Less Use of Extreme Response Options by Asians to Standardized Care Scenarios May Explain Some Racial/Ethnic Differences in CAHPS Scores.

BACKGROUND: Asian Americans (hereafter "Asians") generally report worse experiences with care than non-Latino whites (hereafter "whites"), which may reflect differential use of response scales. Past studies indicate that Asians exhibit lower Extreme Response Tendency (ERT)-they less frequently use responses at extreme ends of the scale than whites. OBJECTIVE: To explore whether lower ERT is observed for Asians than whites in response to standardized vignettes depicting patient experiences of care and whether ERT might in part explain Asians reporting worse care than whites. PROCEDURE: A representative US sample (n=575 Asian; n=505 white) was presented with 5 written vignettes describing doctor-patient encounters with differing levels of physician responsiveness. Respondents evaluated the encounters using modified CAHPS communication questions. RESULTS: Case-mix-adjusted repeated-measures multivariate models show that Asians provided more positive responses than whites to several vignettes with less-responsive physicians but less positive responses than whites for the vignette with the most physician responsiveness (P<0.01 for each). While all respondents provided more positive ratings for vignettes with greater physician responsiveness, the increase was 15% less for Asian than white respondents. CONCLUSIONS: Asians exhibit lower ERT than whites in response to standardized scenarios. Because CAHPS reponses are predominantly near the positive end of the scale and the most responsive scenario is most typical of the score observed in real-world settings, lower ERT in Asians may partially explain observations of lower observed mean CAHPS scores for Asians in real-world settings. Case-mix adjustment for Asian race/ethnicity or its correlates may improve quality of care measurement.

Use of CAHPS patient experience surveys to assess the impact of health care innovations.

BACKGROUND: The Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys are the standard for collecting information about patient experience of care in the United States. However, despite their widespread use, including in pay-for-performance and public reporting efforts and various provisions of the Affordable Care Act, knowledge about the use of CAHPS in assessing the impact of quality improvement efforts is limited. A study was conducted to examine the use of patient experience surveys in assessing the impact of innovations implemented in health care settings. METHODS: Innovation profiles identified on the Agency for Healthcare Research and Quality (AHRQ) Health Care Innovations Exchange website that included patient experience (including patient satisfaction) as an outcome (N = 201), were analyzed with a variety of qualitative analysis methods. RESULTS: Fewer than half of the innovations used a patient experience measure, most commonly employing global measures such as an overall rating. Most innovations assessed patient experience at a single time point, with only one third using techniques such as pre-post comparisons, time trends, or comparisons to control groups. Ten domains of measures addressed reports of patient experience, all of which could be assessed by existing CAHPS instruments. Similarly, CAHPS measures are available to assess all of the organizational processes that are addressed by innovations in the profiles and for which patients are the best source of information. While 120 of the innovations that use patient experience measures report using surveys to collect these data, only 6 reported using a CAHPS measure. CONCLUSIONS: Although innovations targeting quality improvement are often evaluated using surveys, there is considerable untapped potential for using CAHPS measures or surveys to assess their effectiveness.

Racial/Ethnic differences in Medicare experiences and immunization: the role of disease burden.

BACKGROUND: Although Medicare provides beneficiaries with primary access to the health care system, racial/ethnic disparities in health care experiences and preventive care are well documented in the Medicare population. OBJECTIVE: To investigate disease burden and its possible impact on racial/ethnic health disparities for measures of secondary and tertiary access to health care, such as access to health plan information, obtaining recommended care in a timely manner, and immunization. SUBJECTS: A total of 355,874 beneficiaries over the age of 64 years who responded to the 2008 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 patient experience and immunization from race/ethnicity, a 0 to 6 count of disease burden, and their interaction. RESULTS: Disparities between non-Hispanic whites and other racial/ethnic groups are largest among beneficiaries with no major health conditions. Disparities between whites and other racial/ethnic groups on getting care quickly and immunization are mitigated at higher levels of disease burden. Disparities persist at higher levels of disease burden for getting information from one's health plan. DISCUSSION: Whites have better overall access to care than other beneficiaries with Medicare in the absence of major health conditions. Disparities in getting care quickly and immunizations are smaller among beneficiaries with greater disease burden, perhaps as a function of integration into the health care system gained through management of health issues. These results underscore the importance of outreach to minorities with low utilization and few or no major health conditions.

