Do Racial/Ethnic Disparities in Quality and Patient Experience within Medicare Plans Generalize across Measures and Racial/Ethnic Groups?

The Use of External Anchors When Examining Differences in Scale Performance in Patient Experience Surveys

OBJECTIVES

To present an example of using vignettes as an external anchor to assess measurement equivalence for patient experience measures.

BACKGROUND

Evaluating measurement equivalence and differences in scale use is helpful for identifying disparities in patient experience based on patient surveys. External anchors, often in the form of scored vignettes, provide an attractive approach to examining differences in scale use but are not commonly used.

METHODS

We analyzed a UK dataset based on the General Practice Patient Survey and a U.S. dataset based on the Consumer Assessment of Healthcare Providers and Systems Clinician and Group survey. A total of 560 White British and 560 Pakistani adults were recruited from various locations across England; 575 Asian American and 505 non-Hispanic White patients were recruited from an internet panel in the United States. Patient encounters and rated the quality of communication using 5 General Practice Patient Survey questions and 3 Consumer Assessment of Healthcare Providers and Systems Clinician and Group questions.

RESULTS

Using an external anchor in both United States and UK data produced substantial evidence of differential item functioning (DIF). However, an "internal" DIF analysis (without an external anchor) produced little evidence of DIF.

CONCLUSIONS

Using an external anchor does not require the assumption made by internal methods that some items do not display between-group DIF. These assumptions may not hold for patient experience items if a single factor, such as extreme or negative response tendency, governs all items equally.

Enrollee, Plan, and State Characteristics Associated With Experience of Care Among Adults in Medicaid Managed Care

OBJECTIVE

To examine five enrollee-reported experience of care metrics and assess enrollee, plan, and state characteristics associated with higher care ratings.

STUDY SETTING AND DESIGN

We conducted a repeated cross-sectional study using multivariable linear probability models and predictors that captured various enrollee, plan, and state characteristics. We evaluated five enrollee-reported experience of care measures: being "always or usually" easy to get needed care (yes/no), having a personal doctor (yes/no), having timely access to a checkup or routine care (yes/no), having timely access to specialty care (yes/no), and healthcare rating (0-10).

DATA SOURCES AND ANALYTIC SAMPLE

We used enrollee-level data for adults aged 18-64 from the National Committee on Quality Assurance (NCQA) Adult Medicaid Managed Care Member Experience Survey in 2018 and 2020.

PRINCIPAL FINDINGS

The study included 94,296 adults enrolled in 172 Medicaid managed care plans in 38 states and who responded to the member experience survey. Enrollees from racially and ethnically minoritized groups reported significantly worse experiences of care than non-Hispanic White enrollees on all outcomes. Larger plan size was associated with a lower likelihood of timely access to checkups (-5.44 percentage points [PP] difference) but a higher likelihood of having a personal doctor (4.52 PP). Plan for-profit status was associated with a lower likelihood of having access to needed care (-2.24 PP) or having a personal doctor (-4.07 PP). Enrollees in states with Medicaid managed care quality incentives for improving consumer experience of care were significantly more likely to report timely access to specialty care (5.16 PP).

CONCLUSIONS

Enrollees from racially and ethnically minoritized groups with poor health status report worse access to care, with characteristics such as for-profit plan status and large plan size being associated with access to care. Strategies to improve care experiences may include targeted outreach, equity initiatives, and strengthening provider networks and availability.

