The Demographics and Education of Emergency Medical Services (EMS) Professionals: A National Longitudinal Investigation.

OBJECTIVES: The objectives of this study were to assess longitudinal and cross-sectional changes in Emergency Medical Technician (EMT)-Basics and Paramedics: (1) demographics, (2) employment characteristics, and (3) initial Emergency Medical Services (EMS) education. METHODS: These data were collected between 1999 and 2008 employing survey techniques aimed at collecting valid data. A random, stratified sample was utilized to allow results to be generalizable to the nationally certified EMS population. Survey weights that were adjusted for each stratum's response were estimated. Weighted percentages, averages for continuous variables, and 95% confidence intervals (CIs) were calculated. Significant changes over time were noted when the CIs did not overlap. RESULTS: In all 10 years of data collection, the proportion of EMT-Paramedics who were male was greater than the proportion of EMT-Basics who were male. A substantial proportion of respondents performed EMS services for more than one agency: between 39.8% and 43.5% of EMT-Paramedics and 18.4% and 22.4% of EMT-Basic respondents reported this. The most common type of employer for both EMT-Basics and EMT-Paramedics was fire-based organizations. About one-third of EMT-Basics (32.3%-40.1%) and almost one-half of EMT-Paramedics (43.1%-45.3%) reported that these organizations were their main EMS employer. Rural areas (<25,000 residents) were the most common practice settings for EMT-Basics (52.1%-63.7%), while more EMT-Paramedics worked in urban settings (65.2%-77.7%). CONCLUSIONS: This analysis serves as a useful baseline to measure future changes in the EMS profession. This study described the demographic and work-life characteristics of a cohort of nationally certified EMT-Basics and Paramedics over a 10-year period. This analysis also summarized initial EMS education changes over time. Bentley MA , Shoben A , Levine R . The demographics and education of Emergency Medical Services (EMS) professionals: a national longitudinal investigation. Prehosp Disaster Med. 2016;31(Suppl. 1):s18-s29.

The Longitudinal Emergency Medical Technician (EMT) Attributes and Demographics Study (LEADS): The First 10 Years and a Look at Public Perception of Emergency Medical Services (EMS).

Crowe RP , Bentley MA , Levine R . The Longitudinal Emergency Medical Technician (EMT) Attributes and Demographics Study (LEADS): the first 10 years and a look at public perception of Emergency Medical Services (EMS). Prehosp Disaster Med. 2016;31(Suppl. 1):s1-s6.

Public Perception of Emergency Medical Services in the United States.

OBJECTIVE: The objective of this study was to assess the public's experience, expectations, and perceptions related to Emergency Medical Services (EMS). METHODS: A population-based telephone interview of adults in the United States was conducted. The survey instrument consisted of 112 items. Demographic variables including age, race, political beliefs, and household income were collected. Data collection was performed by trained interviewers from Kent State University's (Kent, Ohio USA)Social Research Laboratory. Descriptive statistics were calculated. Comparative analyses were conducted between those who used EMS at least once in the past five years and those who did not use EMS using χ2 and t tests. RESULTS: A total of 2,443 phone calls were made and 1,348 individuals agreed to complete the survey (55.2%). There were 297 individuals who requested to drop out of the survey during the phone interview, leaving a total of 1,051 (43.0%) full responses. Participants ranged in age from 18 to 94 years with an average age of 57.5 years. Most were Caucasian or white (83.0%), married (62.8%), and held conservative political beliefs (54.8%). Three-fourths of all respondents believed that at least 40% of patients survive cardiac arrest when EMS services are received. Over half (56.7%) believed that Emergency Medical Technician (EMT)-Basics and EMT-Paramedics provide the same level of care. The estimated median hours of training required for EMT-Basics was 100 hours (IQR: 40-200 hours), while the vast majority of respondents estimated that EMT-Paramedics are required to take fewer than 1,000 clock hours of training (99.3%). The majority believed EMS professionals should be screened for illegal drug use (97.0%), criminal background (95.9%), mental health (95.2%), and physical fitness (91.3%). Over one-third (37.6%) had used EMS within the past five years. Of these individuals, over two-thirds (69.6%) rated their most recent experience as "excellent." More of those who used EMS at least once in the past five years reported a willingness to consent to participate in EMS research compared with those who had not used EMS (69.9% vs. 61.4%, P=.005). CONCLUSIONS: Most respondents who had used EMS services rated their experience as excellent. Nevertheless, expectations related to survival after cardiac arrest in the out-of-hospital setting were not realistic. Furthermore, much of the public was unaware of the differences in training hour requirements and level of care provided by EMT-Basics and EMT-Paramedics. Crowe RP , Levine R , Rodriguez S , Larrimore AD , Pirrallo RG . Public perception of Emergency Medical Services in the United States. Prehosp Disaster Med. 2016;31(Suppl. 1):s112-s117.

