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Quigley DD, Elliott MN, Qureshi N, Predmore Z, Hays RD. How the CAHPS Clinician and Group Patient Experience Survey Data Have Been Used in Research: A Systematic Review. J Patient Cent Res Rev 2024; 11:88-96. [PMID: 39044849 PMCID: PMC11262838 DOI: 10.17294/2330-0698.2056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2024] Open
Abstract
Purpose Patient experience is a key aspect of care quality. The Consumer Assessment of Healthcare Providers and Systems Clinician and Group (CG-CAHPS®) survey measures experiences with ambulatory care providers to inform public reporting, pay-for-performance initiatives, interventions, patient choice of physicians/practices, and quality improvement. Since the survey's 2007 release, no systematic review of its use in research has been published. Methods We reviewed English-language, peer-reviewed articles published since 2008 using CG-CAHPS survey data in the U.S. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and used the Checklist for Analytical Cross-Sectional Studies. Results We examined 126 articles and included 52. Twenty-seven articles focused on general primary care, and the others focused on ambulatory specialty care. Of the 52 studies, 37 were cross-sectional, and the majority conducted patient-level regression analysis, controlling for patient characteristics. The most-used CAHPS measures were overall provider rating and the provider communication composite. CG-CAHPS data were primarily utilized to evaluate interventions (24 studies) and examine cross-sectional associations (21 studies) of site-level (eg, organizational climate), provider-level (physician empathy), and patient-level (medication adherence) factors with patient experience. Four studies reported disparities in patient experience. Conclusions The widespread use of CG-CAHPS data implies the survey's value in measuring and improving care quality. Unlike facility or plan surveys, the CG-CAHPS survey was designed to allow attribution to medical groups and clinicians, which, as evidence shows, is its main strength. Policymakers, researchers, clinicians, and health care leaders can leverage CG-CAHPS data in quality improvement efforts and interventions supporting patient-centered care.
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Affiliation(s)
| | | | | | | | - Ron D. Hays
- RAND Corporation, Santa Monica, CA
- UCLA David Geffen School of Medicine & Department of Medicine, Los Angeles, CA
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Edwards PJ, Roberts I, Clarke MJ, DiGuiseppi C, Woolf B, Perkins C. Methods to increase response to postal and electronic questionnaires. Cochrane Database Syst Rev 2023; 11:MR000008. [PMID: 38032037 PMCID: PMC10687884 DOI: 10.1002/14651858.mr000008.pub5] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
BACKGROUND Self-administered questionnaires are widely used to collect data in epidemiological research, but non-response reduces the effective sample size and can introduce bias. Finding ways to increase response to postal and electronic questionnaires would improve the quality of epidemiological research. OBJECTIVES To identify effective strategies to increase response to postal and electronic questionnaires. SEARCH METHODS We searched 14 electronic databases up to December 2021 and manually searched the reference lists of relevant trials and reviews. We contacted the authors of all trials or reviews to ask about unpublished trials; where necessary, we also contacted authors to confirm the methods of allocation used and to clarify results presented. SELECTION CRITERIA Randomised trials of methods to increase response to postal or electronic questionnaires. We assessed the eligibility of each trial using pre-defined criteria. DATA COLLECTION AND ANALYSIS We extracted data on the trial participants, the intervention, the number randomised to intervention and comparison groups and allocation concealment. For each strategy, we estimated pooled odds ratios (OR) and 95% confidence intervals (CI) in a random-effects model. We assessed evidence for selection bias using Egger's weighted regression method and Begg's rank correlation test and funnel plot. We assessed heterogeneity amongst trial odds ratios using a Chi2 test and quantified the degree of inconsistency between trial results using the I2 statistic. MAIN RESULTS Postal We found 670 eligible trials that evaluated over 100 different strategies of increasing response to postal questionnaires. We found substantial heterogeneity amongst trial results in half of the strategies. The odds of response almost doubled when: using monetary incentives (odds ratio (OR) 1.86; 95% confidence interval (CI) 1.73 to 1.99; heterogeneity I2 = 85%); using a telephone reminder (OR 1.96; 95% CI 1.03 to 3.74); and when clinical outcome questions were placed last (OR 2.05; 95% CI 1.00 to 4.24). The odds of response increased by about half when: using a shorter questionnaire (OR 1.58; 95% CI 1.40 to 1.78); contacting participants before sending questionnaires (OR 1.36; 95% CI 1.23 to 1.51; I2 = 87%); incentives were given with questionnaires (i.e. unconditional) rather than when given only after participants had returned their questionnaire (i.e. conditional on response) (OR 1.53; 95% CI 1.35 to 1.74); using personalised SMS reminders (OR 1.53; 95% CI 0.97 to 2.42); using a special (recorded) delivery service (OR 1.68; 95% CI 1.36 to 2.08; I2 = 87%); using electronic reminders (OR 1.60; 95% CI 1.10 to 2.33); using intensive follow-up (OR 1.69; 95% CI 0.93 to 3.06); using a more interesting/salient questionnaire (OR 1.73; 95% CI 1.12 to 2.66); and when mentioning an obligation to respond (OR 1.61; 95% CI 1.16 to 2.22). The odds of response also increased with: non-monetary incentives (OR 1.16; 