Comparing Medicare Fee-for-Service Beneficiaries with ESKD Who Switched to Medicare Advantage versus Remained in Traditional Medicare

Patients choosing Medicare Advantage versus Medicare fee-for-service (FFS) differ with respect to race, socioeconomic status, and burden of disease. However, it is unclear whether these differences also occur among patients with kidney failure, who were newly allowed to switch to Medicare Advantage after the 21st Century Cares Act. We used data from the United States Renal Data System to examine differences in characteristics of dialysis patients and kidney transplant recipients who switched from FFS to Medicare Advantage compared with those who stayed with FFS in 2021, the first year such switching was allowed. We used unadjusted and adjusted logistic regression to compare odds of switching among demographic and geographic subgroups. Among 411,513 patients with FFS coverage in 2020, 10.1% switched to Medicare Advantage in 2021. Switchers constituted 12% of the dialysis population and 5% of the kidney transplant population. In the dialysis population, patients of Black race and Hispanic ethnicity were more likely to switch than patients of White race (adjusted odds ratio [OR], 1.69; 95% confidence interval [CI], 1.64 to 1.73 and OR, 1.42; 95% CI, 1.40 to 1.47; respectively), as were patients with dual eligibility for Medicaid (adjusted OR, 1.12; 95% CI, 1.09 to 1.15). Patients living in the South were also more likely to switch to Medicare Advantage than those living in the West (adjusted OR, 1.48; 95% CI, 1.43 to 1.52). Similar differences were observed among kidney transplant recipients. Patients who switched from FFS to Medicare Advantage were disproportionately from historically marginalized groups, including Black, Hispanic, and low-income individuals. They were also more likely to live in the South. These differences may threaten the generalizability of United States Renal Data System data that relies on FFS insurance claims and suggest that comparisons of outcomes between FFS and medicare advantage beneficiaries with kidney failure should be adjusted for key patient characteristics.

Assessing the difference in racial and ethnic disparities in access to and use of care between Traditional Medicare and Medicare Advantage

OBJECTIVE

Test whether racial-ethnic disparities in the access and use of care differ between Traditional Medicare (TM) and Medicare Advantage (MA).

DATA SOURCE

Secondary data from the 2015-2018 Medicare Current Beneficiary Survey (MCBS).

STUDY DESIGN

Measure Black-White and Hispanic-White disparities in access to care and use of preventive services within TM, within MA, and assess the difference-in-disparities between the two programs with and without controls for factors that could influence enrollment, access, and use.

DATA COLLECTION/EXTRACTION

Pool 2015-2018 MCBS data and restrict to non-Hispanic Black, non-Hispanic White, or Hispanic respondents.

PRINCIPAL FINDINGS

Black enrollees have worse access to care relative to White enrollees in TM and MA, particularly for cost-related measures such as not having problems paying medical bills (11-13 pp. lower for Black enrollees; p < 0.05) and satisfaction with out-of-pocket costs (5-6 pp. lower; p < 0.05). We find no difference in Black-White disparities between TM and MA. Hispanic enrollees have worse access to care relative to White enrollees in TM but similar access relative to White enrollees in MA. Hispanic-White disparities in not delaying care due to cost and not reporting problems paying medical bills are narrower in MA relative to TM by about 4 pp (significant at the p < 0.05 level) each. We find no consistent evidence that Black-White or Hispanic-White differences in the use of preventive services differ between TM and MA.

CONCLUSIONS

Across the measures of access and use studied here, racial and ethnic disparities in MA are not substantially narrower than in TM for Black and Hispanic enrollees relative to White enrollees. For Black enrollees, this study suggests that system-wide reforms are required to reduce existing disparities. For Hispanic enrollees, MA does narrow some disparities in access to care relative to White enrollees but, in part, because White enrollees do not do as well in MA as they do in TM.

Differences in racial/ethnic disparities in patient care experiences between prostate cancer survivors and males without cancer: A SEER-CAHPS study

INTRODUCTION

Our purpose was to evaluate whether racial/ethnic disparities in patient care experiences (PCEs) differ between males with prostate cancer ("PCa group") and males without cancer ("non-cancer group").

MATERIALS AND METHODS

This retrospective study used 2007-2015 National Cancer Institute's Surveillance, Epidemiology and End Results registry data linked to Consumer Assessment of Healthcare Providers and Systems surveys. PCa and non-cancer groups were propensity score matched 1:5 on demographic and clinical characteristics. Differences in racial/ethnic disparities (DRD) (non-Hispanic Black [NHB], Hispanic, non-Hispanic Asian [NHA], and Other Races compared to non-Hispanic White [NHW]) in PCEs (getting needed care, getting care quickly, doctor communication, customer service, and getting needed prescription drugs) were compared between matched PCa and non-cancer groups. Per prior literature, DRD in PCE scores were categorized as small (<3), medium (≥3 but <5) or large (≥5).

