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.

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.

Development of a Medicare plan dashboard to promote health equity.

OBJECTIVE: To describe a multistage process of designing and evaluating a dashboard that presents data on how equitably health plans provide care for their members. STUDY DESIGN: We designed a dashboard for presenting summative and finer-grained data to health plans for characterizing how well plans are serving individuals who belong to racial/ethnic minority groups and individuals with low income. The data presented in the dashboard were based on CMS' Health Equity Summary Score (HESS) for Medicare Advantage plans. METHODS: Interviews and listening sessions were conducted with health plan representatives and other stakeholders to assess understanding, perceived usefulness, and interpretability of HESS data. Usability testing was conducted with individuals familiar with quality measurement and reporting to evaluate dashboard design efficiency. RESULTS: Listening session participants understood the purpose of the HESS and expressed a desire for this type of information. Usability testing revealed a need to improve dashboard navigability and to streamline content. CONCLUSIONS: The HESS dashboard is a potentially useful tool for presenting data on health equity to health plans. The multistage process of continual testing and improvement used to develop the dashboard could be a model for targeting and deciding upon quality improvement efforts in the domain of health equity.

Measuring Equity in the Hospital Setting: An HCAHPS Application of the Health Equity Summary Score.

BACKGROUND: Health care quality varies by patient factors, including race-and-ethnicity and preferred language. Addressing inequities requires identifying them and incentivizing equity. OBJECTIVES: We apply an approach first implemented in the Medicare Advantage setting to measure equity in patient experiences by race-and-ethnicity [Asian American and Native Hawaiian or Pacific Islander (AA and NHPI), Black, Hispanic, vs. White] and language preference (English-preferring vs. another-language-preferring). We identify characteristics of hospitals providing high-quality equitable care. RESEARCH DESIGN: We estimated, standardized, and combined performance measures into a Health Equity Summary Score (HESS) using 2016-2019 Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey data. The HCAHPS HESS considered current cross-sectional performance, within-hospital improvement, and overall improvement by race-and-ethnicity and language preference. SUBJECTS: A total of 3333 US hospitals with 2019 HCAHPS Star Ratings. RESULTS: The HCAHPS HESS was calculable for 44% of hospitals. High-scoring (4-5 diamonds on a 1-diamond to 5-diamond scale) hospitals tended to be smaller than intermediate-scoring [3 diamonds (14% of high-scoring hospitals had <100 beds vs. 7% of intermediate-scoring hospitals, P <0.001) and were less often for-profit (20% vs. 31%, P <0.001)]. While a significant percentage (29%) of patients served by high-scoring hospitals were AA and NHPI, Black, or Hispanic, and 9% were another-language-preferring, there were smaller proportions of Black and Hispanic patients in high-scoring versus other hospitals. HESS performance was negatively associated with the percentage of patients preferring another language to English. HESS scores were moderately correlated with overall Star Ratings ( r =0.70). CONCLUSIONS: The HCAHPS HESS and practices of high-scoring hospitals could promote more equitable patient experiences.

Poor self-rated mental health and Medicare beneficiaries' routine care-seeking.

OBJECTIVES: To assess the relationship between self-rated mental health (SRMH) and infrequent routine care among Medicare beneficiaries and to investigate the roles of managed care and having a personal doctor. STUDY DESIGN: Cross-sectional analysis of data from the 2018 Medicare Consumer Assessment of Healthcare Providers and Systems survey. METHODS: Logistic regression was used to predict infrequent routine care (having not made an appointment for routine care in the last 6 months) from SRMH, Medicare coverage type (fee-for-service [FFS] vs Medicare Advantage [MA], the managed care version of Medicare), and the interaction of these variables. Models that did and did not include having a personal doctor were compared. All models controlled for demographics and physical health. RESULTS: Overall, 14.9% of beneficiaries did not make a routine care appointment in the last 6 months, with rates adjusted for demographics and physical health ranging from 14.5% for those with "excellent" SRMH to 19.2% for those with "poor" SRMH. Beneficiaries with poor SRMH were less likely to make a routine care appointment in FFS than in MA (20.1% vs 16.4%, respectively, had not done so in the last 6 months; P < .05). Accounting for having a personal doctor reduced the association between SRMH and infrequent routine care by about a third. CONCLUSIONS: Extra efforts are needed to ensure receipt of routine care by beneficiaries with poor mental health-particularly in FFS, where more should be done to ensure that beneficiaries have a personal doctor.

Patient Experience for Hispanic Older Adults Varies by Language Preference.

