Background and Objective
On March 11, 2009, the Veterans Health Administration (VA) implemented an electronic health record (EHR)-based intervention that required all pathology results to be transmitted to ordering providers via mandatory automated notifications. We examined the impact of this intervention on improving follow-up of abnormal outpatient pathology results.
Research Design and Subjects
We extracted pathology reports from the EHR of two VA sites. From 16,738 pre- and 17,305 post-intervention reports between 09/01/2008 and 09/30/2009, we randomly selected about 5% and evaluated follow-up outcomes using a standardized chart review instrument. Documented responses to the alerted report (e.g., ordering follow-up tests or referrals, notifying patients, and prescribing/changing treatment) were recorded.
Primary outcome measures included proportion of timely follow-up responses (within 30 days) and median time to direct response for abnormal reports.
Of 816 pre- and 798 post-intervention reports reviewed, 666 (81.6%) and 688 (86.2%) were abnormal. Overall, there was no apparent intervention effect on timely follow-up (69% vs. 67.1%;p=0.4) or median time to direct response (8 days vs. 8 days; p=0.7). However, logistic regression uncovered a significant intervention effect (pre-intervention OR, 0.7; 95%CI 0.5-1.0) after accounting for site-specific differences in follow-up, with a lower likelihood of timely follow-up at one site (OR,0.4; 95%CI 0.2-0.7).
An electronic intervention to improve test result follow-up at two VA institutions using the same EHR was found effective only after accounting for certain local contextual factors. Aggregating the effect of EHR interventions across different institutions and EHRs without controlling for contextual factors might underestimate their potential benefits.
Anatomic pathology; electronic health record; communication; follow-up; post-analytic phase
We investigated the size profile of US primary care and behavioral health physician practices since size may impact the ability to institute care management processes (CMPs) that can enhance care quality.
We utilized 2009 claims data from a nationwide commercial insurer to estimate practice size by linking providers via tax identification number. We determined the proportion of primary care physicians, psychiatrists, and behavioral health providers practicing in venues of >20 providers per practice (the lower bound for current CMP practice surveys).
Among primary care physicians (n= 350,350), only 2.1% of practices consisted of >20 providers. Among behavioral health practitioners (n=146,992) and psychiatrists (n=44,449), 1.3% and 1.0% of practices, respectively, had >20 providers. Sensitivity analysis excluding single-physician practices as “secondary” confirmed findings, with primary care and psychiatrist practices of >20 providers comprising, respectively, only 19.4% and 8.8% of practices (difference: p<0.0001). In secondary analyses, bipolar disorder was used as an tracer condition to estimate practice census for a high-complexity, high-cost behavioral health condition; only 1.3-18 patients per practice had claims for this condition.
The tax identification number method for estimating practice size has strengths and limitations that complement those of survey methods. The proportion of practices below the lower bound of prior CMP studies is substantial, and care models and policies will need to address the needs of such practices and their patients. Achieving a critical mass of patients for disorder-specific CMPs will require coordination across multiple small practices.
This study tested two hypotheses: (1) chemotherapy increases the rate of cognitive decline in breast and colorectal cancer patients beyond what is typical of normal aging and (2) chemotherapy results in systematic cognitive declines when compared with breast and colorectal cancer patients who did not receive chemotherapy.
Data came from personal interviews with a prospective cohort of patients with breast (n = 141) or colorectal cancer (n = 224) with incident disease drawn from the nationally representative Health and Retirement Study (1998–2006) with linked Medicare claims.
The 27-point modified Telephone Interview for Cognitive Status was used to assess cognitive functioning, focusing on memory and attention. We defined the smallest clinically significant change as 0.4 points per year.
We used Bayesian hierarchical linear models to test the hypotheses, adjusting for multiple possible confounders. Eighty-eight patients were treated with chemotherapy; 277 were not. Mean age at diagnosis was 75.5. Patients were followed for a median of 3.1 years after diagnosis, with a range of 0 to 8.3 years. We found no differences in the rates of cognitive decline before and after diagnosis for patients who received chemotherapy in adjusted models (p=.86, one-sided 95% PI lower bound: 0.09 worse after chemotherapy), where patients served as their own controls. Moreover, the rate of cognitive decline after diagnosis did not differ between patients who had chemotherapy and those who did not (p=0.84, one-sided 95% PI lower bound: 0.11 worse for chemotherapy group in adjusted model).
