Trends in HCAHPS Survey Scores, 2008-2019: A Quality Improvement Perspective.

BACKGROUND: HCAHPS' 2008 initial public reporting, 2012 inclusion in the Hospital Value-Based Purchasing Program (HVBP), and 2015 inclusion in Hospital Star Ratings were intended to improve patient experiences. OBJECTIVES: Characterize pre-COVID-19 (2008-2019) trends in hospital consumer assessment of healthcare providers and systems (HCAHPS) scores. RESEARCH DESIGN: Describe HCAHPS score trends overall, by phase: (1) initial public reporting period (2008-2013), (2) first 2 years of HVBP (2013-2015), and (3) initial HCAHPS Star Ratings reporting (2015-2019); and by hospital characteristics (HCAHPS decile, ownership, size, teaching affiliation, and urban/rural). SUBJECTS: A total of 3909 HCAHPS-participating US hospitals. MEASURES: HCAHPS summary score (HCAHPS-SS) and 9 measures. RESULTS: The mean 2007-2019 HCAHPS-SS improvement in most-positive-category ("top-box") responses was +5.2 percentage points/pp across all hospitals (where differences of 5pp, 3pp, and 1pp are "large," "medium," and "small"). Improvement rate was largest in phase 1 (+0.8/pp/year vs. +0.2pp/year and +0.1pp/year for phases 2 and 3, respectively). Improvement was largest for Overall Rating of Hospital (+8.5pp), Discharge Information (+7.3pp), and Nurse Communication (+6.5pp), smallest for Doctor Communication (+0.8pp). Some measures improved notably through phases 2 and 3 (Nurse Communication, Staff Responsiveness, Overall Rating of Hospital), but others slowed or reversed in Phase 3 (Communication about Medicines, Quietness). Bottom-decile hospitals improved more than other hospitals for all measures. CONCLUSIONS: All HCAHPS measures improved rapidly 2008-2013, especially among low-performing (bottom-decile) hospitals, narrowing the range of performance and improving scores overall. This initial improvement may reflect widespread, general quality improvement (QI) efforts in lower-performing hospitals. Subsequent slower improvement following the introduction of HVBP and Star Ratings may have reflected targeted, resource-intensive QI in higher-performing hospitals.

Survey Protocols, Response Rates, and Representation of Underserved Patients: A Randomized Clinical Trial.

Importance: Surveys often underrepresent certain patients, such as underserved patients. Methods that improve their response rates (RRs) would help patient surveys better represent their experiences and assess equity and equity-targeted quality improvement efforts. Objective: To estimate the effect of adding an initial web mode to existing Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey protocols and extending the fielding period on RR and representativeness of underserved patient groups. Design, Setting, and Participants: This randomized clinical trial included 36 001 patients discharged from 46 US hospitals from May through December 2021. Data analysis was performed from May 2022 to September 2023. Exposures: Patients were randomized to 1 of 6 survey protocols: 3 standard HCAHPS protocols (mail only, phone only, mail-phone) plus 3 web-enhanced protocols (web-mail, web-phone, web-mail-phone). Main Outcomes and Measures: RR and number of respondents per 100 survey attempts (yield) were calculated and compared for each of the 6 survey protocols, overall, and by patient age, service line, sex, and race and ethnicity. Results: A total of 34 335 patients (median age range, 55-59 years; 59.3% female individuals and 40.7% male individuals) were eligible and included in the study. Of the respondents, 6.9% were Asian American or Native Hawaiian or Other Pacific Islander, 0.7% were American Indian or Alaska Native, 11.5% were Black, 17.4% were Hispanic, 61.0% were White, and 2.6% were multiracial. Of the 6 protocols, RRs were highest in web-mail-phone (36.5%), intermediate for the 3 two-mode survey protocols (mail-phone, web-mail, web-phone, 30.3%-31.1%), and lowest for the 2 single-mode protocols (mail only, phone only, 22.1%-24.3%). Web-mail-phone resulted in the highest yield for 3 racial and ethnic groups (Black, Hispanic, and White patients) and second highest for another (multiracial patients). Otherwise, the highest or second highest yield was almost always a 2-mode protocol. Mail only was the lowest-yield protocol for Black, Hispanic, and multiracial patients and phone-only was the lowest-yield protocol for White patients; these 2 protocols tied for lowest-yield for Asian American or Native Hawaiian or Other Pacific Islander patients. Gains from multimode approaches were often 2 to 3 times as large for Asian American or Native Hawaiian or Other Pacific Islander, Black, Hispanic, and multiracial patients as for White patients. Web-mail-phone had the highest RR for 6 of 8 age groups and 4 of 5 combinations of service line and sex. Conclusions and Relevance: In this randomized clinical trial, web-first multimode survey protocols significantly improved the RR and representativeness of patient surveys. The best-performing protocol based on RR and representativeness was web-mail-phone. Web-phone performed well for young and diverse patient populations, and web-mail for older and less diverse patient populations. The US Centers for Medicare & Medicaid Services will allow hospitals to use the web-mail, web-phone, and web-mail-phone protocols for HCAHPS administration beginning in 2025.