RESULTS

There were 7312 males in the PCa group and 36,559 matched males in the non-cancer group. Within each group, all racial/ethnic minority categories reported worse scores compared to NHW individuals (p < 0.05) for ≥3 PCE composite measures. Compared to PCa group, a larger NHA-NHW difference was observed in non-cancer group for getting needed care (-4.65 in PCa vs. -7.77 in non-cancer; DRD = 3.11, p = 0.029) and doctor communication (-2.46 in PCa vs. -4.85 in non-cancer; DRD = 2.38, p = 0.023).

DISCUSSION

In both PCa and non-cancer groups, racial/ethnic minorities reported worse experiences compared to NHW individuals for several PCE measures. However, the difference in getting needed care and doctor communication between NHA and NHW individuals were more pronounced in non-cancer group than PCa group.

Types of usual sources of care and their association with healthcare outcomes among cancer survivors: a Medical Expenditure Panel Survey (MEPS) study

PURPOSE

To assess associations between usual source of care (USC) type and health status, healthcare access, utilization, and expenses among adult cancer survivors.

METHODS

This retrospective cross-sectional analysis using 2013-2018 Medical Expenditure Panel Survey included 2690 observations representing 31,953,477 adult cancer survivors who were currently experiencing cancer and reporting one of five USC types: solo practicing physician (SPP), a specific person in a non-hospital facility, a specific person in a hospital-based facility, a non-hospital facility, and a hospital-based facility. We used logistic regressions and generalized linear models to determine associations of USC type with health status, healthcare access, utilization, and expenses, adjusting for patient demographic and clinical characteristics.

RESULTS

All non-SPP USC types were associated with reporting more difficulties contacting USC by telephone during business hours (p < 0.05). Compared to SPP, non-hospital facility was associated with more difficulty getting needed prescriptions (OR: 1.81, p = 0.036) and higher annual expenses ($5225, p = 0.028), and hospital-based facility was associated with longer travel time (OR: 1.61, p = 048), more ED visits (0.13, p = 0.049), higher expenses ($6028, p = 0.014), and worse self-reported health status (OR: 1.93, p = 0.001), although both were more likely to open on nights/weekends (p < 0.05). Cancer survivors with a specific person in a hospital-based facility (vs. SPP) as USC were > twofold as likely (p < 0.05) to report difficulty getting needed prescriptions and contacting USC afterhours.

CONCLUSIONS

Among adult cancer survivors who were currently experiencing cancer, having a non-SPP type of UCS was associated with reporting more difficulties accessing care, worse health, more ED visits, and higher total expenses.

IMPLICATIONS FOR CANCER SURVIVORS

Transitioning to SPP type of USC may result in better healthcare outcomes.

Medicare Advantage Enrollment Among Beneficiaries With End-Stage Renal Disease in the First Year of the 21st Century Cures Act

Importance

Before 2021, most Medicare beneficiaries with end-stage renal disease (ESRD) were unable to enroll in private Medicare Advantage (MA) plans. The 21st Century Cures Act permitted these beneficiaries to enroll in MA plans effective January 2021.

Objective

To examine changes in MA enrollment among Medicare beneficiaries with ESRD after enactment of the 21st Century Cures Act overall and by race or ethnicity and dual-eligible status.

Design, Setting, and Participants

This cross-sectional time-trend study used data from Medicare beneficiaries with ESRD (both kidney transplant recipients and those undergoing dialysis) between January 2019 and December 2021. Data were analyzed between June and October 2022.

Exposures

21st Century Cures Act.

