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Using data from 335,249 Medicare beneficiaries who responded to the 2007 Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS®) survey, along with data from 22 cognitive interviews, we investigated the reliability and validity of an instrument designed to assess beneficiaries' experiences with their prescription drug plans. Composite measures derived from the instrument had acceptable internal consistency and sufficient planlevel reliability to inform consumer choice, quality improvement, and payor oversight. These measures were positively associated with members' overall rating of the plan and their willingness to recommend the plan. Moreover, each was independently useful in predicting beneficiaries' global ratings of their plan. This instrument can be an important tool for helping beneficiaries to choose a plan that best meets their needs. [ABSTRACT FROM AUTHOR]

The objective of this study was to compare physician-level survey instruments and estimate the number of patients needed per physician to provide reliable estimates of health care. The setting consisted of 3 health plans and 1 large physician group in the greater Cincinnati metro area. Surveys were mailed to patients of 100 primary care physicians. Patients were mailed either the Consumer Assessment of Health Plans Study (CAHPS) or DoctorGuide survey instrument. A total of 4245 CAHPS surveys and 5519 DoctorGuide surveys were returned. Internal consistency reliability estimates for the multi-item scales (access to care, communication, and preventive care) for both surveys were adequate. The number of patient responses needed to obtain a reliability of 0.70 at the physician level for the access to care, communication, and preventive care scales were 32, 43, and 38, respectively, for the CAHPS survey and 26, 25, and 47, respectively, for the DoctorGuide survey. These results indicate similar and parallel psychometric performance for the DoctorGuide and CAHPS survey instruments. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

BACKGROUND:: Classical test theory and item response theory methods can provide useful and potentially different insights into the performance of items in a survey designed to elicit parental perceptions of dental care delivered to children in publicly funded programs. OBJECTIVES:: We sought to illustrate the use of both classical test theory and item response theory to evaluate survey instruments. METHODS:: Using 2 years of cross-sectional data collected from enrollees in dental plans in 2001 and 2002, we studied families with children between ages 4 to 18 who were enrolled in 1 of 5 dental plans for 12 months or longer. The 2001 survey yielded a total of 2536 usable surveys and the 2002 survey yielded 2232 useable surveys (50% and 46% response rate, respectively) for a total sample size of 4036 children who used the plan for most or all of their care. MEASURES:: The beta version of the CAHPS(R) dental care survey instrument includes 2 global rating items (dental care, dental plan) and multi-item scales assessing getting needed care, getting care quickly, communication with dental providers, office staff, and customer service. RESULTS:: Item missing data rates were low. Item-scale correlations for hypothesized scales (corrected for overlap) tended to exceed correlations of items with other scales. Classical test theory analyses identified 5 of 10 communication items that did not perform well. Internal consistency reliability estimates for the scales ranged from 0.73 to 0.86. Item response theory painted a more promising picture than classical test theory for the 2 communication items that assessed access to an interpreter when needed. CONCLUSIONS:: The beta CAHPS(R) dental survey performed well and the revised instrument is recommended for future studies. Classical test theory and item response theory can provide complementary information about survey items. [ABSTRACT FROM AUTHOR]

Background: There has been limited evaluation of health-related quality of life (HRQOL) in rectal cancer patients receiving neoadjuvant chemoradiotherapy. HRQOL outcomes in the National Surgical Adjuvant Breast and Bowel Project R-04 trial are examined in this article., Methods: Between 2004 and 2010, R-04 patients were invited to enroll in the HRQOL substudy, with questionnaires administered before randomization, after completion of chemoradiotherapy, and 1-year after surgery. HRQOL measures included: Functional Assessment of Cancer Therapy for colorectal cancer (FACT-C); Short Form-36v.2 Vitality scale; a treatment-specific symptom scale; and the FACT neurotoxicity scale. A 5-year postsurgery assessment was added to the protocol in 2012. Mixed-effects models examined neoadjuvant therapy treatment effects in the 1-year sample and models that explored associations of host factors and treatment impact on 5-year HRQOL., Results: A total of 1373 patients completed baseline HRQOL and at least one additional assessment. The average age was 58 years (range, 23-85 years), male (68%), and 59% Stage II. There were no statistically significant differences in HRQOL outcomes by treatment arm, but HRQOL worsened from baseline to postneoadjuvant chemoradiotherapy, with statistically significant effect sizes changes ranging from 0.6 (Vitality) to 0.9 (FACT-C Trial Outcome Index). Neurotoxicity was greater in the oxaliplatin-treated groups. Obese/overweight patients had statistically significantly worse FACT-C Trial Outcome Index scores than did underweight/normal weight groups. At 5 years, younger patients and those with normal baseline weight had statistically significantly better physical function scores and older patients had better mental health outcomes., Conclusions: HRQOL did not differ across the four R-04 treatment arms; however, host factors explained significant variation in posttreatment HRQOL., Clinicaltrials: gov: NCT00058474 (https://ClinicalTrials.gov/ct2/show/NCT00058474)., Lay Summary: This article reports on the health-related quality of life (HRQOL) outcomes of patients treated with four different chemotherapy regimens combined with radiation in rectal cancer patients before definitive surgical treatment. There were no significant differences in HRQOL by treatment regimen, but all patients experienced decreased vitality (energy) and physical functioning. By 1 year after treatment, most patients had returned to pretreatment vitality and physical functioning, with the exception of increased neurotoxicity. In a subsample of patients assessed at 5 years after surgery, physical function was better in those who at pretreatment were younger, normal weight, and had better performance status. Mental function was better in those who at pretreatment were older and had better performance status., (© 2022 The Authors. Cancer published by Wiley Periodicals LLC on behalf of American Cancer Society.)

Objective: This study examines Patient-Reported Outcome Measurement Information System (PROMIS®)-29 v1.0 outcomes of chiropractic care in a multi-site, pragmatic clinical trial and compares the PROMIS measures to: 1) worst pain intensity from a numerical pain rating 0-10 scale, 2) 24-item Roland-Morris Disability Questionnaire (RMDQ); and 3) global improvement (modified visual analog scale)., Design: A pragmatic, prospective, multisite, parallel-group comparative effectiveness clinical trial comparing usual medical care (UMC) with UMC plus chiropractic care (UMC+CC)., Setting: Three military treatment facilities., Subjects: 750 active-duty military personnel with low back pain., Methods: Linear mixed effects regression models estimated the treatment group differences. Coefficient of repeatability to estimate significant individual change., Results: We found statistically significant mean group differences favoring UMC+CC for all PROMIS®-29 scales and the RMDQ score. Area under the curve estimates for global improvement for the PROMIS®-29 scales and the RMDQ, ranged from 0.79 to 0.83., Conclusions: Findings from this pre-planned secondary analysis demonstrate that chiropractic care impacts health-related quality of life beyond pain and pain-related disability. Further, comparable findings were found between the 24-item RMDQ and the PROMIS®-29 v1.0 briefer scales., (© The Author(s) 2022. Published by Oxford University Press on behalf of the American Academy of Pain Medicine.)

