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BackgroundData from surveys of patient care experiences are a cornerstone of public reporting and pay-for-performance initiatives. Recently, increasing concerns have been raised about survey response rates and how to promote equity by ensuring that responses represent the perspectives of all patients.ObjectiveReview evidence on survey administration strategies to improve response rates and representativeness of patient surveys.Research designSystematic review adhering to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines.Study selectionForty peer-reviewed randomized experiments of administration protocols for patient experience surveys.ResultsMail administration with telephone follow-up provides a median response rate benefit of 13% compared with mail-only or telephone-only. While surveys administered only by web typically result in lower response rates than those administered by mail or telephone (median difference in response rate: -21%, range: -44%, 0%), the limited evidence for a sequential web-mail-telephone mode suggests a potential response rate benefit over sequential mail-telephone (median: 4%, range: 2%, 5%). Telephone-only and sequential mixed modes including telephone may yield better representation across patient subgroups by age, insurance type, and race/ethnicity. Monetary incentives are associated with large increases in response rates (median increase: 12%, range: 7%, 20%).ConclusionsSequential mixed-mode administration yields higher patient survey response rates than a single mode. Including telephone in sequential mixed-mode administration improves response among those with historically lower response rates; including web in mixed-mode administration may increase response at lower cost. Other promising strategies to improve response rates include in-person survey administration during hospital discharge, incentives, minimizing survey language complexity, and prenotification before survey administration.

OBJECTIVE The objective of this study was to compare results of using web-based and mail (postal) Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) data collection protocols. RESEARCH DESIGN Patients who had been hospitalized in a New England Hospital were surveyed about their hospital experience. Patients who provided email addresses were randomized to 1 of 3 data collection protocols: web-alone, web with postal mail follow-up, and postal mail only. Those who did not provide email addresses were surveyed using postal mail only. Analyses compared response rates, respondent characteristics, and patient-reported experiences. SUBJECTS For an 8-week period, patients were discharged from the study hospital to home. MEASURES Measures included response rates, characteristics of respondents, 6 composite measures of their patient experiences, and 2 ratings of the hospital. RESULTS Response rates were significantly lower for the web-only protocol than the mail or combined protocols, and those who had not provided email addresses had lower response rates. Those over 65 were more likely than others to respond to all protocols, especially for the mail-only protocols. Respondents without email addresses were older, less educated, and reported worse health than those who provided email addresses. After adjusting for respondent differences, those in the combined protocol differed significantly from the mail (postal) only respondents on 2 measures of patient experience; those in the web-only protocol differed on one. Those not providing an email address differed from those who did on one measure. CONCLUSION If web-based protocols are used for HCAHPS surveys, adjustments for a mode of data collection are needed to make results comparable.

BACKGROUND Primary care training schools and programs lack a validated tool to assess their oral health curriculum, and researchers lack a tool to compare oral health curricula across programs/schools and different disciplines. OBJECTIVE This study describes the process and results of creating a 15-item oral health curriculum evaluation tool (OHCET). METHODS Three-phased development of the OHCET from 2018 to 2020 including (a) Delphi group/tool development; (b) tool pilot test; and (c) tool validation/cognitive interviews. RESULTS A total of 23 program deans/directors participated in the tool validation/cognitive interviews. Summarizing accuracy scores of all 15 items, the mean accuracy score was 87.1. There was a high correlation (0.917) between the program's total score and the program director's self-assessed competence of their learners at the time of graduation. CONCLUSIONS The OHCET was validated and can be used in primary care training programs and schools across the country for institutional evaluation and for research purposes. Program directors and deans can also have some confidence that their ability to subjectively assess their learner's oral health knowledge and skills at graduation is accurate.

With declining response rates and challenges of using RDD sampling for telephone surveys, collecting data from address-based samples has become more attractive. Two approaches are doing telephone interviews at telephone numbers matched to addresses and asking those at sampled addresses to call into an Interactive Voice Response (IVR) system to answer questions. This study used in-person interviewing to evaluate the effects of nonresponse and problems matching telephone numbers when telephone and IVR were used as the initial modes of data collection. The survey questions were selected from major US federal surveys covering a variety of topics. Both nonresponse and, for telephone, inability to find matches result in important nonresponse error for nearly half the measures across all topics, even after adjustments to fit the known demographic characteristics of the residents. Producing credible estimates requires using supplemental data collection strategies to reduce error from nonresponse.

COVID-19 related policies introduced extraordinary social disruption in nursing homes. In response to the unprecedented COVID-19 pandemic, congregated long term care living facilities attempted and/or implemented innovative intervention strategies to alleviate loneliness in residents. We surveyed Directors of Nursing/Administrators of 1,669 homes sampled in strata defined by size (number of beds 30–99, 100+) and quality ratings (1, 2–4, 5) between February-May 2022. The response rate was 30%. Almost 2/3rds of respondents completed it online and the rest via paper. Analyses included nonresponse survey weights to provide nationally representative results. Among a list of 17 situations that occurred, staff shortages was identified as extremely stressful by the majority. Staff were extremely stressed about doing more to meet resident needs and keeping up with rapidly changing regulations which often lacked clinical sense. One third of respondents were extremely concerned about their home’s ability to meet residents’ social needs before vaccines, dropping to 13% after vaccines. Nursing homes tried and perceived as most useful using technology (tablets, phones, emails), assigning staff as a family contact, and staff spending more time with residents. Nearly 60% were extremely concerned about staff burnout/mental health before vaccines and 40% remained extremely concerned after vaccines. Many nursing homes attempted to mitigate the harmful effects of social isolation during the pandemic, despite the stressful circumstances in which staff worked. The extent to which various approaches were implemented varied. While concerns about social isolation reduced after vaccines were available, administrators remain extremely concerned about staff burnout and mental health.