Main Outcomes and Measures

Primary outcomes were the proportion of Medicare beneficiaries with prevalent ESRD who switched from traditional Medicare to MA between 2020 and 2021 and those with incident ESRD who newly enrolled in MA in 2021. Individuals who stayed in traditional Medicare were enrolled in 2020 and 2021 and those who switched to MA were enrolled in traditional Medicare in 2020 and MA in 2021.

Results

Among 575 797 beneficiaries with ESRD in 2020 or 2021 (mean [SD] age, 64.7 [14.2] years, 42.2% female, 34.0% Black, and 7.7% Hispanic or Latino), the proportion of beneficiaries enrolled in MA increased from 24.8% (December 2020) to 37.4% (December 2021), a relative change of 50.8%. The largest relative increases in MA enrollment were among Black (72.8% relative increase), Hispanic (44.8%), and dual-eligible beneficiaries with ESRD (73.6%). Among 359 617 beneficiaries with TM and prevalent ESRD in 2020, 17.6% switched to MA in 2021. Compared with individuals who stayed in traditional Medicare, those who switched to MA had modestly more chronic conditions (6.3 vs 6.1; difference, 0.12 conditions [95% CI, 0.10-0.16]) and similar nondrug spending in 2020 (difference, $509 [95% CI, -$58 to $1075]) but were more likely to be Black (difference, 19.5 percentage points [95% CI, 19.1-19.9]) and have dual Medicare-Medicaid eligibility (difference, 20.8 percentage points [95% CI, 20.4-21.2]). Among beneficiaries who were newly eligible for Medicare ESRD benefits in 2021, 35.2% enrolled in MA.

Conclusions and Relevance

Results suggest that increases in MA enrollment among Medicare beneficiaries with ESRD were substantial the first year after the 21st Century Cures Act, particularly among Black, Hispanic, and dual-eligible individuals. Policy makers and MA plans may need to assess network adequacy, disenrollment, and equity of care for beneficiaries who enrolled in MA.

Racial and ethnic differences in patient ratings of colorectal and non-small-cell lung cancer care: A SEER-CAHPS study

PURPOSE

Although significant racial and ethnic disparities exist in colorectal and lung cancer treatment and survival, racial differences in patient-reported experience of care are not well understood. The purpose of this study was to examine differences in patient-reported ratings of colorectal and non-small-cell lung cancer care by race/ethnicity.

METHODS

Medicare beneficiaries with AJCC stage I-IV colorectal and non-small-cell lung cancer (2003-2013) who completed a Medicare Consumer Assessment of Healthcare Providers (CAHPS) survey within 5 years of cancer diagnosis were identified in the linked SEER-CAHPS dataset. Scores were compared by race/ethnicity, defined as White, Black, or any other race/ethnicity.

RESULTS

Of the 2,621 identified patients, 161 (6.1%) were Black, 2,279 (87.0%) White, and 181 (6.9%) any other race/ethnicity. Compared to White patients, Black patients were younger, had lower educational level, and had higher census tract poverty indicator (p < 0.001). Black patients rated their ability to get care quickly significantly lower than White patients (63.5 (SE 3.38) vs. 71.4 (SE 2.12), p < 0.01), as did patients of any other race/ethnicity (LS mean 66.2 (SE 2.89), p = 0.02). Patients of any other race/ethnicity reported their ability to get needed care significantly lower than White patients (LS mean 81.9 (SE 2.46) vs. 86.7 (SE 1.75), p = 0.02); however, there was no difference in ability to get needed care between Black and White patients.

CONCLUSION

Patient ratings for getting care quickly were lower in non-White patients, indicating racial disparities in perceived timeliness of care.

Weak correlations in health services research: Weak relationships or common error?

OBJECTIVE

To examine whether the correlation between a provider's effect on one population of patients and the same provider's effect on another population is underestimated if the effects for each population are estimated separately as opposed to being jointly modeled as random effects, and to characterize how the impact of the estimation procedure varies with sample size.