BACKGROUND: Hispanic people with Medicare report worse patient experiences than non-Hispanic White counterparts. However, little research examines how these disparities may vary by language preference (English/Spanish). OBJECTIVES: Using Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey data, assess whether 2014-2018 disparities in patient experiences for Hispanic people with Medicare vary by language preference. RESEARCH DESIGN: We fit a series of linear, case-mix adjusted models predicting Medicare CAHPS measures by race/ethnicity/language preference (Hispanic Spanish-respondents; Hispanic Spanish-preferring English-respondents; Hispanic English-preferring respondents; and non-Hispanic White English-respondents). SUBJECTS: A total of 1,006,543 Hispanic and non-Hispanic White respondents to the Medicare 2014-2018 CAHPS surveys. RESULTS: There were disparities for all Hispanic groups relative to non-Hispanic White English-respondents. Hispanic Spanish-preferring English-respondents reported worse experience than Hispanic Spanish-respondents for getting care quickly (-8 points), getting needed care (-5 points), doctor communication (-2 points), and customer service (-1 point), but better experiences for flu immunization (+2 points). Similarly, Hispanic Spanish-preferring English-respondents reported worse experience than Hispanic English-preferring respondents for getting care quickly (-4 points) and getting needed care (-2 points). Hispanic English-preferring respondents reported worse experience than Hispanic Spanish-respondents for getting care quickly (-4 points), getting needed care (-3 points), doctor communication and customer service (-2 points each), but better experience for flu immunization (+2 points). CONCLUSIONS: Regardless of language preference, Hispanic people with Medicare experience disparities in patient care relative to non-Hispanic White English-preferring counterparts. Hispanic Spanish-preferring English-respondents report the worse experiences, followed by Hispanic English-preferring respondents. Hispanic Spanish-respondents experienced the least disparities of the three Hispanic language subgroups.

Measuring Inconsistency in Quality Across Patient Groups to Target Quality Improvement.

BACKGROUND: Quality improvement (QI) may be aimed at improving care for all patients, or it may be targeted at only certain patient groups. Health care providers have little guidance when determining when targeted QI may be preferred. OBJECTIVES: The aim was to develop a method for quantifying performance inconsistency and guidelines for when inconsistency indicates targeted QI, which we apply to the performance of health plans for different patient groups. RESEARCH DESIGN AND MEASURES: Retrospective analysis of 7 Health Care Effectiveness Data and Information Set (HEDIS) measures of clinical care quality. SUBJECTS: All Medicare Advantage (MA) beneficiaries eligible for any of 7 HEDIS measures 2015-2018. RESULTS: MA plans with higher overall performance tended to be less inconsistent in their performance (r=-0.2) across groups defined by race-and-ethnicity and low-income status (ie, dual eligibility for Medicaid or receipt of Low-Income Subsidy). Plan characteristics were usually associated with only small differences in inconsistency. The characteristics associated with differences in consistency [eg, size, Health Maintenance Organization (HMO) status] were also associated with differences in overall performance. We identified 9 (of 363) plans that had large inconsistency in performance across groups (>0.8 SD) and investigated the reasons for inconsistency for 2 example plans. CONCLUSIONS: This newly developed inconsistency metric may help those designing and evaluating QI efforts to appropriately determine when targeted QI is preferred. It can be used in settings where performance varies across groups, which can be defined by patient characteristics, geographic areas, hospital wards, etc. Effectively targeting QI efforts is essential in today's resource-constrained health care environment.

Disparities in Care Experienced by Older Hispanic Medicare Beneficiaries in Urban and Rural Areas.

BACKGROUND: Hispanic older adults face substantial health disparities compared with non-Hispanic-White (hereafter "White") older adults. To the extent that these disparities stem from cultural and language barriers faced by Hispanic people, they may be compounded by residence in rural areas. OBJECTIVE: The objective of this study was to investigate possible interactions between Hispanic ethnicity and rural residence in predicting the health care experiences of older adults in the United States, and whether disparities in care for rural Hispanic older adults differ in Medicare Advantage versus Medicare Fee-for-Service. SUBJECTS: Medicare beneficiaries age 65 years and older who responded to the 2017-2018 nationally representative Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys. METHODS: We fit a series of linear, case-mix-adjusted models predicting Medicare CAHPS measures of patient experience (rescaled to a 0-100 scale) from ethnicity, place of residence, and Medicare coverage type. RESULTS: In all residential areas, Hispanic beneficiaries reported worse experiences with getting needed care (-3 points), getting care quickly (-4 points), and care coordination (-1 point) than White beneficiaries (all P's<0.001). In rural areas only, Hispanic beneficiaries reported significantly worse experiences than White beneficiaries on doctor communication and customer services (-3 and -9 points, respectively, P<0.05). Tests of a 3-way interaction between ethnicity, rural residence, and coverage type were nonsignificant. CONCLUSIONS: There is a need to improve access to care and care coordination for Hispanic beneficiaries overall and doctor-patient communication and customer service for rural Hispanic beneficiaries. Strategies for addressing deficits faced by rural Hispanics may involve cultural competency training and provision of language-appropriate services for beneficiaries (perhaps as telehealth services).

