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Purpose: The Patient-Reported Outcomes Measurement Information System (PROMIS®) initiative was developed to advance the methodology of PROs applicable to chronic diseases. Chronic obstructive pulmonary disease (COPD) is a progressive chronic disease associated with poor health. This study was designed to examine the correlation of PROMIS health-related quality of life (HRQOL) scales and clinical measures among COPD patients. Methods: A cross-sectional analysis was conducted comparing patients who were stable (n = 100) with those currently experiencing a COPD exacerbation (n = 85). All PROMIS measures for adults available at the time of the study (2008), disease-targeted and other HRQOL instruments, health literacy, percent predicted FEV1, and a 6-min walk distance were assessed when patients were considered clinically stable. Results: Stable COPD patients reported significantly (p ≤ 0.05) better health-related quality of life on PROMIS domains than patients experiencing an exacerbation. PROMIS domain scores were significantly (p ≤ 0.01) correlated with each of legacy measures. Six-min walk scores were most highly correlated with the PROMIS physical function domain scores (r = 0.53) followed by the fatigue (r = −0.26), social (r = 0.24) and to a lesser extent depression (r = −0.23), and anxiety (r = −0.22) domain scores. Percent predicted FEV1 score was significantly associated with PROMIS physical function scores (r = 0.27). Conclusion: This study provides support for the validity of the PROMIS measures in COPD patients.

ObjectiveTo develop and test the psychometric properties of a 25-item version of the National Eye Institute Visual Function Questionnaire (NEI VFQ-25).DesignProspective observational cohort study of persons with 1 of 5 chronic eye diseases or low vision who were scheduled for nonurgent visits in ophthalmology practices and a reference sample of persons without eye disease.SettingEleven university-based ophthalmology practices and the NEI Clinical Center.PatientsEligible participants had to have 1 of the following eye conditions: age-related cataracts, age-related macular degeneration, diabetic retinopathy, primary open-angle glaucoma, cytomegalovirus retinitis, or low vision from any cause. Seven of the 12 sites also enrolled persons in a reference sample. Reference sample participants had no evidence of underlying eye disease but were scheduled for either screening eye examinations or correction of refractive error. All eligible persons had to be 21 years or older, English speaking, and cognitively able to give informed consent and participate in a health status interview.Measurements and main resultsTo provide the data needed to create the NEI VFQ-25, all subjects completed an interview that included the 51-item NEI VFQ. Estimates of internal consistency indicate that the subscales of the NEI VFQ-25 are reliable. The validity of the NEI VFQ-25 is supported by high correlations between the short- and long-form versions of the measure, observed between-group differences in scores for persons with different eye diseases of varying severity, and the moderate-to-high correlations between the NEI VFQ-25 subscales that have the most to do with central vision and measured visual acuity.ConclusionsThe reliability and validity of the NEI VFQ-25 are comparable to those of the 51-item NEI VFQ field test version of the survey. This shorter version will be more feasible in settings such as clinical trials where interview length is a critical consideration. In addition, preliminary analyses indicate that the psychometric properties of the NEI VFQ-25 are robust for the eye conditions studied; this suggests that the measure will provide reproducible and valid data when used across multiple conditions of varying severity.

ObjectiveTo develop and test the psychometric properties of a 25-item version of the National Eye Institute Visual Function Questionnaire (NEI VFQ-25).DesignProspective observational cohort study of persons with 1 of 5 chronic eye diseases or low vision who were scheduled for nonurgent visits in ophthalmology practices and a reference sample of persons without eye disease.SettingEleven university-based ophthalmology practices and the NEI Clinical Center.PatientsEligible participants had to have 1 of the following eye conditions: age-related cataracts, age-related macular degeneration, diabetic retinopathy, primary open-angle glaucoma, cytomegalovirus retinitis, or low vision from any cause. Seven of the 12 sites also enrolled persons in a reference sample. Reference sample participants had no evidence of underlying eye disease but were scheduled for either screening eye examinations or correction of refractive error. All eligible persons had to be 21 years or older, English speaking, and cognitively able to give informed consent and participate in a health status interview.Measurements and main resultsTo provide the data needed to create the NEI VFQ-25, all subjects completed an interview that included the 51-item NEI VFQ. Estimates of internal consistency indicate that the subscales of the NEI VFQ-25 are reliable. The validity of the NEI VFQ-25 is supported by high correlations between the short- and long-form versions of the measure, observed between-group differences in scores for persons with different eye diseases of varying severity, and the moderate-to-high correlations between the NEI VFQ-25 subscales that have the most to do with central vision and measured visual acuity.ConclusionsThe reliability and validity of the NEI VFQ-25 are comparable to those of the 51-item NEI VFQ field test version of the survey. This shorter version will be more feasible in settings such as clinical trials where interview length is a critical consideration. In addition, preliminary analyses indicate that the psychometric properties of the NEI VFQ-25 are robust for the eye conditions studied; this suggests that the measure will provide reproducible and valid data when used across multiple conditions of varying severity.

