Assessment of the equivalence of the Spanish and English versions of the CAHPS Hospital Survey on the quality of inpatient care.

OBJECTIVE: To describe translation and cultural adaptation procedures, and examine the degree of equivalence between the Spanish and English versions of the Agency for Healthcare Research and Quality's (AHRQ) Consumer Assessments of Healthcare Providers and Systems (CAHPS) Hospital Survey (H-CAHPS) of patient experiences with care. DATA SOURCES: Cognitive interviews on survey comprehension with 12 Spanish-speaking and 31 English-speaking subjects. Psychometric analyses of 586 responses to the Spanish version and 19,134 responses to the English version of the H-CAHPS survey tested in Arizona, Maryland, and New York in 2003. STUDY DESIGN: A forward/backward translation procedure followed by committee review and cognitive testing was used to ensure a translation that was both culturally and linguistically appropriate. Responses to the two language versions were compared to evaluate equivalence and assess the reliability and validity of both versions. DATA COLLECTION/EXTRACTION METHODS: Comparative analyses were carried out on the 32 items of the shortened survey version, focusing on 16 items that comprise seven composites representing different aspects of hospital care quality (communication with nurses, communication with doctors, communication about medicines, nursing services, discharge information, pain control, and physical environment); three items that rate the quality of the nursing staff, physician staff, and the hospital overall; one item on intention to recommend the hospital. The other 12 items used in the analyses addressed mainly respondent characteristics. Analyses included item descriptives, correlations, internal consistency reliability of composites, factor analysis, and regression analysis to examine construct validity. PRINCIPAL FINDINGS: Responses to both language versions exhibit similar patterns with respect to item-scale correlations, factor structure, content validity, and the association between each of the seven qualities of care composites with both the hospital rating and intention to recommend the hospital. Internal consistency reliability was slightly, yet significantly lower for the Spanish-language respondents for five of the seven composites, but overall the composites were generally equivalent across language versions. CONCLUSIONS: The results provide preliminary evidence of the equivalence between the Spanish and English versions of H-CAHPS. The translated Spanish version can be used to assess hospital quality of care for Spanish speakers, and compare results across these two language groups.

Measuring the efficacy of a quality improvement program in dialysis adequacy with changes in center effects.

End-stage renal disease (ESRD) patients treated with hemodialysis have a high mortality rate, which is largely due to inadequate dialysis. Dialysis adequacy, measured by the urea reduction ratio (URR), tends to be correlated within dialysis facilities with wide variations in average center adequacy. These are characteristics of a center effect, which can have an important impact on dialysis adequacy. This study measured the center effect observed in an ESRD Network before and after a successful quality improvement project (QIP). URR values were recorded on patients sampled from 196 facilities in ESRD Network 6 before (pre-QIP, n = 5309) and after (post-QIP, n = 5753). These data was used to determine the within center correlation (rho) of individual URR values and between center variation in aggregate URR values in both samples. The overall mean URR improved from the pre- to post-QIP sample (mean URR 64.7 +/- 0.1 versus 69.8 +/- 0.1, respectively; P = 0.001). There was a high degree of within center correlation in dialysis adequacy across the facilities, which significantly diminished post-QIP (rho, 0.15 [95% CI, 0.12 to 0.18] versus rho, 0.06 [95% CI, 0.04 to 0.08]). The between center variation in mean URR also declined from the pre-QIP to the post-QIP sample (SD, 3.6 versus 2.8). In conclusion, there is a center effect on dialysis adequacy measurable in an ESRD Network, which diminishes after a successful QIP; therefore, when implementing a QIP to improve dialysis adequacy, changes in the center effect should be considered a potential indicator of the efficacy of the intervention.

Pretransplant serum C-reactive protein and the risk of chronic allograft nephropathy in renal transplant recipients: a pilot case-control study.