There was no evidence of cognitive decline associated with chemotherapy in this sample of older adults with breast and colorectal cancer.
breast cancer; cancer care; cancer survivors; colorectal cancer; cognition; chemotherapy
The quality of nursing home care for residents with advanced dementia has been described as suboptimal. One relatively understudied factor is the impact of special care units (SCUs) for dementia for residents at the end-stage of this disease.
To examine the association between residence in an SCU and the quality of end-of-life care for nursing home residents with advanced dementia.
This study employed longitudinal data on 323 nursing home residents with advanced dementia living in 22 Boston-area facilities. Using multivariate methods, we analyzed the association between residence in an SCU and measures of quality of end-of-life care including: treatment of pain and dyspnea, prevalence of pressure ulcers, hospitalization, tube feeding, antipsychotic drug use, advance care planning, and health care proxy (HCP) satisfaction with care.
A total of 43.7% residents were cared for in an SCU. After multivariate adjustment, residents in SCUs were more likely to receive treatment for dyspnea, had fewer hospitalizations, were less likely to be tube fed, and more likely to have a do-not-hospitalize order, compared to non-SCU residents. However, non-SCU residents were more likely to be treated for pain, had fewer pressure ulcers, and less frequent use of antipsychotic drugs than SCU residents. HCPs of SCU residents reported greater satisfaction with care than HCPs of non-SCU residents.
Residence in an SCU is associated with some, but not all, markers of better quality end-of-life care among nursing home residents with advanced dementia.
special care units; quality of care; dementia; end-of-life care
American Indians who live in rural reservation communities face substantial geographic barriers to care that may limit their use of health services and contribute to their well-documented health disparities. The purpose of this study was to examine the impact of geographical factors in access to care on the use of services for physical and mental health problems and to explore American Indians’ use of traditional healing services in relation to use of biomedical services.
We analyzed survey data collected from two tribes (Southwest and Northern Plains). Geographical access to the closest biomedical service was measured using a Geographic Information System, including road travel distance, elevation gain and reservation boundary crossing.
Use of biomedical services was unaffected by geographical access for Northern Plains tribal members with mental health problems and for Southwest tribal members with physical or mental health problems. For members of the Northern Plains tribe with physical health problems, travel distance (p=0.007) and elevation gain (p=0.029) significantly predicted a lower likelihood of service use. The use of traditional healing was unrelated to biomedical service use for members of the Northern Plains tribe with physical or mental health problems and for members of the Southwest tribe with physical health problems. For members of the Southwest tribe with mental health problems, the use of biomedical services increased the likelihood of using traditional healing services.
Findings suggest that biomedical services are geographically accessible to most tribal members and that tribal members are not substituting traditional healing for biomedical treatments because of poor geographical access.
American Indians; geographical accessibility; traditional healing
Patients diagnosed with serious mental illness (SMI) who qualify for nursing home placement tend to require high levels of both psychiatric and nursing care. It is unknown, however, whether they are equally likely to be admitted to nursing homes with adequate quality of care compared to other patients.
We analyzed a national cohort of over 1.3 million new nursing home admissions in 2007 using the Minimum Data Set. The total and healthcare-related deficiency citations for each facility were obtained from the Online Survey, Certification, and Reporting file. Bivariate and multivariate regression analyses determined the association of schizophrenia or bipolar disorder with admissions to facilities with higher deficiencies.
Compared to other patients, patients with schizophrenia (n=23,767) tended to enter nursing homes with both more total deficiencies (13.3 vs 11.2, p<0.001) and more healthcare-related deficiencies (8.6 vs 7.2, p<0.001); and patients with bipolar disorder (n=19,741) were more likely to enter facilities with more problematic care too (12.5 vs 11.2, p<0.001 for total deficiencies; and 8.2 vs 7.2, p<0.001 for healthcare-related deficiencies). After sequentially controlling for the within-county choice of facilities, patient characteristics, and facility covariates, the association of SMI with admitting to higher-deficiency nursing homes persisted.
Patients diagnosed with schizophrenia or bipolar disorder (ie, SMI) were more likely than other patients to be admitted to nursing homes with higher deficiency citations for both overall quality and clinical care quality. Future research is necessary to understand the reasons behind the disparity in quality of nursing home care associated with SMI.
serious mental illness; deficiency citations; nursing home quality; schizophrenia; bipolar disorder
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.