Health information management and perceptions of the quality of care for children with tracheotomy: a qualitative study.

BACKGROUND: Children with tracheotomy receive health care from an array of providers within various hospital and community health system sectors. Previous studies have highlighted substandard health information exchange between families and these sectors. The aim of this study was to investigate the perceptions and experiences of parents and providers with regard to health information management, care plan development and coordination for children with tracheotomy, and strategies to improve health information management for these children. METHODS: Individual and group interviews were performed with eight parents and fifteen healthcare (primary and specialty care, nursing, therapist, equipment) providers of children with tracheotomy. The primary tracheotomy-associated diagnoses for the children were neuromuscular impairment (n = 3), airway anomaly (n = 2) and chronic lung disease (n = 3). Two independent reviewers conducted deep reading and line-by-line coding of all transcribed interviews to discover themes associated with the objectives. RESULTS: Children with tracheotomy in this study had healthcare providers with poorly defined roles and responsibilities who did not actively communicate with one another. Providers were often unsure where to find documentation relating to a child's tracheotomy equipment settings and home nursing orders, and perceived that these situations contributed to medical errors and delayed equipment needs. Parents created a home record that was shared with multiple providers to track the care that their children received but many considered this a burden better suited to providers. Providers benefited from the parent records, but questioned their accuracy regarding critical tracheotomy care plan information such as ventilator settings. Parents and providers endorsed potential improvement in this environment such as a comprehensive internet-based health record that could be shared among parents and providers, and between various clinical sites. CONCLUSIONS: Participants described disorganized tracheotomy care and health information mismanagement that could help guide future investigations into the impact of improved health information systems for children with tracheotomy. Strategies with the potential to improve tracheotomy care delivery could include defined roles and responsibilities for tracheotomy providers, and improved organization and parent support for maintenance of home-based tracheotomy records with web-based software applications, personal health record platforms and health record data authentication techniques.

Emergency department care in the United States: a profile of national data sources.

STUDY OBJECTIVE: Emergency departments (EDs) are an integral part of the US health care system, and yet national data sources on the care received in the ED are poorly understood, thereby limiting their usefulness for analyses. We provide a comparison of data sources that can be used to examine utilization and quality of care in the ED nationally. DATA SOURCES AND COMPARISONS: This article compares 7 data sources available in 2005 for conducting analyses of ED encounters: the American Hospital Association Annual Survey Database(), Hospital Market Profiling Solution(c), National Emergency Department Inventory, Nationwide Emergency Department Sample, National Hospital Ambulatory Medical Care Survey, National Electronic Injury Surveillance System-All-Injury Program, and the National Health Interview Survey. In addition to describing the type and scope of data collection, available characteristics, and sponsor of the ED data sources, we compare (where possible) estimates of the total number of EDs, national and regional volume of ED visits, national and regional admission rates (percentage of ED visits resulting in hospital admission), patient characteristics, hospital characteristics, and reasons for visit generated by the various data sources. MAJOR FINDINGS: The different data sources yielded estimates of the number of EDs that ranged from 4,609 to 4,884 and the number of ED encounters from more than 109 million to more than 116 million. Admission rates across data sources varied from 12.0% to 15.3%. Although comparisons of the 7 data sources were somewhat limited by differences in available information and operational definitions, variation in estimates of utilization and patterns of care existed by region, expected payer, and patient and hospital characteristics. The rankings and estimates of the top 5 first-listed conditions seen in the ED are relatively consistent between the 2 data sources with diagnoses, although the Nationwide Emergency Department Sample estimates 1.3 to 5.8 times more ED visits for each chronic and acute all-listed condition examined relative to the National Hospital Ambulatory Medical Care Survey. CONCLUSION: Each of the data sources described in this article has unique advantages and disadvantages when used to examine patterns of ED care, making the different data sources appropriate for different applications. Analysts should select a data source according to its construction and should bear in mind its strengths and weaknesses in drawing conclusions based on the estimates it yields.

