MACRA Palliative Care Quality Measure Development-Testing Summary Report: Measure Name: Receiving Desired Help for Pain.

Palliative care has expanded rapidly in the past 20 years, especially in the ambulatory (office) setting, and there is growing consensus regarding the need to systematically measure and incentivize high-quality care. The Centers for Medicare & Medicaid Services entered a cooperative agreement with the American Academy of Hospice and Palliative Medicine (AAHPM) as part of the Medicare Access and CHIP Reauthorization Act of 2015 to develop two patient-reported measures of ambulatory palliative care experience: Feeling Heard and Understood and Receiving Desired Help for Pain. Under contract to AAHPM, RAND Health Care researchers developed and tested both measures over a three-year project period. Researcher efforts included identifying, developing, testing, and validating appropriate patient-reported data elements for each measure; developing and fielding a survey instrument to collect necessary data in a national beta field test with 44 ambulatory palliative care programs; and collecting and analyzing data about measure reliability and validity to establish measure performance and final specifications. Further, the authors elicited provider and program perspectives on the use and value of the performance measures and their implementation and elicited the perspectives of patients from racial and ethnic minorities to understand their experience of ambulatory palliative care and optimal approaches to measurement. In this study, the authors present results from their test of the Receiving Desired Help for Pain performance measure, which they demonstrate to be a reliable and valid measure that is ready for use in quality improvement and quality payment programs.

MACRA Palliative Care Quality Measure Development-Testing Summary Report: Measure Name: Feeling Heard and Understood.

Palliative care has expanded rapidly in the past 20 years, especially in the ambulatory (office) setting, and there is growing consensus regarding the need to systematically measure and incentivize high-quality care. The Centers for Medicare & Medicaid Services entered a cooperative agreement with the American Academy of Hospice and Palliative Medicine (AAHPM) as part of the Medicare Access and CHIP Reauthorization Act of 2015 to develop two patient-reported measures of ambulatory palliative care experience: Feeling Heard and Understood and Receiving Desired Help for Pain. Under contract to AAHPM, RAND Health Care researchers developed and tested both measures over a three-year project period. Researcher efforts included identifying, developing, testing, and validating appropriate patient-reported data elements for each measure; developing and fielding a survey instrument to collect necessary data in a national beta field test with 44 ambulatory palliative care programs; and collecting and analyzing data about measure reliability and validity to establish measure performance and final specifications. Further, the authors elicited provider and program perspectives on the use and value of the performance measures and their implementation and elicited the perspectives of patients from racial and ethnic minorities to understand their experience of ambulatory palliative care and optimal approaches to measurement. In this study, the authors present results from their test of the Feeling Heard and Understood performance measure, which they demonstrate to be a reliable and valid measure that is ready for use in quality improvement and quality payment programs.

Improving Behavioral Health Care for U.S. Army Personnel: Identifying Predictors of Treatment Outcomes.

This article identifies factors associated with changes in outcomes for soldiers who received Army behavioral health (BH) specialty care and provides recommendations to improve BH care and outcomes. RAND researchers identified three samples of soldiers who received Army BH care with diagnoses of posttraumatic stress disorder (PTSD), depression, or anxiety and whose symptoms were assessed during their care. Multivariate analyses included 141 patient and treatment variables to identify factors associated with symptom improvement. Analyses also examined patterns in how the symptoms changed over time. Analyses suggest that the Behavioral Health Data Portal, an online system that allows for collection of multiple patient- and clinician-reported measures, is widely used to track symptoms of PTSD, depression, and anxiety, but there are opportunities to expand symptom tracking. Two treatment factors-therapeutic alliance and receipt of benzodiazepines-were associated with treatment outcomes. Specifically, a stronger therapeutic relationship or alliance with providers, as reported by soldiers, was associated with improved PTSD, depression, and anxiety outcomes. Further, receipt of more than a 30-day supply of benzodiazepines was associated with poorer PTSD, depression, and anxiety outcomes. Many soldiers' trajectories of symptom change did not demonstrate improvement. Recommendations include providing feedback and guidance to providers on how to strengthen alliance with their patients, expanding tracking and feedback on benzodiazepine prescribing, and increasing provider use of measurement-based BH care.

Association of Primary and Specialty Care Integration on Physician Communication and Cancer Screening in Safety-Net Clinics.