A Longitudinal Description of Emergency Medical Services Professionals by Race/Ethnicity.

OBJECTIVE: The objective of this paper was to compare demographics, employment variables, satisfaction, and motivation for entering the field of Emergency Medical Services (EMS) between members of under-represented races/ethnicities and members of the majority group. METHODS: A cohort of nationally certified EMS professionals was followed for 10 years through annual surveys; however, race/ethnicity was only available for 9 years (2000-2008). Descriptive statistics and 95% confidence intervals (CIs) were calculated and significance was determined by lack of CI overlap. RESULTS: From 2000 through 2008, the range of proportions of nationally certified EMS professionals by race/ethnicity was as follows: whites: 83.5%-86.0%, Hispanics: 4.2%-5.9%, and African-Americans: 2.5%-4.6%. There were no significant changes in the proportion of minority EMS professionals over the study period. Hispanics and African-Americans combined increased slightly from 6.7% of the population in 2000 to 9.9% in 2008. Likewise, the proportion of all under-represented races/ethnicities increased slightly from 2000 (14.0%) to 2008 (16.5%). Females were under-represented in all years. Nationally certified African-Americans were significantly more likely to be certified at the Emergency Medical Technician (EMT)-Basic level (compared with the EMT-Paramedic level) than whites in all but one survey year. The proportion of Hispanics registered at the EMT-Basic level was significantly higher than whites in three survey years. Accordingly, a larger proportion of whites were nationally registered at the EMT-Paramedic level than both African-Americans and Hispanics. A significantly larger proportion of African-Americans reported working in urban communities (population >25,000) compared with whites for nine of the 10 survey years. Similarly, a significantly larger proportion of Hispanics worked in urban communities compared with whites in 2002 and from 2005 to 2008. For satisfaction measures, there were no consistent differences between races/ethnicities. Among factors for entering EMS, the proportion of whites who reported having a friend or family member in the field was significantly higher than African-Americans in all years and significantly higher than Hispanics in four of the nine years. CONCLUSION: The ethnic/racial diversity of the population of nationally certified EMS professionals is not representative of the population served and has not improved over the 2000-2008 period. Similar to other health care professions, Hispanics and African-Americans are under-represented in EMS compared with the US population. This study serves as a baseline to examine under-represented populations in EMS. Crowe RP , Levine R , Eggerichs JJ , Bentley MA . A longitudinal description of Emergency Medical Services professionals by race/ethnicity. Prehosp Disaster Med. 2016;31(Suppl. 1):s30-s69.

Longitudinal Emergency Medical Technician Attributes and Demographic Study (LEADS) Design and Methodology.