95% CI 1.11 to 1.21; I2 = 80%); a larger monetary incentive (OR 1.24; 95% CI 1.15 to 1.33); a larger non-monetary incentive (OR 1.15; 95% CI 1.00 to 1.33); when a pen was included (OR 1.44; 95% CI 1.38 to 1.50); using personalised materials (OR 1.15; 95% CI 1.09 to 1.21; I2 = 57%); using a single-sided rather than a double-sided questionnaire (OR 1.13; 95% CI 1.02 to 1.25); using stamped return envelopes rather than franked return envelopes (OR 1.23; 95% CI 1.13 to 1.33; I2 = 69%), assuring confidentiality (OR 1.33; 95% CI 1.24 to 1.42); using first-class outward mailing (OR 1.11; 95% CI 1.02 to 1.21); and when questionnaires originated from a university (OR 1.32; 95% CI 1.13 to 1.54). The odds of response were reduced when the questionnaire included questions of a sensitive nature (OR 0.94; 95% CI 0.88 to 1.00). Electronic We found 88 eligible trials that evaluated over 30 different ways of increasing response to electronic questionnaires. We found substantial heterogeneity amongst trial results in half of the strategies. The odds of response tripled when: using a brief letter rather than a detailed letter (OR 3.26; 95% CI 1.79 to 5.94); and when a picture was included in an email (OR 3.05; 95% CI 1.84 to 5.06; I2 = 19%). The odds of response almost doubled when: using monetary incentives (OR 1.88; 95% CI 1.31 to 2.71; I2 = 79%); and using a more interesting topic (OR 1.85; 95% CI 1.52 to 2.26). The odds of response increased by half when: using non-monetary incentives (OR 1.60; 95% CI 1.25 to 2.05); using shorter e-questionnaires (OR 1.51; 95% CI 1.06 to 2.16; I2 = 94%); and using a more interesting e-questionnaire (OR 1.85; 95% CI 1.52 to 2.26). The odds of response increased by a third when: offering survey results as an incentive (OR 1.36; 95% CI 1.16 to 1.59); using a white background (OR 1.31; 95% CI 1.10 to 1.56); and when stressing the benefits to society of response (OR 1.38; 95% CI 1.07 to 1.78; I2 = 41%). The odds of response also increased with: personalised e-questionnaires (OR 1.24; 95% CI 1.17 to 1.32; I2 = 41%); using a simple header (OR 1.23; 95% CI 1.03 to 1.48); giving a deadline (OR 1.18; 95% CI 1.03 to 1.34); and by giving a longer time estimate for completion (OR 1.25; 95% CI 0.96 to 1.64). The odds of response were reduced when: "Survey" was mentioned in the e-mail subject (OR 0.81; 95% CI 0.67 to 0.97); when the email or the e-questionnaire was from a male investigator, or it included a male signature (OR 0.55; 95% CI 0.38 to 0.80); and by using university sponsorship (OR 0.84; 95%CI 0.69 to 1.01). The odds of response using a postal questionnaire were over twice those using an e-questionnaire (OR 2.33; 95% CI 2.25 to 2.42; I2 = 98%). Response also increased when: providing a choice of response mode (electronic or postal) rather than electronic only (OR 1.76 95% CI 1.67 to 1.85; I2 = 97%); and when administering the e-questionnaire by computer rather than by smartphone (OR 1.62 95% CI 1.36 to 1.94). AUTHORS' CONCLUSIONS Researchers using postal and electronic questionnaires can increase response using the strategies shown to be effective in this Cochrane review.
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Affiliation(s)
- Philip James Edwards
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Ian Roberts
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Mike J Clarke
- Centre for Public Health, Queens University Belfast, Belfast, UK
| | - Carolyn DiGuiseppi
- Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Benjamin Woolf
- School of Psychological Science, University of Bristol, Bristol, UK
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Hays RD, Walling AM, Sudore RL, Chau A, Wenger NS. Support for Use of Consumer Assessment of Healthcare Providers and Systems Communication Items Among Seriously Ill Patients. J Palliat Med 2023; 26:1234-1239. [PMID: 37093298 PMCID: PMC10623076 DOI: 10.1089/jpm.2022.0572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2023] [Indexed: 04/25/2023] Open
Abstract
Background: High-quality doctor-patient communication is essential for patients with serious illnesses. The reliability and validity of Consumer Assessment of Healthcare Providers and Systems (CAHPS®) communication items among these patients are unknown. Methods: Five CAHPS communication items, a 4-item Advance Care Planning (ACP) engagement scale, 5-item confidence in others' knowledge of ACP medical wishes scale, and a question about confidence in filling out ACP-related medical forms were administered to 1100 patients (20% response rate) with serious illness receiving primary care at three University of California Health Systems. Results: Average age was 69 (range 22-102); 52% male, 18% Hispanic, 9% Asian, and 7% Black; 24% had high school or less education. Eigenvalues and internal consistency reliability (0.88) supported a 5-item communication scale. Item characteristic curves showed a monotonic relationship of response options with the communication score. Item thresholds indicated that most patients reported positive patient experiences (i.e., items were negatively skewed). Item slopes ranging from 2.52 to 5.10 confirmed that all items were strongly related to the communication score. Information (reliability) of the communication scale was higher for assessing patients with negative experiences of care than for the positive end of the spectrum. Communication was positively correlated with confidence in other's knowledge of ACP medical wishes (r = 0.32, p < 0.0001), ACP engagement (r = 0.14, p < 0.0001), and confidence in filling out ACP-related medical forms (r = 0.09, p = 0.0022). Conclusions: These findings support the use of CAHPS survey items to assess communication among patients with serious illnesses in primary care. Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT04012749.