Interventions and Hospital Characteristics Associated With Patient Experience: An Update of the Evidence.

Patient experience is a key hospital quality measure. We review and characterize the literature on interventions, care and management processes, and structural characteristics associated with better inpatient experiences as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. Prior reviews identified several promising interventions. We update these previous efforts by including more recent peer-reviewed literature and expanding the review's scope to include observational studies of HCAHPS measures with process measures and structural characteristics. We used PubMed to identify U.S. English-language peer-reviewed articles published in 2017 to 2020 and focused on hospital patient experience. The two HCAHPS domains for which we found the fewest potential quality improvement interventions were Communication with Doctors and Quietness. We identified several modifiable processes that could be rigorously evaluated in the future, including electronic health record patient engagement functionality, care management processes, and nurse-to-patient ratios. We describe implications for future policy, practice, and research.

Do Hospital Characteristics Predict Racial-and-Ethnic Disparities in Patient Experience? National Results From the HCAHPS Survey.

OBJECTIVE: Assess whether hospital characteristics associated with better patient experiences overall are also associated with smaller racial-and-ethnic disparities in inpatient experience. BACKGROUND: Hospitals that are smaller, non-profit, and serve high proportions of White patients tend to be high-performing overall, but it is not known whether these hospitals also have smaller racial-and-ethnic disparities in care. RESEARCH DESIGN: We used linear mixed-effect regression models to predict a summary measure that averaged eight Hospital CAHPS (HCAHPS) measures (Nurse Communication, Doctor Communication, Staff Responsiveness, Communication about Medicines, Discharge Information, Care Coordination, Hospital Cleanliness, and Quietness) from patient race-and-ethnicity, hospital characteristics (size, ownership, racial-and-ethnic patient-mix), and interactions of race-and-ethnicity with hospital characteristics. SUBJECTS: Inpatients discharged from 4,365 hospitals in 2021 who completed an HCAHPS survey ( N =2,288,862). RESULTS: While hospitals serving larger proportions of Black and Hispanic patients scored lower on all measures, racial-and-ethnic disparities were generally smaller for Black and Hispanic patients who received care from hospitals serving higher proportions of patients in their racial-and-ethnic group. Experiences overall were better in smaller and non-profit hospitals, but racial-and-ethnic differences were slightly larger. CONCLUSIONS: Large, for-profit hospitals and hospitals serving higher proportions of Black and Hispanic patients tend to be lower performing overall but have smaller disparities in patient experience. High-performing hospitals might look at low-performing hospitals for how to provide less disparate care whereas low-performing hospitals may look to high-performing hospitals for how to improve patient experience overall.

Changes in Patient Experiences of Hospital Care During the COVID-19 Pandemic.