To develop a set of items to supplement the CAHPS® Hospital Survey (HCAHPS) to assess how well hospitals communicate health information to inpatients.
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.
A total of 1,013 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.
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 health care providers in a hospital setting have communicated effectively with their patients and as a tool for quality improvement.
Health literacy; HCAHPS®; patient survey; hospital survey; patient-provider communication
Prior research has documented sociodemographic disparities in the use of antiretroviral therapy (ART). Recent therapeutic developments and changing epidemiological profiles may have altered such disparities. We examine the extent to which socio-demographic differences in prescribed ART have changed between 2002 and 2008.
We analyzed data abstracted from medical records at 13 US sites participating in the Human Immunodeficiency Virus Research Network. Prescription of ART was assessed for each year in care for each patient. A total of 14,092 patients were followed up for 39,251 person-years. We examined ART use as a function of sex, race/ethnicity, human immunodeficiency virus risk group, age, and CD4 history (no test <500 cells/mm3, one or more tests between 500 and 350 cells/mm3, 1 test ≤350 cells/mm3, and 2 or more tests ≤350 cells/mm3). Using multiple logistic regression, we ascertained interactions between each of these variables and calendar year.
The overall percentage prescribed ART increased from 60% to 80% between 2002 and 2008. Among those with 2 or more CD4 tests ≤350 cells/mm3, the percentage increased from 82% to 92%. ART rates were higher for those with lower CD4 counts but increased over time for all CD4 groups and for all demographic groups. Nevertheless, sex and racial/ethnic disparities persisted. Significant interactions were obtained for CD4 history by year, age by year, and age by CD4 history.
Although prescription of ART became more widespread from 2002 to 2008, patients who were female, black, or younger still had lower ART rates than male, white, or older patients.
ART; disparities; time trends; utilization; sociodemographic differences
We sought to determine the accuracy with which Medicare billing data documents elderly Medicare cancer patients’ receipt of common multi-agent chemotherapy regimens.
We merged gold-standard clinical trial data from 406 elderly cancer patients known to be treated on one of six Cancer and Leukemia Group B (CALGB) breast, colorectal, and lung cancer trials (trial numbers; 9344, 9730, 9235,9732, 80203, 89803) with their Medicare claims data from Centers for Medicare and Medicaid Services (CMS). Comparing CMS chemotherapy codes to gold-standard CALGB treatment data, we estimated Medicare data’s sensitivity at measuring the correct drugs and schedule for each of the multi-agent chemotherapy regimens.
Overall 92% (375/406) of CALGB patients had contemporaneous CMS claims indicating receipt of chemotherapy. The overall sensitivity of CMS ambulatory claims for documenting treatment with the correct drugs and on the correct schedule (i.e., all drugs had to be billed on the same day) for the five common multi-agent chemotherapy regimens was 78% (275/354) for those potentially treated in the ambulatory setting. The sensitivity was similar for all treatment regimens: carboplatin and paclitaxel 83%, 5FU and leucovorin 80%, FOLFIRI 76%, doxorubicin and cyclophosphamide 75%, and cisplatin and etoposide 75%.
We identified at least three-quarters of elderly Medicare cancer patients treated on a clinical trial with standard first-line multi-agent chemotherapy regimens in the ambulatory setting by applying coding algorithms. The algorithms may be useful in identifying cohorts of elderly Medicare patients for observational studies of the comparative effectiveness of standard multi-agent chemotherapy regimens.
Elderly; Cancer; Medicare; Chemotherapy; Comparative Effectiveness Research
Colonoscopy outcomes, such as polyp detection or complication rates, may differ by procedure indication.
To develop methods to classify colonoscopy indications from administrative data, facilitating study of colonoscopy quality and outcomes.
We linked 14,844 colonoscopy reports from the Clinical Outcomes Research Initiative, a national repository of endoscopic reports, to the corresponding Medicare Carrier and Outpatient File claims. Colonoscopy indication was determined from the procedure reports. We developed algorithms using classification and regression trees and linear discriminant analysis to classify colonoscopy indication. Predictor variables included ICD-9CM and CPT/HCPCS codes present on the colonoscopy claim or in the 12 months prior, patient demographics, and site of colonoscopy service. Algorithms were developed on a training set of 7,515 procedures, then validated using a test set of 7,329 procedures.