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Affiliation(s)
- Ron D. Hays
- Department of Medicine, University of California, Los Angeles, California, USA
| | - Anne M. Walling
- Department of Medicine, University of California, Los Angeles, California, USA
- VA Greater Los Angeles Health System, Los Angeles, California, USA
| | - Rebecca L. Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Aaron Chau
- Department of Medicine, University of California, Irvine, Irvine, California, USA
| | - Neil S. Wenger
- Department of Medicine, University of California, Los Angeles, California, USA
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Quigley DD, Elliott MN, Slaughter ME, Talamantes E, Hays RD. Shadow Coaching Improves Patient Experience for English-Preferring Patients but not for Spanish-Preferring Patients. J Gen Intern Med 2023; 38:2494-2500. [PMID: 36797540 PMCID: PMC10465456 DOI: 10.1007/s11606-023-08045-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 01/20/2023] [Indexed: 02/18/2023]
Abstract
BACKGROUND Shadow coaching, a type of one-on-one provider counseling by trained peers, is an effective strategy for improving provider behaviors and patient interactions, but its effects on improving patient experience for English- and Spanish-preferring patients is unknown. OBJECTIVE Assess effects of shadow coaching on patient experience for English- and for Spanish-preferring patients. DESIGN We analyzed 2012-2019 Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) data (n=46,089) from an urban Federally Qualified Health Center with 44 primary care practices and 320 providers. One-third (n=14,631) were Spanish-preferring patients. We fit mixed-effects regression models with random effects for provider (the level of treatment assignment) and fixed effects for time (a linear spline for time with a knot and "jump" at coaching date), patient characteristics, and site indicators, stratified by preferred language. PARTICIPANTS The 74 providers who had a 6-month average top-box score on the CAHPS overall provider rating below 90 (on a 100-point scale) were shadow coached. Similar percentages of English-preferring (45%) and Spanish-preferring patients (43%) were seen by coached providers. INTERVENTION Trained providers observed patient care by colleagues and provided suggestions for improvement. Verbal feedback was provided immediately after the observation and the participant received a written report summarizing the comments and recommendations from the coaching session. MAIN MEASURES CG-CAHPS Visit Survey 2.0 provider communication composite and overall provider rating (0-100 scoring). KEY RESULTS We found a statistically significant 2-point (small) jump in CAHPS provider communication and overall provider rating among English-preferring patients of coached providers. There was no evidence of a coaching effect on patient experience for Spanish-preferring patients. CONCLUSIONS Coaching improved care experiences for English-preferring patients but may not have improved patient experience for Spanish-preferring patients. Selection and training of providers to communicate effectively with Spanish-preferring patients is needed to extend the benefits of shadow coaching to Spanish-preferring patients.
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Affiliation(s)
| | - Marc N. Elliott
- RAND Corporation, 1776 Main Street, Santa Monica, CA 90407 USA
| | | | | | - Ron D. Hays
- UCLA David Geffen School of Medicine & Department of Medicine, 1100 Glendon Avenue, Los Angeles, CA 90024-1736 USA
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Anhang Price R, Quigley DD, Hargraves JL, Sorra J, Becerra-Ornelas AU, Hays RD, Cleary PD, Brown J, Elliott MN. A Systematic Review of Strategies to Enhance Response Rates and Representativeness of Patient Experience Surveys. Med Care 2022; 60:910-918. [PMID: 36260705 PMCID: PMC9645551 DOI: 10.1097/mlr.0000000000001784] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Data from surveys of patient care experiences are a cornerstone of public reporting and pay-for-performance initiatives. Recently, increasing concerns have been raised about survey response rates and how to promote equity by ensuring that responses represent the perspectives of all patients. OBJECTIVE Review evidence on survey administration strategies to improve response rates and representativeness of patient surveys. RESEARCH DESIGN Systematic review adhering to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. STUDY SELECTION Forty peer-reviewed randomized experiments of administration protocols for patient experience surveys. RESULTS Mail administration with telephone follow-up provides a median response rate benefit of 13% compared with mail-only or telephone-only. While surveys administered only by web typically result in lower response rates than those administered by mail or telephone (median difference in response rate: -21%, range: -44%, 0%), the limited evidence for a sequential web-mail-telephone mode suggests a potential response rate benefit over sequential mail-telephone (median: 4%, range: 2%, 5%). Telephone-only and sequential mixed modes including telephone may yield better representation across patient subgroups by age, insurance type, and race/ethnicity. Monetary incentives are associated with large increases in response rates (median increase: 12%, range: 7%, 20%). CONCLUSIONS Sequential mixed-mode administration yields higher patient survey response rates than a single mode. Including telephone in sequential mixed-mode administration improves response among those with historically lower response rates; including web in mixed-mode administration may increase response at lower cost. Other promising strategies to improve response rates include in-person survey administration during hospital discharge, incentives, minimizing survey language complexity, and prenotification before survey administration.