DATA SOURCES

Medicare claims and enrollment data on emergency department (ED) visits, including patient characteristics, the patient's hospitalization status, and identification of the doctor responsible for the decision to hospitalize the patient.

STUDY DESIGN

We used a three-pronged investigation consisting of analytical derivation, simulation experiments, and analysis of administrative data to demonstrate the fallibility of stratified estimation. Under each investigation method, results are compared between the joint modeling approach to those based on stratified analyses.

DATA COLLECTION/EXTRACTION METHODS

We used data on ED visits from administrative claims from traditional (fee-for-service) Medicare from January 2012 through September 2015.

PRINCIPAL FINDINGS

The simulation analysis demonstrates that the joint modeling approach is generally close to unbiased, whereas the stratified approach can be severely biased in small samples, a consequence of joint modeling benefitting from bivariate shrinkage and the stratified approach being compromised by measurement error. In the administrative data analyses, the estimated correlation of doctor admission tendencies between female and male patients was estimated to be 0.98 under the joint model but only 0.38 using stratified estimation. The analogous correlations for White and non-White patients are 0.99 and 0.28 and for Medicaid dual-eligible and non-dual-eligible patients are 0.99 and 0.31, respectively. These results are consistent with the analytical derivations.

CONCLUSIONS

Joint modeling targets the parameter of primary interest. In the case of population correlations, it yields estimates that are substantially less biased and higher in magnitude than naive estimators that post-process the estimates obtained from stratified models.

Disparities in Care Experienced by Older Hispanic Medicare Beneficiaries in Urban and Rural Areas

BACKGROUND

Hispanic older adults face substantial health disparities compared with non-Hispanic-White (hereafter "White") older adults. To the extent that these disparities stem from cultural and language barriers faced by Hispanic people, they may be compounded by residence in rural areas.

OBJECTIVE

The objective of this study was to investigate possible interactions between Hispanic ethnicity and rural residence in predicting the health care experiences of older adults in the United States, and whether disparities in care for rural Hispanic older adults differ in Medicare Advantage versus Medicare Fee-for-Service.

SUBJECTS

Medicare beneficiaries age 65 years and older who responded to the 2017-2018 nationally representative Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys.

METHODS

We fit a series of linear, case-mix-adjusted models predicting Medicare CAHPS measures of patient experience (rescaled to a 0-100 scale) from ethnicity, place of residence, and Medicare coverage type.

RESULTS

In all residential areas, Hispanic beneficiaries reported worse experiences with getting needed care (-3 points), getting care quickly (-4 points), and care coordination (-1 point) than White beneficiaries (all P's<0.001). In rural areas only, Hispanic beneficiaries reported significantly worse experiences than White beneficiaries on doctor communication and customer services (-3 and -9 points, respectively, P<0.05). Tests of a 3-way interaction between ethnicity, rural residence, and coverage type were nonsignificant.

CONCLUSIONS

There is a need to improve access to care and care coordination for Hispanic beneficiaries overall and doctor-patient communication and customer service for rural Hispanic beneficiaries. Strategies for addressing deficits faced by rural Hispanics may involve cultural competency training and provision of language-appropriate services for beneficiaries (perhaps as telehealth services).

A Review of Unsolicited Comments on the CAHPS 5.0 Health Plan Survey

The CAHPS Health Plan Survey (CAHPS 5.0) collects invaluable information regarding consumer experiences with their health plans, and these data inform healthcare policies at both the state and federal levels. The purpose of this paper was to explore unsolicited comments provided on the CAHPS 5.0 survey of one state's Medicaid program. Secondary data analysis was conducted of unsolicited, written comments received from Medicaid recipients who completed the CAHPS 5.0 adult or child postal survey between 2016 and 2018. The majority of unsolicited comments were moderately or very negative in attitude (or tone) for adult and child surveys. Analysis of unsolicited comments yielded 3 themes: positive experiences with Medicaid, limitations of coverage, and direct requests for assistance. Providing space for Medicaid patients to share comments and receiving further guidance for content analysis would provide valuable context for interpreting overall survey results. Comments may also help Medicaid program administrators respond to the frequently complex and challenging experiences of navigating a continually evolving state health insurance program by the most vulnerable populations.