Background. John Henryism is defined as a measure of active coping in response to stressful experiences. John Henryism has been linked with health conditions such as diabetes, prostate cancer, and hypertension, but rarely with health behaviors. Aims. We hypothesized that reporting higher scores on the John Henryism Scale may be associated with poorer medication adherence, and trust in providers may mediate this relationship. Method. We tested this hypothesis using data from the TRUST study. The TRUST study included 787 African Americans with hypertension receiving care at a safety-net hospital. Ordinal logistic regression was used to examine the relationship between John Henryism and medication adherence. Results. Within our sample of African Americans with hypertension, lower John Henryism scores was associated with poorer self-reported adherence (low, 20.62; moderate, 19.19; high, 18.12; p < .001). Higher John Henryism scores were associated with lower trust scores (low John Henryism: 40.1; high John Henryism: 37.9; p < .001). In the adjusted model, each 1-point increase in the John Henryism score decreased the odds of being in a better cumulative medication adherence category by a factor of 4% (odds ratio = 0.96, p = .014, 95% confidence interval = 0.93-0.99). Twenty percent of the association between medication adherence and John Henryism was mediated by trust (standard deviation = 0.205, 95% confidence interval = 0.074-0.335). Discussion. This study provides important insights into the complex relationship between psychological responses and health behaviors. It also contributes to the body of literature examining the construct of John Henryism among African Americans with hypertension. Conclusion. The findings of this study support the need for interventions that promote healthful coping strategies and patient–provider trust.

The COVID-19 pandemic had dramatic, sometimes devastating impacts on nursing homes, residents, and staff. Rapid deployment of innovative approaches to resident care was required even while under sustained distress. We collected textual responses to open-ended questions about COVID-19 experiences through a national nursing home survey of Directors of Nursing/Administrators in February-May 2022. We employed a stratified (by size and quality ratings) sample of 1,669 nursing homes. Response rate was 30%, and 51% of responders answered > 1 open-ended question. We conducted an iterative thematic qualitative analysis yielding 10 themes. Respondents described addressing social isolation using new technology; enlisting staff from across the nursing home [beyond-the-call effort, gifting of voluntary time], and new ways for residents to safely connect with family. Respondents felt severely limited by COVID regulations that seemed to ignore residents’ mental health needs. The majority of respondents felt significant professional and personal impact of the pandemic experience: “The pandemic was the most stressful situation I have encountered in 26 years of nursing” – “What a toll it took on all us emotionally, physically, and mentality” – “Every day was a challenge and I felt hopeless” – Some respondents plan to quit: “I am now seeking other employment. It has been too much for too long and has directly affected my mental health.” Nursing homes reported extraordinary efforts put forth by administration and staff to meet the needs of residents. Efforts to retain nursing staff are needed given profound impacts of the pandemic on their personal and professional lives.

Background: Home remedies (HRs) are described as foods, herbs, and other house­hold products used to manage chronic conditions. The objective of this study was to examine home remedy (HR) use among Blacks with hypertension and to determine if home remedy use is correlated with blood pressure and medication adherence. Methods: Data for this cross-sectional study were obtained from the TRUST study con­ducted between 2006-2008. Medication adherence was measured using the Morisky Medication Adherence Scale, and HR use was self-reported. Multivariable associa­tions were quantified using ordinal logistic regression. Results: The study sample consisted of 788 Blacks with hypertension living in the south­ern region of the United States. HR use was associated with higher systolic (HR users 152.79, nonusers 149.53; P=.004) and diastolic blood pressure (HR users 84.10, nonusers 82.14 P=.005). Use of two or more HRs was associated with low adher­ence (OR: .55, CI: .36-.83, P= .004). Conclusion: The use of HR and the number of HRs used may be associated with medi­cation nonadherence, and higher systolic and diastolic blood pressure among Blacks with hypertension. Medication nonadher­ence is of critical importance for individuals with hypertension, and it is essential that health care providers be aware of health behaviors that may serve as barriers to medication adherence, such as use of home remedies. Ethn Dis . 2020;30(3):451-458; doi:10.18865/ed.30.3.451