Sensitivity was lowest for identifying average risk screening colonoscopies, varying between 55% and 86% for the different algorithms, but specificity for this indication was consistently over 95%. Sensitivity for diagnostic colonoscopy varied between 77% and 89%, with specificity between 55% and 87%. Algorithms with classification and regression trees with 7 variables or linear discriminant analysis with 10 variables had similar overall accuracy, and generally lower accuracy than the algorithm using linear discriminant analysis with 30 variables.
Algorithms using Medicare claims data have moderate sensitivity and specificity for colonoscopy indication, and will be useful for studying colonoscopy quality in this population. Further validation may be needed before use in alternative populations.
Colonoscopy; Health Services Research; Electronic Health Records; Algorithms
Few valid and reliable measures exist for health care professionals interested in determining their levels of cultural and linguistic competence.
To evaluate the measurement properties of the Cultural Competence Health Practitioner Assessment (CCHPA-129).
The CCHPA-129 is a 129-item web-based instrument, developed by the National Center for Cultural Competence (NCCC). Responses on the CCHPA -129 were examined using factor analysis; Rasch modeling; and Differential Item Functioning (DIF) across race, ethnicity, gender, and profession.
2504 practitioners, including 1864 nurses (RN/LPN,/BSN); 341 clinicians (PA/NP); and 299 physicians (MD/DO), who completed the CCHPA-129 online between 2005 and 2008.
Three factors representing domains of knowledge, adapting practice, and promoting health for culturally and linguistically diverse populations accounted for 46% of the variance. Among Knowledge factor items, 53% (23/43) fit the Rasch model, item difficulties ranged from −1.01 logits (least difficult) to +1.11 logits (most difficult), separation index (SI) 13.82, and Cronbach’s α 0.92. Forty-seven percent (21/44) Adapting Practice factor items fit the model, item difficulties −0.07 to +1.11 logits, SI 11.59, Cronbach’s α 0.88; and 58% (23/39). Promoting Health factor items fit the model, item difficulties −1.01 to +1.38 logits, SI 22.64, Cronbach’s α 0.92. Early evidence of validity was established by known groups having statistically different scores.
The 67-item CCHPA-67 is psychometrically sound. This shorted instrument can be used to establish associations between practitioners’ cultural and linguistic competence and health outcomes as well as to evaluate interventions to increase practitioners’ cultural and linguistic competence.
cultural competency and linguistic competency; measure; measurement; Rasch modeling; item response theory; differential item functioning
Similar patient populations and favorable regulations have led many home health agencies to become Medicare and/or Medicaid certified as hospice agencies (mixed), but home health and hospice programs differ in focus and scope. Little research has been performed examining the differences between mixed hospices and those agencies only certified as hospices (non-mixed).
To describe the differences in agency characteristics between mixed and non-mixed agencies; and to compare frequencies of service provision by mixed and non-mixed agencies.
Cross-sectional study using data from the 2000 National Home and Hospice Care Survey.
760 Medicare and/or Medicaid certified hospice agencies providing services during the survey, including 393 mixed agencies (52% of sample) and 367 non-mixed hospices.
Survey responses by administrators about services provided by agency
Non-mixed agencies were significantly more likely than mixed agencies to provide many types of services, including: volunteers (96.1% vs. 77.4%, respectively, OR 7.27, 95%CI (5.26-10.05)), social services (96.1% vs. 93.5%, OR 1.70 (1.20-2.40)), spiritual care (95.1% vs. 77.8%, OR 5.53 (4.13-7.41)), bereavement care (93.5% vs. 79.8%, OR 3.63 (2.80-4.72)), counseling (89.5% vs. 70.2%, OR 3.62 (2.92-4.48)), and physician services (87.2% vs. 52.0%, OR 6.30 (5.18-7.66)). In logistic regression models, these differences remained significant after adjustment for census region, operation by a hospital, number of patients and number of hospice patients, and Medicare and Medicaid hospice certification status.
Mixed agencies provide a narrower range of services to hospice patients than non-mixed agencies, including fewer services considered cornerstones of hospice treatment.
hospice & palliative medicine; Medicare; Medicaid; home care; care delivery system
Concern regarding wide variations in spending and intensive care unit use for patients at the end of life hinges on the assumption that such treatment offers little or no survival benefit.