Objective: The purpose of this study was to estimate the significance of individual change using 5 statistical indicators in 2 samples of patients treated for low back pain., Methods: This secondary analysis used observational and clinical trial data from 2 samples of patients with low back pain to compare 5 ways of estimating significant individual change on the Impact Stratification Score (ISS) administered at the following 2 time points: 3 months apart in an observational study of 1680 patients undergoing chiropractic care, and 6 weeks apart in a randomized trial of 750 active-duty military personnel with low back pain. The following 5 methods were compared: (1) standard deviation index; (2) standard error of measurement (SEM); (3) standard error of estimate (SEE); (4) standard error of prediction (SEP); and (5) the reliable change index (RCI). The ISS is the sum of the Patient-Reported Outcomes Measurement Information System (PROMIS)-29 v2.1 physical function, pain interference, and pain intensity scores and is scored to have a possible range of 8 (least impact) to 50 (greatest impact)., Results: The amount of change on the ISS needed for significant individual change in both samples was 5 for the SEM and for the SEE and 7 for the SEP and RCI., Conclusions: The results of the current study provide some preliminary support for use of the SEP or the RCI to identify significant individual change and provide estimated thresholds of individual change that can be used for the ISS. The SEP and RCI estimates of significant change were consistent with retrospective ratings of change of at least moderately better in prior research. These 2 were less likely than other methods to classify people with low back pain as responders who have not actually gotten better (false positive). In contrast, the SEM and SEE were less likely to miss real change (false negative)., (Copyright © 2022. Published by Elsevier Inc.)

The reliable change index has been used to evaluate the significance of individual change in health-related quality of life. We estimate reliable change for two measures (physical function and emotional distress) in the Patient-Reported Outcomes Measurement Information System (PROMIS®) 29-item health-related quality of life measure (PROMIS-29 v2.1). Using two waves of data collected 3 months apart in a longitudinal observational study of chronic low back pain and chronic neck pain patients receiving chiropractic care, and simulations, we compare estimates of reliable change from classical test theory fixed standard errors with item response theory standard errors from the graded response model. We find that unless true change in the PROMIS physical function and emotional distress scales is substantial, classical test theory estimates of significant individual change are much more optimistic than estimates of change based on item response theory., (© 2021. The Author(s).)

Purpose: The toxicity index (TI) is a summary index that accounts for toxicity grades associated with cancer symptoms that is more sensitive than other toxicity systems to treatment differences. The TI can be used with patient-reported symptoms but requires that scores for different items represent equivalent severity. The purpose of this article is to provide an example of scoring patient-reported symptoms that satisfies the requirement of equivalent symptom severity., Methods: A sample of 1232 adults with rectal cancer from a Phase III clinical trial self-reported 18 symptoms on the European Organization for Research and Treatment of Cancer colorectal cancer measure using a 4-category response scale (not at all, a little bit, quite a bit, or very much). The participants were 22 to 85 years of age (mean age, 57 years), 30% were female, 85% were non-Hispanic white, 59% had stage II cancer, and 41% had stage III cancer. A recoded TI was created using item response theory category thresholds., Findings: The recoded TI had larger rank-order correlations than the original TI with Karnofsky performance status index, hemoglobin level, symptom bother, and other aspects of health-related quality of life., Implications: Recoding items based on category thresholds yielded a more valid TI score that can be used to summarize adverse events., (Copyright © 2021 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Musculoskeletal disorders are the second leading cause of disability worldwide., Objective: Examine experiences of chiropractic patients in the United States with chronic low back or neck pain., Method: Observational study of 1853 chronic low back pain and neck pain patients (74% female) who completed an online questionnaire at the 3-month follow-up that included Consumer Assessment of Healthcare Providers and Systems (CAHPS) items assessing their experiences with care., Results: We found similar reports of communication for the chiropractic sample and patients in the 2016 CAHPS National Database, but 85% in the database versus 79% in the chiropractic sample gave the most positive response to the time spent with provider item. More patients in the CAHPS database rated their provider at the top of the scale (8 percentage points). More chiropractic patients reported always getting answers to questions the same day (16 percentage points) and always being seen within 15 minutes of their appointment time (29 percentage points)., Conclusions: The positive experiences of patients with chronic back and neck pain are supportive of their use of chiropractic care., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2019.)

Background: Chronic obstructive pulmonary disease (COPD) is a progressive chronic disease characterized by airflow obstruction that leads to shortness of breath and substantial negative impacts on health-related quality of life (HRQL). The course of COPD includes periodic acute exacerbations that require changes in treatment and/or hospitalizations. This study was designed to examine the responsiveness of Patient-Reported Outcomes Measurement Information System® (PROMIS®) measures to changes associated with COPD exacerbation recovery., Methods: A longitudinal analysis using mixed-effects models was conducted of people who were enrolled while stable (n = 100) and those who experienced an acute exacerbation (n = 85). PROMIS (physical function, pain interference, pain behavior, fatigue, anxiety, depression, anger, social roles, discretionary social activities, Global Health, dyspnea severity and dyspnea functional limitations) and COPD-targeted HRQL measures were completed at baseline and at 12 weeks., Results: We administered PROMIS measures using computer adaptive testing (CAT), followed by administration of any remaining short form (SF) items that had not yet been administered by CAT. Examination of the difference between group differences from baseline to 12 weeks in the stable and exacerbation groups revealed that the exacerbation group changed (improved) significantly more than the stable group in anxiety (p < .001 to p < .01; f 2 effect size [ES] = 0.023/0.021), fatigue (p < .0001; ES = 0.036/0.047) and social roles (p < .001 to p < .05; ES = 0.035/0.024). All effect sizes were small in magnitude and smaller than hypothesized. Depression was also statistically significant (p < .05, SF only) but the ES was trivial. For all other PROMIS domains, the differences were not significant and ES were trivial., Conclusions: This longitudinal study provides some support for the validity of the PROMIS fatigue, anxiety, and social roles domains in COPD, but further evaluation of responsiveness is warranted.