Importance: It is important to assess how the COVID-19 pandemic was adversely associated with patients' care experiences. Objective: To describe differences in 2020 to 2021 patient experiences from what would have been expected from prepandemic (2018-2019) trends and assess correlates of changes across hospitals. Design, Setting, and Participants: This cohort study compared 2020 to 2021 data with 2018 to 2019 data from 3 900 887 HCAHPS respondents discharged from 3381 HCAHPS-participating US hospitals. The data were analyzed from 2022 to 2023. Main Outcomes and Measures: The primary outcome was an HCAHPS summary score (HCAHPS-SS), which averaged 10 HCAHPS measures. The primary analysis estimated whether HCAHPS scores from patients discharged from 2020 to 2021 differed from scores that would be expected based on quarterly and linear trends from 2018 to 2019 discharges. Secondary analyses stratified hospitals by prepandemic overall star ratings and staffing levels. Results: Of the 3 900 887 HCAHPS 2020 to 2021 respondents, 59% were age 65 years or older, and 35% (11%) were in the surgical (maternity) service lines. Compared with trends expected based on prepandemic (2018-2019) data, HCAHPS-SS was 1.2 percentage points (pp) lower for quarter (Q) 2/2020 discharges and -1.9 to -2.0 pp for Q3/2020 to Q1/2021, which then declined to -3.6 pp by Q4/2021. The most affected measures (Q4/2021) were staff responsiveness (-5.6 pp) and cleanliness (-4.9 pp); the least affected were discharge information (-1.6 pp) and quietness (-1.8 pp). Overall rating and hospital recommendation measures initially exhibited smaller-than-average decreases, but then fell as much as the more specific experience measures by Q2/2021. Quietness did not decline until Q2/2021. The HCAHPS-SS fell most for hospitals with the lowest prepandemic staffing levels; hospitals with bottom-quartile staffing showed the largest decrements, whereas top-quartile hospitals showed smaller decrements in most quarters. Hospitals with better overall prepandemic quality showed consistently smaller HCAHPS-SS drops, with effects for 5-star hospitals about 25% smaller than for 1-star and 2-star hospitals. Conclusions and Relevance: The results of this cohort study of HCAHPS-participating hospitals found that patient experience scores declined during 2020 to 2021. By Q4/2021, the HCAHPS-SS was 3.6 pp lower than would have been expected, a medium effect size. The most affected measures (staff responsiveness and cleanliness) showed large effect sizes, possibly reflecting high illness-associated hospital workforce absenteeism. Hospitals that were lower performing and less staffed prepandemic may have been less resilient to reduced staff availability and other pandemic-associated challenges. However, by Q4/2021, even prepandemic high-performing hospitals had similar declines.

The hospital care experiences of older patients compared to younger patients.

BACKGROUND: Hospitals may provide less positive patient experiences for older than younger patients. METHODS: We used 2019 HCAHPS data from 4358 hospitals to compare patient-mix adjusted HCAHPS Survey scores for 19 experience of care items for patients ages 75+ versus 55-74 years and tested for interactions of age group with patient and hospital characteristics. We contrasted the age patterns observed for inpatient experiences with those among respondents to the 2019 Medicare CAHPS (MCAHPS) Survey of overall experience. RESULTS: Patients 75+ years (31% of all HCAHPS respondents) reported less-positive experiences than those 55-74 (46% of respondents) for 18 of 19 substantive HCAHPS items (mean difference -3.3% points). Age differences in HCAHPS top-box scores were large (>5 points) for 1 of 3 Nurse Communication items, 1 of 3 Doctor Communication, 2 of 2 Communication about Medication items, 1 of 2 Discharge Information items, and 2 of 3 Care Transition items. In contrast, for MCAHPS, those 75+ reported similar experiences to younger adults. The magnitude of age differences varied considerably across hospitals; some hospitals had very large age disparities for older patients (age 75+ vs. ages 55-74), while others had none. These age differences were generally smaller for patients in government and non-profit than in for-profit hospitals, and in the Pacific region than in other parts of the United States. This variation in age disparities across hospitals may help to identify best practices. CONCLUSIONS: Patients ages 75+ reported less-positive experiences than patients ages 55-74, especially for measures of communication. These differences may be specific to inpatient care. Further study should investigate the effectiveness of hospital staffs' communication with older patients. Hospital protocols designed for younger patients may need to be adjusted to meet the needs of older patients. There may also be opportunities to learn from outpatient interactions with older patients.