Do dual eligible beneficiaries experience better health care in special needs plans?

OBJECTIVE: Dual Eligible Special Needs Plans (D-SNPs) were intended to provide better care for beneficiaries eligible for both Medicare and Medicaid through better coordination of these two programs. DATA SOURCES: 671 913 dual eligible (DE) respondents to the 2009-2019 Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. STUDY DESIGN: We compared the 2015-2019 experiences of DE beneficiaries in D-SNPs relative to fee-for-service Medicare (FFS) and non-SNP Medicare Advantage (MA) using propensity-score weighted linear regression. Comparisons were made to 2009-2014. 12 patient experience measures were considered. DATA COLLECTION METHODS: Annual mail survey with telephone follow-up of non-respondents. PRINCIPAL FINDINGS: More than 65% of DE beneficiaries enrolled in FFS. Of 12 measures, D-SNP performance was higher than non-SNP MA on two (P < .05), lower than non-SNP MA on two (P < .05), and higher than FFS on four (P < .01). DE beneficiaries did not report better coordination of care in D-SNPs. D-SNP performance was often worse than other coverage types in prior periods. CONCLUSIONS: Relative to FFS Medicare, DE beneficiaries report higher immunization rates in D-SNPs, but slight or no better performance on other dimensions of patient experience. New requirements in 2021 may help D-SNPs attain their goal of better care coordination.

Incentivizing Excellent Care to At-Risk Groups with a Health Equity Summary Score.

BACKGROUND: Social risk factors (SRFs) such as minority race-and-ethnicity or low income are associated with quality-of-care, health, and healthcare outcomes. Organizations might prioritize improving care for easier-to-treat groups over those with SRFs, but measuring, reporting, and further incentivizing quality-of-care for SRF groups may improve their care. OBJECTIVE: To develop, as a proof-of-concept, a Health Equity Summary Score (HESS): a succinct, easy-to-understand score that could be used to promote high-quality care to those with SRFs in Medicare Advantage (MA) health plans, which provide care for almost twenty million older and disabled Americans and collect extensive quality measure and SRF data. DESIGN: We estimated, standardized, and combined performance scores for two sets of quality measures for enrollees in 2013-2016 MA health plans, considering both current levels of care, within-plan improvement, and nationally benchmarked improvement for those with SRFs (specifically, racial-and-ethnic minority status and dual-eligibility for Medicare and Medicaid). PARTICIPANTS: All MA plans with publicly reported quality scores and 500 or more 2016 enrollees. MAIN MEASURES: Publicly reported clinical quality and patient experience measures. KEY RESULTS: Almost 90% of plans measured for MA Star Ratings received a HESS; plans serving few patients with SRFs were excluded. The summary score was moderately positively correlated with publicly reported overall Star Ratings (r = 0.66-0.67). High-scoring plans typically had sizable enrollment of both racial-and-ethnic minorities (38-42%) and dually eligible beneficiaries (29-38%). CONCLUSIONS: We demonstrated the feasibility of developing and estimating a HESS that is intended to promote and incentivize excellent care for racial-and-ethnic minorities and dually eligible MA enrollees. The HESS measures SRF-specific performance and does not simply duplicate overall plan Star Ratings. It also identifies plans that provide excellent care to large numbers of those with SRFs. Our methodology could be extended to other SRFs, quality measures, and settings.

Disparities in Care Experienced by American Indian and Alaska Native Medicare Beneficiaries.