To explore the relationship between hospital “end-of-life” (EOL) treatment intensity and postadmission survival.
Retrospective cohort analysis of Pennsylvania Health Care Cost Containment Council discharge data April 2001 to March 2005 linked to vital statistics data through September 2005 using hospital-level correlation, admission-level marginal structural logistic regression, and pooled logistic regression to approximate a Cox survival model.
A total of 1,021,909 patients ≥65 years old, incurring 2,216,815 admissions in 169 Pennsylvania acute care hospitals.
EOL treatment intensity (a summed index of standardized intensive care unit and life-sustaining treatment use among patients with a high predicted probability of dying [PPD] at admission) and 30- and 180-day postadmission mortality.
There was a nonlinear negative relationship between hospital EOL treatment intensity and 30-day mortality among all admissions, although patients with higher PPD derived the greatest benefit. Compared with admission at an average intensity hospital, admission to a hospital 1 standard deviation below versus 1 standard deviation above average intensity resulted in an adjusted odds ratio of mortality for admissions at low PPD of 1.06 (1.04–1.08) versus 0.97 (0.96–0.99); average PPD: 1.06 (1.04–1.09) versus 0.97 (0.96–0.99); and high PPD: 1.09 (1.07–1.11) versus 0.97 (0.95– 0.99), respectively. By 180 days, the benefits to intensity attenuated (low PPD: 1.03 [1.01–1.04] vs. 1.00 [0.98–1.01]; average PPD: 1.03 [1.02–1.05] vs. 1.00 [0.98–1.01]; and high PPD: 1.06 [1.04–1.09] vs. 1.00 [0.98–1.02]), respectively.
Admission to higher EOL treatment intensity hospitals is associated with small gains in postadmission survival. The marginal returns to intensity diminish for admission to hospitals above average EOL treatment intensity and wane with time.
intensive care; terminal care; mortality; hospitals; efficiency; quality
Adverse events from inappropriate medications are preventable risk factors for nursing home admissions.
We sought to investigate the relationship between inappropriate medications in older adults and transitions to nursing home.
A retrospective cohort of Medicare beneficiaries with employer-sponsored supplemental health insurance was analyzed using a longitudinal data set of Medicare supplemental insurance claims. After a baseline year with no nursing home admissions, subjects were followed until the first month of transition to nursing home, loss to follow-up, or the end of the 24-month follow-up period. Survival analysis was used to compare the risk of nursing home transition among those with and without inappropriate drug use in the previous 3 months.
Of the 487,383 subjects in the cohort, 22,042 (4.5%) had a nursing home admission. Use of inappropriate drugs was associated with a 31% increase in risk of nursing home admission, compared with no use of inappropriate drugs (adjusted relative risk 1.31, 99% confidence interval [CI] 1.26–1.36). Analyses of individual drug classes showed the risk of nursing home admission was similar, or lower, for inappropriate drugs versus other drugs of the same class. For example, the relative risk of nursing home admission was 2.34 (99% CI 2.20–2.47) for inappropriate narcotics and 2.68 (99% CI 2.55–2.82) for other narcotics, compared with no narcotic use.
Inappropriate drug use was associated with increased risk of nursing home transition, but the increased risk may be explained by underlying patient conditions for which the drugs were prescribed rather than the inappropriate drug.
elderly; drug utilization; cohort study; nursing home admission; transitions
Acute lymphoblastic leukemia (ALL) accounts for almost one quarter of pediatric cancer in the United States. Despite cooperative group therapeutic trials, there remains a paucity of large cohort data on which to conduct epidemiology and comparative effectiveness research studies.
We designed a three-step process utilizing ICD-9 discharge diagnoses codes and chemotherapy exposure data contained in the Pediatric Health Information System administrative database to establish a cohort of children with de novo ALL. This process was validated by chart review at one of the pediatric centers.
An ALL cohort of 8,733 patients was identified with a sensitivity of 88% (95% CI: 83–92%) and a positive predictive value of 93% (95% CI: 89–96%). The 30-day all cause inpatient case fatality rate using this three-step process was 0.80% (95% CI: 0.63–1.01%), which was significantly different than the case fatality rate of 1.40% (95% CI: 1.23–1.60%) when ICD-9 codes alone were used.