Responses of Massachusetts hospitals to a state mandate to collect race, ethnicity and language data from patients: a qualitative study.

BACKGROUND: A Massachusetts regulation implemented in 2007 has required all acute care hospitals to report patients' race, ethnicity and preferred language using standardized methodology based on self-reported information from patients. This study assessed implementation of the regulation and its impact on the use of race and ethnicity data in performance monitoring and quality improvement within hospitals. METHODS: Thematic analysis of semi-structured interviews with executives from a representative sample of 28 Massachusetts hospitals in 2009. RESULTS: The number of hospitals using race, ethnicity and language data internally beyond refining interpreter services increased substantially from 11 to 21 after the regulation. Thirteen of these hospitals were utilizing patient race and ethnicity data to identify disparities in quality performance measures for a variety of clinical processes and outcomes, while 16 had developed patient services and community outreach programs based on findings from these data. Commonly reported barriers to data utilization include small numbers within categories, insufficient resources, information system requirements, and lack of direction from the state. CONCLUSIONS: The responses of Massachusetts hospitals to this new state regulation indicate that requiring the collection of race, ethnicity and language data can be an effective method to promote performance monitoring and quality improvement, thereby setting the stage for federal standards and incentive programs to eliminate racial and ethnic disparities in the quality of health care.

Reducing disparities and improving quality: understanding the needs of small primary care practices.

OBJECTIVES: Small practices provide a significant proportion of care in the United States and should be an essential focus of efforts to reduce racial/ethnic disparities and improve the quality of care for minority patients. This project sought to identify the resources and tools small practices need to conduct quality improvement activities to reduce disparities. DESIGN: We surveyed small practices about their capabilities for conducting quality improvement activities for minority and limited English proficiency patients. A subset of practices also completed a brief chart review. SETTINGS: Grantees of the National Committee for Quality Assurance Program were independent practices required to have five or fewer physicians with little or no experience with quality improvement (mean number of physicians = 1.4). At least one-quarter of the patients served by the practice were required to be minorities. PARTICIPANTS: Twenty-two practices from California and New Jersey. MAIN OUTCOME MEASURES: Surveys assessed clinician preparedness, use of systematic processes, and availability of information technology to improve care for minority patients. The chart review exercise elicited information on challenges and enabling factors in recent encounters with racial/ethnic minority patients. RESULTS: Small practices face considerable challenges in caring for minority patients. They have limited staff and fewer resources than larger group practices, increasing the difficulty of making improvements on their own. The main challenges identified were patient adherence to treatment recommendations, staffing, language barriers and lack of information systems. CONCLUSIONS: Small practices will require substantial support from external organizations in order to contribute to national reductions in racial/ethnic disparities in health care.

Urgent care centers in the U.S.: findings from a national survey.

BACKGROUND: Due to long waits for primary care appointments and extended emergency department wait times, newer sites for episodic primary care services, such as urgent care centers, have developed. However, little is known about these centers. The purpose of this study is to provide information about the organization and functioning of urgent care centers based on a nationally representative U.S. sample. METHODS: We conducted a mail survey with telephone follow-up of urgent care centers identified via health insurers' websites, internet searches, and a trade association mailing list. Descriptive statistics are presented. RESULTS: Urgent care centers are open beyond typical office hours, and their scope of services is broader than that of many primary care offices. While these characteristics are similar to hospital emergency departments, such centers employ significant numbers of family physicians. The payer distribution is similar to that of primary care, and physicians' average salaries are comparable to those for family physicians overall. Urgent care centers report early adoption of electronic health records, though our findings are qualified by a lack of strictly comparable data. CONCLUSION: While their hours and scope of services reflect some characteristics of emergency departments, urgent care centers are in many ways similar to family medicine practices. As the health care system evolves to cope with expanding demands in the face of limited resources, it is unclear how patients with episodic care needs will be treated, and what role urgent care centers will play in their care.