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Affiliation(s)
| | | | - J. Lee Hargraves
- Center for Survey Research, University of Massachusetts Boston, Boston, MA
| | | | | | - Ron D. Hays
- David Geffen School of Medicine, UCLA, Los Angeles, CA
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Silva MA, Arriola NB, Radwan CK, Womble BM, Healey EA, Lee JM, Aloia MS, Nakase-Richardson R. Improving sleep apnea treatment adherence after traumatic brain injury: A nonrandomized feasibility study. Rehabil Psychol 2022; 67:461-473. [PMID: 36355639 PMCID: PMC10166197 DOI: 10.1037/rep0000473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
PURPOSE/OBJECTIVE To evaluate the feasibility of a psychological intervention designed to increase Positive Airway Pressure (PAP) adherence, adapted with cognitive accommodations for comorbid obstructive sleep apnea (OSA) and traumatic brain injury (TBI). RESEARCH METHOD/DESIGN This was an open-label single arm (nonrandomized) study. Eligibility criteria were moderate-to-severe TBI, OSA diagnosis, prescribed PAP, nonadherent, and able to consent. Participants were recruited from inpatient and outpatient settings at a tertiary care hospital. The four-module manualized intervention was delivered primarily via telehealth. Feasibility aspects measured included eligibility, recruitment, and retention rates; session duration and attendance; and characteristics of outcome and process measures (e.g., completion rates, data distribution). Symptom measures included the Epworth Sleepiness Scale, Fatigue Severity Scale, Functional Outcomes of Sleep Questionnaire, Self-Efficacy Measure for Sleep Apnea, OSA Treatment Barriers Questionnaire (OTBQ), and Kim Alliance Scale-Revised. RESULTS Of 230 persons screened, 14.3% were eligible. Recruitment rate (n = 17) was 51.5%. Retention rate (n = 13) was 76.5%. Treatment completers had no missing data. The OTBQ deviated from normality, but other measures had adequate skew (< 2.0) and kurtosis (< 7.0) and were free from significant floor and ceiling effects (<15%). Change score effect sizes were minimal to moderate (d = .10-.77). There were no adverse events. CONCLUSIONS/IMPLICATIONS These results inform ways in which procedures should be modified to enhance the success of a future clinical trial testing the efficacy of this adherence intervention. Inclusion criteria should be reconsidered, and recruitment sites expanded, to capture eligible persons and adequately power an efficacy study. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
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Affiliation(s)
- Marc A. Silva
- Mental Health and Behavioral Sciences Service, James A. Haley Veterans’ Hospital
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Internal Medicine, University of South Florida
- Department of Psychiatry and Behavioral Neurosciences, University of South Florida
| | | | | | - Brent M. Womble
- Mental Health Service Line, Hunter Holmes McGuire VA Medical Center
| | - Erica A. Healey
- Mental Health and Behavioral Sciences Service, James A. Haley Veterans’ Hospital
| | - Jaylene M. Lee
- Mental Health and Behavioral Sciences Service, James A. Haley Veterans’ Hospital
| | - Mark S. Aloia
- National Jewish Health, 1400 Jackson St, Denver, CO 8020 USA
- Philips, Inc., Amstelplein 2, 1096 BC Amsterdam, Netherlands
| | - Risa Nakase-Richardson
- Mental Health and Behavioral Sciences Service, James A. Haley Veterans’ Hospital
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Internal Medicine, University of South Florida
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Quigley DD, Elliott MN, Slaughter ME, Burkhart Q, Chen AY, Talamantes E, Hays RD. Shadow Coaching Improves Patient Experience With Care, But Gains Erode Later. Med Care 2021; 59:950-960. [PMID: 34387621 PMCID: PMC8516705 DOI: 10.1097/mlr.0000000000001629] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Health care organizations strive to improve patient care experiences. Some use one-on-one provider counseling (shadow coaching) to identify and target modifiable provider behaviors. OBJECTIVE We examined whether shadow coaching improves patient experience across 44 primary care practices in a large urban Federally Qualified Health Center. RESEARCH DESIGN Seventy-four providers with "medium" (ie, slightly below average) overall provider ratings received coaching and were compared with 246 uncoached providers. We fit mixed-effects regression models with random effects for provider (level of treatment assignment) and fixed effects for time (linear spline with a knot and "jump" at coaching date), patient characteristics and site indicators. By design, coached providers performed worse at selection; models account for the very small (0.2 point) regression-to-the-mean effects. We assessed differential effects by coach. SUBJECTS A total of 46,452 patients (from 320 providers) who completed the Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) Visit Survey 2.0. MEASURES CAHPS overall provider rating and provider communication composite (scaled 0-100). RESULTS Providers not chosen for coaching had a nonsignificant change in performance during the period when selected providers were coached. We observed a statistically significant 2-point (small-to-medium) jump among coached providers after coaching on the CAHPS overall provider rating and provider communication score. However, these gains disappeared after 2.5 years; effects differed by coach. CONCLUSIONS Shadow coaching improved providers' overall performance and communication immediately after being coached. Regularly planned shadow coaching "booster" sessions might maintain or even increase the improvement gained in patient experience scores, but research examining additional coaching and optimal implementation is needed.