Study Design: A prospective observational study., Objective: The aim of this study was to evaluate group-level and individual-level change in health-related quality of life among persons with chronic low back pain or neck pain receiving chiropractic care in the United States., Summary of Background Data: Chiropractors treat chronic low back and neck pain, but there is limited evidence of the effectiveness of their treatment METHODS.: A 3-month longitudinal study of 2024 patients with chronic low back pain or neck pain receiving care from 125 chiropractic clinics at six locations throughout the United States was conducted. Ninety-one percent of the sample completed the baseline and 3-month follow-up survey (n = 1835). Average age was 49, 74% females, and most of the sample had a college degree, were non-Hispanic White, worked full-time, and had an annual income of $60,000 or more. Group-level (within-group t tests) and individual-level (coefficient of repeatability) changes on the Patient-Reported Outcomes Measurement Information System (PROMIS-29) v2.0 profile measure was evaluated: six multi-item scales (physical functioning, pain, fatigue, sleep disturbance, social health, emotional distress) and physical and mental health summary scores., Results: Within-group t tests indicated significant group-level change (P < 0.05) for all scores except for emotional distress, and these changes represented small improvements in health (absolute value of effect sizes ranged from 0.08 for physical functioning to 0.20 for pain). From 13% (physical functioning) to 30% (PROMIS-29 v2.0 Mental Health Summary Score) got better from baseline to 3 months later according to the coefficient of repeatability., Conclusion: Chiropractic care was associated with significant group-level improvement in health-related quality of life over time, especially in pain. But only a minority of the individuals in the sample got significantly better ("responders"). This study suggests some benefits of chiropractic on functioning and well-being of patients with low back pain or neck pain., Level of Evidence: 3.

It is generally assumed that the latent trait is normally distributed in the population when estimating logistic item response theory (IRT) model parameters. This assumption requires that the latent trait be fully continuous and the population homogenous (i.e., not a mixture). When this normality assumption is violated, models are misspecified, and item and person parameter estimates are inaccurate. When normality cannot be assumed, it might be appropriate to consider alternative modeling approaches: (a) a zero-inflated mixture, (b) a log-logistic, (c) a Ramsay curve, or (d) a heteroskedastic-skew model. The first 2 models were developed to address modeling problems associated with so-called quasi-continuous or unipolar constructs, which apply only to a subset of the population, or are meaningful at one end of the continuum only. The second 2 models were developed to address non-normal latent trait distributions and violations of homogeneity of error variance, respectively. To introduce these alternative IRT models and illustrate their strengths and weaknesses, we performed real data application comparing results to those from a graded response model. We review both statistical and theoretical challenges in applying these models and choosing among them. Future applications of these and other alternative models (e.g., unfolding, diffusion) are needed to advance understanding about model choice in particular situations.

Purpose: The PROMIS-29 v2.0 profile assesses pain intensity using a single 0-10 numeric rating item and seven health domains (physical function, fatigue, pain interference, depressive symptoms, anxiety, ability to participate in social roles and activities, and sleep disturbance) using four items per domain. This paper describes the development of physical and mental health summary scores for the PROMIS-29 v2.0., Method: We conducted factor analyses of PROMIS-29 scales on data collected from two internet panels (n = 3000 and 2000)., Results: Confirmatory factor analyses provided support for a physical health factor defined by physical function, pain (interference and intensity), and ability to participate in social roles and activities, and a mental health factor defined primarily by emotional distress (anxiety and depressive symptoms). Reliabilities for these two summary scores were 0.98 (physical health) and 0.97 (mental health). Correlations of the PROMIS-29 v2.0 physical and mental health summary scores with chronic conditions and other health-related quality of life measures were consistent with a priori hypotheses., Conclusions: This study develops and provides preliminary evidence supporting the reliability and validity of PROMIS-29 v2.0 physical and mental health summary scores that can be used in future studies to assess impacts of health care interventions and track changes in health over time. Further evaluation of these and alternative summary measures is recommended.

Purpose: To assess the equivalence of self-reports of physical functioning between pediatric respondents to the English- and Spanish-language patient-reported outcomes measurement information system (PROMIS ® ) physical functioning item banks., Methods: The PROMIS pediatric physical functioning item banks include 29 upper extremity items and 23 mobility items. A sample of 5091 children and adolescents (mean age = 12 years, range 8-17; 49% male) completed the English-language version of the items. A sample of 605 children and adolescents (mean age = 12 years, range 8-17; 55% male; 96% Hispanic) completed the Spanish-language version of the items., Results: We found language (English versus Spanish) differential item functioning (DIF) for 4 upper extremity items and 7 mobility items. Product-moment correlations between estimated upper extremity and mobility scores using the English versus the equated Spanish item parameters for Spanish-language respondents were 0.98 and 0.99, respectively. After excluding cases with significant person misfit, we found DIF for the same 4 upper extremity items that had DIF in the full sample and for 12 mobility items (including the same 7 mobility items that had DIF in the full sample). The identification of DIF items between English- and Spanish-language respondents was affected slightly by excluding respondents displaying person misfit., Conclusions: The results of this study provide support for measurement equivalence of self-reports of physical functioning by children and adolescents who completed the English- and Spanish-language surveys. Future analyses are needed to replicate the results of this study in other samples.

Background: About 70% of Latinos, 5 years old or older, in the United States speak Spanish at home. Measurement equivalence of the PROMIS ® pain interference (PI) item bank by language of administration (English versus Spanish) has not been evaluated., Methods: A sample of 527 adult Spanish-speaking Latinos completed the Spanish version of the 41-item PROMIS ® pain interference item bank. We evaluate dimensionality, monotonicity and local independence of the Spanish-language items. Then we evaluate differential item functioning (DIF) using ordinal logistic regression with item response theory scores estimated from DIF-free "anchor" items., Results: One of the 41 items in the Spanish version of the PROMIS ® PI item bank was identified as having significant uniform DIF., Conclusions: English- and Spanish-speaking subjects with the same level of pain interference responded differently to 1 of the 41 items in the PROMIS ® PI item bank. This item was not retained due to proprietary issues. The original English language item parameters can be used when estimating PROMIS ® PI scores.