Current and Projected Characteristics and Unique Health Care Needs of the Patient Population Served by the Department of Veterans Affairs.

The Veterans Access, Choice, and Accountability Act of 2014 addressed the need for access to timely, high-quality health care for veterans. Section 201 of the legislation called for an independent assessment of various aspects of veterans' health care. The RAND Corporation was tasked with an assessment of the current and projected demographics and health care needs of patients served by the Department of Veterans Affairs (VA). The number of U.S. veterans will continue to decline over the next decade, and the demographic mix and geographic locations of these veterans will change. While the number of veterans using VA health care has increased over time, demand will level off in the coming years. Veterans have more favorable economic circumstances than non-veterans, but they are also older and more likely to be diagnosed with many health conditions. Not all veterans are eligible for or use VA health care. Whether and to what extent an eligible veteran uses VA health care depends on a number of factors, including access to other sources of health care. Veterans who rely on VA health care are older and less healthy than veterans who do not, and the prevalence of costly conditions in this population is projected to increase. Potential changes to VA policy and the context for VA health care, including effects of the Affordable Care Act, could affect demand. Analysis of a range of data sources provided insight into how the veteran population is likely to change in the next decade.

Who can't pay for health care?

BACKGROUND: In an era of rising health care costs, many Americans experience difficulty paying for needed health care services. With costs expected to continue rising, changes to private insurance plans and public programs aimed at containing costs may have a negative impact on Americans' ability to afford care. OBJECTIVES: To provide estimates of the number of adults who avoid health care due to cost, and to assess the association of income, functional status, and type of insurance with the extent to which people with health insurance report financial barriers. RESEARCH DESIGN: Cross-sectional observational study using data from the Commonwealth Fund 2001 Health Care Quality Survey, a nationally representative telephone survey. PARTICIPANTS: U.S. adults age 18 and older (N=6,722). MEASURES: Six measures of avoiding health care due to cost, including delaying or not seeking care; not filling prescription medicines; and not following recommended treatment plan. RESULTS: The proportion of Americans with difficulty affording health care varies by income and health insurance coverage. Overall, 16.9% of Americans report at least 1 financial barrier. Among those with private insurance, the poor (28.4%), near poor (24.3%), and those with functional impairments (22.9%) were more likely to report avoiding care due to cost. In multivariate models, the uninsured are more likely (OR, 2.3; 95% CI, 1.7 to 3.0) to have trouble paying for care. Independent of insurance coverage and other demographic characteristics, the poor (OR, 3.6; 95% CI, 2.1 to 4.6), near poor (OR, 2.1; 95% CI, 1.9 to 3.7), and middle-income (OR, 1.8; 95% CI, 1.3 to 2.5) respondents as well as those with functional impairments (OR, 1.6; 95% CI, 1.3 to 2.0) are significantly more likely to avoid care due to cost. CONCLUSIONS: Privately and publicly insured individuals who have low incomes or functional impairments encounter significant financial barriers to care despite having health insurance. Proposals to expand health insurance will need to address these barriers in order to be effective.

Pre-Deployment Stress, Mental Health, and Help-Seeking Behaviors Among Marines.

The Marine Corps Operational Stress Control and Readiness (OSCAR) program is designed to provide mental health support to marines by embedding mental health personnel within Marine Corps units and increasing the capability of officers and senior noncommissioned officers to improve the early recognition and intervention of marines exhibiting signs of stress. The Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury have asked RAND to evaluate the OSCAR program. As part of this evaluation, RAND conducted a large survey of marines who were preparing for a deployment to Iraq or Afghanistan in 2010 or 2011. This article describes the methods and findings from this survey. The results are among the first to shed light on the pre-deployment mental health status of marines, as well as the social resources they draw on when coping with stress and their attitudes about seeking help for stress-related problems. The 2,620 marines in the survey sample had high rates of positive screens for current major depressive disorder (12.5 percent) and high-risk drinking (25.7 percent) and reported having experienced more potentially traumatic events over their lifetime than adult males in the general population. Marines in the sample also reported relying on peers for support with stress and perceiving moderate levels of support from the Marine Corps for addressing stress problems.