Inpatient care experiences differ by preferred language within racial/ethnic groups.

OBJECTIVE: To describe differences in patient experiences of hospital care by preferred language within racial/ethnic groups. DATA SOURCE: 2014-2015 HCAHPS survey data. STUDY DESIGN: We compared six composite measures for seven languages (English, Spanish, Russian, Portuguese, Chinese, Vietnamese, and Other) within applicable subsets of five racial/ethnic groups (Hispanics, Asian/Pacific Islanders, American Indian/Alaska Natives, Blacks, and Whites). We measured patient-mix adjusted overall, between- and within-hospital differences in patient experience by language, using linear regression. DATA COLLECTION METHODS: Surveys from 5 480 308 patients discharged from 4517 hospitals 2014-2015. PRINCIPAL FINDINGS: Within each racial/ethnic group, mean reported experiences for non-English-preferring patients were almost always worse than their English-preferring counterparts. Language differences were largest and most consistent for Care Coordination. Within-hospital differences by language were often larger than between-hospital differences and were largest for Care Coordination. Where between-hospital differences existed, non-English-preferring patients usually attended hospitals whose average patient experience scores for all patients were lower than the average scores for the hospitals of their English-preferring counterparts. CONCLUSIONS: Efforts should be made to increase access to better hospitals for language minorities and improve care coordination and other facets of patient experience in hospitals with high proportions of non-English-preferring patients, focusing on cultural competence and language-appropriate services.

Adapting the Vulnerable Elders Survey-13 to Predict Mortality Using Responses to the Medicare Health Outcomes Survey.

OBJECTIVES: To use items from the Medicare Health Outcomes Survey (HOS) to adapt or validate a simple method for identifying community-dwelling older adults at greater risk of death and to extend the method to identify a very high-risk group. DESIGN: Analysis of longitudinal data. SETTING: National sample of beneficiaries from Medicare Advantage plans with 500 or more enrollees. PARTICIPANTS: Medicare beneficiaries aged 65 and older responding to 2009 baseline and 2011 follow-up HOS (N = 238,687). MEASUREMENTS: Bivariate and multivariate analyses of the HOS; adaptation and validation of a previously validated Vulnerable Elders Survey-13 (VES-13) scoring system that uses age and self-reported function to predict mortality. RESULTS: A modified predictive model, that uses substitutes for several items in the previously validated VES-13, predicted 2-year mortality; 10.6% of those scoring 3 or more, and 2.4% of those scoring less than 3 died within 2 years (relative risk of death 4.4, similar to 4.2 for the original VES-13 sample), and 15.5% of those scoring 7 or more died within 2 years (relative risk of death (relative to scores <3) of 6.5). Sixteen percent of HOS beneficiaries were missing some data; 2-year mortality for those with missing items was 9.5%, versus 7.1% for those with no missing items (P < .001). Imputation of median values for missing VES-13 items results in valid predictions of mortality for those with partially missing data. CONCLUSION: The VES-13 algorithm is robust to substitution of functional items and can be used to identify very high-risk older adults. Multiple imputation of missing items reduces loss-to-follow-up bias and increases sample size.

Understanding The Role Played By Medicare's Patient Experience Points System In Hospital Reimbursement.