Importance: Patient-reported outcome (PRO) measures for laser in situ keratomileusis (LASIK) are needed., Objective: To develop PRO measures to assess satisfaction, eye-related symptoms, and their effect on functioning and well-being following LASIK based on patient and expert input., Design, Setting, and Participants: The Patient-Reported Outcomes With LASIK (PROWL) studies were prospective observational studies of patients undergoing LASIK surgery for myopia, hyperopia, or astigmatism. PROWL-1 was a single-center study of active-duty US Navy personnel and PROWL-2 was a 5-center study of civilians. PROWL-1 enrolled 262 active-duty service personnel and PROWL-2 enrolled 312 civilians 21 years or older who spoke English; 241 individuals in PROWL-1 and 280 in PROWL-2 completed a baseline questionnaire before surgery. The analytic sample included those also completing 1 or more follow-up questionnaires: 240 (99.6%) of those in PROWL-1 and 271 (94.4%) of those in PROWL-2. Questionnaires were self-administered through the internet preoperatively and at 1 and 3 months postoperatively in both studies and at 6 months postoperatively in PROWL-1. PROWL-1 began in August 2011 and was completed May 30, 2014; PROWL-2 began in July 2012 and was completed June 27, 2014. Data were analyzed from June 28, 2014, to October 24, 2016., Main Outcomes and Measures: Scales assessing visual symptoms (double images, glare, halos, and starbursts), dry eye symptoms, satisfaction with vision, and satisfaction with LASIK surgery. Items from the National Eye Institute (NEI) Refractive Error Quality of Life Instrument (NEI-RQL-42), NEI Visual Function Questionnaire (NEI-VFQ), and the Ocular Surface Disease Index (OSDI) were included. All scales are scored on a 0 to 100 possible range. Construct validity and responsiveness to change were evaluated (comparing scores before and after surgery)., Results: The median age of the 240-person PROWL-1 analytic sample was 27 years (range, 21-52 years); 49 were women (20.4%). The median age of the 271-person PROWL-2 analytic sample was 30 years (range, 21-57 years); 147 were women (54.2%). Internal consistency reliabilities for the 4 visual symptom scales ranged from 0.96 to 0.98 in PROWL-1 and from 0.95 to 0.97 in PROWL-2. The median (interquartile range) test-retest intraclass correlation was 0.69 (0.57-0.79) and 0.76 (0.68-0.84) in PROWL-1 and PROWL-2, respectively. Product-moment correlations of satisfaction with surgery with visual symptom scales at follow-up evaluations ranged from r = 0.24 to r = 0.49. Measures improved from baseline to follow-up, with effect sizes of 0.14 to 1.98, but scores on the NEI-RQL-42 glare scale worsened at the 1-month follow-up. Hours of work did not change significantly from baseline to 1-month follow-up, with the mean number (mean [SD] difference) in PROWL-1 of 41.7 vs 40.9 hours (-0.8 [18.7]) and in PROWL-2 of 38.8 vs 38.2 hours (-0.6 [17.1])., Conclusions and Relevance: The results of these studies support the reliability and validity of visual symptom scales to evaluate the effects of LASIK surgery in future studies.

Background: Self-reports of health provide useful information about function and well-being that can improve communication between patients and clinicians. Global health items provide summary information that are predictive of health care utilization and mortality. There is a need for parsimonious global health scales for use in large sample surveys. This study evaluates the reliability and validity of brief measures of global physical health and mental health in the Patient Reported Outcomes Measurement and Information System (PROMIS®) project., Methods: A total of 21,133 persons included in the PROMIS development sample: 52% female; 82% White, 9% Black, 9% Hispanic; median age of 50 years. We identified two global physical health items (GPH-2) and two global mental health items (GMH-2) with highest discrimination parameters and compared their reliabilities and construct validity to that of the original 4-item scales (GPH-4 and GMH-4) and a single global health item (Global01)., Results: Internal consistency reliability was 0.73 for the GPH-2 (versus 0.81 for the GPH-4) and 0.81 for the GMH-2 (versus 0.86 for the GMH-4). Marginal reliabilities were 0.55 for Global01 , 0.70 for GPH-2, 0.79 for GPH-4, 0.80 for GMH-2, and 0.86 for GMH-4. The product-moment correlation between the GPH-2 and GPH-4 was 0.94 and between GMH-2 and GMH-4 was 0.97. The 2-item and 4-item versions of the scales had similar correlations with PROMIS domain scores, the EQ-5D-3L and comorbidities, but the 4-item scales were more strongly correlated with these measures., Conclusions: Adding a single item to a large cross-sectional population survey can cost as much as $100,000. The 2-item variants of the PROMIS global health scales reduce the cost of use on national surveys by 50%, a substantial cost savings. These briefer scales are also more practical for use in clinical practice. The 2-item versions of the PROMIS global health scales display adequate reliability for group comparisons and their associations with other indicators of health are similar to that of the original 4-item scales. The briefer scales are psychometrically sound and reduce burden of survey administration., Competing Interests: The study was conducted in accordance with the Declaration of Helsinki and patients provided informed consent to participate.The authors have no conflicts of interests associated with this manuscript.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Background: Preference-based health-related quality of life (HR-QOL) scores are useful as outcome measures in clinical studies, for monitoring the health of populations, and for estimating quality-adjusted life-years., Methods: This was a secondary analysis of data collected in an internet survey as part of the Patient-Reported Outcomes Measurement Information System (PROMIS(®)) project. To estimate Health Utilities Index Mark 3 (HUI-3) preference scores, we used the ten PROMIS(®) global health items, the PROMIS-29 V2.0 single pain intensity item and seven multi-item scales (physical functioning, fatigue, pain interference, depressive symptoms, anxiety, ability to participate in social roles and activities, sleep disturbance), and the PROMIS-29 V2.0 items. Linear regression analyses were used to identify significant predictors, followed by simple linear equating to avoid regression to the mean., Results: The regression models explained 48 % (global health items), 61 % (PROMIS-29 V2.0 scales), and 64 % (PROMIS-29 V2.0 items) of the variance in the HUI-3 preference score. Linear equated scores were similar to observed scores, although differences tended to be larger for older study participants., Conclusions: HUI-3 preference scores can be estimated from the PROMIS(®) global health items or PROMIS-29 V2.0. The estimated HUI-3 scores from the PROMIS(®) health measures can be used for economic applications and as a measure of overall HR-QOL in research.