This is the first report of assembly and validation of a cohort of de novo ALL patients from a database representative of free standing children's hospitals across the United States. Our data demonstrate that the use of ICD-9 codes alone to establish cohorts will lead to substantial patient misclassification and result in biased outcome estimates. Systematic methods beyond the use of just ICD-9 codes must be employed prior to analysis to establish accurate cohorts of patients with malignancy. A similar approach should be followed when establishing future cohorts from administrative data.
leukemia; health administrative data; children
Professional organizations recommend a preventive dental visit by one year of age. This study compared dental treatment and expenditures for Medicaid children who have a preventive visit before age 18-months to those who have a visit at age 18-42 months.
This retrospective cohort study used reimbursement claims for 19,888 children enrolled in North Carolina Medicaid (1999-2006). We compared the number of dental treatment procedures at age 43-72 months for children who had a visit by age 18-months to children who had a visit at age 18-24, 25-30, 31-36 and 37-42 months using a zero inflated negative binomial model. The likelihood and amount of expenditures at age 43-72 months were compared by group using a logit and ordinary least squares regression.
Children who had a primary or secondary preventive visit by age 18-months had no difference in subsequent dental outcomes compared to children in older age categories. Among children with existing disease, those who had a tertiary preventive visit by age 18-months had lower rates of subsequent treatment (18-24 months IDR: 1.19, 95% CI: 1.03-1.38; 25-30 months IDR: 1.21, 95% CI: 1.06 – 1.39; 37-42 months IDR: 1.39, 95% CI: 1.22 – 1.59) and lower treatment expenditures compared to children in older age categories.
In this sample of preventive dental users in Medicaid, we found that children at highest risk of dental disease benefited from a visit before age 18-months, but most children could delay their first visit until age 3-years without an effect on subsequent dental outcomes.
Early Childhood Caries; dental treatment; Medicaid claims
The English and Spanish versions of the Consumer Assessments of Healthcare Providers and Systems (CAHPS®) Cultural Competence Survey (CAHP-CC) assess patients’ experiences with culturally competent care. The possibility exists that even when Spanish and an English speakers experience the same levels of culturally competent care, responses describing their care may differ. This is called measurement bias. To deliver reliable and valid information across language, responses must provide equivalent measurement across versions. In this study, we examined whether measurement bias on the CAHPS-CC impedes valid measurement across the English and Spanish versions.
We used multiple group (MG) confirmatory factor analyses (CFA) to examine measurement bias across English (n = 851) and Spanish (n = 113) speakers. Participants came from a 2008 sample of two Medicaid managed care plans, in New York and California.
MG-CFA provided general support for the equivalence of the CAHPS-CC in measuring Doctor Communication-Positive Behaviors, Doctor Communication-Negative Behaviors, Doctor Communication-Preventative Care, Equitable Treatment, and Trust. We did observe statistically significant differences in the thresholds associated with the item asking whether a doctor gave easier to understand instructions. However, analyses indicated that bias did not meaningfully influence conclusions about average experiences using the English and Spanish versions of the CAHPS-CC.
Our results support the use of the English and Spanish versions of the CAHPS-CC. Though we found some bias, analyses demonstrated that it did not substantively impact conclusions for the studied domains. Health providers can place confidence in the two different CAHPS-CC translations.
Cultural competence; CAHPS®; Spanish; translation; ethnicity; measurement equivalence
Providing culturally competent care shows promise as a mechanism to reduce healthcare inequalities. Until the recent development of the CAHPS Cultural Competency Item Set (CAHPS-CC), no measures capturing patient-level experiences with culturally competent care have been suitable for broad-scale administration.
We performed confirmatory factor analysis and internal consistency reliability analysis of CAHPS-CC among patients with type 2 diabetes (n=600) receiving primary care in safety-net clinics. CAHPS-CC domains were also correlated with global physician ratings.
A 7-factor model demonstrated satisfactory fit (χ2(231)=484.34, p<.0001) with significant factor loadings at p<.05. Three domains showed excellent reliability – Doctor Communication- Positive Behaviors (α=.82), Trust (α=.77), and Doctor Communication- Health Promotion (α=.72). Four domains showed inadequate reliability either among Spanish speakers or overall (overall reliabilities listed): Doctor Communication- Negative Behaviors (α=.54), Equitable Treatment (α=.69), Doctor Communication- Alternative Medicine (α=.52), and Shared Decision-Making (α=.51). CAHPS-CC domains were positively and significantly correlated with global physician rating.