Background Uncontrolled hypertension is a significant public health problem in the U.S. with about one half of people able to keep blood pressure (BP) under control. Uncontrolled hypertension leads to increased risk of stroke, heart attack, and death. Furthermore, the social and economic costs of poor hypertension control are staggering. People living with hypertension can benefit from additional educational outreach and support. Methods This randomized trial conducted at two Community Health Centers (CHCs) in Massachusetts assessed the effect of community health workers (CHWs) assisting patients with hypertension. In addition to the support provided by CHWs, the study uses video narratives from patients who have worked to control their BP through diet, exercise, and better medication adherence. Participants enrolled in the study were randomly assigned to immediate intervention (I) by CHWs or a delayed intervention (DI) (4 to 6 months later). Each participant was asked to meet with the CHW 5 times (twice in person and three times telephonically). Study outcomes include systolic and diastolic BP, diet, exercise, and body mass index. Conclusion CHWs working directly with patients, using multiple approaches to support patient self-management, can be effective agents to support change in chronic illness management. Moreover, having culturally appropriate tools, such as narratives available through videos, can be an important, cost effective aid to CHWs. Recruitment and intervention delivery within a busy CHC environment required adaptation of the study design and protocols for staff supervision, data collection and intervention delivery and lessons learned are presented. Retrospective trial registration Clinical Trials.gov registration submitted 8/17/16: Protocol ID# 5P60MD006912-02 and Clinical trials.gov ID# NCT02874547 Community Health Workers Using Patient Stories to Support Hypertension Management.

OBJECTIVE: To examine the effect of changing the sampling and reference periods for the CAHPS (®) Clinician & Group Survey from 12 to 6 months. DATA SOURCES/STUDY SETTING: Adult patients with a visit in the last 12 months to New England community health centers. STUDY DESIGN: We randomly assigned patients to receive a survey with either a 12‐ or 6‐month recall period. DATA COLLECTION/EXTRACTION METHODS: Questionnaires were mailed to patients, with a second questionnaire mailed to nonrespondents, followed by six attempts to complete a telephone interview. PRINCIPAL FINDINGS: If the sampling criterion was a visit in the last 6 months, 9 percent of those with a visit in the last 12 months would not have been surveyed. A total of 1837 patients completed 6‐month surveys (44.9 percent response rate); 588 completed 12‐month surveys (46.0 percent response rate). Shortening the reference from 12 to 6 months reduced the proportion of respondents reporting a blood test, X‐ray, or other tests. Adjusting for respondent characteristics, the most positive response was selected more often on the 6‐month survey for 12 out of 13 questions, and three of these differences were statistically significant (P

Purpose Significant gaps exist in health care transition (HCT) preparation that can impact care and outcomes in young adults with chronic illness. No quality measure exists to directly assess adolescent experiences of HCT preparation. Our objective was to develop an adolescent-reported measure of the quality of HCT preparation received from pediatric health care providers. Methods The Adolescent Assessment of Preparation for Transition (ADAPT) is a 26-item mailed survey designed for completion by 16- and 17-year-old adolescents with a chronic health condition. Adolescents from three samples (two large Medicaid insurance plans [n = 3,000 each] and one large tertiary care pediatric hospital [n = 623]) were mailed the survey. An iterative developmental process included focus groups and cognitive interviews, and validity was assessed using confirmatory factor analysis and ordinal reliability coefficients. Results Reliability and validity was evaluated for the following three prespecified composite measures: (1) counseling on transition self-management; (2) counseling on prescription medication; and (3) transfer planning. Across the three samples, all but one measure had good internal consistency (ordinal reliability coefficient ≥ .7). Confirmatory factor analysis using tetrachoric correlation coefficients was stable across samples and supported the construct validity of the first two composite measures. Conclusions ADAPT is a reliable, validated instrument measuring the quality of HCT preparation experiences reported by adolescents with chronic disease. ADAPT will enable clinical programs and health care delivery systems to assess the quality of HCT preparation and provide targets for improvement in adolescent counseling related to transition.

Background: As the USA seeks to expand the conduct and dissemination of comparative effectiveness research (CER), views of key stakeholders will help guide the way. Methods: We surveyed 60 medical and pharmacy directors from 46 state Medicaid programs. Results: Over 90% felt that CER would lead to better clinical decision-making and overall value within 5 years and were willing to consider cost–effectiveness in setting medical policy. However, perceived poor quality, inconclusive research, restrictive legislative mandates, lack of budget impact and coverage recommendations, and lack of an independent body to interpret study results were major barriers cited to using CER evidence. Conclusion: Given the significant resources being invested in CER, it is critical that these barriers are overcome to maximize its usefulness for stakeholders.

Increasingly popular electronic cigarettes (e-cigarettes) may be the most promising development yet to end cigarette smoking. However, there is sparse evidence that their use promotes cessation. We investigated whether e-cigarette use increases smoking cessation and/or has a deleterious effect on quitting smoking and motivation to quit.Representative samples of adults in 2 US metropolitan areas were surveyed in 2011/2012 about their use of novel tobacco products. In 2014, follow-up interviews were conducted with 695 of the 1,374 baseline cigarette smokers who had agreed to be re-contacted (retention rate: 51%). The follow-up interview assessed their smoking status and history of electronic cigarette usage. Respondents were categorized as intensive users (used e-cigarettes daily for at least 1 month), intermittent users (used regularly, but not daily for more than 1 month), and non-users/triers (used e-cigarettes at most once or twice).At follow-up, 23% were intensive users, 29% intermittent users, 18% had used once or twice, and 30% had not tried e-cigarettes. Logistic regression controlling for demographics and tobacco dependence indicated that intensive users of e-cigarettes were 6 times more likely than non-users/triers to report that they quit smoking (OR: 6.07, 95% CI = 1.11, 33.2). No such relationship was seen for intermittent users. There was a negative association between intermittent e-cigarette use and 1 of 2 indicators of motivation to quit at follow-up.Daily use of electronic cigarettes for at least 1 month is strongly associated with quitting smoking at follow-up. Further investigation of the underlying reasons for intensive versus intermittent use will help shed light on the mechanisms underlying the associations between e-cigarette use, motivation to quit, and smoking cessation.