OBJECTIVES: The objective of this study is to describe the Longitudinal Emergency Medical Technician (EMT) Attributes and Demographic Study (LEADS) design, instrument development, pilot testing, sampling procedures, and data collection methodology. Response rates are provided, along with results of follow-up surveys of non-responders (NRs) and a special survey of Emergency Medical Services (EMS) professionals who were not nationally certified. METHODS: Annual surveys from 1999 to 2008 were mailed out to a random, stratified sample of nationally registered EMT-Basics and Paramedics. Survey weights were developed to reflect each respondent's probability of selection. A special survey of NRs was mailed out to individuals who did not respond to the annual survey to estimate the probable extent and direction of response bias. Individuals who indicated they were no longer in the profession were mailed a special exit survey to determine their reasons for leaving EMS. RESULTS: Given the large number of comparisons between NR and regular (annual) survey respondents, it is not surprising that some statistically significant differences were found. In general, there were few differences. However, NRs tended to report higher annual EMS incomes, were younger, healthier, more physically fit, and were more likely to report that they were not practicing EMS. Comparisons of the nationally certified EMS professionals with EMS professionals who were not nationally certified indicated that nationally certified EMS providers were younger, had less EMS experiences, earned less, were more likely to be female and work for private EMS services, and less likely to work for fire-based services. These differences may reflect state and local policy and practice, since many states and local agencies do not require maintenance of national certification as a requirement to practice. When these differences were controlled for statistically, there were few systematic differences between non-nationally certified and nationally certified EMS professionals. CONCLUSIONS: The LEADS study is the only national, randomized, and longitudinal data source for studying EMS professionals in the United States. Although not without flaws, this study remains an excellent source of information about EMS provider demographics, attributes, attitudes, workplace issues and concerns, and how the profession has changed from 1999 to 2008. Levine R . Longitudinal Emergency Medical Technician Attributes and Demographic Study (LEADS) design and methodology. Prehosp Disaster Med. 2016;31(Suppl. 1):s7-s17.

A National Assessment of the Health and Safety of Emergency Medical Services Professionals.

OBJECTIVES: The objectives were to assess changes in (1) health and physical fitness, (2) the prevalence of selected health problems, (3) risk behaviors, (4) ambulance safety issues, and (5) the preparedness of Emergency Medical Services (EMS) professionals. In addition, the incidence of patient-initiated violence directed toward EMS personnel and associated factors were assessed. METHODS: Data were obtained from a sample of nationally certified EMS professionals via annual questionnaires between 1999 and 2008. Stratification was based upon national certification level, self-reported race, and experience level. Weighted percentages, averages for continuous variables, and 95% confidence intervals (CIs) were calculated. Significant changes over time were noted by lack of CI overlap. RESULTS: The proportion reporting "excellent" health declined significantly from 1999 (38.5%) to 2008 (32.2%). High rates of sleeping problems (20%-27%), back problems (20%-24%), and hearing problems (7%-10%) were reported as having occurred in the past year. These rates remained constant over time. As a result of sleepiness, 8.0% of nationally certified EMS professionals reported difficulty in driving an emergency vehicle for short distances and 17.5% reported difficulty in driving long distances. The proportion of daily tobacco smokers significantly declined from over one-third (35.3%) to about one-fifth (20.3%). The proportion of providers who had ever been involved in an ambulance crash increased slightly from 2004 (14.5%) to 2008 (15.8%). In 2000, the majority of EMS professionals reported that they and/or their partner had been assaulted by a patient. Finally, there was a significant decrease in the amount of training time devoted to the recognition of biological, chemical, and nuclear (BCN) threats, use of personal protective equipment (PPE), and treatment and management of patients exposed to BCN from an average from 8.4 hours in 2003 to 6.2 hours in 2008. CONCLUSIONS: The overall health and physical fitness of EMS professionals as well as their health problems, risk behaviors, ambulance safety, and patient-initiated violence in the prehospital emergency setting are areas of concern for the nation's emergency medical system. The prevalence of these problems and overall health and physical fitness has shown little or no improvement from 1999 to 2008. Bentley MA , Levine R . A national assessment of the health and safety of Emergency Medical Services professionals. Prehosp Disaster Med. 2016;31(Suppl. 1):s96-s104.

Quality of care in sickle cell disease: Cross-sectional study and development of a measure for adults reporting on ambulatory and emergency department care.

