Patient experience during a large primary care practice transformation initiative.

OBJECTIVES: To determine how the multipayer Comprehensive Primary Care (CPC) initiative that transformed primary care delivery affected patient experience of Medicare fee-for-service beneficiaries. The study examines whether patient experience changed during the 4-year initiative, whether ratings of CPC practices changed relative to ratings of comparison practices, and areas in which practices still have an opportunity to improve patient experience. STUDY DESIGN: Prospective study using 2 cross-sectional samples of more than 25,000 Medicare fee-for-service beneficiaries attributed to 490 CPC practices and more than 8000 beneficiaries attributed to 736 comparison practices. METHODS: We analyzed patient experience 8 to 12 months and 45 to 48 months after CPC began, measured using 5 domains of the Consumer Assessment of Healthcare Providers and Systems Clinician and Group survey with Patient-Centered Medical Home items, version 2.0. A regression-adjusted analysis compared differences in the proportion of beneficiaries giving the best responses (and, as a sensitivity test, mean responses) to survey questions over time and between CPC and comparison practices. RESULTS: Patient ratings of care over time were generally comparable for CPC and comparison practices. CPC had favorable effects on measures of follow-up care after hospitalizations and emergency department visits. CONCLUSIONS: Practice transformation did not alter patient experience. The lack of favorable findings raises questions about how future efforts in primary care can succeed in improving patient experience.

Patient experience midway through a large primary care practice transformation initiative.

OBJECTIVES: To determine how the multipayer Comprehensive Primary Care (CPC) initiative that transforms primary care delivery affects the patient experience of Medicare fee-for-service beneficiaries. The study examines how experience changed between the first and second years of CPC, how ratings of CPC practices have changed relative to ratings of comparison practices, and areas in which practices still have opportunities to improve patient experience. STUDY DESIGN: Prospective study using 2 serial cross-sectional samples of more than 25,000 Medicare fee-for-service beneficiaries attributed to 496 CPC practices and nearly 9000 beneficiaries attributed to 792 comparison practices. METHODS: We analyzed patient experience 8 to 12 months and 21 to 24 months after CPC began, measured using 6 domains of the Consumer Assessment of Healthcare Providers and Systems Clinician and Group 12-Month Survey with Patient-Centered Medical Home supplemental items. We compared changes over time in patients giving the best responses between CPC and comparison practices using a regression-adjusted difference-in-differences analysis. RESULTS: Patient ratings of care over time were generally comparable for CPC and comparison practices, with slightly more favorable differences-generally of small magnitude-for CPC practices than expected by chance. There were small, statistically significant, favorable effects for 2 of 6 composite measures measured using both the proportion giving the best responses and mean responses: getting timely appointments, care, and information; providers support patients in taking care of their own health; and providers discuss medication decisions. There was an additional small favorable effect on the proportion of patients giving the best response in getting timely appointments, care, and information; there was no effect on the mean. CONCLUSIONS: During the first 2 years of CPC, CPC practices showed slightly better year-to-year patient experience ratings for selected items, indicating that transformation did not negatively affect patient experience and improved some aspects slightly. Patient ratings for the 2 groups were generally comparable, and both faced substantial room for improvement.

The Feeding Infants and Toddlers Study 2008: study design and methods.

OBJECTIVE: Describe the study design, data collection methods, 24-hour dietary recall protocol, and sample characteristics of the Feeding Infants and Toddlers Study (FITS) 2008. DESIGN: A cross-sectional study designed to obtain information on the diets and feeding patterns of US infants, toddlers, and preschoolers ages birth to 47 months. Telephone interviews with parents and caregivers were conducted from June 2008 through January 2009 and included a household interview to recruit the household and collect information on household and child demographics and nutrition-related characteristics, and a dietary interview, including a 24-hour dietary recall collected using the 2008 Nutrition Data System for Research. A second dietary recall was collected on a random subsample to estimate usual nutrient intake distributions. Data collection instruments were built on those used in FITS 2002, with expanded survey content to address emerging issues in childhood nutrition and obesity. The dietary protocol was improved to increase reporting accuracy on portion sizes, and a bridging study was conducted to test effects of the changes in the food model booklet and protocol since FITS 2002 (n=240 cases aged 4 to 23 months). SUBJECTS: A national random sample of 3,273 infants, toddlers, and preschoolers from birth up to age 4 years, with 2 days of dietary intake data for 701 cases. RESULTS: Among sampled households with an age-eligible child, the response rate was 60% for the recruitment interview. Of recruited households, the response rate for the dietary interview was 78%. CONCLUSIONS: The FITS 2008 provides rigorous, well-tested methods and survey questions for nutrition researchers to use in other dietary studies of young children. FITS 2008 findings on the food and nutrient intakes of US children from birth up to age 4 years can inform dietetics practitioners, pediatric health practitioners, and policymakers about the dietary issues of young children.

Prevalence of unclaimed prescriptions at military pharmacies.

