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Een belangrijk onderdeel van de CQ-index is het vergelijken van zorginstellingen. Onderzoek heeft aangetoond dat patientkenmerken zoals geslacht, leeftijd, opleiding en ervaren gezondheid de ervaren zorg systematisch beinvloeden. Om toch een zuivere vergelijking tussen de zorginstellingen mogelijk te maken wordt ‘case-mix adjustment’ toegepast. Dit betekent dat bij het vergelijken van de ervaren zorg geleverd door zorginstellingen gecorrigeerd wordt voor verschillen in patientkenmerken tussen zorginstellingen. In de ‘case-mix adjustment’ wordt ook een instellingseffect geschat, wat een indicatie is van de verschillen in ervaren zorg die zijn toe te schrijven aan verschillen tussen zorginstellingen. Echter, het is onbekend welke instellingskenmerken dit effect verklaren. In dit onderzoek is met behulp van een multi-level analyse op basis van gegevens van 21.796 patienten uit 76 ziekenhuizen aangetoond dat instellingskenmerken (in dit geval ziekenhuiskenmerken) invloed hebben op het rapportcijfer voor de ervaren zorg. Het ziekenhuistype, de stedelijkheid van de ziekenhuisomgeving en de aanwezigheid van andere ziekenhuizen in de omgeving van een ziekenhuis hebben een significant effect. Ziekenhuisgrootte heeft geen effect. Hoewel het effect van ziekenhuiskenmerken op het rapportcijfer vrij klein is vergeleken bij de patientenkenmerken, moeten onderzoekers bij nieuwe CQ-indices overwegen instellingskenmerken in de analyses op te nemen, bijv. in de verdiepingsanalyses.

OBJECTIVES: To assess the reliability and validity of a translated version of the American Hospital-level Consumer Assessment of Health Plans Survey (H-CAHPS) instrument for use in Dutch health care. DATA SOURCES/STUDY SETTING: Primary survey data from adults aged 18 years or more who were recently discharged from two multispecialty city hospitals in the Netherlands. STUDY DESIGN: We used forward and backward translation procedures and a panel of experts to adapt the 66-item pilot H-CAHPS into a 70-item Dutch instrument. Descriptive statistics and standard psychometric methods were then used to test the reliability and validity of the new instrument. DATA COLLECTION: From late November 2003 to early January 2004, the survey was administered by mail to 1,996 patients discharged within the previous 2 months. PRINCIPAL FINDINGS: Analyses supported the reliability and validity of the following 7-factor H-CAHPS structure for use in Dutch hospitals: on doctor's communication, nurses' communication, discharge information, communication about medication, pain control, physical environment of hospital, and nursing services. The internal consistency reliability of the scales ranged from 0.60 to 0.88. Items related to "family receiving help when on visit,""hospital staff introducing self," and "admission delays" did not improve the psychometric properties of the new instrument. CONCLUSIONS: These findings suggest that the H-CAHPS instrument is reliable and valid for use in the Dutch context. However, more research will be needed to support its equivalence to the United States version, and its use for between-hospital comparisons.

Background: In the Dutch social insurance system, based on regulated competition, sickness funds should attract clients by contracting efficient and qualitatively good services. For that sake, sickness funds need information about their own performance and about the quality of care they contract, as perceived by their insured. In the Unites States, the Consumer Assessment of Health Plan Surveys (CAHPS) have been developed specifically for that purpose. CAHPS instruments focus on the patient-centeredness of health care (e.g. respect, dignity, prompt attention) and the service of the health plan. These surveys have recently been adopted by the largest Dutch sickness fund (AGIS). Aim: This paper presents the results of a validation study, commissioned by AGIS Zorgverzekeringen, looking at: a) Can the CAHPS be adapted for use in the context of the Dutch social insurance system? b) Do these questionnaires generate valid information about the quality of health care and the performance of Dutch sickness funds? Methods: The American core CAHPS was translated forward and backward. It was subsequently piloted in a sample of 977 AGIS clients (response rate 56%, with a slight over-representation of elderly). Internal validation consisted of evaluations of item response rates, distributions of scores, reliability analyses, and tests of internal consistency. For external validation data are compared with the American CAHPS benchmark data, and with results of other Dutch studies. Results: In general, the questionnaires are filled out completely and consistently. As expected, the distribution of scores on the perceived quality of care is somewhat skewed towards positive answers. The questionnaire contains a reliable scale about the patient-centerednesscenteredness of care (Cronbach’s alpha .83). That scale correlates significantly with respondents’ general rating of the quality of health care on scale of 0 to 10. The comparison with the American CAHPS benchmark data showed that respondents in the US’ system experience more problems with the accessibility of care than do their Dutch counterparts. However, once patients manage to get into the system, the patient-centeredness of the two health care systems is remarkably similar. Conclusions: It is possible to import American patient questionnaires into the Dutch social insurance system and use them to improve the accountability of sickness funds. Particularly, questions that refer to the primary process in health care (the doctor-patient interaction) generate scores that are quite comparable between the American and the Dutch health system.