Documented deficiencies in adult sickle cell disease (SCD) care include poor access to knowledgeable providers and inadequate treatment in emergency departments (EDs).The aim of this study was to create patient-reported outcome measures of the quality of ambulatory and ED care for adults with SCD.We developed and pilot tested SCD quality of care questions consistent with Consumer Assessments of Healthcare Providers and Systems surveys. We applied psychometric methods to develop scores and evaluate reliability and validity.The participants of this study were adults with SCD (n = 556)-63% aged 18 to 34 years; 64% female; 64% SCD-SS-at 7 US sites.The measure used was Adult Sickle Cell Quality of Life Measurement information system Quality of Care survey.Most participants (90%) reported at least 1 severe pain episode (pain intensity 7.8 ±â€Š2.3, 0-10 scale) in the past year. Most (81%) chose to manage pain at home rather than the ED, citing negative ED experiences (83%). Using factor analysis, we identified Access, Provider Interaction, and ED Care composites with reliable scores (Cronbach α 0.70-0.83) and construct validity (r = 0.32-0.83 correlations with global care ratings). Compared to general adult Consumer Assessments of Healthcare Providers and Systems scores, adults with SCD had worse care, adjusted for age, education, and general health.Results were consistent with other research reflecting deficiencies in ED care for adults with SCD. The Adult Sickle Cell Quality of Life Measurement Quality of Care measure is a useful self-report measure for documenting and tracking disparities in quality of SCD care.

A National Description of Violence toward Emergency Medical Services Personnel.

INTRODUCTION: EMS personnel often work in unpredictable environments and are at high risk for sustaining occupational injuries. One potential source of injury that is of growing concern is violence toward EMS personnel. OBJECTIVE: To describe the prevalence of violence directed at EMS personnel by type and source, and to identify characteristics associated with experiencing violence. METHODS: The 2013 Longitudinal EMT Attributes and Demographics Study contained 14 items assessing violence experienced in the past 12 months. Violence was categorized by type (physical or verbal) and by source (the patient or a patient's family member or bystander). EMS personnel characteristics included sex, age, race, marital status, certification level, firefighter, volunteerism, agency type, and community size. Descriptive and comparative analyses were performed on personnel whose primary role was providing patient care. Multivariable logistic regression modelling was used to assess associations between provider characteristics and experiencing violence. RESULTS: A total of 2,515/4,238 (59.3%) responses were received and 1,789 met inclusion criteria. Over two-thirds (69.0%) experienced at least one form of violence in the past 12 months. Verbal violence was more prevalent than physical (67.0% vs. 43.6%). Using multivariable logistic regression to control for other demographic and employment characteristics, paramedics had nearly triple the odds of experiencing physical (OR = 2.67, 95% CI = 2.06-3.46) and verbal (OR = 2.63, 95% CI = 1.99-3.46) violence as EMTs. Urban personnel had increased odds of experiencing physical (OR = 1.53, 95% CI = 1.21-1.93) and verbal violence (OR = 1.32, 95% CI = 1.02-1.71). Each additional weekly transport increased the odds of experiencing physical (OR = 1.04, 95% CI = 1.03-1.05) and verbal (OR = 1.04, 95% CI = 1.03-1.06) violence by 4%. Those who were volunteers at their main EMS jobs had decreased odds of experiencing physical (OR = 0.68, 95% CI = 0.50-0.92) and verbal (OR = 0.59, 95% CI = 0.44-0.78) violence. CONCLUSIONS: Over two-thirds of EMS personnel experienced at least one form of violence in the last 12 months. Demographic and employment characteristics associated with experiencing violence were identified. Our findings may be used in education initiatives to raise awareness of the high prevalence of violence toward EMS personnel and factors associated with experiencing violence.

Prehospital Helicopter Air Ambulances Part 1: Access, Protocols, and Utilization.