BACKGROUND: Little is known about the health care experiences of American Indians and Alaska Natives (AIANs) due to limited data. OBJECTIVE: The objective of this study was to investigate the health care experiences of AIAN Medicare beneficiaries relative to non-Hispanic Whites using national survey data pooled over 5 years. SUBJECTS: A total of 1,193,248 beneficiaries who responded to the nationally representative 2012-2016 Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys. METHODS: Linear regression models predicted CAHPS measures from race and ethnicity. Scores on the CAHPS measures were linearly transformed to a 0-100 range and case-mix adjusted. Three AIAN groups were compared with non-Hispanic Whites: single-race AIANs (n=2491; 0.4% of the total sample), multiple-race AIANs (n=15,502; 1.3%), and Hispanic AIANs (n=2264; 0.2%). RESULTS: Among AIAN groups, single-race AIANs were most likely to live in rural areas and areas served by the Indian Health Service; Hispanic AIANs were most likely to be Spanish-language-preferring (P's<0.05). Compared with non-Hispanic Whites, single-race AIANs reported worse experiences with getting needed care (adjusted disparity of -5 points; a "large" difference), getting care quickly (-4 points; a "medium" difference), doctor communication (-2 points; a "small" difference), care coordination (-2 points), and customer service (-7 points; P<0.001 for all comparisons). Disparities were similar for Hispanic AIANs but more limited for multiple-race AIANs. CONCLUSIONS: Quality improvement efforts are needed to reduce disparities faced by older AIANs. These findings may assist in developing targeted efforts to address cultural, communication, and health system factors presumed to underlie disparities in health care access and customer service.

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.

Indirect Estimation of Race/Ethnicity for Survey Respondents Who Do Not Report Race/Ethnicity.

BACKGROUND: Researchers are increasingly interested in measuring race/ethnicity, but some survey respondents skip race/ethnicity items. OBJECTIVES: The main objectives of this study were to investigate the extent to which racial/ethnic groups differ in skipping race/ethnicity survey items, the degree to which this reflects reluctance to disclose race/ethnicity, and the utility of imputing missing race/ethnicity. RESEARCH DESIGN: We applied a previously developed method for imputing race/ethnicity from administrative data (Medicare Bayesian Improved Surname and Geocoding 2.0) to data from a national survey where race/ethnicity was usually self-reported, but was sometimes missing. A linear mixed-effects regression model predicted the probability of self-reporting race/ethnicity from imputed racial/ethnic probabilities. SUBJECTS: In total, 508,497 Medicare beneficiaries responding to the 2013-2014 Medicare Consumer Assessment of Healthcare Providers and Systems surveys were included in this study. MEASURES: Self-reported race/ethnicity and estimated racial/ethnic probabilities. RESULTS: Black beneficiaries were most likely to not self-report their race/ethnicity (6.6%), followed by Hispanic (4.7%) and Asian/Pacific Islander (4.7%) beneficiaries. Non-Hispanic whites were the least likely to skip these items (3.2%). The 3.7% overall rate of missingness is similar to adjacent demographic items. General patterns of item missingness rather than a specific reluctance to disclose race/ethnicity appears to explain the elevated rate of missing race/ethnicity among Asian/Pacific Islander and Hispanic beneficiaries and most but not all among Black beneficiaries. Adding imputed cases to the data set did not substantially alter the estimated overall racial/ethnic distribution, but it did modestly increase sample size and statistical power. CONCLUSIONS: It may be worthwhile to impute race/ethnicity when this information is unavailable in survey data sets due to item nonresponse, especially when missingness is high.

Effects of Survey Mode on Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Survey Scores.

OBJECTIVES: To examine the effect of mode of survey administration on response rates and response tendencies for the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Survey and develop appropriate adjustments. DESIGN: Survey response data were obtained after sampling and fielding of the CAHPS Hospice Survey in 2015. Sampled caregivers and decedents were randomized to one of three modes: mail only, telephone only, and mixed mode (mail with telephone follow-up). Linear regression analysis was used to examine the effect of mode on individual responses to questions (6 composite measures and 2 global measures that examine hospice quality). SETTING: U.S. hospice programs (N = 57). PARTICIPANTS: Primary caregivers of individuals who died in hospice (N = 7,349). MEASUREMENTS: Outcomes were 8 hospice quality measures (6 composite measures, 2 global measures). Analyses were adjusted for differences in case-mix (e.g., decedent age, payer for hospice care, primary diagnosis, length of final episode of hospice care, respondent age, respondent education, relationship of decedent to caregiver, survey language, and language spoken at home) between hospices. RESULTS: Response rates were 42.6% for those randomized to mail only, 37.9%, for those randomized to telephone only, and 52.6% for those randomized to mixed mode (P < .001 for difference). There were significant mode effects (P < .05) for 10 of the 24 questions that compose the quality measures, with mail-only respondents being significantly more likely to report better experiences than telephone-only respondents. CONCLUSION: Unlike results observed in previous mode experiments for hospital CAHPS, hospice primary caregivers tend to respond more negatively by telephone than by mail. Valid comparisons of hospice performance require that reported hospice scores be adjusted for survey mode.

