Effects of Caregiver and Decedent Characteristics on CAHPS Hospice Survey Scores.

CONTEXT: The Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Hospice Survey assesses the care experiences of hospice patients and their families. Public reporting of hospice performance on these survey measures began in February 2018. OBJECTIVES: Develop an appropriate case-mix adjustment (CMA) model to allow for fair comparisons between hospices. METHODS: We analyzed CAHPS Hospice Survey data reflecting experiences of 915,442 patients who received care from 2513 hospice programs between April 2015 and March 2016. Decedent and caregiver characteristics were identified for inclusion in CMA based on their variation across hospices (as measured by intraclass correlation coefficients [ICCs]) and how predictive they were of responses to survey questions (as assessed by linear regression). RESULTS: The final CMA model included decedent age, payer for hospice care, primary diagnosis, length of final episode of hospice care, caregiver age, caregiver education, relationship to decedent, survey language/language spoken at home, and response percentile. The characteristics that varied most across hospices were language (ICC = 0.48 for Spanish survey or home language) and payer for hospice care (ICC = 0.42 for Medicare only; ICC = 0.35 for Medicare and private insurance). The characteristics that were most predictive of caregivers' survey responses were payer for hospice care, caregiver education, and survey language/language spoken at home. Lack of appropriate adjustment would incorrectly rank hospices by 1.2-5.4 percentile points. CONCLUSION: To ensure fair comparisons across hospices, CAHPS Hospice Survey measure scores should be adjusted for several caregiver and decedent characteristics.

Challenges Of Measuring Quality Of Community-Based Programs For Seriously Ill Individuals And Their Families.

For many individuals and their families, acknowledging and confronting a serious illness such as cancer or advanced heart failure is a sentinel life event. From a health policy perspective, many individuals confronting such illnesses are high-need, high-cost patients who are increasingly cared for by community-based programs that may have competing goals: improving quality and reducing costs. Providing care to high-need, high-cost patients tests a health care system's ability to coordinate care and adapt to highly variable disease trajectories that could result in improved health for some, sudden and unexpected death for others, and a prolonged period of functional impairment for the majority. With the rapid growth in the number of community-based programs, efforts are needed to ensure transparency and accountability for this vulnerable population. In this article we outline the challenges in measuring quality of care for seriously ill patients, offer potential solutions, and call for new research to produce quality measures that ensure accountability for the care provided to seriously ill individuals and their families.

Black And Hispanic Patients Receive Hospice Care Similar To That Of White Patients When In The Same Hospices.

Little is known about racial and ethnic variation in the quality of hospice care. We used data on 292,516 respondents for 2015-16 from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Survey to assess how the patient and family experience of hospice care differed among black, Hispanic, and white patients. We found that, on average, black and Hispanic patients received care from poorer quality hospices. Within a given hospice, we found that friends and relatives who served as caregivers of black and Hispanic patients reported significantly better hospice care experiences than their peers serving as caregivers of white patients on five of seven outcomes. However, caregivers of black and Hispanic patients reported receiving their desired level of emotional and religious support less often than caregivers of white patients did. As more black and Hispanic patients enroll in hospice care, it is critical to ensure that they have access to high-quality, culturally competent hospice services.

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.

Effects of direct-to-consumer advertising and clinical guidelines on appropriate use of human papillomavirus DNA tests.

BACKGROUND: Both clinical guidelines and direct-to-consumer (DTC) advertising influence the use of new health care technologies, but little is known about their relative effects. The introduction of a cervical cancer screening test in 2000 offered a unique opportunity to assess the 2 strategies. OBJECTIVE: To evaluate the effects of clinical guidelines and a targeted DTC advertising campaign on overall and appropriate use of human papillomavirus (HPV) DNA tests. RESEARCH DESIGN: Quasi-experimental study using difference-in-differences analysis. Data were MarketScan private insurance claims for 500,000 women aged 21 to 64 enrolled at least 12 consecutive months from January 2001 through December 2005. RESULTS: Both clinical guidelines and DTC advertising were associated with increases in overall HPV DNA test use. DTC advertising was associated with a statistically significant increase in HPV DNA test use in 2 groups of DTC cities (+5.57%, P < 0.0001; +2.54%, P < 0.0001). DTC advertising was associated with comparable increases in the probability of appropriate and inappropriate use of the HPV DNA test in primary screening. Clinical guideline releases from the American College of Obstetricians and Gynecologists, and by a cosponsored panel, were associated with greater increases in HPV DNA tests for appropriate primary screening than for inappropriate primary screening (ß = 0.3347, P < 0.05 and ß = 0.4175, P < 0.01). CONCLUSIONS: DTC advertising was associated with increased overall use of a cervical cancer screening test, whereas clinical guidelines were differentially associated with increased appropriate use. These findings suggest distinct influences of consumer marketing and professional guidelines on the use of health care products and services.

Association between physician specialty and uptake of new medical technologies: HPV tests in Florida Medicaid.

BACKGROUND: It is well established that specialists often adopt new medical technologies earlier than generalists, and that racial and ethnic minority patients are less likely than White patients to receive many procedures and prescription drugs. However, little is known about the role that specialists or generalists may play in reducing racial and ethnic disparities in uptake of new medical technologies. Human papillomavirus (HPV) DNA tests, introduced as a cervical cancer screening tool in 2000, present a rich context for exploring patterns of use across patient and provider subgroups. OBJECTIVE: To identify patient characteristics and the provider specialty associated with overall and appropriate use of HPV DNA tests over time, and to examine the associations between clinical guidelines and adoption of the test in an underserved population. DESIGN: Retrospective longitudinal study using Florida Medicaid administrative claims data. PARTICIPANTS: Cervical cancer screening test claims for 415,239 female beneficiaries ages 21 to 64 from July 2001 through June 2006. MAIN MEASURES: Overall and appropriate use of HPV DNA tests. KEY RESULTS: Although minority women were initially less likely than White women to receive HPV DNA tests, test use grew more rapidly among Black and Hispanic women compared to White women. Obstetricians/gynecologists were significantly more likely than primary care providers to administer HPV DNA tests. Release of the first set of clinical guidelines was associated with a large increase in the use of HPV DNA tests (adjusted odds ratio: 2.46, p<0.0001); subsequent guidelines were associated with more modest increases. CONCLUSIONS: Uptake of new cervical cancer screening protocols can occur quickly among traditionally underserved groups and may be aided by early adoption by specialists.

Factors in quality care--the case of follow-up to abnormal cancer screening tests--problems in the steps and interfaces of care.

To achieve the benefit of cancer screening, appropriate follow-up of abnormal screening test results must occur. Such follow-up requires traversing the transition between screening detection and diagnosis, including several steps and interfaces in care. This article reviews factors and interventions associated with follow-up of abnormal tests for cervical, breast and colorectal cancers. We synthesized 12 reviews of descriptive and intervention studies published between 1980 and 2008. There was wide variability in definition of follow-up, setting, study population, and reported prevalence rates. Correlates of follow-up included patient characteristics (eg, knowledge and age), social support, provider characteristics, practice (eg, having reminders systems), community and professional norms (eg, quality measures), and policy (eg, federal programs). Effective interventions included patient education and support; delivery systems design changes, such as navigation; and information system changes, most notably patient tracking and physician reminders. Few studies focused explicitly on interfaces and steps of care, such as communication between primary care and specialists, or simultaneously targeted the multilevel factors that affect care. Future practice and research priorities should include development of clear operational definitions of the steps and interfaces related to patients, providers, and organizations; reflect evolving guidelines and new technologies; determine priorities for intervention testing; and improve measures and apply appropriate study designs.