INTRODUCTION: Primary care providers who lack reliable referral relationships with specialists may be less likely than those who do have such relationships to conduct cancer screenings. Community health centers (CHCs), which provide primary care to disadvantaged populations, have historically reported difficulty accessing specialty care for their patients. This study aimed to describe strategies CHCs use to integrate care with specialists and examine whether more strongly integrated CHCs have higher rates of screening for colorectal and cervical cancers and report better communication with specialists. METHODS: Using a 2017 survey of CHCs in 12 states and the District of Columbia and administrative data, we estimated the association between a composite measure of CHC/specialist integration and 1) colorectal and cervical cancer screening rates, and 2) 4 measures of CHC/specialist communication using multivariate regression models. RESULTS: Integration strategies commonly reported by CHCs included having specialists deliver care on-site (80%) and establishing referral agreements with specialists (70%). CHCs that were most integrated with specialists had 5.6 and 6.8 percentage-point higher colorectal and cervical cancer screening rates, respectively, than the least integrated CHCs (P < .05). They also had significantly higher rates of knowing that specialist visits happened (67% vs 42%), knowing visit outcomes (65% vs 42%), receiving information after visits (47% vs 21%), and timely receipt of information (44% vs 27%). CONCLUSION: CHCs use various strategies to integrate primary and specialty care. Efforts to promote CHC/specialist integration may help increase rates of cancer screening.

California Community College Faculty and Staff Help Address Student Mental Health Issues.

This study determines the preliminary impact of CalMHSA's prevention and early intervention activities on the knowledge, attitudes, and behaviors of California community college faculty and staff regarding supporting students' mental health needs.

Using the Early Childhood Environment Rating Scale-Revised in High Stakes Contexts: Does Evidence Warrant the Practice?

Increasingly, states establish different thresholds on the Early Childhood Environment Rating Scale-Revised (ECERS-R), and use these thresholds to inform high-stakes decisions. However, the validity of the ECERS-R for these purposes is not well established. The objective of this study is to identify thresholds on the ECERS-R that are associated with preschool-aged children's social and cognitive development. Applying non-parametric modeling to the nationally-representative Early Childhood Longitudinal Study Birth Cohort (ECLS-B) dataset, we found that once classrooms achieved a score of 3.4 on the overall ECERS-R composite score, there was a leveling-off effect, such that no additional improvements to children's social, cognitive, or language outcomes were observed. Additional analyses found that ECERS-R subscales that focused on teaching and caregiving processes, as opposed to the physical environment, did not show leveling-off effects. The findings suggest that the usefulness of the ECERS-R for discerning associations with children's outcome may be limited to certain score ranges or subscales.

Quantifying Magnitude of Group-Level Differences in Patient Experiences with Health Care.

OBJECTIVE: Review approaches assessing magnitude of differences in patient experience scores between different providers. DATA SOURCES: 1990-2016 literature. STUDY DESIGN: Systematic literature review. DATA EXTRACTION METHODS: Of 812 articles mentioning "CAHPS," "patient experience," "patient satisfaction," "important(ce)," "difference," or "significance," we identified 79 possible articles, yielding 35 for data abstraction. We included 22 articles measuring magnitude of differences in patient experiences. PRINCIPAL FINDINGS: We identified three main ways of estimating magnitude of differences in patient experience scores: (1) by distribution/range of patient experience variable, (2) against external anchor, and (3) comparing a difference in patient experience on one covariate to differences in patient experience on other covariates. CONCLUSIONS: We suggest routine estimation of magnitude in patient experience research. More work is needed documenting magnitude of differences between providers to make patient experience data more interpretable and usable.

Improving Outcomes for Children Exposed to Violence: Safe Start Promising Approaches.

Children's exposure to violence is common and can lead to mental health problems and delinquent behaviors. Because many interventions have focused on specific violence types or symptoms and been difficult to implement in real-world settings, the evidence base is still emerging. The Office of Juvenile Justice and Delinquency Prevention's Safe Start Promising Approaches (SSPA) initiative focused on preventing and reducing the impact of children's exposure to violence through interventions in ten diverse communities. The evaluation examined the effectiveness of the SSPA interventions to address issues for children and families exposed to violence. The ten sites were diverse in their intervention approaches, types of violence exposure targeted, and implementation settings. To evaluate each approach's effectiveness in reducing violence's harmful effects, RAND researchers partnered with the community-based sites to develop a rigorous controlled evaluation design for each intervention, with either a randomized control group or a comparison group selected on similar characteristics. The longitudinal analyses found that families in both the intervention and comparison groups had positive gains on many outcomes, but there was no evidence that the intervention groups improved more. Among those who received Safe Start services, one site produced large, significant improvements in posttraumatic stress disorder symptoms, and another site produced medium, significant effects on several outcomes (child self-control, posttraumatic stress disorder, and behavior; caregiver depression; and family conflict). Although the initiative added to knowledge about how to address the problem, there was no clear case for using a particular intervention to help these children and their families.