Multiple factors contribute to the development of chronic allograft nephropathy (CAN) in renal transplant recipients, and atherogenesis is considered to be an important pathologic process contributing to the development of this disease. There is growing acknowledgment of the role of inflammation in the pathogenesis of atherosclerosis, and markers of inflammation, such as C-reactive protein (CRP), have been shown to predict atherosclerotic vascular disease in the general and end-stage renal disease populations. In this pilot study, we hypothesized that elevations in pretransplant concentrations of CRP predict an increased incidence of CAN after renal transplantation. This case-control study compared pretransplant CRP levels in patients with allograft dysfunction and biopsy-proven CAN (n = 15) with a control group of transplant recipients with normal allograft function (n = 43). The median concentration of serum CRP was significantly higher in the CAN versus the control patients (13.1 +/- 3.9 mg/L versus 3.5 +/- 2.5 mg/L; P = 0.01). This difference was sustained when restricting to patients who did not experience acute rejection. When dividing the patients into tertiles based on CRP concentration, the adjusted risk of CAN increased more than threefold with each increment in CRP by tertile (adjusted odds ratio, 3.16; P = 0.03). The findings of our pilot study show an association between pretransplant elevations of CRP and CAN in end-stage renal disease patients who go on to receive a renal transplant. Cohort studies in larger groups of transplant patients are needed to confirm a causal pathway between pretransplant inflammation, atherogenesis, and CAN.

Optimal strategies for modeling the reciprocal of creatinine versus time in renal transplant recipients and patients with native chronic renal disease.

Few studies have evaluated the least squares (LS) or alternative regression methods to estimate loss of renal function using the reciprocal of creatinine over time in renal transplant recipients or have compared their performances in patients with chronic renal insufficiency (CRI). We evaluated the LS and alternative methods using the proportion of explained variance, measured by R2, and prediction of the final creatinine level. The study included two groups of transplant recipients: (1) patients who developed graft failure (FAIL; n = 31) and (2) patients with an episode of biopsy-proven acute rejection with or without subsequent renal function loss (BXAR; n = 98) and a third group of individuals with CRI (n = 28). The LS method performed poorly in both transplant groups (mean R2 range, 0.35 to 0.44; 32% to 45% with final creatinine(actual) - creatinine(predicted) +/- 0.05 mg/dL), but better in the CRI group (mean R2, 0.57; 75% with final creatinine(actual) - creatinine(predicted) +/- 0.05). The best alternative was the two-phase regression line after exclusion of outliers, which provided similar results across the FAIL, BXAR, and CRI groups (mean R2, 0.71, 0.64, and 0.73; 81%, 84%, and 96% with final creatinine(actual) - creatinine(predicted) +/- 0.05, respectively; P = not significant) and had the best performance in patients with greater nadir creatinine values. The LS method is not suited to measure kidney function loss in renal transplant recipients. Use of the two-phase regression line after exclusion of outliers is a more reliable method in renal transplant recipients, especially patients with impaired baseline function, and has results similar to those of patients with CRI.

Effect of center- versus patient-specific factors on variations in dialysis adequacy.

Efforts to improve the delivery of hemodialysis have focused mostly on identifying patient-related factors that lead to inadequate dialysis. Less consideration has been given to the impact of the dialysis center on adequacy. This study evaluated whether the dialysis facility or individual-level factors were the primary influence on variations in dialysis adequacy. This was a retrospective analysis of 4971 hemodialysis patients in 189 centers with urea reduction ratio (URR) values obtained in the final quarter of 1997. The between-center variation and the within-center correlation in URR values were quantified to determine the contribution of a center effect on variations in adequacy; furthermore, the proportion of variance attributable to the centers' effect and individual-level dialysis covariates were compared. There was a wider between-center variation in mean URR values (SD, 4.8%) than expected if there were no center effect (SD, 2.5%). There was a strong within-center correlation in URR values, measured by the parameter rho, which was only minimally diminished after adjusting for individual-level covariates (adjusted rho, 0.14; P < 0.0001). The variation in URR attributable to the center effect, quantified by R(2), was greater than that related to individual-level dialysis factors (facility- and individual-level dialysis covariates R(2), 23.6 and 11.3%, respectively). Initiatives to improve the delivery of dialysis in patients with end-stage renal disease should be directed at facility policies governing dialysis care, along with patient-specific problems, because center effects have a major influence on dialysis adequacy.