Racial/Ethnic Disparities in Medicare Beneficiaries' Care Coordination Experiences.

BACKGROUND: Little is known about racial/ethnic differences in the experience of care coordination. To the extent that they exist, such differences may exacerbate health disparities given the higher prevalence of some chronic conditions among minorities. OBJECTIVE: To investigate the extent to which racial/ethnic disparities exist in the receipt of coordinated care by Medicare beneficiaries. SUBJECTS: A total of 260,974 beneficiaries who responded to the 2013 Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. METHODS: We fit a series of linear, case-mix adjusted models predicting Medicare CAHPS measures of care coordination from race/ethnicity. RESULTS: Hispanic, black, and Asian/Pacific Islander (API) beneficiaries reported that their personal doctor had medical records and other relevant information about their care significantly less often than did non-Hispanic white beneficiaries (-2 points for Hispanics, -1 point for blacks, and -4 points for APIs on a 100-point scale). These 3 groups also reported significantly greater difficulty getting timely follow-up on test results than non-Hispanic white beneficiaries (-9 points for Hispanics, -1 point for blacks, -5 points for APIs). Hispanic and black beneficiaries reported that help was provided in managing their care significantly less often than did non-Hispanic white beneficiaries (-2 points for Hispanics, -3 points for blacks). API beneficiaries reported that their personal doctor discussed their medications and had up-to-date information on care from specialists significantly less often than did non-Hispanic white beneficiaries (-2 and -4 points, respectively). DISCUSSION: These results suggest a need for efforts to address racial/ethnic disparities in care coordination to help ensure high-quality care for all patients. Public reporting of plan-level performance data by race/ethnicity may also be helpful to Medicare beneficiaries and their advocates.

Diabetes and Cardiovascular Disease Risk in Cambodian Refugees.

UNLABELLED: To determine rates of diabetes, hypertension, and hyperlipidemia in Cambodian refugees, and to assess the proportion whose conditions are satisfactorily managed in comparison to the general population. Self-report and laboratory/physical health assessment data obtained from a household probability sample of U.S.-residing Cambodian refugees (N = 331) in 2010-2011 were compared to a probability sample of the adult U.S. population (N = 6,360) from the 2009-2010 National Health and Nutrition Examination Survey. Prevalence of diabetes, hypertension and hyperlipidemia in Cambodian refugees greatly exceeded rates found in the age- and gender-adjusted U.S. POPULATION: Cambodian refugees with diagnosed hypertension or hyperlipidemia were less likely than their counterparts in the general U.S. population to have blood pressure and total cholesterol within recommended levels. Increased attention should be paid to prevention and management of diabetes and cardiovascular disease risk factors in the Cambodian refugee community. Research is needed to determine whether this pattern extends to other refugee groups.

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

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

Do Experiences with Medicare Managed Care Vary According to the Proportion of Same-Race/Ethnicity/Language Individuals Enrolled in One's Contract?

OBJECTIVE: To examine whether care experiences and immunization for racial/ethnic/language minority Medicare beneficiaries vary with the proportion of same-group beneficiaries in Medicare Advantage (MA) contracts. DATA SOURCES/STUDY SETTING: Exactly 492,495 Medicare beneficiaries responding to the 2008-2009 MA Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey. DATA COLLECTION/EXTRACTION METHODS: Mixed-effect regression models predicted eight CAHPS patient experience measures from self-reported race/ethnicity/language preference at individual and contract levels, beneficiary-level case-mix adjustors, along with contract and geographic random effects. PRINCIPAL FINDINGS: As a contract's proportion of a given minority group increased, overall and non-Hispanic, white patient experiences were poorer on average; for the minority group in question, however, high-minority plans may score as well as low-minority plans. Spanish-preferring Hispanic beneficiaries also experience smaller disparities relative to non-Hispanic whites in plans with higher Spanish-preferring proportions. CONCLUSIONS: The tendency for high-minority contracts to provide less positive patient experiences for others in the contract, but similar or even more positive patient experiences for concentrated minority group beneficiaries, may reflect cultural competency, particularly language services, that partially or fully counterbalance the poorer overall quality of these contracts. For some beneficiaries, experiences may be just as positive in some high-minority plans with low overall scores as in plans with higher overall scores.