Examining the associations between daily caregiving discontinuity and children's social-emotional outcomes.

Many child care centers temporarily move children and teachers in and out of their assigned classrooms throughout the day. Such practices create frequent discontinuity in children's experiences in child care, including discontinuity in their peer and teacher relationships. This study examined the prevalence and patterns of teacher and child movement between classrooms, the characteristics of teachers and children who were more likely to move between classrooms on a daily basis, and the associations between children's and teachers' rate of daily movement between classrooms with children's social-emotional outcomes. A moderate to high prevalence of child and teacher movement between classrooms was observed (29% and 83%, respectively). Children who were younger, considered solitary, and who had been enrolled in their classroom for shorter periods of time were less likely to transition between classrooms. Children's rate of movement was a positive predictor of teachers' perceived conflict with children in their care, and a negative predictor of teachers' perceived closeness. In addition, the more frequently teachers moved, the less children were inclined to indicate liking their teachers or centers. However, the more frequently children moved, the more likely children were to indicate liking their peers and for their peers to indicate liking them. Results are interpreted in light of additional research avenues that can inform sensible daily teacher continuity practices.

Out of the Shadows: The Health and Well-Being of Private Contractors Working in Conflict Environments.

Over the past decade, private contractors have been deployed extensively around the globe. In addition to supporting U.S. and allied forces in Iraq and Afghanistan, contractors have assisted foreign governments, nongovernmental organizations, and private businesses by providing a wide range of services, including base support and maintenance, logistical support, transportation, intelligence, communications, construction, and security. At the height of the conflicts in Iraq and Afghanistan, contractors outnumbered U.S. troops deployed to both theaters. Although these contractors are not supposed to engage in offensive combat, they may nonetheless be exposed to many of the stressors that are known to have physical and mental health implications for military personnel. RAND conducted an online survey of a sample of contractors who had deployed on contract to a theater of conflict at least once between early 2011 and early 2013. The survey collected demographic and employment information, along with details about respondents' deployment experience (including level of preparation for deployment, combat exposure, and living conditions), mental health (including probable posttraumatic stress disorder, depression, and alcohol misuse), physical health, and access to and use of health care. The goal was to describe the contractors' health and well-being and to explore differences across the sample by such factors as country of citizenship, job specialty, and length and frequency of contract deployment. The findings provide a foundation for future studies of contractor populations and serve to inform policy decisions affecting contractors, including efforts to reduce barriers to mental health treatment for this population.

Using generalized additive modeling to empirically identify thresholds within the ITERS in relation to toddlers' cognitive development.

Research linking high-quality child care programs and children's cognitive development has contributed to the growing popularity of child care quality benchmarking efforts such as quality rating and improvement systems (QRIS). Consequently, there has been an increased interest in and a need for approaches to identifying thresholds, or cutpoints, in the child care quality measures used in these benchmarking efforts that differentiate between different levels of children's cognitive functioning. To date, research has provided little guidance to policymakers as to where these thresholds should be set. Using the Early Childhood Longitudinal Study, Birth Cohort (ECLS-B) data set, this study explores the use of generalized additive modeling (GAM) as a method of identifying thresholds on the Infant/Toddler Environment Rating Scale (ITERS) in relation to toddlers' performance on the Mental Development subscale of the Bayley Scales of Infant Development (the Bayley Mental Development Scale Short Form-Research Edition, or BMDSF-R). The present findings suggest that simple linear models do not always correctly depict the relationships between ITERS scores and BMDSF-R scores and that GAM-derived thresholds were more effective at differentiating among children's performance levels on the BMDSF-R. Additionally, the present findings suggest that there is a minimum threshold on the ITERS that must be exceeded before significant improvements in children's cognitive development can be expected. There may also be a ceiling threshold on the ITERS, such that beyond a certain level, only marginal increases in children's BMDSF-R scores are observed.