Researching disparities: strategies for primary data collection.

Comparatively little disparities research to date has focused on emergency medicine. However, the body of disparities research developed in other areas of health care has identified a number of issues that are directly applicable. To promote research on disparities in emergency medicine, this article addresses several of these issues related to collecting and classifying data on race/ethnicity and socioeconomic status and selected methodologic issues that are particularly important for evaluating disparities.

Differences between Hispanics and non-Hispanic Whites in use of hospital procedures for cerebrovascular disease.

OBJECTIVE: This study examined disparities in the use of in-hospital diagnostic and therapeutic procedures for Hispanics with cerebrovascular disease compared to their non-Hispanic White counterparts. DESIGN: This is a cross-sectional study using 1996 hospital administrative data. METHODS: Hispanics and non-Hispanic Whites with diagnosis codes indicating occlusion or stenosis of precerebral arteries or transient cerebral ischemia were included, with a total of 18,674 New York patients (5.1% Hispanic) and 22,624 California patients (11.1% Hispanic). Adjusted odds ratios compared Hispanics with non-Hispanic Whites for six diagnostic and therapeutic procedures for cerebrovascular disease, controlling for patient and hospital characteristics. RESULTS: Hispanics had higher rates of non-invasive diagnostic procedures (head CT scan, head/neck diagnostic ultrasound, echocardiogram, and head MRI). The odds of invasive diagnostic testing (cerebral arteriogram) and therapeutic procedures (carotid endarterectomy) were lower for Hispanics. Most findings remained unchanged in logistic regression models with patient and hospital characteristics. Adding a measure of the concentration of Hispanic patients by hospital eliminated or reduced observed differences between Hispanics and Whites. CONCLUSIONS: Controlling for each hospital's experience with Hispanic patients eliminated or reduced the magnitude of the disparities in procedure use, suggesting that the concentration of Hispanic patients in a hospital is associated with different patterns of procedure use.

A Systematic Process to Facilitate Evidence-Informed Decisionmaking Regarding Program Expansion.

While the Department of Defense supports more than 200 psychological health and traumatic brain injury programs, it lacks an approach and process to systematically develop, track, and assess the performance of this portfolio of programs. Further, there is not yet a uniform approach to decisionmaking around program support and expansion of particularly promising, evidence-based programs. This lack of centralized oversight may result in the proliferation of untested programs that are developed without an evidence base; an inefficient use of resources; and added cost and administrative inefficiencies. RAND researchers developed a potential model and tools to support a centralized, systematic, and ongoing process to help in making decisions around continued program support, and by which expansion can be facilitated. This study includes two tools. The first is a Program Abstraction Form, which collects relevant background information from programs and asks explicitly about program effectiveness and the design of the program evaluation used to assess program effectiveness, as a poor evaluation design may lead to incorrect conclusions about the effectiveness of the program. The second is the RAND Program Expansion Tool, which provides a standardized summary of the quality and outcome of a program evaluation. The focus of these tools is on decisionmaking around program expansion, and does not preclude or address initial funding decisions of particularly promising new programs that may not yet have a solid evidence base.

An Evaluation of the Implementation and Perceived Utility of the Airman Resilience Training Program.