ObjectiveTo identify the content area for a questionnaire designed to measure vision-targeted health-related quality of life and to determine whether problems with vision-related functioning are qualitatively similar across different common eye diseases.DesignTwenty-six condition-specific focus groups were conducted with 246 patients from 5 geographic regions to identify the content area for a questionnaire for use among persons with diabetic retinopathy, glaucoma, macular degeneration, cytomegalovirus retinitis, and cataract. A standard protocol was used to structure each focus group discussion. Sessions were audiotaped, transcribed, and coded in preparation for a content analysis.SettingsFive university-based ophthalmology practices and 1 nonprofit eye care foundation.ParticipantsEligible participants had to have 1 of the following eye conditions: age-related cataracts, age-related macular degeneration, diabetic retinopathy, primary open angle glaucoma, cytomegalovirus retinitis, or low vision from any cause. All eligible persons were older than 21 years, spoke English, and had sufficient cognitive function to provide informed consent.ResultsAmong the 246 participants, 2623 problems with vision-related functioning were mentioned. The mean number of problems per person ranged from 13.5 for those with diabetic retinopathy to 7.9 for persons with glaucoma. For the sample overall, reading problems were mentioned most frequently, followed by driving, general problems with seeing clearly, and mental health complaints caused by vision. Although the proportion of persons who reported each problem varied by condition, at least some persons with each eye disease reported each problem. The 3 most common descriptors associated with each problem were difficulty or ease of performance (13%), psychological distress associated with performance of the activity (11%), and complete inability to participate in a visual activity (11%).ConclusionAn item-generation strategy for a new questionnaire using a standardized focus group method identified content areas and aspects of visual disability that are not included in currently available vision-specific instruments that assess the impact of common eye diseases on visual functioning in every-day life. Although participants mentioned problems that were unique to their disease, across conditions the problems mentioned were similar. These findings provide empirical evidence of content validity for a vision-targeted, health-related quality-of-life survey designed for use across conditions.

Objective: To examine racial/ethnic group differences in adults' reports and ratings of care using data from the National Consumer Assessment of Health Plans (CAHPS) survey Benchmarking Database (NCBD) 1.0.Data Source: Adult data from the NCBD 1.0 is comprised of CAHPS 1.0 survey data from 54 commercial and 31 Medicaid health plans from across the United States. A total of 28,354 adult respondents (age > or = 18 years) were included in this study. Respondents were categorized as belonging to one of the following racial/ethnic groups: Hispanic (n = 1,657), white (n = 20,414), black or African American (n = 2,942), Asian and Pacific Islander (n = 976), and American Indian or Alaskan native (n = 588).Study Design: Four single-item global ratings (personal doctor, specialty care, overall rating of health plan, and overall rating of health care) and five multiple-item report composites (access to needed care, provider communication, office staff helpfulness, promptness of care, and health plan customer service) from CAHPS 1.0 were examined. Statistical Analyses. Multiple regression models were estimated to assess differences in global ratings and report composites between whites and members of other racial/ethnic groups, controlling for age, gender, perceived health status, educational attainment, and insurance type.Principal Findings: Members of racial/ethnic minority groups, with the exception of Asians/Pacific Islanders, reported experiences with health care similar to those of whites. However, global ratings of care by Asians/Pacific Islanders are similar to those of whites.Conclusions: Improvements in quality of care for Asians/Pacific Islanders are needed. Comparisons of care in racially and ethnically diverse populations based on global ratings of care should be interpreted cautiously. [ABSTRACT FROM AUTHOR]

Objective: To compare models for the case-mix adjustment of consumer reports and ratings of health care.Data Sources: The study used the Consumer Assessment of Health Plans (CAHPS) survey 1.0 National CAHPS Benchmarking Database data from 54 commercial and 31 Medicaid health plans from across the United States: 19,541 adults (age > or = 18 years) in commercial plans and 8,813 adults in Medicaid plans responded regarding their own health care, and 9,871 Medicaid adults responded regarding the health care of their minor children.Study Design: Four case-mix models (no adjustment; self-rated health and age; health, age, and education; and health, age, education, and plan interactions) were compared on 21 ratings and reports regarding health care for three populations (adults in commercial plans, adults in Medicaid plans, and children in Medicaid plans). The magnitude of case-mix adjustments, the effects of adjustments on plan rankings, and the homogeneity of these effects across plans were examined.Data Extraction: All ratings and reports were linearly transformed to a possible range of 0 to 100 for comparability.Principal Findings: Case-mix adjusters, especially self-rated health, have substantial effects, but these effects vary substantially from plan to plan, a violation of standard case-mix assumptions.Conclusion: Case-mix adjustment of CAHPS data needs to be re-examined, perhaps by using demographically stratified reporting or by developing better measures of response bias. [ABSTRACT FROM AUTHOR]