Background: The most commonly used self-reported health question asks people to rate their general health from excellent to poor. This is one of the Patient-Reported Outcomes Measurement Information System (PROMIS) global health items. Four other items are used for scoring on the PROMIS global physical health scale. Because the single item is used on the majority of large national health surveys in the U.S., it is useful to construct scores that can be compared to U.S. general population norms., Objective: To estimate the PROMIS global physical health scale score from the responses to the single excellent to poor self-rated health question for use in public health surveillance, research, and clinical assessment., Design: A cross-sectional survey of 21,133 individuals, weighted to be representative of the U.S. general population., Participants: The PROMIS items were administered via a Web-based survey to 19,601 persons in a national panel and 1,532 subjects from PROMIS research sites. The average age of individuals in the sample was 53 years, 52 % were female, 80 % were non-Hispanic white, and 19 % had a high school degree or lower level of education., Main Outcome Measures: PROMIS global physical health scale., Key Results: The product-moment correlation of the single item with the PROMIS global physical health scale score was 0.81. The estimated scale score based on responses to the single item ranged from 29 (poor self-rated health, 2.1 SDs worse than the general population mean) to 62 (excellent self-rated health, 1.2 SDs better than the general population mean) on a T-score metric (mean of 50)., Conclusions: This item can be used to estimate scores for the PROMIS global physical health scale for use in monitoring population health and achieving public health objectives. The item may also be used for individual assessment, but its reliability (0.52) is lower than that of the PROMIS global health scale (0.81).

Objective: To estimate responsiveness (sensitivity to change) and minimally important difference (MID) for the Patient-Reported Outcomes Measurement Information System (PROMIS) 20-item physical functioning scale (PROMIS PF-20)., Methods: The PROMIS PF-20, short form 36 (SF-36) physical functioning scale, and Health Assessment Questionnaire (HAQ) were administered at baseline, and 6 and 12 months later to a sample of 451 persons with rheumatoid arthritis. A retrospective change (anchor) item was administered at the 12-month follow-up. We estimated responsiveness between 12 months and baseline, and between 12 months and 6 months using one-way analysis of variance F-statistics. We estimated the MID for the PROMIS PF-20 using prospective change for people reporting getting 'a little better' or 'a little worse' on the anchor item., Results: F-statistics for prospective change on the PROMIS PF-20, SF-36 and HAQ by the anchor item over 12 and 6 months (in parentheses) were 16.64 (14.98), 12.20 (7.92) and 10.36 (12.90), respectively. The MID for the PROMIS PF-20 was 2 points (about 0.20 of an SD)., Conclusions: The PROMIS PF-20 is more responsive than two widely used ('legacy') measures. The MID is a small effect size. The measure can be useful for assessing physical functioning in clinical trials and observational studies., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objective: To create upper-extremity and mobility subdomain scores from the Patient-Reported Outcomes Measurement Information System (PROMIS) physical functioning adult item bank., Design: Expert reviews were used to identify upper-extremity and mobility items from the PROMIS item bank. Psychometric analyses were conducted to assess empirical support for scoring upper-extremity and mobility subdomains., Setting: Data were collected from the U.S. general population and multiple disease groups via self-administered surveys., Participants: The sample (N=21,773) included 21,133 English-speaking adults who participated in the PROMIS wave 1 data collection and 640 Spanish-speaking Latino adults recruited separately., Interventions: Not applicable., Main Outcome Measures: We used English- and Spanish-language data and existing PROMIS item parameters for the physical functioning item bank to estimate upper-extremity and mobility scores. In addition, we fit graded response models to calibrate the upper-extremity items and mobility items separately, compare separate to combined calibrations, and produce subdomain scores., Results: After eliminating items because of local dependency, 16 items remained to assess upper extremity and 17 items to assess mobility. The estimated correlation between upper extremity and mobility was .59 using existing PROMIS physical functioning item parameters (r=.60 using parameters calibrated separately for upper-extremity and mobility items)., Conclusions: Upper-extremity and mobility subdomains shared about 35% of the variance in common, and produced comparable scores whether calibrated separately or together. The identification of the subset of items tapping these 2 aspects of physical functioning and scored using the existing PROMIS parameters provides the option of scoring these subdomains in addition to the overall physical functioning score., (Copyright © 2013 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate the equivalence of the PROMIS(®) physical functioning item bank by language of administration (English versus Spanish)., Methods: The PROMIS(®) wave 1 English-language physical functioning bank consists of 124 items, and 114 of these were translated into Spanish., Analysis: Item frequencies, means and standard deviations, item-scale correlations, and internal consistency reliability were calculated. The IRT assumption of unidimensionality was evaluated by fitting a single-factor confirmatory factor analytic model. IRT threshold and discrimination parameters were estimated using Samejima's Graded Response Model. DIF by language of administration was evaluated., Results: Item means ranged from 2.53 (SD = 1.36) to 4.62 (SD = 0.82). Coefficient alpha was 0.99, and item-rest correlations ranged from 0.41 to 0.89. A one-factor model fits the data well (CFI = 0.971, TLI = 0.970, and RMSEA = 0.052). The slope parameters ranged from 0.45 ("Are you able to run 10 miles?") to 4.50 ("Are you able to put on a shirt or blouse?"). The threshold parameters ranged from -1.92 ("How much do physical health problems now limit your usual physical activities (such as walking or climbing stairs)?") to 6.06 ("Are you able to run 10 miles?"). Fifty of the 114 items were flagged for DIF based on an R(2) of 0.02 or above criterion. The expected total score was higher for Spanish- than English-language respondents., Conclusions: English- and Spanish-speaking subjects with the same level of underlying physical function responded differently to 50 of 114 items. This study has important implications in the study of physical functioning among diverse populations.

Purpose: To evaluate the equivalence of the PROMIS® wave 1 physical functioning item bank, by age (50 years or older versus 18-49)., Materials and Methods: A total of 114 physical functioning items with 5 response choices were administered to English- (n=1504) and Spanish-language (n=640) adults. Item frequencies, means and standard deviations, item-scale correlations, and internal consistency reliability were estimated. Differential Item Functioning (DIF) by age was evaluated., Results: Thirty of the 114 items were fagged for DIF based on an R-squared of 0.02 or above criterion. The expected total score was higher for those respondents who were 18-49 than those who were 50 or older., Conclusions: Those who were 50 years or older versus 18-49 years old with the same level of physical functioning responded differently to 30 of the 114 items in the PROMIS® physical functioning item bank. This study yields essential information about the equivalence of the physical functioning items in older versus younger individuals.