BACKGROUND: Prescriptions that are ordered by physicians but not picked up by patients represent a potential quality improvement opportunity in health systems. Previous research has demonstrated that anywhere from as little as 0.28% to as much as 30.0% of prescriptions are unclaimed, and that 0.45% to 22.0% of patients fail to claim prescriptions. In the Military Health System (MHS), prescriptions filled at military pharmacies are dispensed with no copayment, providing an opportunity to examine the factors that contribute to unclaimed prescriptions other than out-of-pocket cost. OBJECTIVES: To estimate the prevalence of unclaimed prescriptions in the MHS, investigate reasons for unclaimed prescriptions, and compare self-reported noncompliance, defined as the failure to pick up at least 1 prescription in a 12-month period, with evidence from an administrative database of prescription orders and dispensings. METHODS: Research methods included pharmacy staff interviews at 6 military pharmacies, a telephone survey of beneficiaries who filled prescriptions at these pharmacies, descriptive analysis of survey data, and comparison of administrative pharmacy data with self-reported survey data. Beneficiary interviews, conducted from May through July 2004, covered background characteristics, medical conditions, and unclaimed prescriptions, relying on 12 months of recall regarding noncompliance. Interviews with pharmacy staff covered day-to-day operations, factors that alleviate or exacerbate noncompliance, and the burden that noncompliance places on pharmacies. Administrative data from the Pharmacy Data Transaction Service (pharmacy claims) and Composite Health Care System (CHCS: prescription orders and dispensings) databases were used to select a random sample for the beneficiary survey. Survey respondents' CHCS data were matched to their responses to determine the degree of agreement between self-reports and administrative data. RESULTS: Pharmacy interviews were completed with 30 staff members at 6 military pharmacies, and telephone interviews were completed with 1,214 beneficiaries (60.6% response rate). Beneficiary respondents filled an average of 7 prescriptions in the 5 months approximately surrounding the survey administration time frame (from March to July 2004). More than half (56.8%) of respondents were female, and nearly 60.6% were retired military or their dependents. Among all respondents at all study pharmacies, 8.0% reported failing to claim at least 1 prescription during the prior 12 months. Among survey respondents deemed compliant by CHCS data, 93.8% correctly identified themselves as compliant. However, among patients identified as noncompliant using CHCS data, only 16.0% selfidentified as noncompliant. The administrative data were not concordant with self-report data: of 105 survey respondents identifying themselves as noncompliant in the prior year and matched to administrative data (CHCS), only 58.1% were noncompliant per administrative data, and of 1,065 selfidentifying as compliant, only 61.1% were compliant per administrative data. The most common reasons cited by respondents for not picking up their prescriptions were: no perceived need for the prescription (18.5% of the noncompliant), forgot to pick it up (17.3%), the prescription was not in stock (14.8%), long wait time (11.1%), the prescription was not yet available (10.5%), was out of town (9.9%), and was too busy to pick up the prescription (6.2%). Factors associated with unclaimed prescriptions were: younger age, active duty military status, lower educational levels, and the absence of certain chronic medical conditions (i.e., no claims for cardiovascular medications, no self-reported arthritis). CONCLUSIONS: The present study's survey findings of an 8.0% selfreported noncompliance rate fall in the midrange of noncompliance rates reported in previous literature: between 0.45% and 22.0% in nonmilitary populations. Although reported reasons for noncompliance were generally consistent with those identified in previously published studies, they were only partially consistent with previous military pharmacy literature, which also found that patients did not know they had a prescription waiting or had some of the prescribed medicine at home. Concordance between measures of noncompliance, comparing administrative data with patient self-report based on 12-month recall, was poor.

Feeding Infants and Toddlers Study (FITS): development of the FITS survey in comparison to other dietary survey methods.

OBJECTIVE: This article describes the steps in the planning and development of the 2002 Feeding Infants and Toddlers Study. METHODS: We describe the study's rationale, sampling methodology, survey questionnaire development, dietary methodology, field data collection, and data processing and analysis. A brief review of existing national nutrition surveys and studies of infants and toddlers, and available study designs and dietary methods, is also included. SUBJECTS/SETTING: Most national studies have been cross-sectional and assessed breastfeeding rates, dietary intake, and nutritional status among general and high-risk populations. Other specialized studies have been longitudinal and tracked dietary intake and nutritional status from infancy to the preschool years, or focused on studying a specific research topic, such as the relationship between fluoride intake and dental caries. CONCLUSIONS: The 2002 Feeding Infants and Toddlers Study has advanced the knowledge base on infant and toddler nutrition by using state-of-the-art methodology and by providing researchers with updated information to develop further research questions. Our findings can be used by child health and nutrition organizations to develop dietary recommendations and improved nutrition education materials. Clinicians and practitioners in the fields of public health and wellness can use the information to provide practical advice to parents in a variety of settings to help give children a more healthful start.

Feeding infants and toddlers study: overview of the study design.

OBJECTIVE: Describe the design, data collection procedures, and sample characteristics of the Feeding Infants and Toddlers Study. DESIGN: We conducted up to three telephone interviews with a random sample of parents or caregivers of infants and toddlers four to 24 months of age from March to July 2002. The three interviews included (a) a recruitment and household interview; (b) a 24-hour dietary recall, with supplementary questions on growth, development, and feeding patterns; and (c) a second dietary recall for a random subset of the sample. Two age subgroups of infants (four to six months and nine to 11 months) were over sampled. Sample weights adjusted for over sampling, nonresponse, and under coverage of some subgroups in the sample frame. SUBJECTS: A national random sample of 3,022 infants and toddlers, with two days of dietary recall available for 703 sample members. RESULTS: Of sampled households that could be located and had an eligible child in the study age range, the response rate to the recruitment interview was 73%. Of recruited households, the response rate for the dietary recall interview was 94%. APPLICATIONS/CONCLUSIONS: The Feeding Infants and Toddlers Study (FITS) provides a wealth of data on the food and nutrient intakes, background characteristics, growth and development milestones, and feeding patterns and transitions for a nationally representative sample of infants and toddlers. Subsequent papers in this journal issue present study findings and conclusions from in-depth analysis of the FITS data.