Objective: This study examines whether parents' reports and ratings of pediatric health care vary by race/ethnicity and language in Medicaid managed care.Data Sources: The data analyzed are from the National Consumer Assessment of Health Plans (CAHPS) Benchmarking Database 1.0 and consist of 9,540 children enrolled in Medicaid managed care plans in Arkansas, Kansas, Minnesota, Oklahoma, Vermont, and Washington state from 1997 to 1998.Data Collection: The data were collected by telephone and mail, and surveys were administered in Spanish and English. The mean response rate for all plans was 42.1 percent.Study Design: Data were analyzed using multiple regression models. The dependent variables are CAHPS 1.0 ratings (personal doctor, specialist, health care, health plan) and reports of care (getting needed care, timeliness of care, provider communication, staff helpfulness, plan service). The independent variables are race/ethnicity (white, African American, American Indian, Asian, and Hispanic), Hispanic language (English or Spanish), and Asian language (English or other), controlling for gender, age, education, and health status.Principal Findings: Racial/ethnic minorities had worse reports of care than whites. Among Hispanics and Asians language barriers had a larger negative effect on reports of care than race/ethnicity. For example, while Asian non-English-speakers had lower scores than whites for staff helpfulness (beta = -20.10), timeliness of care (beta = -18.65), provider communication (beta = -17.19), plan service (beta = -10.95), and getting needed care (beta = -8.11), Asian English speakers did not differ significantly from whites on any of the reports of care. However, lower reports of care for racial/ethnic groups did not translate necessarily into lower ratings of care.Conclusions: Health plans need to pay increased attention to racial/ethnic differences in assessments of care. This study's finding that language barriers are largely responsible for racial/ethnic disparities in care suggests that linguistically appropriate health care services are needed to address these gaps. [ABSTRACT FROM AUTHOR]

Purpose: The Consumer Assessment of Health Plans Study (CAHPS) produced surveys and report templates to obtain information on health plan enrollees' experiences. This article reports on the development of a parallel set of items for chiropractic. Method: Literature in chiropractic and previously tested patient instruments for assessing chiropractic care were used. In addition, focus groups were held, one-on-one cognitive interviews were conducted, and a survey instrument was developed and administered. Results: Ten potential items for a CAHPS supplemental item set were identified. Eight of these items have parallel CAHPS items and relate to communication, courtesy and respect shown by staff, getting needed care, and a global rating of chiropractic care. The final two items on communication issues have no CAHPS counterpart. Conclusion: This study produced 10 items that are compatible with the CAHPS core items and are recommended for inclusion as supplemental CAHPS survey items. Copyright © 2000 by Aspen Publishers, Inc. [ABSTRACT FROM AUTHOR]

The National Consumer Assessment of Health Plans Study (CAHPS) Benchmarking Database was used to assess the factor structure and invariance of the CAHPS 1.0 Core Survey. Separate analyses were conducted with Latino and non-Latino Caucasian consumers drawn from commercial and Medicaid sectors (N = 15,092). Results demonstrated that the 23 CAHPS 1.0 report items measure consumer reports of experiences with 5 aspects of health plan performance: Access to Care, Timeliness of Care, Provider Communication, Health Plan Consumer Service, and Office Staff Helpfulness. Four items assessed global ratings of care. Analyses revealed an identical pattern of fixed and free factor loadings across all samples. Magnitude of factor loadings and correlations among factors was essentially equivalent within a common health service sector. A higher order factor analysis revealed that rating and reports of care showed marked convergence. [ABSTRACT FROM AUTHOR]