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Affiliation(s)
| | | | | | - Q Burkhart
- RAND Corporation, 1776 Main Street, Santa Monica, CA 90407
| | - Alex Y. Chen
- Health Net, 21650 Oxnard St, Woodland Hills, CA 91367
| | | | - Ron D. Hays
- UCLA David Geffen School of Medicine & Department of Medicine, 1100 Glendon Avenue, Los Angeles, CA 90024-1736
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Park C, Zakare-Fagbamila RT, Dickson W, Garcia AN, Gottfried ON. The limited influence of neurosurgeons' behavior on inpatient satisfaction: a retrospective multihospital analysis. J Neurosurg 2021; 134:1983-1989. [PMID: 32736359 DOI: 10.3171/2020.5.jns20923] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 05/04/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a survey that assesses patient satisfaction, which is an important measure of the quality of hospital care and ultimately the overall hospital rating (OHR). However, the survey covers several elements of patient satisfaction beyond the patient-surgeon interaction. In this study, authors investigated which admission and experience factors had the highest impact on the OHR. METHODS This was a retrospective cohort analysis of HCAHPS surveys from patients who, in the period between August 1, 2016, and January 31, 2018, had been discharged from the neurosurgical or orthopedic service at three hospitals serving a single metropolitan area. The top-box score was defined as the highest rating obtainable for each survey question. Baseline admission attributes were obtained, and multivariate logistic regression was used to determine predictors of the top-box OHR. RESULTS After application of the inclusion and exclusion criteria, 1470 patients remained in the analysis. Categories on the HCAHPS included OHR, communication, education, environment, pain management, and responsiveness. After excluding identifying questions from the survey and adjusting for subspecialty and hospital, 7 of 17 HCAHPS survey items were significant predictors of OHR. Only 2 of these were related to the surgeon: 1) discharge, "Did you get information in writing about what symptoms or health problems to look out for after you left the hospital?" (OR 5.93, 95% CI 2.52-13.94); and 2) doctor, "Did doctors explain things in a way you could understand?" (OR 2.78, 95% CI 1.73-4.46). The top three strongest correlating items were 1) discharge; 2) nursing, "Did nurses treat you with courtesy and respect?" (OR 3.86, 95% CI 2.28-6.52); and 3) hospital environment, "Were your room and bathroom kept clean?" (OR 2.86, 95% CI 1.96-4.17). CONCLUSIONS The study findings demonstrated that there are several nonmodifiable factors (i.e., specialty, experience) and items that are not under the direct purview of the neurosurgeon (e.g., nursing communication, hospital environment) that are significant influences on overall inpatient satisfaction on the HCAHPS survey. Furthermore, components of the survey that ultimately influence the OHR vary across different hospitals. Hence, HCAHPS survey results should be broadly interpreted as a way to make health systems more aware of the overall hospital factors that can improve quality of care and patient experience.
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Affiliation(s)
- Christine Park
- 1Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | | | - Wes Dickson
- 3Department of Performance Services, Duke University Health System, Durham; and
| | - Alessandra N Garcia
- 4Division of Doctor of Physical Therapy, Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - Oren N Gottfried
- 1Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
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Zakare-Fagbamila RT, Howell E, Choi AY, Cheng TZ, Clement M, Neely M, Gottfried ON. Clinic Satisfaction Tool Improves Communication and Provides Real-Time Feedback. Neurosurgery 2020; 84:908-918. [PMID: 29669027 DOI: 10.1093/neuros/nyy137] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 03/22/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Patient-reported assessments of the clinic experience are increasingly important for improving the delivery of care. The Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) survey is the current standard for evaluating patients' clinic experience, but its format gives 2-mo delayed feedback on a small proportion of patients in clinic. Furthermore, it fails to give specific actionable results on individual encounters. OBJECTIVE To develop and assess the impact of a single-page Clinic Satisfaction Tool (CST) to demonstrate real-time feedback, individualized responses, interpretable and actionable feedback, improved patient satisfaction and communication scores, increased physician buy-in, and overall feasibility. METHODS We assessed CST use for 12 mo and compared patient-reported outcomes to the year prior. We assessed all clinic encounters for patient satisfaction, all physicians for CG-CAHPS global rating, and physician communication scores, and evaluated the physician experience 1 yr after implementation. RESULTS During implementation, 14 690 patients were seen by 12 physicians, with a 96% overall CST utilization rate. Physicians considered the CST superior to CG-CAHPS in providing immediate feedback. CG-CAHPS global scores trended toward improvement and were predicted by CST satisfaction scores (P < .05). CG-CAHPS physician communication scores were also predicted by CST satisfaction scores (P < .01). High CST satisfaction scores were predicted by high utilization (P < .05). Negative feedback dropped significantly over the course of the study (P < .05). CONCLUSION The CST is a low-cost, high-yield improvement to the current method of capturing the clinic experience, improves communication and satisfaction between physicians and patients, and provides real-time feedback to physicians.
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Affiliation(s)
| | | | - Ashley Y Choi
- School of Medicine, Duke University, Durham, North Carolina
| | - Tracy Z Cheng
- School of Medicine, Duke University, Durham, North Carolina
| | - Mary Clement
- Department of Musculoskeletal and Spine Services, Duke University Medical Center, Durham, North Carolina
| | - Megan Neely
- Depart-ment of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Oren N Gottfried
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
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Evaluating Primary Health Care Performance from User Perspective in China: Review of Survey Instruments and Implementation Issues. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16060926. [PMID: 30875833 PMCID: PMC6466226 DOI: 10.3390/ijerph16060926] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Revised: 03/04/2019] [Accepted: 03/11/2019] [Indexed: 12/28/2022]
Abstract
This review aims to summarize the progress of patient evaluation studies focusing on primary health care (PHC) in China, specifically in relation to survey instruments and implementation issues. Eligible studies published in English or Chinese were obtained through online searches of PubMed and China National Knowledge Infrastructure. A descriptive reporting approach was used due to variations in the measurements and administration methods between studies. A total of 471 articles were identified and of these articles; of those 91 full-text articles were included in the final analysis. Most studies used author-developed measurements with five-point Likert response scales and many used the Chinese translations of validated tools from other countries. Most instruments assessed the physical environment, medical equipment, clinical competency and convenience aspects of PHC using a satisfaction rating instead of care experience reporting. Many studies did not report the sampling approach, patient recruitment procedures and survey administration modes. The patient exit survey was the most commonly used survey implementation method. The focus on the structural dimensions of PHC, inconsistent wording, categories of response options that use satisfaction rating, and unclear survey implementation processes are common problems in patient evaluation studies of PHC in China. Further studies are necessary to identify population preferences of PHC in China in order to move towards developing Chinese value-based patient experience measurements.