Objectives. We sought to determine if reported racial discrimination was associated with medication nonadherence among African Americans with hypertension and if distrust of physicians was a contributing factor. Methods. Data were obtained from the TRUST project conducted in Birmingham, Alabama, 2006 to 2008. All participants were African Americans diagnosed with hypertension and receiving care at an inner city, safety net setting. Three categories of increasing adherence were defined based on the Morisky Medication Adherence Scale. Trust in physicians was measured with the Hall General Trust Scale, and discrimination was measured with the Experiences of Discrimination Scale. Associations were quantified by ordinal logistic regression, adjusting for gender, age, education, and income. Results. The analytic sample consisted of 227 African American men and 553 African American women, with a mean age of 53.7 ±9.9 years. Mean discrimination scores decreased monotonically across increasing category of medication adherence (4.1, 3.6, 2.9; P = .025), though the opposite was found for trust scores (36.5, 38.5, 40.8; P Conclusions. Within our sample of inner city African Americans with hypertension, racial discrimination was associated with lower medication adherence, and this association was partially mediated by trust in physicians. Patient, physician and system approaches to increase “earned” trust may enhance existing interventions for promoting medication adherence.

Community health workers (CHWs) have gained prominence in health care, recognizing the influence of community and environment on health. This study evaluates CHWs' efforts to assess patients' readiness to change and facilitate self-management goal setting. Six pairs of community health centers were randomly assigned to employ CHWs on health care teams. Each team worked with a defined population of patients. We assessed changes in documented patient self-management goals and clinical measures from both control and intervention CHCs before and after deploying CHWs, finding a significant increase in self-management goal setting between the intervention and control health centers.

Background: Predictive models are increasingly used in guidelines and informed decision-making interventions. We compared predictions from 2 prominent models for diabetes: the United Kingdom Prospective Diabetes Study (UKPDS) outcomes model and the Archimedes-based Diabetes Personal Health Decisions (PHD) model. Methods: Ours was a simulation study comparing 10-year and 20-year model predictions for risks of myocardial infarction (MI), stroke, amputation, blindness, and renal failure for representative test cases. Results: The Diabetes PHD model predicted substantially higher risks of MI and stroke in most cases, particularly for stroke and for 20-year outcomes. In contrast, the UKPDS model predicted risks of amputation and blindness ranging from 2-fold to infinitely higher than the Diabetes PHD model. Predictions for renal failure all differed by more than 2-fold but in a complicated pattern varying by time frame and specific risk factors. Relative to their predictions for white men, the UKPDS model predicted much lower MI and stroke risks for women and Afro-Caribbean men than the Diabetes PHD model did for women and black men. A substantial majority of the Diabetes PHD point estimates fell outside of the UKPDS outcomes model’s 95% CIs. Conclusions: These models produced markedly different predictions. Patients and providers considering risk estimates from such models need to understand their substantial uncertainty and risk of misclassification.(J Am Board Fam Med 2011;24:399‐406.)

Objective To estimate the reliability and validity of survey measures used to evaluate health plans and providers from the consumer's perspective.

Background: We evaluated how diabetic patients understand and respond to the presentation of personalized risk information. Methods: This was a mixed methods study involving 56 patients with type 2 diabetes and at least 1 additional cardiovascular risk factor. We assessed participants9 perceptions of diabetes-related risks; asked them to rank order 6 events (death, heart attack, stroke, blindness, amputation, and kidney failure) by likelihood of occurrence in a specified time frame; presented them with personalized risk estimates; and asked them to re-rank the risks. The final 18 participants were tested to verify understanding before re-ranking risks. Qualitative analysis of interview transcripts identified themes and concepts underlying participants9 ways of perceiving and reacting to risk. Results: While mortality was the most likely outcome for almost all participants, nearly all estimated it to be least likely; only 28% adjusted their mortality rankings to match model predictions. Some did not understand the risk information: only two thirds of those asked could rank risks according to the information presented. Risk perceptions were influenced by factors including “knowing myself,” powerful anecdotes, and belief that a “warning shot” would occur before death. Conclusions: Personalized risk estimates, particularly about mortality, had limited salience. Some participants could not understand the information, despite presentation in ways suggested by previous research.

OBJECTIVE: To examine whether patients’ experiences with nontechnical aspects of care such as patient education and discharge planning are associated with long-term outcomes.

CONTEXT: Career satisfaction among physicians is a topic of importance to physicians in practice, physicians in training, health system administrators, physician organization executives, and consumers. The level of career satisfaction derived by physicians from their work is a basic yet essential element in the functioning of the health care system.