OBJECTIVE: In the prehospital setting, helicopter air ambulances (HAAs) are used to bring advanced care to patients and reduce time to definitive care. Research related to emergency medical service (EMS) professionals' access to medical helicopters, protocols for HAA use, and prevalence of HAA transport for different patient types is sparse. Our first objective was to describe EMS professionals' access to HAA and the prevalence of written protocols regarding their use. Next, we looked at HAA use for specific patient types (trauma, nontraumatic chest pain, stroke, and pediatric). METHODS: We conducted a census survey of nationally certified EMS professionals. Descriptive analyses were performed. RESULTS: There were 15,366 responses. Over 90% of nationally certified EMS professionals had access to at least 1 HAA service. Of these, 86% had the authority to request a medical helicopter, and two thirds reported having written HAA protocols. Although HAAs were used mostly for trauma patients, EMS professionals also used these resources for nontrauma transports of patients with time-sensitive conditions. CONCLUSION: Most nationally certified EMS professionals had access to a medical helicopter service and used these resources mainly for trauma patients. About one third reported they did not have or were unsure if their agency had written protocols for HAA use.

Prehospital Helicopter Air Ambulances Part 2: Utilization Criteria and Training.

OBJECTIVES: The decision to request a helicopter air ambulance (HAA) is critical and complex. Emergency medical service (EMS) professionals must know how to appropriately and safely use HAA resources. We sought to describe important criteria for using HAA and the prevalence of HAA-related training among EMS professionals. Then, we identified characteristics associated with receiving training. METHODS: We sent an electronic questionnaire to all nationally certified EMS professionals. We performed descriptive analyses and multivariable logistic regression modeling. RESULTS: We received 15,366 responses. Nearly all respondents reported that time to nearest trauma center and mechanism of injury were important in their last decision to use a HAA. About two thirds received HAA safety training (66.7%), whereas 69.0% received HAA utilization training within the past 24 months. Nearly three fourths (74.2%) received training in at least 1 HAA-related topic. Providers working at advanced life support levels, fire-based services, agencies providing 911 response, or in rural communities had greater odds of having received HAA training, whereas women, members of minority ethic/racial groups, and those with higher weekly call volumes had decreased odds. CONCLUSION: Although their decision-making criteria appear to include the major factors recommended within current evidence-based guidelines, many nationally certified EMS professionals had not received recent HAA training.

Development and evaluation of the CAHPS (Consumer Assessment of Healthcare Providers and Systems) survey for in-center hemodialysis patients.

BACKGROUND: The US Centers for Medicare & Medicaid Services assess patient experiences of care as part of the end-stage renal disease prospective payment system and Quality Incentive Program. This article describes the development and evaluation of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) In-Center Hemodialysis Survey. STUDY DESIGN: We conducted formative research to generate survey questions and performed statistical analyses to evaluate the survey's measurement properties. SETTING & PARTICIPANTS: Formative research included focus groups, cognitive interviews, and field testing the survey with dialysis patients. MEASUREMENTS & OUTCOMES: We assessed internal consistency reliability (Cronbach alpha) and center-level reliability for 3 multi-item scales. We evaluated construct validity using correlations of the scales with global ratings of the kidney doctor, staff, and dialysis center. RESULTS: Response rate was 46% (1,454 completed surveys). Analyses support 3 multi-item scales: Nephrologists' Communication and Caring (7 items, alpha=0.89), Quality of Dialysis Center Care and Operations (22 items, alpha=0.93), and Providing Information to Patients (11 items, alpha=0.75). The communication scale was correlated the most strongly with the global rating of the "kidney doctor" (r=0.78). The Dialysis Center Care and Operations scale was correlated most strongly with global ratings of staff (r=0.75) and the center (r=0.69). Providing Information to Patients was correlated most strongly with the global rating of the staff (r=0.41). LIMITATIONS: A relatively small number of patients completed the survey in Spanish. CONCLUSIONS: This study provides support for the reliability and validity of the CAHPS In-Center Hemodialysis Survey for assessing patient experiences of care at dialysis facilities. The survey can be used to compare care provided at different facilities.

Adult sickle cell quality-of-life measurement information system (ASCQ-Me): conceptual model based on review of the literature and formative research.