In 2015 the Medicare Hospital Value-Based Purchasing (VBP) program paid hospitals $1.4 billion in performance-based incentives; 30 percent of a hospital's VBP Total Performance Score was based on performance on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) measures of the patient experience of care. Hospitals receive patient experience points based on three components: achievement, improvement, and consistency. For 2015 we examined how the three components affected reimbursement for 3,152 hospitals, including their impact on low-performing and high-minority hospitals. Achievement accounted for 96 percent of the differences among hospitals in total HCAHPS points. Although achievement had the biggest influence on payments, payments related to improvement and consistency were more beneficial for low-performing hospitals that disproportionately served minority patients. The findings highlight the important inducement that paying for improvement provides to initially low-performing hospitals to improve care and the role this incentive structure plays in minimizing resource redistributions away from hospitals serving minority populations. Additional emphasis on improvement points could benefit hospitals serving disadvantaged patients.

Accelerating Improvement and Narrowing Gaps: Trends in Patients' Experiences with Hospital Care Reflected in HCAHPS Public Reporting.

OBJECTIVE: Measure HCAHPS improvement in hospitals participating in the second and fifth years of HCAHPS public reporting; determine whether change is greater for some hospital types. DATA: Surveys from 4,822,960 adult inpatients discharged July 2007-June 2008 or July 2010-June 2011 from 3,541 U.S. hospitals. STUDY DESIGN: Linear mixed-effect regression models with fixed effects for time, patient mix, and hospital characteristics (bedsize, ownership, Census division, teaching status, Critical Access status); random effects for hospitals and hospital-time interactions; fixed-effect interactions of hospital characteristics and patient characteristics (gender, health, education) with time predicted HCAHPS measures correcting for regression-to-the-mean biases. DATA COLLECTION METHODS: National probability sample of adult inpatients in any of four approved survey modes. PRINCIPAL FINDINGS: HCAHPS scores increased by 2.8 percentage points from 2008 to 2011 in the most positive response category. Among the middle 95 percent of hospitals, changes ranged from a 5.1 percent decrease to a 10.2 percent gain overall. The greatest improvement was in for-profit and larger (200 or more beds) hospitals. CONCLUSIONS: Five years after HCAHPS public reporting began, meaningful improvement of patients' hospital care experiences continues, especially among initially low-scoring hospitals, reducing some gaps among hospitals.

Health-related quality of life and quality of care in specialized medicare-managed care plans.

Special needs plans (SNPs) were created under the Medicare Modernization Act of 2003 to focus on Medicare beneficiaries who required more coordination of care than most beneficiaries served through the Medicare Advantage program. This research indicates that beneficiaries in 3 types of SNPs show evidence of worse health-related quality of life. Special needs plans demonstrated worse plan performance on the HEDIS osteoporosis testing in older women measure compared with non-SNP Medicare Advantage beneficiaries, but better plan performance on the HEDIS fall risk management measure. Future research should consider broader measures of plan performance, quality of care, and cost.

Obesity utilization and health-related quality of life in Medicare enrollees.

The obese, with disproportionate chronic disease incidence, consume a large share of health care resources and drive up per capita Medicare spending. This study examined the prevalence of obesity and its association with health status, health-related quality of life (HRQOL), function, and outpatient utilization among Medicare Advantage seniors. Results indicate that obese beneficiaries, much more than overweight beneficiaries, have poorer health, functions, and HRQOL than normal weight beneficiaries and have substantially higher outpatient utilization. While weight loss is beneficial to both the overweight and obese, the markedly worse health status and high utilization of obese beneficiaries may merit particular attention.

A randomized experiment investigating the suitability of speech-enabled IVR and Web modes for publicly reported surveys of patients' experience of hospital care.

The HCAHPS Survey obtains hospital patients' experiences using four modes: Mail Only, Phone Only, Mixed (mail/phone follow-up), and Touch-Tone (push-button) Interactive Voice Response with option to transfer to live interviewer (TT-IVR/Phone). A new randomized experiment examines two less expensive modes: Web/Mail (mail invitation to participate by Web or request a mail survey) and Speech-Enabled IVR (SE-IVR/Phone; speaking to a voice recognition system; optional transfer to an interviewer). Web/Mail had a 12% response rate (vs. 32% for Mail Only and 33% for SE-IVR/Phone); Web/Mail respondents were more educated and less often Black than Mail Only respondents. SE-IVR/Phone respondents (who usually switched to an interviewer) were less often older than 75 years, more often English-preferring, and reported better care than Mail Only respondents. Concerns regarding inconsistencies across implementations, low adherence to primary modes, or low response rate may limit the applicability of the SE-IVR/Phone and Web/Mail modes in HCAHPS and similar standardized environments.