The CAHPS (Consumer Assessment of Healthcare Providers and Systems) Clinician and Group (CG-CAHPS) survey measures patients' experiences with health care providers and their office staff. It was designed to help providers improve the care they deliver (Hays et al. 2003; Solomon et al. 2005; Dyer et al. 2012) and to provide data for patients choosing their health care providers. The CG-CAHPS survey asks patients to report on their experiences in the last 12 months. It is available with 4-category (never, sometimes, usually, always) and 6-category response scales (never, almost never, sometimes, usually, almost always, always) (https://cahps.ahrq.gov/clinician_group/). The original survey used a 4-category response scale to be consistent with other CAHPS surveys (Solomon et al. 2005). Sufficient reliability data were only available for the 6-category response scale version when it was submitted to the National Quality Forum (NQF). Thus, the NQF endorsed the 6-category response scale (AHRQ et al. 2006) and many early adopters of the CG-CAHPS elected to use the 6-category response scale. The CG-CAHPS survey was designed for telephone or mail administration. To reduce costs, some vendors compressed the original 12-page mail questionnaire into fewer pages by removing some instructions and condensing the text. Many shorter ad hoc versions do not follow CAHPS recommendations or general survey development guidelines. Differences in administration and format can influence data obtained from CAHPS surveys (Fowler, Gallagher, and Nederend 1999; Hepner, Brown, and Hays 2005; de Vries et al. 2005; Anastario et al. 2010). How the 4-category and 6-category response scales, mode of administration, and mailed survey format influence the CG-CAHPS surveys' results has not been assessed. In this study, we examined the extent to which different response scales, methods of survey administration, and format of the mailed survey affected survey composite scores, reliability of the survey composite scores, and item response rates. To assess these issues, we randomized potential respondents to one of five conditions: a 12-page mail survey using 4-category response scales, a 12-page mail survey using 6-category response scales, a telephone survey using 4-category response scales, a telephone survey using 6-category response scales, or a four-page mail survey using 4-category response scales.

The experience of racial discrimination among African Americans may contribute to an increased risk of developing hypertension and having poor hypertension control once diagnosed. Although it is a commonly held belief that experiences of discrimination may exert lasting effects on health behavior and physiology, the existing evidence is mixed.The objective of this review was to identify evidence linking the experience of discrimination with hypertension among African Americans and to provide an updated synthesis of the literature.Articles for the review were identified through an electronic search of PubMed, OVID, and other pertinent journals. The review was augmented with a manual search of references. We assessed the quality of included articles using modified Downs and Black criteria.In total, 15 articles were selected for the review, 12 cross-sectional studies and 3 cohort studies. The preponderance of evidence (9 of 15 articles) indicated that discrimination was associated with an increased risk of developing hypertension, difficulty obtaining control of existing hypertension, and/or elevated blood pressure among those without a diagnosis of hypertension.This systematic review supports the association of racial discrimination with an increased risk of developing hypertension; however, the picture is not uniform. Methodological challenges, such as floor or ceiling effects of reported discrimination and low sample size, may have prevented researchers from detecting important associations. A better understanding of the emerging but complex relationship between discrimination and hypertension among African Americans is needed, as we seek to resolve existing cardiovascular health disparities.

Objectives. We explored the benefits of using community health worker (CHW) encounter forms to collect data on patient interactions and assessed the effectiveness of these forms in guiding and directing interactions. Methods. A 1-page standardized encounter form was developed to document topics discussed during visits with diabetes patients. A portion of the form was designed to be used as a script to guide the interaction and assist patients in setting appropriate self-management goals. Data were also collected via CHW work logs and interviews with CHWs and their supervisors to validate findings. Results. Data were collected for 1198 interactions with 540 patients at 6 community health centers. Self-management goals were set during 62% of encounters. With respect to the most recent self-management goal set, patients who had set a challenging goal were more likely to be in the action stage of change than in other stages. Work logs revealed that CHWs engaged in a number of activities not involving direct patient interactions and thus not captured on encounter forms. Conclusions. Evaluating and monitoring CHWs’ daily activities has been challenging. Encounter forms have great potential for documenting the work of CHWs with patients.

The population of persons seeking medical care is linguistically diverse in the United States. Language barriers can adversely affect a patient's ability to explain their symptoms. Among hospitalized patients, these barriers may lead to higher readmission rates and longer hospitalizations. Trained interpreters help overcome communication barriers; however, interpreter usage among patients is suboptimal.To investigate differences among patients with limited English proficiency (LEP) in their length of stay (LOS) and 30-day readmission rate associated with their receiving professional interpretation at admission or discharge.We analyzed the rates of interpretation at admission and discharge of all LEP patients admitted to a tertiary care hospital over a three-year period. We calculated length of stay in days and as log of LOS. We also examined 30-day readmission. Using multivariable regression models, we explored differences among patients who received interpretation at admission, discharge, or both, controlling for patient characteristics, including age, illness severity, language, and gender.All LEP patients admitted between May 1, 2004 and April 30, 2007.Length of hospital stay as related to use of professional interpreters; readmission to the hospital within 30 days.Of the 3071 patients included in the study, 39 % received language interpretation on both admission and discharge date. Patients who did not receive professional interpretation at admission or both admission/discharge had an increase in their LOS of between 0.75 and 1.47 days, compared to patients who had an interpreter on both day of admission and discharge (P0.02). Patients receiving interpretation at admission and/or discharge were less likely than patients receiving no interpretation to be readmitted with 30 days.The length of a hospital stay for LEP patients was significantly longer when professional interpreters were not used at admission or both admission/discharge.