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Mahboub B, Mawasi A, Ali S, Spina C. Patients' satisfaction as a dimension of quality: a survey on outpatients' care in Dubai. Int J Health Care Qual Assur 2019; 31:1030-1043. [PMID: 30415626 DOI: 10.1108/ijhcqa-10-2017-0188] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE The last few years have seen a stronger emphasis on patient-centred care within the international healthcare setting. Patient-centred care is clearly perceived to be important to optimise the satisfaction and well-being of patients. The purpose of this paper is to review current patient-centred practices for outpatients in both private clinics and public hospitals in Dubai. Such a comparison contributes to the identification of best management practices as a means of enhancing healthcare delivery. DESIGN/METHODOLOGY/APPROACH This study is based on an independent survey consisting of self-administered questionnaires, in which patients were asked to rate several aspects of private clinics or government hospitals in Dubai. The questionnaire used has been drawn from the Consumer Assessment of Healthcare Providers and Systems Clinician and Group Survey, Version 3.0. Responses from 420 patients form a data set that is analysed quantitatively. FINDINGS In total, 420 respondents took part in this survey. The results of the survey show that there is a considerable difference between the expectation levels of patients from government hospitals and patients from private clinics. Patients from government hospitals consistently show that time is a critical aspect of the service received, with 68 per cent of the respondents reporting this issue. Additionally, poor customer care, as reported by 14 per cent of the respondents, is also a critical issue. Timely service and appointments are among the main factors that contribute to patient satisfaction. Patients in private clinics, instead, particularly value clear explanations from doctors and nurses - this is corroborated by the fact that 11 per cent of the respondents reported appreciation of this type of service. PRACTICAL IMPLICATIONS This paper draws attention to a patient-centric perspective of healthcare, and highlights the importance of educating patients through clear explanations. ORIGINALITY/VALUE Little evidence exists on the standards of healthcare in Dubai. The authors explore this area and present direct evidence on quality standard implementation, identify implementation shortcomings and make recommendations for future research and practice.
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Affiliation(s)
- Bassam Mahboub
- Medical College, American University of Sharjah , Sharjah, United Arab Emirates
| | - Ahmad Mawasi
- Dubai Health Authority, Dubai Government, Dubai, United Arab Emirates
| | - Souzan Ali
- Dubai Health Authority, Dubai Government, Dubai, United Arab Emirates
| | - Chiara Spina
- Department of Management and Technology, Bocconi University , Milan, Italy
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Gautreau SJ, Gould ON, Allanach WW, Clark AE, Massoeurs SJ, Forsythe ME. Total Knee Arthroplasty Communication Checklist Increases Patient Satisfaction. J Arthroplasty 2019; 34:456-461. [PMID: 30594339 DOI: 10.1016/j.arth.2018.11.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 11/19/2018] [Accepted: 11/21/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Satisfaction with total knee arthroplasty (TKA) is correlated with the fulfillment of expectations. Good surgeon-patient communication impacts how expectations are formed and managed. The TKA communication checklist was developed to help surgeons better understand and manage patients' postoperative expectations in order to increase satisfaction with TKA. METHODS In this prospective cohort study, mean satisfaction scores of a standard of care communication group and a checklist intervention group were compared. The duration of postoperative follow-up appointments was also assessed to determine whether the checklist took significantly more time in practice. RESULTS Sixty patients received the checklist in TKA appointments with surgeons between 6 weeks and 6 months postoperatively and their satisfaction ratings were compared with 67 patients who had received the standard of care communication. The checklist group reported higher satisfaction on overall TKA satisfaction and expectations met (P = .02), care and concern shown by the surgeon (P = .01), surgeons' communication ability (P = .01), and satisfaction with time spent in follow-ups (P < .001). Satisfaction with relief from pain and return to function was not significant (P = .06). More time was spent in the checklist groups' follow-ups, with a mean difference of 1 minute, 51 seconds (P = .001). CONCLUSION The TKA communication checklist significantly improved patients' satisfaction across multiple dimensions. This has practical significance because patient satisfaction is increasingly used as a key performance indicator for surgeons and healthcare institutions alike. Increased TKA satisfaction will benefit patients, surgeons, and the healthcare system overall.
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Affiliation(s)
- Sylvia J Gautreau
- The Moncton Hospital, Orthopaedic Unit, Moncton, New Brunswick, Canada
| | - Odette N Gould
- Department of Psychology, Mount Allison University, Sackville, New Brunswick, Canada
| | | | - Andrew E Clark
- The Moncton Hospital, Orthopaedic Unit, Moncton, New Brunswick, Canada
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Hudson Smith M, Smith D. Directing Improvements in Primary Care Patient Experience through Analysis of Service Quality. Health Serv Res 2018; 53:4647-4666. [PMID: 29862500 PMCID: PMC6232513 DOI: 10.1111/1475-6773.12985] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To examine the influence of dimensions of service quality on patient experience of primary care. DATA SOURCES/STUDY SETTING Data from the national GP Patient Survey in England 2014/15, with responses from 858,351 patients registered at 7,918 practices. STUDY DESIGN Expert panel and principal component analysis helped identify relevant dimensions of service quality. Regression was then used to examine the relationships between these dimensions and reported patient experience. DATA COLLECTION/EXTRACTION METHODS Aggregated scores for each practice were used, comprising the proportion of positive responses to each element of the study. PRINCIPAL FINDINGS Of eight service quality dimensions identified, six have statistically significant impacts on patient experience but only two have large effects. Patient experience is highly influenced by practice responsiveness and the interactions with the physician. Other dimensions have small or even slightly negative influence. Service quality provided by nurses has negligible effect on patient experience. CONCLUSIONS To improve patient experience in primary health care, efforts should focus on practice responsiveness and interactions with the physician. Other areas have little influence over patient experience. This suggests a gap in patients' perspectives on health care, which has policy implications for patient education.