Background: Underutilization of primary care and receipt of preventive health services have been reported among women with opioid use disorder. The aim of this study was to describe perceptions of primary care among women in treatment for opioid use disorder., Methods: Between May and June 2022, 27 women who were receiving treatment for opioid use disorder from one opioid treatment program participated in this study. Participants completed one data collection session which involved a brief questionnaire followed by a semi-structured interview. Participants were asked questions about their overall experience with primary care as well as perceived facilitators and barriers to primary care utilization and quality. Interview transcripts were analyzed using an inductive thematic approach., Results: Three themes emerged from the interviews within the domain of "Facilitators to Primary Care," including: (1) coordination of care, (2) continuity of care, and (3) relationship with health care providers. Four themes emerged from the interviews within the domain of "Barriers to Primary Care," including: (1) perceived judgment from health care providers, (2) childcare needs, (3) issues related to location, and (4) issues related to time., Conclusion: Approaches to primary care that help alleviate barriers to care and highlight the aspects of care that are valued may improve quality and utilization of care, thus enhancing the health and well-being of a vulnerable population., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Previous studies have noted that participation in advanced care planning (ACP) and end-of-life (EOL) discussions remain low among Latino communities. Various studies have found that interventions within Latino communities can positively improve engagement in ACP, however, minimal research exists regarding patient satisfaction of ACP discussions with healthcare providers outside of preorganized educational interventions. Our study aims to understand how conversations about ACP are perceived by Latino patients in a primary care setting., Methods: Subjects were identified from the institution's family medicine clinic from October 2021 to October 2022. Participants were those over the age of 50 who identified as Latino and were available at the clinic on the day of survey administration. An 8-question, 5-point, Likert scale survey assessed perceptions about ACP planning and gauged satisfaction of conversations with health care providers. The survey concluded with a multiple-choice question inquiring about individuals whom patients have spoken to regarding ACP/EOL wishes. Survey data was gathered through Qualtrics., Results: Of the 33 patients, the majority have at least somewhat thought about their EOL wishes (avg = 3.48/5). Most usually felt they were given enough time with their doctor (avg = 4.12/5) and comfortable speaking about ACP and EOL decisions (avg = 4.55/5). Generally, participants felt somewhat happy with how their doctor has spoken about ACP/EOL care (avg = 3.24/5). However, patients only felt a little to somewhat satisfied with the explanation of ACP/EOL from providers (avg = 2.82/5) and a little to somewhat confident in having the proper forms in place (avg = 2.76/5). Religious officials were a little to somewhat important to these conversations (avg = 2.55/5). Overall, patients have discussed ACP more frequently with family members and friends than health care providers, lawyers, or religious leaders., Conclusions: The initial data demonstrates that many Latino patients are engaging in ACP conversations, both with healthcare providers and loved ones. Patients largely feel comfortable discussing EOL wishes with their doctor suggesting a trustful relationship. However, patients are only somewhat happy with these ACP conversations. Our study highlights a need for enhanced ACP education to improve satisfaction and confidence in formal documentation. Physicians should continue to engage and individualize ACP discussions to increase EOL preparedness among Latino patients., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: This study evaluated change in health-related quality of life at the group and individual levels in a consecutive series of patients with chronic myofascial neck pain., Methods: Fifty patients with chronic neck pain self-administered the Short Form-36 Version 2 (SF-36 v2) before treatment and 6 weeks later. Internal consistency reliability was estimated for the 8 scale scores and Mosier's formula was used to estimate reliability of the physical and mental health composite scores. Significance of group-level change was estimated using within-group t statistics. Significance of individual change was evaluated by reliable change index., Results: Statistically significant ( P < .05) group mean improvement over time was found for all SF-36 scores. At the individual level, 20% of the possible changes were statistically significant (17% improvement, 3% decline)., Conclusions: Estimating the significance of individual change in health-related quality of life adds important information in comparing different treatment modalities for chronic myofascial neck pain.

Background: Preference-based measures of health-related quality of life all use the same dead = 0.00 to perfect health = 1.00 scale, but there are substantial differences among measures., Objective: The objective was to examine agreement in classifying patients as better, stable, or worse., Methods: The EQ-5D, Health Utilities Index Mark 2 and Mark 3, Quality of Well-Being-Self-Administered scale, Short-Form 36 (Short-Form 6D), and disease-targeted measures were administered prospectively in 2 clinical cohorts. The study was conducted at academic medical centers: University of California, Los Angeles; University of California, San Diego; University of Wisconsin-Madison; and University of Southern California. Patients undergoing cataract extraction surgery with lens replacement completed the 25-item National Eye Institute Visual Function Questionnaire (NEI-VFQ-25). Patients newly referred to congestive heart failure specialty clinics completed the Minnesota Living with Heart Failure Questionnaire (MLHF). In both cohorts, subjects completed surveys at baseline and at 1 and 6 months. The NEI-VFQ-25 and MLHF were used as gold standards to assign patients to categories of change. Agreement was assessed using κ., Results: There were 376 cataract patients recruited. Complete data for baseline and the 1-month follow-up were available on all measures for 210 cases. Using criteria specified by Altman, agreement was poor for 6 of 9 pairs of comparisons and fair for 3 pairs. There were 160 heart failure patients recruited. Complete data for baseline and the 6-month follow-up were available for 86 cases. Agreement was negligible for 5 pairs and fair for 1. The study was conducted on selected patients at a few academic medical centers., Conclusions: The results underscore the lack of interchangeability among different preference-based measures.