Compared to screening for partner violence, screening for childhood physical and sexual abuse among adult patients has received little attention, despite associated adverse health consequences. The objective of this exploratory study was to describe the practices, skills, attitudes, and perceived barriers of a large sample of family physicians in screening adult patients for childhood sexual or physical abuse.Surveys were mailed to the 833 members of the Massachusetts Academy of Family Physicians in 2007 eliciting information about screening practices. Factors associated with routine or targeted screening among adult primary care patients were evaluated.Less than one-third of providers reported usually or always screening for childhood trauma and correctly estimated childhood abuse prevalence rates; 25% of providers reported that they rarely or never screen patients. Confidence in screening, perceived role, and knowledge of trauma prevalence were associated with routine and targeted screening. Women and physicians reporting fewer barriers were more likely to routinely screen adult patients.Despite the 20%-50% prevalence of child abuse exposure among adult primary care patients, screening for childhood abuse is not routine practice for most physicians surveyed; a large subgroup of physicians never screen patients. Study findings draw attention to a largely unexplored experience associated with considerable health care costs and morbidity. Results highlight the need to develop training programs about when to suspect trauma histories and how to approach adult patients.

This study simulated whether increased community health center (CHC) funding under the Bush administration narrowed racial/ethnic gaps in access to care among low-income people. Expanded CHC funding resulted in small increases in access to care, more so for minorities than for whites. Spanish-speaking Hispanics had the largest improvements in access in the simulation. However, minorities experienced bigger drops in insurance coverage. The net result was no improvements in the access measures for Spanish-speaking Hispanics and slight decreases in access for whites, English-speaking Hispanics, and African Americans. Access gaps either remained the same or worsened slightly for English-speaking Hispanics and African Americans relative to whites.

ContextRates of preventive services remain below national goals.ObjectiveTo identify characteristics of physicians and their practices that are associated with the quality of preventive care their patients receive.DesignCross-sectional analysis of data on US physician respondents to the 2000-2001 Community Tracking Study Physician Survey linked to claims data on Medicare beneficiaries they treated in 2001. Physician variables included training and qualifications and sex. Practice setting variables included practice type, size, sources of revenue, and access to information technology. Analyses were adjusted for patient demographics and comorbidity, as well as community characteristics.Setting and ParticipantsPrimary care delivered by 3660 physicians providing usual care to 24 581 Medicare beneficiaries aged 65 years and older.Main Outcome MeasuresProportion of eligible beneficiaries receiving each of 6 preventive services: diabetic monitoring with hemoglobin A1c measurement or eye examinations, screening for colon or breast cancer, and vaccination for influenza or pneumococcus in 2001.ResultsOverall, the proportion of beneficiaries receiving services was below national goals. Physician and, more consistently, practice-level characteristics were both associated with differences in the delivery of services. The strongest associations were with practice type and the percentage of practice revenue derived from Medicaid. For instance, beneficiaries receiving usual care in practices with less than 6% of revenue from Medicaid were more likely than those with more than 15% of revenue derived from Medicaid to receive diabetic eye examinations (48.9% vs 43%; P = .02), hemoglobin A1c monitoring (61.2% vs 48.4%; P

Overall health insurance rates changed little among nonelderly black, Latino and white Americans between 2001 and 2003, according to new findings from the Center for Studying Health System Change (HSC). But sources of coverage shifted--especially for Latinos--from employment-based insurance to public coverage, suggesting the economic downturn took a greater toll on Latinos. Low-income Latinos and whites were particularly hard hit by declines in employer coverage. Shifting sources of coverage had little effect on access to medical care. With the sole exception of decreased access to specialists among blacks, access to care did not change between 2001 and 2003. Significant gaps in access to care among Latinos, blacks and whites persisted, with Latinos and blacks consistently reporting lower levels of access than whites.