OBJECTIVES: Research-derived evidence about the impact of sickle cell disease (SCD) on the lives of affected adults is lacking. We conducted formative research to provide the basis for a comprehensive description of how SCD affects the lives of adults, with the goal of developing a SCD-specific quality-of-life measurement system. METHODS: We conducted a comprehensive literature review of patient-reported outcomes, followed by a series of focus groups and structured individual interviews with adults with SCD (n=122) and their health care providers (n=15). RESULTS: We reviewed 473 abstracts and included 86 articles in the final review. The literature revealed broad categories of the impact of SCD and its treatment on the lives of adults-pain; emotional distress; social-role functioning; overall quality-of-life; and quality of care. We classified 1213 incidents from the focus groups and interviews into a taxonomy (16 domains) that met the criterion for saturation and was demonstrated to be reliable for the classification of incidents. The final conceptual model was built upon the taxonomy. DISCUSSION: Our conceptual model was similar to previous models with the effects of pain predominating, interwoven with emotional distress, quality of care, and stigmatization. We found a broad range of emotions reflected, including positive effects of SCD. Items for the quality-of-life measure were derived from the taxonomy and the conceptual model may be of use in generating hypotheses for clinical research and improving understanding for clinicians of the lived experience of adults with SCD.

Evaluating health services research capacity building programs: implications for health services and human resource development.

Evaluation of research capacity building programs presents challenges, including defining "research capacity building" and measuring it. The present study evaluates infrastructure capacity-building strategies and barriers and facilitators of two federally funded health-related research capacity building programs within the United States. We developed a conceptual framework and abstracted 223 data elements from existing project files. We administered questionnaires to 17 principal investigators and conducted 2-h interviews of 15 principal investigators. Finally, we conducted one-and-a-half-day site visits with five projects. We aggregated data and analysis results across the two programs. Impacts and strategies were also analyzed as to whether host institutions had little or no existing research infrastructure ("seed projects") or had well-developed research infrastructure ("fertilizer projects"). Projects were associated with increases in publication and presentation rates by Principal Investigators and staff, increases in research funding, changes in organizational research culture, and positive impacts on the community. Project characteristics and activities associated with each of these outcomes were identified. It was also noted that the correlations between these outcomes were small and non-significant.

Comparing physician and patient perceptions of quality in ambulatory care.

OBJECTIVE: If quality improvement interventions, value-based purchasing and/or certification are based on patient assessments, a common definition of quality should be shared by clinicians and patients. The study's objectives were to determine (i) how patients and clinicians define quality care, (ii) in what ways patients' and physicians' definitions differ and (iii) whether patients' definitions vary by ethnicity. DESIGN: We used the critical incident technique to interview participants about behaviors that resulted in office visits being considered either good or poor quality and compared the prevalence of different types of 'quality' behaviors reported to identify commonalities and differences. SETTING: Hawaii and Chicago. PARTICIPANTS: A total of 168 patients and 39 clinicians. RESULTS: We developed a taxonomy, comprising 9 major categories and 106 subcategories of behaviors responsible for quality visits. Almost all clinicians and patients agreed that clinical skill, rapport and health-related communication behaviors were key elements. Patients were more likely to report behaviors demonstrating thoroughness in routine examinations, spending enough time with them, engaging them and being treated with courtesy and respect as drivers of a quality office visit than were physicians. CONCLUSIONS: Increased clinician awareness of the behaviors that patients believe are the drivers of a quality office visit can help clinicians improve patients' experience of care and experience-based measures of quality.

The prevalence of sleep problems in emergency medical technicians.

PURPOSE: To investigate the prevalence, demographic, and work associations of self-reported sleep complaints in US emergency medical technicians (EMTs) METHODS: The mailed 2005 Longitudinal Emergency Medical Technician Attributes and Demographics Study (LEADS) questionnaire was distributed to selected EMTs that included 35 sleep-related questions. Questions were adapted from previously validated sleep medicine surveys, including the Epworth Sleepiness Scale (ESS), and were used to estimate the prevalence of different sleep problems. These sleep problems were analyzed in relation to demographic, health, satisfaction, and workplace characteristics. Responses of individuals who were not working as EMTs were used as a comparison group. RESULTS: Sleep problems in working EMTs were more prevalent than in a comparison group. Seventy percent of working EMTs had at least one sleep problem. The most common sleep problem was a risk of long sleep onset disorder (50%). EMTs with tiredness-related work difficulties were more than 50% as likely to report this problem. The prevalence of excessive daytime sleepiness (ESS > 10) was 36%; 6% of the EMTs had an ESS > 16. EMTs reporting tiredness-related work difficulties were more than twice as likely to have ESS scores >10 and more than three times as likely to ESS scores >16. Symptom-defined risk of sleep apnea was present in 5%. Risks of sleep onset and maintenance disorder problems were more prevalent among those who worked longer shifts and had longer work weeks and were associated with poorer job satisfaction and poorer health. CONCLUSIONS: Severe sleep problems and severe sleepiness at a level that may contribute to health and job issues are common in US EMTs. Although breathing disorders are common, behaviorally related sleep issues are more prevalent. These data support an increased focus on sleep onset and maintenance disorders.