Objectives: The Patient-Reported Outcomes Measurement Information System (PROMIS) allows assessment of the impact of chronic conditions on health-related quality of life (HRQL) across diseases. We report on the HRQL impact of individual and comorbid conditions as well as conditions that are described as limiting activity., Study Design and Setting: Data were collected through online and clinic recruitment as part of the PROMIS item calibration sample (n=21,133). Participants reported the presence or absence of 24 chronic health conditions and whether their activity was limited by each condition., Results: Across health status domains, the presence of a chronic condition was associated with poorer scores than those without a diagnosis, particularly for those individuals who reported that their condition was disabling. The magnitude of detriment in HRQL was more pronounced for individuals with two or more chronic conditions and could not be explained by sociodemographic factors. Patterns of HRQL deficits varied across disease and comorbidity status., Conclusion: The impact of chronic conditions, particularly when experienced with comorbid disease, is associated with detriments in HRQL. The negative impact on HRQL varies across symptoms and functional areas within a given condition., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Objective: To examine the extent to which racial/ethnic differences in Consumer Assessment of Health Plans Study (CAHPS) ratings and reports of Medicaid managed care can be attributed to differential treatment by the same health plans (within-plan differences) as opposed to racial/ethnic minorities being disproportionately enrolled in plans with lower quality of care (between-plan differences)., Design: Data are from the National CAHPS Benchmarking Database (NCBD) 3.0. Data were analyzed using linear regression models to determine the overall effects, within-plan effects, and between-plan effects of race/ethnicity and language on patient assessments of care. Standard errors were adjusted for nonresponse weights and the clustered nature of the data., Patients/participants: A total of 49,327 adults enrolled in Medicaid managed care plans in 14 states from 1999 to 2000., Main Results: Non-English speakers reported worse experiences compared to those of whites, while Asian non-English speakers had the lowest scores for most reports and ratings of care. An analysis of between-plan effects showed that African Americans, Hispanic-Spanish speakers, American Indian/Whites, and White-Other language were more likely than White-English speakers to be clustered in worse plans as rated by consumers. However, the majority of the observed racial/ethnic differences in CAHPS reports and ratings of care are attributable to within-plan effects. The ratio of between to within variance of racial/ethnic effects ranged from 0.07 (provider communication) to 0.42 (health plan rating)., Conclusions: The observed racial/ethnic differences in CAHPS ratings and reports of care are more a result of different experiences with care for people enrolled in the same plans than a result of racial/ethnic minorities being enrolled in plans with worse experiences. Health care organizations should engage in quality improvement activities to address the observed racial/ethnic disparities in assessments of care.

Objective: To evaluate the associations of presbyopia and its correction, particularly monovision optical correction, with vision-targeted health-related quality of life., Methods: The National Eye Institute Refractive Error Quality of Life (NEI-RQL) Instrument was prospectively self-administered by subjects from 6 medical centers in the following age and correction categories: subjects with emmetropia younger than 45 years (n = 75), subjects with emmetropia aged 45 years or older (n = 38), and subjects with ametropia aged 45 years or older without monovision (n = 486) or corrected with monovision (n = 38). Differences in the 13 NEI-RQL Instrument subscale scores among subjects in the 4 groups were examined. The age of 45 years or older was used as a surrogate for presbyopia., Results: A comparison of older (age > or =45 years) vs younger (age <45 years) persons with emmetropia suggests that presbyopia was associated with reduced scores in 7 of 13 subscales (P<.05). In those aged 45 years or older, correction of presbyopia with monovision was associated with statistically significantly better scores on 3 subscales (expectations, dependence on correction, and appearance) compared with single-vision correction. One subscale (dependence on correction) showed worsening scores with increasing age without adjustment for need or type of correction. Older persons with monovision correction had significantly worse scores than younger subjects with emmetropia on all subscales except suboptimal correction and appearance., Conclusions: Presbyopia is associated with worse vision-targeted health-related quality of life compared with younger subjects with emmetropia. Monovision correction of presbyopia is related to some improvements in health-related quality of life, but it is still worse than that for younger subjects with emmetropia in several areas.

Objective: Consumer assessments of health care provide important information about how well health plans and clinicians meet the needs of the people they serve. The purpose of this study was to examine whether consumer reports and ratings of care in Medicaid managed care vary by race/ethnicity and language., Data Sources: Data were derived from the National CAHPS Benchmarking Database (NCBD) 3.0 and consisted of 49,327 adults enrolled in Medicaid managed care plans in 14 states in 2000., Data Collection: The CAHPS data were collected by telephone and mail. Surveys were administered in Spanish and English. The response rate across plans was 38 percent., Study Design: Data were analyzed using linear regression models. The dependent variables were CAHPS 2.0 global rating items (personal doctor, specialist, health care, health plan) and multi-item reports of care (getting needed care, timeliness of care, provider communication, staff helpfulness, plan service). The independent variables were race/ethnicity, language spoken at home (English, Spanish, Other), and survey language (English or Spanish). Survey respondents were assigned to one of nine racial/ethnic categories based on Hispanic ethnicity and race: White, Hispanic/Latino, Black/African American, Asian/Pacific Islanders, American Indian/Alaskan native, American Indian/White, Black/White, Other Multiracial, Other Race/Ethnicity. Whites, Asians, and Hispanics were further classified into language subgroups based on the survey language and based on the language primarily spoken at home. Covariates included gender, age, education, and self-rated health., Principal Findings: Racial/ethnic and linguistic minorities tended to report worse care than did whites. Linguistic minorities reported worse care than did racial and ethnic minorities., Conclusions: This study suggests that racial and ethnic minorities and persons with limited English proficiency face barriers to care, despite Medicaid-enabled financial access. Health care organizations should address the observed disparities in access to care for racial/ethnic and linguistic minorities as part of their quality improvement efforts.