Family income and early achievement across the urban-rural continuum.

Rural and suburban children account for the majority of poor children in the United States. Yet, most research examining poverty's associations with child development is focused on urban samples. Using nationally representative data from the Early Childhood Longitudinal Study, Birth Cohort (N ≈ 6,600), this study examines whether the form and magnitude of income's relationship with early achievement differ across the urban-rural continuum. Results suggest that there are urbanicity-related differences in the functional form of the association between income and early achievement, with nonlinear associations in urban and suburban areas and a linear relationship in rural areas. The magnitude of the association between income and early reading and math skills also differs across the urban-rural continuum, such that income increases are related to the greatest improvements in early academic skills in large urban areas and only slight improvements in rural areas.

Evaluating the Impact of Prevention and Early Intervention Activities on the Mental Health of California's Population.

In 2004, California voters passed the Mental Health Services Act, which was intended to transform California's community mental health system from a crisis-driven system to one that included a focus on prevention and wellness. The vision was that prevention and early intervention (PEI) services comprised the first step in a continuum of services designed to identify early symptoms and prevent mental illness from becoming severe and disabling. Twenty percent of the act's funding was dedicated to PEI services. The act identified seven negative outcomes that PEI programs were intended to reduce: suicide, mental health-related incarcerations, school failure, unemployment, prolonged suffering, homelessness, and removal of children from the home. The Mental Health Services Oversight and Accountability Commission (MHSOAC) coordinated with the California Mental Health Services Authority (CalMHSA), an independent administrative and fiscal intergovernmental agency, to seek development of a statewide framework for evaluating and monitoring the short- and long-term impact of PEI funding on the population. CalMHSA selected the RAND Corporation to develop a framework for the statewide evaluation. This article describes the approach, the data sources, and the frameworks developed: an overall approach framework and outcome-specific frameworks.

A graphical method for assessing risk factor threshold values using the generalized additive model: the multi-ethnic study of atherosclerosis.

Continuous variable dichotomization is a popular technique used in the estimation of the effect of risk factors on health outcomes in multivariate regression settings. Researchers follow this practice in order to simplify data analysis, which it unquestionably does. However thresholds used to dichotomize those variables are usually ad-hoc, based on expert opinions, or mean, median or quantile splits and can add bias to the effect of the risk factors on specific outcomes and underestimate such effect. In this paper, we suggest the use of a semi-parametric method and visualization for improvement of the threshold selection in variable dichotomization while accounting for mixture distributions in the outcome of interest and adjusting for covariates. For clinicians, these empirically based thresholds of risk factors, if they exist, could be informative in terms of the highest or lowest point of a risk factor beyond which no additional impact on the outcome should be expected.

The Modified Kalman Filter Macro: User's Guide.

The Modified Kalman Filter approach for pooling information across time and across outcomes is shown to improve accuracy in national estimates of health outcomes, including cancer, diabetes, and hypertension, especially in small racial/ethnic subgroups. The developed SAS macro models true health states in each subgroup assuming a linear time evolution and an autoregressive deviation around such trend. The macro provides multiple options for users.

Differential item functioning by survey language among older Hispanics enrolled in Medicare managed care: a new method for anchor item selection.

OBJECTIVE: To propose a permutation-based approach of anchor item detection and evaluate differential item functioning (DIF) related to language of administration (English vs. Spanish) for 9 questions assessing patients' perceptions of their providers from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Medicare 2.0 survey. METHOD AND STUDY DESIGN: CAHPS 2.0 health plan survey data collected from 703 Hispanics who completed the survey in Spanish were matched on personal characteristics to 703 Hispanics that completed the survey in English. Steps to be followed for the detection of anchor items using the permutation tests are proposed and these tests in conjunction with item response theory were used for the identification of anchor items and DIF detection. RESULTS: Of the questions studied, 4 were selected as anchor items and 3 of the remaining questions were found to have DIF (P < 0.05). The 3 questions with DIF asked about seeing the doctor within 15 minutes of the appointment time, respect for what patients had to say, and provider spending enough time with patients. CONCLUSIONS: Failure to account for language differences in CAHPS survey items may result in misleading conclusions about disparities in health care experiences between Spanish and English speakers. Statistical adjustments are needed when using the items with DIF.

Smoothing across time in repeated cross-sectional data.

