences in inpatient experiences and how they vary by dimensions of care and other patient characteristics. DATA SOURCE A total of 1,971,632 patients (medical and surgical service lines) discharged from 3,830 hospitals, July 2007-June 2008, and completing the HCAHPS survey. STUDY DESIGN We compare the experiences of male and female inpatients on 10 HCAHPS dimensions using multiple linear regression, adjusting for survey mode and patient mix. Additional models add additional patient characteristics and their interactions with patient gender. PRINCIPAL FINDINGS We find generally less positive experiences for women than men, especially for Communication about Medicines, Discharge Information, and Cleanliness. Gender differences are similar in magnitude to previously reported HCAHPS differences by race/ethnicity. The gender gap is generally larger for older patients and for patients with worse self-reported health status. Gender disparities are largest in for-profit hospitals. CONCLUSIONS Targeting the experiences of women may be a promising means of improving overall patient experience scores (because women comprise a majority of all inpatients); the experiences of older and sicker women, and those in for-profit hospitals, may merit additional examination.

Toward a More Comprehensive Understanding of Violence Against Impoverished Women

Research and knowledge of violence against impoverished women continues to be limited. To achieve a more comprehensive understanding of violence against impoverished women and therefore inform prevention and intervention efforts for this population, the authors report on recent (past 6 months) physical, sexual, and psychological violence among 898 women who were randomly sampled from temporary shelter settings (n = 460) and low-income housing (n = 438) in Los Angeles County. Women experienced notable rates of violence during the past 6 months (e.g., 23% of sheltered women and 9% of housed women reported physical violence). Perpetrators were diverse, particularly for the sheltered women, including sexual partners, family, and strangers. These findings, and others suggesting that the different types of violence are distinct and severe, may call for more comprehensive screening and intervention efforts to enhance the safety of impoverished women.

Experiences of Care Among Medicare Beneficiaries With ESRD: Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey Results

BACKGROUND Patients with end-stage renal disease (ESRD) have special health needs; little is known about their care experiences. STUDY DESIGN Secondary analysis of 2009-2010 Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) data, using representative random samples of Medicare beneficiaries. Description of Medicare beneficiaries with ESRD and investigation of differences in patient experiences by sociodemographic characteristics and coverage type. SETTING & PARTICIPANTS Data were collected from 823,564 Medicare beneficiaries (3,794 with ESRD) as part of the Medicare CAHPS survey, administered by mail with telephone follow-up of nonrespondents. PREDICTOR ESRD status, age, education, self-reported general and mental health status, race/ethnicity, sex, Medicare coverage type, state of residence, and other demographic measures. OUTCOMES 6 composite measures of patient experience in 4 care domains (access to care, physician communication, customer service, and access to prescription drugs and drug information) and 4 ratings (overall care, personal physician, specialist physician, and prescription drug plan). RESULTS Patients with ESRD reported better care experiences than non-ESRD beneficiaries for 7 of 10 measures (P < 0.05) after adjustment for patient characteristics, geography, and coverage type, although to only a small extent (adjusted mean difference, <3 points [scale, 0-100]). Black patients with ESRD and less educated patients were more likely than other patients with ESRD to report poor experiences. LIMITATIONS Inability to distinguish patient experiences of care for different treatment modalities. CONCLUSIONS On average, beneficiaries with ESRD report patient experiences that are at least as positive as non-ESRD beneficiaries. However, black and less educated patients with ESRD reported worse experiences than other ESRD patients. Stratified reporting of patient experience by race/ethnicity or education in patients with ESRD can be used to monitor this disparity. Physician choice and confidence and trust in physicians may be particularly important for patients with ESRD.

Sampling with Field Burden Constraints: An Application to Sheltered Homeless and Low-Income Housed Women

In this article, the authors present a statistically efficient, cost-effective way of collecting a probability sample in the presence of certain field burden constraints: restrictions on the maximum number of participants that can be sampled within a given institution and a small population size relative to the sample size dictated by the study aims. The authors suggest the use of disproportionate stratified random sampling as an alternative to two-stage sampling under these circumstances and illustrate how to account, via weighting, for the participants’ differential probabilities of inclusion. They describe their approach with respect to a study of impoverished women, for which this sampling scheme was quite effective.

Relationship Commitment and Its Implications for Unprotected Sex Among Impoverished Women Living in Shelters and Low-Income Housing in Los Angeles County

OBJECTIVE To examine how relationship commitment among impoverished women is associated with their frequency of unprotected sex. DESIGN Cross-sectional analyses were conducted on survey data from a probability sample of 445 women initially sampled from shelters and low-income housing in Los Angeles County. MAIN OUTCOME MEASURE Frequency of unprotected sex in a typical month was derived as the product of 2 items: how often the woman had sex with her partner in a typical month and how often a male condom was used. RESULTS For both sheltered and housed women, relationship commitment predicted more frequent engagement in unprotected sex with their partner, even after controlling for the type of relationship (primary vs. casual). However, this association could not be accounted for by perceived partner monogamy, ability to refuse unwanted sex, perceived HIV susceptibility, and condom use self-efficacy. Among housed women only, never asking the partner to use a condom partially accounted for more frequent engagement in unprotected sex among women with stronger relationship commitment. CONCLUSION Results emphasize the importance of relationship commitment issues in HIV prevention interventions with impoverished women, and the need for a better understanding of relationship commitment and its influence on condom use in this population.

Racial/ethnic disparities in Medicare Part D experiences.

Objective:To examine racial/ethnic differences in Medicare beneficiary experiences with Medicare Part D prescription drug (PD) coverage. Data Sources/Study Setting:2008 Consumer Assessment of Health Care Providers and Systems survey of U.S. Medicare beneficiaries. Study Design:Surveys were administered by mail with phone follow-up to a nationally representative sample (61% response rate). This study examines 201,496 beneficiaries of age 65 and older with PD coverage [6% Hispanic, 7% non-Hispanic Black, 3% non-Hispanic Asian or Pacific Islander (API)]. Key variables are self-reported race/ethnicity and Consumer Assessment of Health Care Providers and Systems getting information and needed PDs measures. Data Collection/Extraction Methods:We generated weighted case-mix adjusted means for 4 racial/ethnic groups and for Hispanics separately by English-language or Spanish-language preference status. We calculated within-plan disparities using a linear mixed-effect model, with fixed effects for race/ethnicity, coverage type and case-mix variables, and random effects for contract and contract by race/ethnicity interactions. Principal Findings:Disparities for Hispanic, Black, and API beneficiaries on obtaining needed PDs and information regarding coverage range from −2 to −11 points (0–100 scale) relative to non-Hispanic Whites, with the greatest disparities observed for Spanish-preferring Hispanics and API beneficiaries, especially those with low income. There is wide variation in disparities across contracts, and contracts with the largest disparities for Hispanics have higher proportions of beneficiaries with lower education and income. Conclusions:Quality improvement efforts may be needed to reduce racial/ethnic disparities in beneficiary experience with PD coverage. Cultural, language, and health literacy barriers in navigating Medicare’s Part D program may partially explain the observed disparities.