Select CAHPS-CC domains are suitable for broad-scale administration among safety-net patients. Those domains may be used to target quality-improvement efforts focused on providing culturally competent care in safety-net settings.
The Consumer Assessment of Healthcare Providers and Systems Cultural Competency (CAHPS-CC) Item Set assesses patient perceptions of aspects of the cultural competence of their health care.
To determine characteristics of patients who identify the care they receive as less culturally competent
Cross-sectional survey consisting of face-to-face interviews
Safety-net population of patients with type 2 diabetes (n=600) receiving ongoing primary care
Participants completed the CAHPS-CC and answered questions about their race/ethnicity, gender, age, education, health status, depressive symptoms, insurance coverage, English proficiency, duration of relationship with primary care provider, and co-morbidities.
In adjusted models, depressive symptoms were significantly associated with poor cultural competency in the Doctor Communication – Positive Behaviors domain (OR 1.73, 95%CI 1.11, 2.69). African-Americans were less likely than Whites to report poor cultural competence in the Doctor Communication – Positive Behaviors domain (OR 0.52, 0.28–0.97). Participants who reported a longer relationship (≥3 years) with their primary care provider were less likely to report poor cultural competence in the Doctor Communication – Health Promotion (OR 0.35, 0.21–0.60) and Trust domains (OR 0.4, 0.24–0.67), while participants with lower educational attainment were less likely to report poor cultural competence in the Trust domain (OR 0.51, 0.30–0.86). Overall, however, sociodemographic and clinical differences in reports of poor cultural competence were insignificant or inconsistent across the various domains of cultural competence examined.
Cultural competence interventions in safety-net settings should be implemented across populations, rather than being narrowly focused on specific sociodemographic or clinical groups.
The Consumer Assessments of Healthcare Providers and Systems (CAHPS®) Cultural Competence Survey assesses patients’ experiences with culturally competent care. This study evaluates the equivalence of responses to this survey across different racial and ethnic subgroups. In this study, we examined whether measurement bias on the CAHPS Cultural Competence Survey impedes valid measurement across White, Black, and Hispanic patients.
We used multiple group (MG) confirmatory factor analyses (CFA) to examine possible measurement bias across non-Hispanic White (n = 146), non-Hispanic Black (n = 148), and Hispanic (n = 339) adults. Participants came from two Medicaid managed care plans, one in New York and the other in California in 2008.
MG-CFA provided general support for the equivalence of the CAHPS Cultural Competence Survey in measuring doctor communication, health promotion and perceived trust across groups. However, we observed statistically significant differences in the thresholds associated with the Doctor Communication-Positive Behaviors. Nevertheless, sensitivity analyses indicated that measurement bias did not meaningfully influence conclusions about average experiences with culturally competent care across non-Hispanic White, non-Hispanic Black, and Hispanic patients in our sample.
Our results support the use of the CAHPS Cultural Competence Survey across non-Hispanic White, non-Hispanic Black, and Hispanic patients. Though we found some statistically significant measurement bias, sensitivity analyses demonstrated that measurement bias does not substantively influence conclusions based on patients’ responses. Health providers at various levels can place confidence in the CAHPS Cultural Competence Survey and use it in diverse populations to evaluate patients’ experiences with culturally competent care.
Cultural competence; CAHPS®; race; ethnicity; measurement equivalence
Prior studies have shown that racial/ethnic minorities have lower Consumer Assessments of Healthcare Providers and Systems (CAHPS®) scores. Perceived discrimination may mediate the relationship between race/ethnicity and patient experiences with care.
To examine the relationship between perceived discrimination based on race/ethnicity and Medicaid insurance and CAHPS® reports and ratings of care.
The study analyzed 2007 survey data from 1,509 Florida Medicaid beneficiaries. CAHPS® reports (getting needed care, timeliness of care, communication with doctor, and health plan customer service) and ratings (personal doctor, specialist care, overall health care, and health plan) of care were the primary outcome variables. Patient perceptions of discrimination based on their race/ethnicity and having Medicaid insurance were the primary independent variables. Regression analysis modeled the effect of perceptions of discrimination on CAHPS® reports and ratings controlling for age, gender, education, self-rated health status, race/ethnicity, survey language, and fee-for-service enrollment. Standard errors were corrected for correlation within plans.