Objectives: Older adults can incur problems at low levels of alcohol consumption because of age-related physiological changes, declining health and functional status, and medication use. We have developed and tested a screening measure specifically for older people, the Alcohol-Related Problems Survey (ARPS), to identify older adults with these risks., Design: Survey., Setting: Academic and community primary care clinics., Participants: Five hundred forty-nine current drinkers aged 65 and older, mostly white with high school or more education., Measures: Alcohol use was classified as harmful, hazardous, or nonhazardous depending upon consumption alone or combined with selected comorbidities and medication use. Harmful drinking (including alcohol abuse or dependence) means the presence of problems (e.g., hypertension, adverse drug events, legal problems) due to drinking. Hazardous drinking means risks for problems are likely. Nonhazardous drinking poses no known risks for problems., Results: Eleven percent of subjects were harmful drinkers and 35% were hazardous drinkers. Harmful drinking was more common in men than women and in persons younger than 75 than those aged 75 and older. Similar proportions of men and women and younger and older age groups were hazardous drinkers. Most harmful drinkers were identified by their use of alcohol with their comorbidity, whereas most hazardous drinkers were identified by their use of alcohol with medications. Test-retest reliability was substantial (kappa = 0.65)., Conclusion: Physicians are urged to screen for alcohol-related problems in older persons. The ARPS reliably identifies harmful, hazardous, and nonhazardous drinking in older adults resulting most often from the interaction between alcohol and disease and medication use.

Background: There is a dearth of validated information about lesbian and bisexual women's health. To better understand some of these issues, we used population-based data to assess variations in health behaviors, health status, and access to and use of health care based on sexual orientation., Methods: Our study population was drawn from a population-based sample of women, the 1997 Los Angeles County Health Survey. Participants reported their sexual orientation and these analyses included 4697 women: 4610 heterosexual women, 51 lesbians, and 36 bisexual women. We calculated adjusted relative risks to assess the effect of sexual orientation on important health issues., Results: Lesbians and bisexual women were more likely than heterosexual women to use tobacco products and to report any alcohol consumption, but only lesbians were significantly more likely than heterosexual women to drink heavily. Lesbians and bisexual women were less likely than heterosexual women to have health insurance, more likely to have been uninsured for health care during the preceding year, and more likely to have had difficulty obtaining needed medical care. During the preceding 2 years, lesbians, but not bisexual women, were less likely than heterosexual women to have had a Papanicolaou test and a clinical breast examination., Conclusions: In this first population-based study of lesbian and bisexual women's health, we found that lesbians and bisexual women were more likely than heterosexual women to have poor health behaviors and worse access to health care. These findings support our hypothesis that sexual orientation has an independent effect on health behaviors and receipt of care, and indicate the need for the increased systematic study of the relationship between sexual orientation and various aspects of health and health care. Arch Fam Med. 2000;9:1043-1051

Background: Satisfaction with health plan performance has been assessed frequently, but assessment of physician group performance is rare., Objective: To present ratings of the care provided by physician groups to enrollees in a variety of capitated health maintenance organization plans., Methods: A random sample was drawn of adult enrollees receiving managed health care from 48 physician groups in a group practice association. Each individual in the sample was mailed a 12-page questionnaire and 7093 were returned (59% response rate). The mean age of those returning the questionnaire was 51 years; 65% were women., Results: Reliability estimates for 6 multi-item satisfaction scales were excellent, and noteworthy differences in ratings among groups were observed. In particular, ratings of overall quality ranged from a low of 28 to a high of 68 (mean, 50; SD, 10). Average scores for physician groups were strongly correlated across all scales, but no single group scored consistently highest or lowest on the different scales. Negative ratings of care were significantly related to the following: intention to switch to another physician group, difficulty in getting appointments, lengthy waiting periods in the reception area and examination room, the inability to get consistent care from one physician for routine visits, and not being informed by the office staff when there was a delay in seeing the primary care provider., Conclusions: Monitoring of health care quality at the physician group level is possible, and could be used for benchmarking, internal quality improvement, and for providing information to the public about how these physician groups will meet its needs.

Objective: To identify the content area for a questionnaire designed to measure vision-targeted health-related quality of life and to determine whether problems with vision-related functioning are qualitatively similar across different common eye diseases., Design: Twenty-six condition-specific focus groups were conducted with 246 patients from 5 geographic regions to identify the content area for a questionnaire for use among persons with diabetic retinopathy, glaucoma, macular degeneration, cytomegalovirus retinitis, and cataract. A standard protocol was used to structure each focus group discussion. Sessions were audiotaped, transcribed, and coded in preparation for a content analysis., Settings: Five university-based ophthalmology practices and 1 nonprofit eye care foundation., Participants: Eligible participants had to have 1 of the following eye conditions: age-related cataracts, age-related macular degeneration, diabetic retinopathy, primary open angle glaucoma, cytomegalovirus retinitis, or low vision from any cause. All eligible persons were older than 21 years, spoke English, and had sufficient cognitive function to provide informed consent., Results: Among the 246 participants, 2623 problems with vision-related functioning were mentioned. The mean number of problems per person ranged from 13.5 for those with diabetic retinopathy to 7.9 for persons with glaucoma. For the sample overall, reading problems were mentioned most frequently, followed by driving, general problems with seeing clearly, and mental health complaints caused by vision. Although the proportion of persons who reported each problem varied by condition, at least some persons with each eye disease reported each problem. The 3 most common descriptors associated with each problem were difficulty or ease of performance (13%), psychological distress associated with performance of the activity (11%), and complete inability to participate in a visual activity (11%)., Conclusion: An item-generation strategy for a new questionnaire using a standardized focus group method identified content areas and aspects of visual disability that are not included in currently available vision-specific instruments that assess the impact of common eye diseases on visual functioning in every-day life. Although participants mentioned problems that were unique to their disease, across conditions the problems mentioned were similar. These findings provide empirical evidence of content validity for a vision-targeted, health-related quality-of-life survey designed for use across conditions.