Background In the United States, black patients generally receive lower-quality health care than white patients. Black patients may receive their care from a subgroup of physicians whose qualifications or resources are inferior to those of the physicians who treat white patients. Methods We performed a cross-sectional analysis of 150,391 visits by black Medicare beneficiaries and white Medicare beneficiaries 65 years of age or older for medical “evaluation and management” who were seen by 4355 primary care physicians who participated in a biannual telephone survey, the 2000–2001 Community Tracking Study Physician Survey. Results Most visits by black patients were with a small group of physicians (80 percent of visits were accounted for by 22 percent of physicians) who provided only a small percentage of care to white patients. In a comparison of visits by white patients and black patients, we found that the physicians whom the black patients visited were less likely to be board certified (77.4 percent) than were the physicians visited by the white patients (86.1 percent, P=0.02) and also more likely to report that they were unable to provide high-quality care to all their patients (27.8 percent vs. 19.3 percent, P=0.005). The physicians treating black patients also reported facing greater difficulties in obtaining access for their patients to high-quality subspecialists, high-quality diagnostic imaging, and nonemergency admission to the hospital. Conclusions Black patients and white patients are to a large extent treated by different physicians. The physicians treating black patients may be less well trained clinically and may have less access to important clinical resources than physicians treating white patients. Further research should be conducted to address the extent to which these differences may be responsible for disparities in health care.

n youth, people often take their bodies for granted. After a trauma or an illness, some may perceive the body as an object existing in opposition to one's self. These phenomenological observations form the theoretical foundation of Hudak and colleagues' analysis of patient satisfaction with hand surgery. These 2 papers, one theory generating' and the other theory testing,2 revisit the issue of how to measure and understand patient satisfaction. They begin by trying to understand patients' perceptions of satisfaction. Hudak, McKeever, and Wright' ask the question, "What do people mean when they say that they are satisfied with medical care and the outcome of surgery?" They then embark upon testing several alternate theories of satisfaction with medical care. Twenty-five years have passed since researchers began seriously conceptualizing, measuring, and testing theories of patient satisfaction with health and health care.3'4'5 In a conceptual paper that reviewed much of the satisfaction literature, Cleary and McNeil6 concluded "A major gap in the satisfaction literature is the relative lack of studies of patient satisfaction with hospital care and medical outcomes." Satisfaction with hospital care was thoroughly explored in the 1990s. But, in fact, satisfaction with outcomes remains relatively unexplored territory. Hudak, McKeever, and Wright1 begin their work pointing to a paradox in patient satisfaction research-patients may be satisfied with poor care or dissatisfied with excellent medical care. A long held criticism of satisfaction research is that patient satisfaction may be influenced by many factors other than the care provided to patients. As an outcome variable, patient satisfaction can be influenced by a host of external influences, such as social desirability' or age and gender.6 In interviews with patients following hand surgery, Hudak et al find a similar disconnect between outcomes and satisfaction. They report, "In this study, some participants expressed satisfaction despite less than expected outcomes, suggesting that although satisfaction with treatment outcome may involve in part a meeting of a priori expectations, this is not a necessary precondition."' They postulate that satisfaction with treatment outcome is tied to a person's experience of his or her body. In other words, they define satisfaction as "a relative lack

Working-age African Americans and Latinos are much more likely than white Americans to report they cannot afford all of their prescription drugs, according to a new study by the Center for Studying Health System Change (HSC). In 2001, nearly one in five blacks and one in six Latinos 18 to 64 years old did not purchase all of their prescriptions because of cost, compared with slightly more than one in 10 whites. Cost-related prescription drug access problems are considerably higher for people with chronic conditions, particularly African Americans. Regardless of race or ethnicity, uninsured working-age people with chronic conditions are at particular risk for not being able to afford all of their prescriptions, with about half reporting cost-related prescription access problems. Increased patient cost sharing for prescription drugs will likely increase prescription drug access disparities for insured African Americans and Latinos, especially those with chronic conditions.

To estimate the reliability and validity of survey measures used to evaluate health plans and providers from the consumer's perspective.Members (166,074) of 306 U.S. health plans obtained from the National CAHPS Benchmarking Database 2.0, a voluntary effort in which sponsors of CAHPS surveys contribute data to a common repository.Members of privately insured health plans serving public and private employers across the United States were surveyed by mail and telephone. Interitem correlations and correlations of items with the composite scores were estimated. Plan-level and internal consistency reliability are estimated. Multivariate associations of composite measures with global ratings are also examined to assess construct validity. Confirmatory factor analysis is used to examine the factor structure of the measure.Plan-level reliability of all CAHPS 2.0 reporting composites is high with the given sample sizes. Fewer than 170 responses per plan would achieve plan-level reliability of .70 for the five composites. Two of the composites display high internal consistency (Cronbach's alphaor = .75), while responses to items in the other three composites were not as internally consistent (Cronbach's alpha from .58 to .62). A five-factor model representing the CAHPS 2.0 composites fits the data better than alternative two- and three-factor models.Two of the five CAHPS 2.0 reporting composites have high internal consistency and plan-level reliability. The other three summary measures were reliable at the plan level and approach acceptable levels of internal consistency. Some of the items that form the CAHPS 2.0 adult core survey, such as the measure of waiting times in the doctor's office, could be improved. The five-dimension model of consumer assessments best fits the data among the privately insured; therefore, consumer reports using CAHPS surveys should provide feedback using five composites.