Since 2001, the U.S. Military has been functioning at an operational tempo that is historically high for the all-volunteer force in which service members are deploying for extended periods on a repeated basis. Even with the drawdown of troops from Iraq in 2011, some service members are returning from deployment experiencing difficulties handling stress, mental health problems, or deficits caused by a traumatic brain injury (TBI). In response to these challenges, the U.S. Department of Defense (DoD) has implemented numerous programs to support service members and their families in these areas. In 2009, the Assistant Secretary of Defense for Health Affairs asked the RAND National Defense Research Institute to develop a comprehensive catalog of existing programs sponsored or funded by DoD to support psychological health and care for TBI, to create tools to support ongoing assessment and evaluation of the DoD portfolio of programs, and to conduct evaluations of a subset of these programs. This article describes RAND's assessment of an Air Force program, Airman Resilience Training (ART), which is a psychoeducational program designed to improve airmen's reactions to stress during and after deployment and to increase the use of mental health services when needed. ART was initiated in November 2010, replacing a previous program named Landing Gear, which had been in place since April 2008. The RAND study took place from August 2011 through November 2011. This study will be of particular interest to officials within the Air Force who are responsible for the psychological health and well-being of airmen, as well as to others within the military who are developing programs for service members to help them cope with stress while in combat situations and after returning from deployment.

The Development and Application of the RAND Program Classification Tool.

As a result of extended military engagements in Iraq and Afghanistan during the past decade, the U.S. Department of Defense (DoD) has implemented numerous programs to support servicemembers and family members who experience difficulty handling stress, face mental health challenges, or are affected by a traumatic brain injury (TBI). As these efforts have proliferated, it has become more challenging to monitor these programs and to avoid duplication. To support DoD in this area, RAND compiled a comprehensive catalog of DoD-funded programs that address psychological health and TBI. In creating the catalog of programs, RAND recognized the need to consistently describe and compare multiple programs according to a set of core program characteristics, driven largely by the lack of a single, clear, widely accepted operational definition of what constitutes a program. To do this, RAND developed the RAND Program Classification Tool (R-PCT) to allow users to describe and compare programs, particularly those related to psychological health and TBI, along eight key dimensions that that define a program. The tool consists of a set of questions and responses for consistently describing various aspects of programs, along with detailed guidance regarding how to select the appropriate responses. The purpose of this article is to describe the R-PCT, to help potential users understand how it was developed, and to explain how the tool can be used.

The RAND Online Measure Repository for Evaluating Psychological Health and Traumatic Brain Injury Programs.

Since 2001, U.S. military forces have been engaged in extended conflicts in Iraq and Afghanistan. While most military personnel cope well across the deployment cycle, the operational tempo may raise the risk of mental health problems, such as post-traumatic stress disorder (PTSD) and major depression, and consequences from traumatic brain injury (TBI). To support servicemembers and their families as they cope with these challenges, the U.S. Department of Defense has implemented numerous programs addressing biological, social, spiritual, and holistic influences on psychological health along the resilience, prevention, and treatment continuum that focus on a variety of clinical and nonclinical concerns. As these efforts have proliferated, evaluating their effectiveness has become increasingly important. To support the design and implementation of program evaluation, RAND developed the RAND Online Measure Repository (ROMR) which indexes and describes measures related to psychological health and TBI. The ROMR is a publicly accessible, online, searchable database containing 171 measures related to psychological health and TBI. This article describes the rationale for developing the ROMR, the content included in the ROMR, and its potential in both civilian and military populations. The ROMR includes information about measure domains, psychometrics, number of items, and costs, which can inform the selection of measures for program evaluations. Included measures address domains of primary importance to psychological health (PTSD, depression, anxiety, suicidal ideation, and resiliency) and TBI (cognition, executive functioning, and memory). Also identified are measures relevant to military units, such as unit cohesion and force readiness.

A Program Manager's Guide for Program Improvement in Ongoing Psychological Health and Traumatic Brain Injury Programs.

Between 2001 and 2011, the U.S. Department of Defense has implemented numerous programs to support service members and their families in coping with the stressors from a decade of the longstanding conflicts in Iraq and Afghanistan. These programs, which address both psychological health and traumatic brain injury (TBI), number in the hundreds and vary in their size, scope, and target population. To ensure that resources are wisely invested and maximize the benefits of such programs, RAND developed a tool to help assess program performance, consider options for improvement, implement solutions, then assess whether the changes worked, with the intention of helping those responsible for managing or implementing programs to conduct assessments of how well the program is performing and to implement solutions for improving performance. Specifically, the tool is intended to provide practical guidance in program improvement and continuous quality improvement for all programs.