Enabling a survey of primary care to measure the health care experiences of adults with disabilities.

PURPOSE: To enable an existing survey on primary care so that it can be used to assess the healthcare experiences reported by adults living with disabilities, and to evaluate its properties. METHODS: Mixed-methods study. We first identified content areas for measurement as compared to the items in the existing instrument and then developed new candidate items. Cognitive testing was conducted in English and Spanish. After revisions to the primary care instrument based on the cognitive testing results, the draft-enabled instrument was field-tested by mail with telephone follow-up, in English and Spanish. RESULTS: Consumer focus groups and a technical expert panel identified eight content areas in primary care that are particularly important to maximise function and well-being of people of with disabilities. Cognitive testing also revealed serious problems with several items in the existing survey when answered by or about people with disabilities. Field testing yielded 1086 surveys, of which 40% were completed by a proxy respondent. Learning disabilities were reported by 38% of respondents. Item non-response for revised and new questions was less than 4%. CONCLUSIONS: It is feasible to enable a survey of primary care and its administration. Survey administration instructions should be modified to accommodate proxy respondents. The screener item to identify people with mobility impairments on walking a distance should be replaced with walking for 6 min. Adding questions from the American Community Survey about functional ability will allow survey sponsors to identify respondents with various limitations, and to compare their experiences to those of people with no limitations. Careful development and testing of the items with input from interested parties throughout the design and testing stages yielded a survey with good psychometric properties and content validity in multiple languages. Health delivery systems can use the survey data to identify clinical processes needing improvement to provide high quality care for people with disabilities.

Gauging U.S. Emergency Medical Services workers' willingness to respond to pandemic influenza using a threat- and efficacy-based assessment framework.

BACKGROUND: Emergency Medical Services workers' willingness to report to duty in an influenza pandemic is essential to healthcare system surge amidst a global threat. Application of Witte's Extended Parallel Process Model (EPPM) has shown utility for revealing influences of perceived threat and efficacy on non-EMS public health providers' willingness to respond in an influenza pandemic. We thus propose using an EPPM-informed assessment of EMS workers' perspectives toward fulfilling their influenza pandemic response roles. METHODOLOGY/PRINCIPAL FINDINGS: We administered an EPPM-informed snapshot survey about attitudes and beliefs toward pandemic influenza response, to a nationally representative, stratified random sample of 1,537 U.S. EMS workers from May-June 2009 (overall response rate: 49%). Of the 586 respondents who met inclusion criteria (currently active EMS providers in primarily EMS response roles), 12% indicated they would not voluntarily report to duty in a pandemic influenza emergency if asked, 7% if required. A majority (52%) indicated their unwillingness to report to work if risk of disease transmission to family existed. Confidence in personal safety at work (OR = 3.3) and a high threat/high efficacy ("concerned and confident") EPPM profile (OR = 4.7) distinguished those who were more likely to voluntarily report to duty. Although 96% of EMS workers indicated that they would probably or definitely report to work if they were guaranteed a pandemic influenza vaccine, only 59% had received an influenza immunization in the preceding 12 months. CONCLUSIONS/SIGNIFICANCE: EMS workers' response willingness gaps pose a substantial challenge to prehospital surge capacity in an influenza pandemic. "Concerned and confident" EMS workers are more than four times as likely to fulfill pandemic influenza response expectations. Confidence in workplace safety is a positively influential modifier of their response willingness. These findings can inform insights into interventions for enhancing EMS workers' willingness to respond in the face of a global infectious disease threat.