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.

Hospital survey shows improvements in patient experience.

Hospitals are improving the inpatient care experience. A government survey that measures patients' experiences with a range of issues from staff responsiveness to hospital cleanliness-the Hospital Consumer Assessment of Healthcare Providers and Systems survey-is showing modest but meaningful gains. Using data from the surveys reported in March 2008 and March 2009, we present the first comprehensive national assessment of changes in patients' experiences with inpatient care since public reporting of the results began. We found improvements in all measures of patient experience, except doctors' communication. These improvements were fairly uniform across hospitals. The largest increases were in measures related to staff responsiveness and the discharge information that patients received.

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.

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.

Characteristics of hospitals demonstrating superior performance in patient experience and clinical process measures of care.

Prior research suggests hospital quality of care is multidimensional. In this study, the authors jointly examine patient experience of care and clinical care measures from 2,583 hospitals based on inpatients discharged in 2006 and 2007. The authors use multinomial logistic regression to identify key characteristics of hospitals that perform in the top quartile on both, either, and neither dimension of quality. Top performers on both quality measures tend to be small (<100 beds), large (>200 beds) and rural, located in the New England or West North Central Census divisions, and nonprofit. Top performers in patient experience only are most often small and rural, located in the East South Central division, and government owned. Top performers in clinical care only are most often medium to large and urban, located in the West North Central division, and non-government owned. These findings provide an overview of how these dimensions of quality vary across hospitals.

Development, implementation, and public reporting of the HCAHPS survey.

The authors describe the history and development of the CAHPS Hospital Survey (also known as HCAHPS) and its associated protocols. The randomized mode experiment, vendor training, and "dry runs" that set the stage for initial public reporting are described. The rapid linkage of HCAHPS data to annual payment updates ("pay for reporting") is noted, which in turn led to the participation of approximately 3,900 general acute care hospitals (about 90% of all such United States hospitals). The authors highlight the opportunities afforded by this publicly reported data on hospital inpatients' experiences and perceptions of care. These data, reported on www.hospitalcompare.hhs. gov, facilitate the national comparison of patients' perspectives of hospital care and can be used alone or in conjunction with other clinical and outcome measures. Potential benefits include increased transparency, improved consumer decision making, and increased incentives for the delivery of high-quality health care.

Utilization of the propensity score method: an exploratory comparison of proxy-completed to self-completed responses in the Medicare Health Outcomes Survey.

BACKGROUND: This research examined the use of the propensity score method to compare proxy-completed responses to self-completed responses in the first three baseline cohorts of the Medicare Health Outcomes Survey, administered in 1998, 1999, and 2000, respectively. A proxy is someone other than the respondent who completes the survey for the respondent. METHODS: The propensity score method of matched sampling was used to compare proxy and self-completed responses. A propensity score is a value that equals the estimated probability of a given individual belonging to a treatment group given the observed background characteristics of that individual. Proxy and self-completed responses were compared on demographics, the SF-36, chronic conditions, activities of daily living, and depression-screening questions. For each individual survey respondent, logistic regression was used to calculate the probability that this individual belonged to the proxy respondent group (propensity score). Pre and post adjustment comparisons were tested by calculating effect sizes. RESULTS: Differences between self and proxy-completed responses were substantially reduced with the use of the propensity score method. However, differences were still found in the SF-36, several demographics, several impaired activities of daily living, several chronic conditions, and one depression-screening question. CONCLUSION: The propensity score method helped to reduce differences between proxy-completed and self-completed survey responses, thereby providing an approximation to a randomized controlled experiment of proxy-completed versus self-completed survey responses.