Medicaid beneficiaries reporting discrimination based on race/ethnicity had lower CAHPS® scores, ranging from 15 points lower (on a 0–100 scale) for getting needed care to 6 points lower for specialist rating, compared to those who never experienced discrimination. Similar results were obtained for perceived discrimination based on Medicaid insurance.
Perceptions of discrimination based on race/ethnicity and Medicaid insurance are prevalent and are associated with substantially lower CAHPS® reports and ratings of care. Practices must develop and implement strategies to reduce perceived discrimination among patients.
Discrimination; CAHPS®; race/ethnicity; Medicaid
There is a need for reliable and valid measures of cultural competence from the patient’s perspective.
This paper evaluates the reliability and validity of the Consumer Assessments of Healthcare Providers and Systems (CAHPS®) Cultural Competence (CC) item set.
Using 2008 survey data, we assessed the internal consistency of the CAHPS CC scales using Cronbach alphas, and examined the validity of the measures using exploratory and confirmatory factor analysis, multitrait scaling analysis, and regression analysis.
A random stratified sample (based on race/ethnicity and language) of 991 enrollees, less than 65 years old, from two Medicaid managed care plans in California and New York.
CAHPS CC item set after excluding screener items and ratings.
Confirmatory factor analysis (CFI= 0.98; TLI= 0.98; RMSEA= 0.06) provided support for a seven-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 one 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 four of the eight composites. All composites were positively and significantly associated with the overall doctor rating.
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.
CAHPS; cultural competence; patient-centered care; measurement
Inequalities in access to palliative care programs (PCP) by age have been shown to exist in Canada and elsewhere. Few studies have been able to provide greater insight by simultaneously adjusting for multiple demographic, health service, and socio-cultural indicators.
To re-examine the relationship between age and registration to specialized community-based PCP programs among cancer patients and identify the multiple indicators contributing to these inequalities.
This retrospective, population-based study was a secondary data analysis of linked individual level information extracted from 6 administrative health databases and contextual (neighborhood level) data from provincial and census information. Subjects included all adults who died due to cancer between 1998 and 2003 living within 2 District Health Authorities in the province of Nova Scotia, Canada. The relationship between registration in a PCP and age was examined using hierarchical nonlinear regression modeling techniques. Identification of potential patient and ecologic contributing indicators was guided by Andersen’s conceptual model of health service utilization.
Overall, 66% of 7511 subjects were registered with a PCP. Older subjects were significantly less likely than those <65 years of age to be registered with a PCP, in particular those aged 85 years and older (adjusted odds ratio: 0.4; 95% confidence interval: 0.3–0.5). Distance to the closest cancer center had a major impact on registration.
Age continues to be a significant predictor of PCP registration in Nova Scotia even after controlling for the confounding effects of many new demographic, health service, and ecologic indicators.
PMID: 19300309 CAMSID: cams3257
aging; disparities; end-of-life care; vulnerable populations
Few studies have rigorously evaluated the associations between organizational characteristics and intervention activities of health care organizations participating in quality improvement collaboratives (QICs).
To examine the relationship between clinic characteristics and intervention activities by primary care clinics that provide HIV care and that participated in a QIC.
Cross-sectional study of Ryan White CARE Act (now called Ryan White HIV/AIDS Treatment Modernization Act) funded clinics that participated in a QIC over 16 months in 2000 and 2001. The QIC was originally planned to be a more typical 12 months long, but was extended to increase the likelihood of success. Data were collected using surveys of clinicians and administrators in participating clinics and monthly reports of clinic improvement activities.
Number of interventions attempted, percent of interventions repeated, percent of interventions evaluated, and organizational characteristics.
Clinics varied significantly in their intervention choices. Organizations with a more open culture and a greater emphasis on quality improvement attempted more interventions (P < 0.01, P < 0.05) and interventions that were more comprehensive (P < 0.01, P < 0.10). Presence of multidisciplinary teams and measurement of progress toward quantifiable goals also were associated with comprehensiveness of interventions (P < 0.01, P < 0.05).
Clinic characteristics predicted intervention activities during a QIC. Further research is needed on how these organizational characteristics affect quality of care through their influence on intervention activities.
organizational structure; quality improvement collaborative; chronic disease