Purpose: To assess the association between structural factors in the health care delivery system and self-reported utilization of ophthalmic services by patients with diabetes in the Medical Outcomes Study (MOS)., Methods: Self-reported utilization of ophthalmic services within the 6 months preceding enrollment into the MOS among 522 of 567 individuals with diabetes in the MOS longitudinal panel was measured. Use of eye care services was regressed (logistic model) on patient demographics, geographic location, physician specialty, type of practice, and finance plan (prepaid or fee-for-service)., Results: None of the variables was significantly associated with a higher or lower likelihood of having used ophthalmic services in the preceding 6 months. Thus, no difference between prepaid or fee-for-service plans or among solo practice, large multispecialty groups, or HMOs were identified. Having seen an internist, family practitioner, or diabetes specialist for diabetes care was not related to use of ophthalmic services., Conclusions: Despite a presumed greater interest in preventive health, prepaid health plans were no more or less likely than the fee-for-service sector to have patients with diabetes reporting an eye examination within the prior 6 months. Thus, steps to improve the rate of eye examinations of diabetics may need to focus beyond the structural elements of the health care delivery system.

In the context of restrictive admissions policies at public inpatient facilities, rates of arrest and incarceration of persons with serious mental illness (SMI) have been increasing, leading to the perception that SMI persons are being unduly "criminalized." This paper describes the characteristics of persons with SMI (N = 177) in Mississippi who have been (1) jailed without charges while awaiting a hospital bed and (2) jailed for a criminal offense. Seventy-five percent (N = 132) of the 177 subjects had been held in local jails awaiting state hospital admission at least once in their lives, most for more than five days. Fifteen percent (N = 26) had contact with the police for a criminal offense in the past year. Rural residence markedly increased the risk for waiting in jail (OR = 4.24) but was not related to committing a criminal offense. Protective factors for any type of criminal justice contact were female gender, caucasian ethnicity, better compliance with medication regimes, and nonrural residence. The phenomenon of rural criminalization, i.e., waiting in jail without criminal charges, differs qualitatively from the criminalization that occurs in urban areas and may require a different solution. To avoid criminalization of SMI persons in rural areas, public mental health systems must develop effective crisis interventions in the community or work with local law enforcement officials and medical and mental health facilities to create more immediate access to acute inpatient care.

To examine the relationship between consumer satisfaction with community mental health clinic (CMHC) services and patterns of outpatient service use, we conducted a survey of 210 schizophrenics in Mississippi, the majority of whom were African American. Subjects with lowest CMHC satisfaction were those who did not identify the CMHC as their primary source of outpatient mental health care. They were more likely to be white, single, and to either receive no outpatient mental health care (46%) or to seek care from sources other than the CMHC (54%), many of which might provide substandard care, such as family doctors, ministers, folk healers, or hospital emergency rooms. Among those who identified the CMHC as their primary source of mental health care, we found little evidence that satisfaction was associated with type, variety, or frequency of services. Even though clinics offered similar services, there were differences in consumer satisfaction ratings by clinics, suggesting that qualities of the clinic itself may influence consumer satisfaction.

Objective: To determine the impact of blurred vision on functional status and well-being, the authors used a cross-sectional analysis of Medical Outcomes Study (MOS) 2-year follow-up data., Methods: One thousand six hundred forty-two respondents were asked to report how often they experienced blurred vision not correctable by glasses or contact lenses, as well as other various symptoms, at the 2-year follow-up. Participants completed the SF-36, a general functioning and well-being instrument. Demographic, medical, and other data also were collected. The association of these symptoms, including blurred vision, and tracer medical conditions with SF-36 scores were evaluated., Results: The unique impact of blurred vision on role limitations due to physical health problems was significantly greater than the impact of hypertension, history of myocardial infarction, type II diabetes mellitus, indigestion, trouble urinating, and headache. Blurred vision also had a significantly greater negative impact on energy than Type I diabetes mellitus, on social function than indigestion, and on physical functioning than trouble urinating., Conclusions: Having blurred vision more than once or twice a month has a detectable and significant impact on functional status and well-being, especially in role limitations due to physical health problems. This demonstrates the impact of a common visual symptom on health status and well-being, as measured by the SF-36. In addition, comparison of the impact of various symptoms and conditions provides important and potentially clinically relevant information.