Role of cognitive testing in the development of the CAHPS Hospital Survey.

OBJECTIVE: To describe how cognitive testing results were used to inform the modification and selection of items for the Consumer Assessment of Health Providers and Systems (CAHPS) Hospital Survey pilot test instrument. DATA SOURCES: Cognitive interviews were conducted on 31 subjects in two rounds of testing: in December 2002-January 2003 and in February 2003. In both rounds, interviews were conducted in northern California, southern California, Massachusetts, and North Carolina. STUDY DESIGN: A common protocol served as the basis for cognitive testing activities in each round. This protocol was modified to enable testing of the items as interviewer-administered and self-administered items and to allow members of each of three research teams to use their preferred cognitive research tools. DATA COLLECTION/EXTRACTION METHODS: Each research team independently summarized, documented, and reported their findings. Item-specific and general issues were noted. The results were reviewed and discussed by senior staff from each research team after each round of testing, to inform the acceptance, modification, or elimination of candidate items. PRINCIPAL FINDINGS: Many candidate items required modification because respondents lacked the information required to answer them, respondents failed to understand them consistently, the items were not measuring the constructs they were intended to measure, the items were based on erroneous assumptions about what respondents wanted or experienced during their hospitalization, or the items were asking respondents to make distinctions that were too fine for them to make. Cognitive interviewing enabled the detection of these problems; an understanding of the etiology of the problem informed item revisions. However, for some constructs, the revisions proved to be inadequate. Accordingly, items could not be developed to provide acceptable measures of certain constructs such as shared decision making, coordination of care, and delays in the admissions process. CONCLUSIONS: Cognitive testing is the most direct way of finding out whether respondents understand questions consistently, have the information needed to answer the questions, and can use the response alternatives provided to describe their experiences or their opinions accurately. Many of the candidate questions failed to meet these standards. Cognitive testing only evaluates the way in which respondents understand and answer questions. Although it does not directly assess the validity of the answers, it is a reasonable premise that cognitive problems will seriously compromise validity and reliability.

Behavioral health risk factors of United States emergency medical technicians: the LEADS Project.

OBJECTIVE: Personal risk behaviors are modifiable. This report describes the 2002 national baseline of behavioral health risk factors of US emergency medical technicians (EMTs) that can guide policy and program development in improving EMT well-being. METHODS: A 19-item Health Behavioral Risk Survey (Appendix) was added to the 2002 Longitudinal Emergency Medical Technician Demographic Study mail survey. Risk survey questions covering physical activity, tobacco use, and alcohol use were modeled after the Centers for Disease Control and Prevention 2002 Behavioral Risk Factor Surveillance System (BRFSS) questionnaire. Personal, non-work related seatbelt use and motor vehicle driving questions were adopted from the 2002 US National Highway Traffic Safety Administration (NHTSA) Motor Vehicle Occupant Safety Survey (MVOSS). Post-stratification adjustment factors were used to allow comparisons with BRFSS and MVOSS national estimates. RESULTS: A total of 1,919 EMT respondents were compared with 239,866 BRFSS and 5,220 MVOSS respondents. These comparisons indicate that EMT-Basics drove more slowly than paramedics; male EMTs drove faster, drank more, and wore their seatbelts less often than did female EMTs; female EMTs smoked more and engaged in vigorous exercise less than males. Those EMTs who reported to be in fair or poor health, smoked more and exercised less than those who reported to be in good or excellent health. Regardless of gender, age, or race, EMTs, on average, wore their seatbelts less often, drove faster than, and were less likely to engage in moderate physical exercise, compared to US adults. CONCLUSION: Stereotypical gender differences in risk behaviors exist among EMTs. An EMT's self-reported health positively correlates with smoking and exercising. Compared to US national estimates, except for smoking and vigorous exercise, EMTs have increased risk behaviors.