Background: Consumer assessment of health care is an important metric for evaluating quality of care. These assessments can help purchasers, health plans, and providers deliver care that fits patients' needs., Objective: To examine differences in reports and ratings of care delivered to adults and children and whether they vary by site., Research Design: This observational study compares adult and child experiences with care at a large west coast medical center and affiliated clinics and a large mid-western health plan using Consumer Assessment of Healthcare Providers and Systems Clinician & Group 1.0 Survey data., Results: Office staff helpfulness and courtesy was perceived more positively for adult than pediatric care in the west coast site. In contrast, more positive perceptions of pediatric care were observed in both sites for coordination of care, shared decision making, overall rating of the doctor, and willingness to recommend the doctor to family and friends. In addition, pediatric care was perceived more positively in the mid-west site for access to care, provider communication, and office staff helpfulness and courtesy. The differences between pediatric care and adult care were larger in the mid-western site than the west coast site., Conclusions: There are significant differences in the perception of care for children and adults with care provided to children tending to be perceived more positively. Further research is needed to identify the reasons for these differences and provide more definitive information at sites throughout the United States.

This paper summarizes steps taken by a large U.S. commercial dental plan to meet measurement challenges through development of a program designed to assess and improve the practices of dentists enrolled in a large preferred provider network. Data collected by trained evaluators who assessed 1,428 dental offices using a structured office assessment instrument were subjected to psychometric analysis by UCLA researchers. Results suggested that the optimal structure for an office assessment instrument consisted of 71 items organized into 10 scales (clusters of measures) reflecting key aspects of dental practice.

Objective: We evaluate the effects of mode and order of administration on health-related quality of life (HRQOL) scores., Method: We analyzed HRQOL data from the Clinical Outcomes and Measurement of Health Study (COMHS). In COMHS, we enrolled patients with heart failure or cataracts at three sites (University of California, San Diego, University of California, Los Angeles, and University of Wisconsin). Patients completed self-administered HRQOL instruments at baseline and months 1 and 6 post-baseline, including the EuroQol (EQ-5D), Health Utilities Index (HUI), Quality of Well-Being Scale--self-administered (QWB-SA), and the Short Form (SF)-36v2. At the 6 months follow-up, individuals were randomized to mail or telephone administration first, followed by the other mode of administration. We used repeated measures mixed effects models, adjusting for site, patient age, education, gender, and race., Results: Included were 121 individuals entering a heart failure program and 326 individuals scheduled for cataract surgery who completed the survey by mail or phone at the 6-month follow-up. The majority of the sample was female (53%) and white (86%). About a quarter of the sample had high school education or less (26%). The average age was 66 (36-91 range). HRQOL scores were higher (more positive) for phone administration following mail administration. The largest differences in scores between phone and mail responses occurred for comparisons of telephone responses for those who were randomized to a mail survey first compared with mail responses for those randomized to a telephone survey first (i.e., mode effects for responses that were given on the second administration of the HRQOL measures). The QWB-SA was the only measure that did not display the pattern of mode effects. The biggest differences between modes were 4 points on the SF-36v2 physical health and mental health component summary scores, 0.06 on the SF-6D, 0.03 on the QWB-SA, 0.08 on the EQ-5D, 0.04 on the HUI2, and 0.10 on the HUI3., Conclusions: Telephone administration yields significantly more positive HRQOL scores for all of the generic HRQOL measures except for the QWB-SA. The magnitude of effects was clearly important, with some differences as large as a half-standard deviation. These findings confirm the importance of considering mode of administration when interpreting HRQOL scores.

There is a need for a psychometrically sound measure of the stigma experienced by diverse persons living with HIV/AIDS (PLHA). The goal of this study was to develop and evaluate a multidimentional measure of internalized HIV stigma that captures stigma related to treatment and other aspects of the disease among sociodemographically diverse PLHA. We developed a 28-item measure of internalized HIV stigma composed of four scales based on previous qualitative work. Internal consistency reliability estimates in a sample of 202 PLHA was 0.93 for the overall measure, and exceeded 0.85 for three of the four stigma scales. Items discriminated well across scales, and correlations of the scales with shame, social support, and mental health supported construct validity. This measure should prove useful to investigators examining in the role of stigma in HIV treatment and health outcomes, and evaluating interventions designed to mitigate the impacts of stigma on PLHA.

This study examined associations between cigarette smoking, cancer, and self-reported physical (SF-36 Physical Component Summary Score, [PCS]) and mental health (SF-36 Mental Component Summary Score, [MCS]) among 123,567 Medicare beneficiaries enrolled in managed care plans. As expected for a sample of older individuals, the SF-36 PCS mean (42.6) was lower than the U.S. general population mean of 50. The SF-36 MCS mean (51.7) for the sample was higher than the general population mean. In addition, least squares means revealed significantly poorer health for current smokers and those who recently quit, regardless of their cancer status. Although statistically significant, the differences between current smokers and never smokers were small among those with or without cancer. Encouraging smokers to quit and providing abstinence support to persons who have recently quit may help reduce health-related impacts of cigarette use.

Patient-centered measures of functioning and well-being are needed to monitor and improve health for HIV-infected persons. We estimated the associations between HRQOL and symptoms over time in HIV-infected persons, adjusting for demographic and clinical characteristics using a longitudinal study of a nationally representative cohort of 2267 patients in care for HIV infection surveyed in 1996 and again in 1998. We used two global measures of HRQOL (overall health and overall quality of life) scored to have a mean of 50 and standard deviation of 10 in the sample. The total number of symptoms decreased (-1.29, p<0.001 for the difference), and overall health (1.09, p<0.001 for the difference) and overall quality of life (1.31, p<0.001 for the difference) improved over the period. Controlling for baseline symptoms and HRQOL, each additional symptom at follow-up (B=-1.14, p<0.001) was associated with worsened overall health and worsened overall quality of life (B=-0.95, p<0.001). The association of two additional symptoms with lower global HRQOL was similar in magnitude to the effect of having significant depressive symptoms or the diagnosis of AIDS. In conclusion, among HIV-infected patients, symptoms are significantly related to HRQOL over time. The functioning and well-being of patients with HIV is inextricably linked to the symptoms they experience.