Repeated cross-sectional samples are common in national surveys of health like the National Health Interview Survey (NHIS). Because population health outcomes generally evolve slowly, pooling data across years can improve the precision of current-year annual estimates of disease prevalence and other health outcomes. Pooling over time is particularly valuable in health disparities research, where outcomes for small groups are often of interest and pooling data across groups would bias disparity estimates. State-space modeling and Kalman filtering are appealing choices for smoothing data across time. However, filtering can be problematic when few time points are available, as is common with annual cross-sectional data. Problems arise because filtering relies on estimated variance components, which can be biased and imprecise when estimated with small samples, especially when estimated in tandem with linear trends. We conduct a simulation study showing that even when trends and variance components are estimated poorly, smoothing with these estimates can improve the mean squared error (MSE) of estimated health states for multiple racial/ethnic groups when the variance components are estimated with the pooled sample. We consider frequentist estimators with no trends, one common trend across groups, and separate trends for every group, as well as shrinkage estimators of trends through a Bayesian model. We show that the Bayesian model offers the greatest improvement in MSE, and that Bayesian Information Criterion (BIC)-based model averaging of the frequentist estimators with different trend assumptions performs nearly as well. We present empirical examples using the NHIS data.

National Evaluation of Safe Start Promising Approaches.

Safe Start Promising Approaches (SSPA) is the second phase of a community-based initiative focused on developing and fielding interventions to prevent and reduce the impact of children's exposure to violence (CEV). This article shares the results of SSPA, which was intended to implement and evaluate promising and evidence-based programs in community settings. Fifteen program sites across the country were selected to implement a range of interventions for helping children and families cope with the effects of CEV. The settings, populations served, intervention types, types of violence addressed, community partners, and program goals differed across the 15 sites.

General Cardiovascular Risk Profile identifies advanced coronary artery calcium and is improved by family history: the multiethnic study of atherosclerosis.

BACKGROUND: The General Cardiovascular Risk Profile is a multivariable model that predicts global cardiovascular disease risk. Our goal was to assess the ability of the General Cardiovascular Risk Profile to identify individuals with advanced coronary artery calcification (CAC) and determine whether identification is improved with family history. METHODS AND RESULTS: Using data from the Multiethnic Study of Atherosclerosis, 3 sex-specific models were developed with ordinal logistic regressions to relate risk factors to CAC scores. Model 1 included covariates in the General Cardiovascular Risk Profile. Then family history was added, defined as having at least 1 first-degree relative with premature coronary heart disease (model 2) or as a weak, moderate, or strong family history based on number of relatives with coronary heart disease, age at onset, and the presence of stroke or diabetes in the family (model 3). For each model, we estimated mathematical CAC risk functions, derived CAC score sheets, evaluated the ability to discriminate persons having positive CAC scores, and assessed reclassification of individuals with low, intermediate, or high probability of CAC >300. Model 1 worked well to identify women and men with positive CAC scores; c-statistics were 0.752 and 0.718 and chi(2) values were 821.2 (P<0.0001) and 730.6 (P<0.0001), respectively. Addition of family history improved discrimination and fit of model 1. However, reclassification of participants with advanced CAC was significantly improved with model 3 only. CONCLUSIONS: The General Cardiovascular Risk Profile identifies advanced CAC, an emerging indication for aggressive risk factor modification. Incorporation of family history, especially comprehensive familial risk stratification, provides incremental prognostic value.

Provider-related barriers to rapid HIV testing in U.S. urban non-profit community clinics, community-based organizations (CBOs) and hospitals.

We examined provider-reported barriers to rapid HIV testing in U.S. urban non-profit community clinics, community-based organizations (CBOs), and hospitals. 12 primary metropolitan statistical areas (PMSAs; three per region) were sampled randomly, with sampling weights proportional to AIDS case reports. Across PMSAs, all 671 hospitals and a random sample of 738 clinics/CBOs were telephoned for a survey on rapid HIV test availability. Of the 671 hospitals, 172 hospitals were randomly selected for barriers questions, for which 158 laboratory and 136 department staff were eligible and interviewed in 2005. Of the 738 clinics/CBOs, 276 were randomly selected for barriers questions, 206 were reached, and 118 were eligible and interviewed in 2005-2006. In multivariate models, barriers regarding translation of administrative/quality assurance policies into practice were significantly associated with rapid HIV testing availability. For greater rapid testing diffusion, policies are needed to reduce administrative barriers and provide quality assurance training to non-laboratory staff.