To examine the extent to which health insurance coverage and available safety net resources reduced racial and ethnic disparities in access to care.Nationally representative sample of 11,692 African American, 10,325 Hispanic, and 74,397 white persons. Nonelderly persons with public or private health insurance and those who were uninsured.Two cross-sectional surveys of households conducted during 1996-1997 and 1998-1999.Commonly used measures of access to and utilization of medical care were constructed for individuals. These measures include the following. (1) percent reporting unmet medical needs, (2) percent without a regular health care provider, and (3) no visit with a physician in the past year.More than 6.5 percent of Hispanic and African Americans reported having unmet medical needs compared to less than 5.6 percent of white Americans. Hispanics were least likely to see the same doctor at their usual source of care (59 percent), compared to African Americans (66 percent) and whites (75 percent). Similarly, Hispanics were less likely than either African Americans or whites to have seen a doctor in the last year (65 percent compared to 76 percent or 79 percent). For Hispanics, more than 80 percent of the difference from whites was due to differences in measured characteristics (e.g., insurance coverage, income, and available safety net services). Differences in measured characteristics between African Americans and whites explained less than 80 percent of the access disparities.Lack of health insurance was the single most important factor in white-Hispanic differences for all three measures and for two of the white-African American differences. Income differences were the second most important factor, with one exception. Community characteristics generally were much less important, with one exception. The positive effects of insurance coverage in reducing disparities outweigh benefits of increasing physician charity care or access to emergency rooms.

Contrary to popular belief that Americans avidly seek health information--especially on the Internet--a majority of Americans in 2001 sought no information about a health concern, according to a Center for Studying Health Systems Change (HSC) study. And, instead of surfing the Internet, the 38 percent of Americans who did obtain health information relied more often on traditional sources such as books or magazines. People living with chronic conditions were more likely to seek information, yet more than half did not. Education is key to explaining differences among people. Those with a college degree are twice as likely to seek health information as people without a high school diploma. As consumers are confronted with more responsibility for making trade-offs among the cost, quality and accessibility of care, credible and understandable information will be critical to empowering consumers to take active roles in managing their care.

Between 1997 and 2001, the proportion of specialists reporting more freedom to make clinical decisions that meet their patients' needs increased significantly, much more so than among primary care physicians (PCPs), according to a new study by the Center for Studying Health System Change (HSC). Specialists now are also more likely to believe they can make clinical decisions in the best interest of their patients without reducing their income and can maintain continuing relationships with their patients to promote high-quality care. In contrast, PCPs' views on these issues have changed little. These findings about physicians' perceptions are likely a reflection of recent changes in managed care. Responding to a strong consumer and physician backlash, health plans gave consumers a broader choice of physicians and eased restrictions on care in the late 1990s

Gaps in access to medical care among working-age white Americans, African Americans and Latinos failed to improve between 1997 and 2001, despite a booming economy and increased national attention to narrowing and eliminating minority health disparities. African Americans and Latinos continue to have less access to a regular health care provider, see a doctor less often and lag behind whites in seeing specialists, according to recent findings from the Center for Studying Health System Change (HSC). Ethnic and racial disparities in access among uninsured Americans are much greater than disparities among the insured. Uninsured whites' greater financial resources may explain why they have fewer problems accessing care. Eliminating disparities in minority health care will be difficult without first eliminating these gaps in minority health insurance.

Large employers’ roles in improving health care quality are shifting away from value-based purchasing toward direct efforts to improve health care delivery within local markets. Although most large employers adopted the tools required for value-based purchasing, inadequate information on quality has frustrated employers and limited their ability to make choices based on quality. More recent quality initiatives aimed at directly improving local health delivery systems may be limited to specific markets where the largest employers can exert substantial influence.

Surveys that rate how persons enrolled in HMOs and other types of health coverage feel about their health care are used to bolster claims that HMOs provide inferior quality care, providing justification for patient protection legislation. This research illustrates that the conventional wisdom regarding inferior care in HMOs may color how people assess their health care in surveys, resulting in survey findings biased toward showing HMOs provide inferior care and reinforcing existing stereotypes. Using merged data from the Community Tracking Study Household and Insurance Followback surveys, we identify privately insured persons who correctly and incorrectly know what kind of health plan they are covered by. Nearly a quarter misidentified their type of health coverage. Differences between responses by HMO and non-HMO enrollees to questions covering satisfaction with health care and physician choice, the quality of the last physician's visit, and patient trust in their physician shrink or disappear when we control for beliefs about what type of plan they are covered by. Results suggest that researchers and policy makers should be cautious about using consumer surveys to assess the relative quality of care provided under different types of health insurance.

The quality of medical care has rarely been evaluated in relation to practitioner or patient gender. Moreover, comparisons between physicians and nonphysicians typically are confounded by practitioner gender. In this study gender and professional role effects were analyzed separately for 162 male and female staff physicians, 191 male and female residents, and 73 female nonphysicians delivering adult and pediatric primary care in 16 ambulatory care practices. Analyses addressed influences of patient and practitioner gender as well as differences between physicians and nonphysicians. Results showed that female staff physicians performed better than male staff physicians for cancer screening in women by breast examination and Pap smears, but that female residents performed worse than male residents for urinary tract infections in children. Patient gender effects occurred for two tasks; for these, superior care was rendered to the gender with higher prevalence for the condition (girls for urinary tract infections, boys for otitis media). The results are considered in the context of the gender-relevance of particular medical tasks or conditions. Comparisons between physicians and nonphysicians were limited to female practitioners. Comparable or superior performance for nonphysicians was found for all tasks but one (cancer screening in women).