Background: Patient perceptions of care and health-related quality of life (HRQOL) are important outcomes for hospitalized patients., Purpose: This study examined patient experiences with hospital care and HRQOL in individuals hospitalized at a west coast teaching hospital., Methods: We assessed patient experiences with care and HRQOL using interviews with 1,207 hospitalized, general medicine patients participating in a multidisciplinary provider team intervention at a large academic medical center. Patient outcome variables included the Picker dimensions of hospital care (Continuity and Transition, Coordination of Care, Emotional Support, Information and Education, Involvement of Family and Friends, Physical Comfort, Respect for Patient Preferences, Overall Impression), the Health Utilities Index Mark 3 (HUI-3), and the SF-12 physical (PCS-12) and mental health (MCS-12) summary scores., Results: Patients randomized to a multidisciplinary intervention reported higher emotional support (b = 3.32), t(903) = 2.01, p =.044, and physical comfort (b = 3.49), t(863) = 2.25, p = .025, from health care providers than did the control group, but these effects became nonsignificant after adjusting for multiple comparisons. The HUI-3, PCS-12, and MCS-12 summary scores improved significantly from baseline to the 30-day, ts(943, 919, 860) = 4.94, 2.20, and 5.31, ps < .0001, = .03, and < .0001, respectively, and the 4-month follow-ups, ts(871, 919, 943) = 7.25, 8.68, and 8.08, ps < .001, < .001, and < .0001, respectively, but change on these measures did not differ between intervention and control patients. Baseline health was significantly associated with patient evaluations of hospital care, but patient evaluations did not predict future health., Conclusions: There were no differences in reports and ratings of hospital care or HRQOL between the control and the intervention groups. Hence, the behavioral changes in hospital staff in the intervention group had no effect on patient-reported outcomes. Mental health at baseline was predictive of patient evaluations of the hospitalization, but evaluations of care were not associated with subsequent HRQOL. Thus, it may be important to adjust patient evaluations of hospital care for case-mix differences in health.

Assessing individual change is feasible and potentially useful in clinical practice. This article provides an overview of the evaluation of statistically significant change in health-related quality of life (HRQOL) for individual patients. We review the standard error of measurement, standard error of prediction, and reliable change indices using a sample of 54 patients receiving care at the UCLA Center for East-West Medicine. The largest amount of change necessary for statistical significance was found for the reliable change index and the smallest change was needed for the standard error of measurement. The amount of change required for statistical significance was intermediate for the standard error of prediction. The median kappa for classifying change (declined, stayed the same, improved) by different indices was .82, indicating a high level of agreement. Future research is needed to determine if one index is most appropriate for evaluating the significance of individual change.

Background: Optimizing health-related quality of life (HRQOL) is an increasingly important goal in the treatment of HIV/AIDS. Interpretation of HRQOL scores in clinical trials is enhanced by comparative data., Purpose: To estimate AIDS Clinical Trials Group (ACTG) QOL 601-602 questionnaire scale scores for a nationally representative sample of persons in care for HIV., Method: The study cohort was from the HIV Cost and Services Utilization Study (HCSUS), a multistage national probability sample. We derived HCSUS HRQOL scale scores from the items shared between the ACTG QOL 601-602 and HCSUS HRQOL questionnaires using regression equations. Cronbach's alpha coefficient was used to estimate the reliability of the multi-item scales in the ACTG QOL 601-602 and HCSUS HRQOL instruments. Correlation Coefficients and R2s of regression models were calculated to determine the concordance of the models. Multiple regression was used to determine if patient characteristics accounted for differences (residuals) between scores observed from the full HCSUS HRQOL instruments and scores predicted using the subset of shared items in ACTG QOL 601-2., Results: Internal consistency reliability estimates were acceptable (>0.70) for all scales in the ACTG QOL 601-602 and HCSUS HRQOL instruments. Correlations between corresponding ACTG QOL 601-602 and HCSUS HRQOL scale scores were high (>0.9). The R2s for predicting HCSUS HRQOL scores from the ACTG QOL 601-602 scales were also high (>0.8). For physical functioning, emotional well-being, and general health perceptions, the predictors of differences (residuals) in observed and predicted HCSUS HRQOL scores were gender and CDC stage of HIV infection (P < .05)., Conclusion: This study provides normative data from the US HIV/AIDS population for comparison to the ACTG QOL 601-602 questionnaire. Accuracy of estimation is enhanced if done separately by gender and HIV disease stage.

Background and Purpose: Sleep is an active and highly organized biological process that is an important component of life. Self-report measures of sleep provide information that can be useful for characterizing the quality of sleep in subgroups of the population. A 12-item self-report sleep measure, the Medical Outcomes Study Sleep measure, was developed and evaluated previously in a sample of 3445 individuals with chronic illness., Patients and Methods: In this study, we evaluate the psychometric properties of the MOS Sleep measure in a nationally representative sample of 1011 US adults aged 18 and older and in a sample of 173 adults with neuropathic pain participating in a clinical drug trial., Results: The average age of the general population sample was 46; 51% were female and 81% were white. The average age of the sample of adults with neuropathic pain was 72; 53% were female and 95% were white. Internal consistency reliability estimates for the MOS Sleep scales were 0.73 or higher, with the exception of the daytime somnolence scale in the US general population, which was 0.63. At baseline of the clinical trial, the neuropathic pain patients reported significantly more sleep disturbance and daytime somnolence, as well as less quantity and adequacy of sleep than patients in the general US population. The MOS Sleep scales were found to be responsive to change in the clinical trial with statistically significant improvements observed after administration of pregabalin for sleep disturbance (standardized response mean, SRM=-0.76, P=0.0007), shortness of breath (SRM=-0.20, P=0.0302), sleep adequacy (SRM=0.57, P=0.0014), sleep quantity (SRM=0.55, P=0.0086), and sleep problems (SRM=-0.62, P=0.0036)., Conclusions: This study provides further support for the reliability and validity of the MOS Sleep measure. The instrument can be used to assess important aspects of sleep perceived by adults in the general population or participating in clinical studies.

Purpose: The purpose of this study was to determine how many patients are needed to provide reliable patient ratings of care at the individual clinician level. SETTING AND SOURCES OF DATA: The study was conducted in an academic medical center and was based on analysis of 34,985 patients who completed a 50-item survey rating the care received during a recent outpatient visit to a physician or midlevel provider., Study Design: Analyses of patient satisfaction surveys was done to: 1) confirm the dimensions of satisfaction with outpatient care in an existing measure, and 2) determine the number of patients required to provide reliable estimates of clinician care for single items and an 11-item composite scale., Principal Findings: Factor analysis showed that the survey measured 2 dimensions of satisfaction: 1) clinician care, and 2) features of visiting the office. The 11-item clinician care scale had high reliability (Cronbach's alpha=0.97). The number of patients needed to achieve reliability of 0.80 at the clinician level was 66 for the 11-item scale and ranged from 52 to 91 for individual items. For primary care physicians only, the comparable number of patients per clinician was 77 for the 11-item scale and ranged from 50 to 147 across items., Conclusions: For the survey items that we analyzed, the answer to the question "How many patients are needed to obtain useful and reliable feedback?" is at least 50, but varies by item type (global vs. specific) and by number of items (composite scale or single-item rating) and by the conditions of use (for self-assessment and learning or reward and punishment).