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Affiliation(s)
| | - David Smith
- Bath Business SchoolBath Spa UniversityBathUK
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Jones AL, Hausmann LRM, Haas GL, Mor MK, Cashy JP, Schaefer JH, Gordon AJ. A national evaluation of homeless and nonhomeless veterans' experiences with primary care. Psychol Serv 2018; 14:174-183. [PMID: 28481602 DOI: 10.1037/ser0000116] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Persons who are homeless, particularly those with mental health and/or substance use disorders (MHSUDs), often do not access or receive continuous primary care services. In addition, negative experiences with primary care might contribute to homeless persons' avoidance and early termination of MHSUD treatment. The patient-centered medical home (PCMH) model aims to address care fragmentation and improve patient experiences. How homeless persons with MHSUDs experience care within PCMHs is unknown. This study compared the primary care experiences of homeless and nonhomeless veterans with MHSUDs receiving care in the Veterans Health Administration's medical home environment, called Patient Aligned Care Teams. The sample included VHA outpatients who responded to the national 2013 PCMH-Survey of Health Care Experiences of Patients (PCMH-SHEP) and had a past-year MSHUD diagnosis. Veterans with evidence of homelessness (henceforth "homeless") were identified through VHA administrative records. PCMH-SHEP survey respondents included 67,666 veterans with MHSUDs (9.2% homeless). Compared with their nonhomeless counterparts, homeless veterans were younger, more likely to be non-Hispanic Black and nonmarried, had less education, and were more likely to live in urban areas. Homeless veterans had elevated rates of most MHSUDs assessed, indicating significant co-occurrence. After controlling for these differences, homeless veterans reported more negative and fewer positive experiences with communication; more negative provider ratings; and more negative experiences with comprehensiveness, care coordination, medication decision-making, and self-management support than nonhomeless veterans. Homeless persons with MHSUDs may need specific services that mitigate negative care experiences and encourage their continuation in longitudinal primary care services. (PsycINFO Database Record
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Affiliation(s)
- Audrey L Jones
- VA Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System
| | - Leslie R M Hausmann
- VA Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System
| | - Gretchen L Haas
- VISN 4 Mental Illness Research, Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System
| | - Maria K Mor
- VA Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System
| | - John P Cashy
- VA Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System
| | - James H Schaefer
- Department of Veterans Affairs Office of Analytics and Business Intelligence
| | - Adam J Gordon
- VA Center for Health Equity Research and Promotion, VISN4 Mental Illness Research, Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System
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Online physician review websites poorly correlate to a validated metric of patient satisfaction. J Surg Res 2018; 227:1-6. [PMID: 29804840 DOI: 10.1016/j.jss.2018.01.037] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 01/15/2018] [Accepted: 01/25/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Physician review websites such as Vitals and Healthgrades are becoming an increasingly popular tool for patients to choose providers. We hypothesized that the scores of these surveys poorly represent the true value of patient satisfaction when compared to a validated survey instrument. METHODS Answers from Vitals and Healthgrades online surveys were compared to the Press Ganey Medical Practice Survey (PGMPS) for 200 faculty members at a university hospital for FY15. Weighted Pearson's correlation was used to compare Healthgrades and Vitals to PGMPS. RESULTS While statistically significant, both Vitals and Healthgrades had very low correlations with the PGMPS with weighted coefficients of 0.18 (95% confidence interval: 0.02-0.34, P = 0.025) and 0.27 (95% confidence interval: 0.12-0.42, P < 0.001), respectively. CONCLUSIONS Online physician rating websites such as Vitals and Healthgrades poorly correlate with the PGMPS, a validated measure of patient satisfaction. Patients should be aware of these limitations and, consequently, should have access to the most accurate measure of patient satisfaction.
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Abstract
BACKGROUND Increasing emphasis is being placed on patient satisfaction, which is linked to reimbursement rates. The Consumer Assessment of Healthcare Providers and Systems (CAHPS) is a national, standardized survey used to assess patient satisfaction. Its limitations include the length of the survey, delay in administration, and generalization to all specialties. Ideal patient satisfaction surveys should collect information in a way that allows for corrective action in a timely manner. OBJECTIVE To evaluate patient dissatisfaction with wait time using a short, in-office, real-time survey. METHODS A cross-sectional study in which patients from one provider's office completed a real-time survey. These results were compared with the CAHPS survey data of the same time period. RESULTS Seven hundred fifty-six patients were seen and 251 surveys were collected. The real-time survey response rate was 33% compared with 9% for the CAHPS survey. Overall, 95.74% of patients who completed the real-time survey were satisfied with their wait times and the duration of their visit, versus 84.2% from the CAHPS survey. CONCLUSION Implementation of a short in-office survey immediately after patient care can provide better feedback that can be used to ensure that improvement measures are aimed at making significant strides in improving overall health outcomes for patients.