This study developed a modified capitation payment method for the Medicare end stage renal disease (ESRD) program designed to support appropriate treatment choices and protect health plans from undue financial risk. The payment method consists of risk-adjusted monthly capitated payments for individuals on dialysis or with functioning kidney grafts, lump sum event payments for expected incremental costs of kidney transplantations or graft failures, and outlier payments for expensive patients. The methodology explained 25 percent of variation in annual payments per patient. Risk adjustment captured substantial variations across patient groups. Outlier payments reduced health plan risk by up to 15 percent.

Objective: Data from a cross-sectional survey of 210 current or former inpatients at Mississippi State Hospital and 197 informants, usually patients' family members, were used to compare the demographic, clinical, and service use characteristics of patients living in rural areas with those of patients living in nonrural areas., Methods: All subjects completed structured face-to-face interviews. Information on recent use of community mental health center (CMHC) services was obtained from CMHC records. Characteristics of rural patients (N = 107) and nonrural patients (N = 103) were compared using chi square and t tests., Results: Rural patients were less likely to have completed high school and more likely to be living with family members. Although rural and nonrural subjects were clinically similar, rural subjects were less likely to have received certain community mental health services such as case management and day treatment and were more likely to have used physical health services and to have been involved with the criminal justice system., Conclusions: Differences between rural and nonrural patients in patterns of service use are most likely a reflection of less availability or accessibility of mental health services in rural areas, resulting in spillover into physical health and criminal justice sectors. Rural community mental health centers need to formally incorporate families, local medical providers, and law enforcement officials into their network of care.

Epilepsy surgery is an increasingly common treatment for intractable epilepsy; yet there is no clear consensus among experts on how to report epilepsy surgery outcome. Most published outcome reporting systems focus on seizure frequency and type but differ in how they define clinically distinct outcome categories. We used a reliable and valid measure of self-reported health-related quality of life (HRQOL), the Epilepsy Surgery Inventory (ESI)-55, as an external standard by which to evaluate seven previously published, seizure-based outcome classification systems. The ESI-55 was administered to 133 adults who had previously undergone surgery for intractable epilepsy, and results were linked to data on their seizure occurrence before and after surgery (over the year prior to their HRQOL reports). These 133 patients were classified according to each seizure-based outcome system, and variation in HRQOL across outcome groups was evaluated using analysis of variance. Results reveal noteworthy variation in the extent to which different systems reflect patients' HRQOL at follow-up. We modified existing systems to derive a seizure-based surgery outcome system that most closely reflects HRQOL when applied over the latest 1-year postoperative interval.

Background: Cross-sectional studies have found that depression is uniquely associated with limitations in well-being and functioning that were equal to or greater than those of chronic general medical conditions such as diabetes and arthritis. However, whether these relative limitations persist over time is not known., Methods: We conducted a 2-year observational study of 1790 adult outpatients with depression, diabetes, hypertension, recent myocardial infarction, and/or congestive heart failure. Change in functional status and well-being was compared for depressed patients vs patients with chronic general medical illnesses, controlling statistically for medical comorbidity, sociodemographics, system, and specialty of care., Results: Over 2 years of follow-up, limitations in functioning and well-being improved somewhat for depressed patients; even so, at the end of 2 years, these limitations were similar to or worse than those attributed to chronic medical illnesses. Similar patterns were observed for depressed patients in the mental health specialty sector and those in the general medical sector, but the patients in the mental health specialty sector improved more. More severely depressed patients improved more in functioning, but even initially depressed patients without depressive disorder had substantial persistent limitations., Conclusion: Depressed patients have substantial and long-lasting decrements in multiple domains of functioning and well-being that equal or exceed those of patients with chronic medical illnesses.

This study was carried out to determine whether levels of physical activity of patients with various chronic diseases are associated with subsequent functioning and well-being. It was an observational 2-year longitudinal design. The setting was offices of medical and mental health practices within health maintenance organizations, large multispecialty groups, and solo practices or small single-specialty group practices in three U.S. cities. Included in the study were 1758 adult patients with one or more of the following: diabetes, hypertension, congestive heart failure, recent myocardial infarction, depressive symptoms, or current depressive disorder. Outcome measures included physical, role, and functioning; energy/fatigue; pain intensity; sleep problems; depressed affect, anxiety, positive affect, and overall psychological distress/well-being; health distress; and current health perceptions. Cross-sectional (base-line), 2-year endpoint, and change score relationships were evaluated between baseline levels of physical activity and each outcome, controlling for chronic conditions, comorbidity, smoking, alcohol use, overweight, self-reported adherence, and other patient and study characteristics. Higher baseline levels of exercise were uniquely associated with better functioning and well-being at baseline and 2 years later for some measures. The magnitude of the differences varied by disease group, but tended to be between 0.17 and 0.39 of the baseline SD. Greater levels of exercise are associated with feeling and functioning better for patients with chronic conditions over a 2-year period, suggesting that this is a fruitful area for further study using controlled interventions.