Objective: Refractive error and the means by which it is corrected may impact substantially on quality of vision and health-related quality of life in ways not captured adequately by standard measures of visual acuity. The goal of this analysis was to evaluate the responsiveness of the National Eye Institute Refractive Error Quality of Life (NEI-RQL) instrument to surgical correction of refractive error., Design: Prospective, multicenter cohort study., Participants: The NEI-RQL, a 42-item measure with 13 scales, was self-administered by 185 patients before and after undergoing surgical correction of myopic or hyperopic refractive error. Preoperative and postoperative clinical information was collected, including refractive error and corrected visual acuity., Methods: Differences between preoperative and postoperative NEI-RQL scores were examined. Responsiveness was assessed using the standardized response mean and the responsiveness statistic. We also compared scales using relative efficiency estimates., Main Outcome Measures: Changes in NEI-RQL scales (clarity of vision, expectations, near vision, far vision, diurnal fluctuations, activity limitations, glare, symptoms, dependence on correction, worry, suboptimal correction, appearance, and satisfaction with correction)., Results: For myopes and hyperopes combined, refractive surgical correction was associated with statistically significant (P<0.05) improvements in scores for 11 of 13 scales. The largest improvements, ranging from 26 to 58 points on the 0 to 100 possible score range, were seen in expectations, activity limitations, dependence on correction, appearance, and satisfaction with correction. Separate analysis of myopes and hyperopes revealed similar effects in the 2 groups. Baseline scores were found to be predictive of change after surgery., Conclusions: The NEI-RQL is responsive to changes in vision-targeted health-related quality of life resulting from keratorefractive surgery. This instrument may prove useful for evaluating the beneficial and adverse impacts of surgical and nonsurgical methods of refractive error correction.

Objective: To estimate the psychometric properties of a vision-targeted measure of health-related quality of life, the National Eye Institute-Refractive Error Quality of Life survey (NEI-RQL), which includes 13 scales designed to assess the impact of refractive error and its correction on day-to-day life., Design: Cross-sectional survey., Participants: The NEI-RQL was self-administered by 667 myopes, 380 hyperopes, and 114 emmetropes recruited from the practices of 6 medical centers. All participants had near and distance visual acuity of 20/32 or better in the worse eye while benefiting from their current method for correction of refractive error (glasses, contact lens, refractive surgery)., Methods: Mean scores, standard deviations, internal consistency reliability, and test-retest intraclass correlations were estimated for the NEI-RQL scales. Item discrimination was assessed by item-scale correlations. Construct validity was evaluated by assessing the sensitivity of scale scores to type of refractive error, type of refractive error correction, and spherical equivalent. Construct validity of the NEI-RQL was compared to those of the Medical Outcomes Study 36-item short-form health survey (SF-36) and the National Eye Institute Vision Functioning Questionnaire (NEI VFQ-25) in a random subsample of respondents., Main Outcome Measures: The 13 NEI-RQL scales-clarity of vision, expectations, near vision, far vision, diurnal fluctuations, activity limitations, glare, symptoms, dependence on correction, worry, suboptimal correction, appearance, and satisfaction with correction., Results: Emmetropes tended to score significantly better on the NEI-RQL scales than myopes and hyperopes. The method of refractive error correction was also associated with NEI-RQL scores. In addition, the NEI-RQL multi-item scales accounted for 29% of the variance in the NEI-RQL satisfaction with correction item beyond that explained by the SF-36 and the NEI VFQ-25., Conclusion: These results support the reliability and construct validity of the NEI-RQL. The instrument appears to be useful for comparisons of people with different types of correction for refractive error.

Background and Methods: We administered the Kidney Disease Quality of Life (KDQOL) short form and a three-item depression screening measure derived from the Diagnostic Interview Schedule to 422 new patients with end-stage renal disease (ESRD; incident cohort) who began maintenance hemodialysis (HD) therapy at 151 outpatient dialysis facilities across the United States., Results: At HD therapy initiation, 56% of patients had hemoglobin levels less than 10 g/dL (100 g/L), and 52% had albumin levels of 3.5 g/dL (35 g/L) or less. The 36-Item Short Form Health Survey (SF-36) scores (part of the KDQOL) for this incident cohort were significantly lower than those of a prevalent HD cohort and a severe chronic disease cohort (P < 0.01 to 0.001), and physical health scores were among the lowest ever reported. SF-36 summary scores were 2 SDs below those of an age- and sex-adjusted US general population in physical health and half an SD below those in mental health. Patients who screened positive for depression (45% of sample) scored even lower on all eight SF-36 scale scores and 9 of 12 of the KDQOL kidney disease-targeted scales (P < 0.05 to 0.01), but did not differ from nondepressed patients on demographic, clinical, or laboratory study variables., Conclusion: The extent to which the profound impairment documented in this study can be improved by more timely high-quality predialysis care requires further investigation. Nevertheless, the high prevalence of anemia, hypoalbuminemia, and depressive symptoms at dialysis therapy initiation suggests the need for more aggressive and broader spectrum pre-ESRD care., (Copyright 2002 by the National Kidney Foundation, Inc.)

Objective: To enhance the validity of a well-known expert panel process, we used data from patient surveys to identify and correct rating errors., Methods: We used the two-round RAND/UCLA panel method to rate indications of harmful (presence of problems), hazardous (at risk for problems), and nonhazardous (no known risks) drinking in older adults. Results from the panel provided guidelines for classifying older individuals as harmful, hazardous, or nonhazardous drinkers, using a survey. The classifications yielded unexpectedly high numbers of harmful and hazardous drinkers. We hypothesized possible misclassifications of drinking risks and used the survey data to identify indications that may have led to invalid ratings. We modified problematic indications and asked three clinician panelists to evaluate the clinical usefulness of the modifications in a third panel round. We revised the indications based on panelist response and reexamined drinking classifications., Results: Using the original indications, 48% of drinkers in the sample were classified as harmful, 31% as hazardous, and 21% as nonhazardous. A review of the indications revealed framing bias in the original rating task and vague definitions of certain symptoms and conditions. The modified indications resulted in classifications of 22% harmful, 47% hazardous, and 31% nonhazardous drinkers., Conclusions: Analysis of survey data led to identification and correction of specific errors occurring during the panel-rating process. The validity of the RAND/UCLA method can be enhanced using data-driven modifications.

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.

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.