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Tyser AR, Abtahi AM, McFadden M, Presson AP. Evidence of non-response bias in the Press-Ganey patient satisfaction survey. BMC Health Serv Res 2016; 16:350. [PMID: 27488567 PMCID: PMC4972948 DOI: 10.1186/s12913-016-1595-z] [Citation(s) in RCA: 114] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 07/28/2016] [Indexed: 12/30/2022] Open
Abstract
Background Measures of patient satisfaction have gained prominence in recent years as changes to the American health care system have led to the incorporation of such metrics into reimbursement models. The response rate for widely-used outpatient satisfaction metrics and variables influencing the probability of survey nonresponse remain largely unknown. Methods We reviewed all unique adult patients (16,779) who completed an outpatient encounter in the Department of Orthopaedic surgery at our academic institution from 1/1/13 to 10/24/13. Survey data was linked to each clinic visit, and patient factors including age, sex, insurance type, zip code, and orthopaedic subspecialty visited were recorded. The overall survey response rate was calculated. Logistic regression was performed, and unadjusted and adjusted odds ratios of patients’ probability of responding to the Press-Ganey survey were calculated. Results Two thousand seven hundred sixty two (16.5 %) of individuals completed a Press-Ganey patient satisfaction survey and 14017 patients did not respond. For those patients considered responders, 906 patients (32.8 %) did not complete all the survey items. Among these 906 patients, the mean number of missing items was 2.24 (Standard Deviation SD: 2.19). Age, sex, insurance type, and orthopaedic subspecialty were all found to be associated with the odds of responding to our patient satisfaction survey. Advancing age increased the odds of responding to the survey (Adjusted Odds Ratio (OR) = 3.396 for ≥65 vs. 18–29, p < 0.001). Several variables were associated with a decreased odds of survey response, and included male sex (Adjusted OR = 0.782 for Males vs. Females, p < 0.001), insurance type (Adjusted OR = 0.311 for Medicaid/Self-Pay vs. Private), and subspecialty type (Adjusted OR = 0.623 for Trauma vs. Adult Reconstruction). Conclusions The response rate to the Press-Ganey Medical Practice Survey of outpatient satisfaction is low in an orthopaedic outpatient population, and furthermore, is impacted by patient characteristics such as age, sex, insurance type, and type of orthopaedic subspecialist encountered. The findings of the present study should inform future non-response weighting procedures in this area. More research is needed to assess non-response bias—including follow-up studies of non-respondents—in order to more accurately measure of patient satisfaction.
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Affiliation(s)
- A R Tyser
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA.
| | - A M Abtahi
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA
| | - M McFadden
- Department of Internal Medicine, Division of Epidemiology, University of Utah, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - A P Presson
- Department of Internal Medicine, Division of Epidemiology, University of Utah, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
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Bjertnaes O, Iversen HH, Garratt AM. The Universal Patient Centeredness Questionnaire: scaling approaches to reduce positive skew. Patient Prefer Adherence 2016; 10:2255-2260. [PMID: 27843304 PMCID: PMC5098548 DOI: 10.2147/ppa.s116424] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Surveys of patients' experiences typically show results that are indicative of positive experiences. Unbalanced response scales have reduced positive skew for responses to items within the Universal Patient Centeredness Questionnaire (UPC-Q). The objective of this study was to compare the unbalanced response scale with another unbalanced approach to scaling to assess whether the positive skew might be further reduced. PATIENTS AND METHODS The UPC-Q was included in a patient experience survey conducted at the ward level at six hospitals in Norway in 2015. The postal survey included two reminders to nonrespondents. For patients in the first month of inclusion, UPC-Q items had standard scaling: poor, fairly good, good, very good, and excellent. For patients in the second month, the scaling was more positive: poor, good, very good, exceptionally good, and excellent. The effect of scaling on UPC-Q scores was tested with independent samples t-tests and multilevel linear regression analysis, the latter controlling for the hierarchical structure of data and known predictors of patient-reported experiences. RESULTS The response rate was 54.6% (n=4,970). Significantly lower scores were found for all items of the more positively worded scale: UPC-Q total score difference was 7.9 (P<0.001), on a scale from 0 to 100 where 100 is the best possible score. Differences between the four items of the UPC-Q ranged from 7.1 (P<0.001) to 10.4 (P<0.001). Multivariate multilevel regression analysis confirmed the difference between the response groups, after controlling for other background variables; UPC-Q total score difference estimate was 8.3 (P<0.001). CONCLUSION The more positively worded scaling significantly lowered the mean scores, potentially increasing the sensitivity of the UPC-Q to identify differences over time and between providers. However, none of the groups exhibited large positive skew and ceiling effects, implying that such effects might not be a big measurement problem for either scaling format. We recommend using the standard scaling in surveys producing external indicators for inter-provider comparisons. The more positively worded scaling has greater relevance for local measurement work where the results of patient experience surveys have shown large positive skew, and intra-provider comparison is the primary goal.
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Affiliation(s)
- Oyvind Bjertnaes
- Unit for Patient-Reported Quality, Norwegian Institute of Public Health, Oslo, Norway
- Correspondence: Oyvind Bjertnaes, Unit for Patient-Reported Quality, Norwegian Institute of Public Health, Postbox 4404 Nydalen, 0403 Oslo, Norway, Tel +47 91 17 60 45, Email
| | - Hilde Hestad Iversen
- Unit for Patient-Reported Quality, Norwegian Institute of Public Health, Oslo, Norway
| | - Andrew M Garratt
- Unit for Patient-Reported Quality, Norwegian Institute of Public Health, Oslo, Norway
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