Growth In Medicare Advantage Greatest Among Black And Hispanic Enrollees

Expansion of the Medicare Advantage program during 2009-18 saw greater enrollment among racial/ethnic minorities and other traditionally marginalized groups. Growth was more rapid among Black, Hispanic, and dually enrolled beneficiaries than among White and nondual beneficiaries. The implications of greater heterogeneity in the program for enrollee outcomes are uncertain.

Incentivizing Excellent Care to At-Risk Groups with a Health Equity Summary Score

BACKGROUND

Social risk factors (SRFs) such as minority race-and-ethnicity or low income are associated with quality-of-care, health, and healthcare outcomes. Organizations might prioritize improving care for easier-to-treat groups over those with SRFs, but measuring, reporting, and further incentivizing quality-of-care for SRF groups may improve their care.

OBJECTIVE

To develop, as a proof-of-concept, a Health Equity Summary Score (HESS): a succinct, easy-to-understand score that could be used to promote high-quality care to those with SRFs in Medicare Advantage (MA) health plans, which provide care for almost twenty million older and disabled Americans and collect extensive quality measure and SRF data.

DESIGN

We estimated, standardized, and combined performance scores for two sets of quality measures for enrollees in 2013-2016 MA health plans, considering both current levels of care, within-plan improvement, and nationally benchmarked improvement for those with SRFs (specifically, racial-and-ethnic minority status and dual-eligibility for Medicare and Medicaid).

PARTICIPANTS

All MA plans with publicly reported quality scores and 500 or more 2016 enrollees.

MAIN MEASURES

Publicly reported clinical quality and patient experience measures.

KEY RESULTS

Almost 90% of plans measured for MA Star Ratings received a HESS; plans serving few patients with SRFs were excluded. The summary score was moderately positively correlated with publicly reported overall Star Ratings (r = 0.66-0.67). High-scoring plans typically had sizable enrollment of both racial-and-ethnic minorities (38-42%) and dually eligible beneficiaries (29-38%).

CONCLUSIONS

We demonstrated the feasibility of developing and estimating a HESS that is intended to promote and incentivize excellent care for racial-and-ethnic minorities and dually eligible MA enrollees. The HESS measures SRF-specific performance and does not simply duplicate overall plan Star Ratings. It also identifies plans that provide excellent care to large numbers of those with SRFs. Our methodology could be extended to other SRFs, quality measures, and settings.

Association of Medicare Advantage Star Ratings With Racial, Ethnic, and Socioeconomic Disparities in Quality of Care

Importance

Medicare Advantage (MA) plans, which disproportionately enroll racial/ethnic minorities and persons with socioeconomic disadvantage, receive bonus payments on the basis of overall performance on a 5-star rating scale. The association between plans' overall quality and disparities in quality is not well understood.

Objective

To examine the association between MA star ratings and disparities in care for racial/ethnic minorities and enrollees with lower income and educational attainment.

Design Setting and Participants

This cross-sectional study included 1 578 564 MA enrollees from 454 contracts across the 2015 and 2016 calendar years. Data analyses were conducted between June 2019 and June 2020.

Exposures

Self-reported race and ethnicity and low socioeconomic status (SES) (defined by low income or less than a high school education) vs high SES (neither low income nor low educational attainment).

Main Outcomes and Measures

Performance on 22 measures of quality and satisfaction determined at the individual enrollee level, aggregated into simulated star ratings (scale, 2-5) stratified by SES and race/ethnicity.

Results

A total of 1 578 564 enrollees were included in this analysis (55.8% female; mean [SD] age, 71.4 [11.3] years; 65.8% White; 12.3% Black; 14.6% Hispanic). Enrollees with low SES had simulated stratified star ratings 0.5 stars lower (95% CI, 0.4-0.6 stars) than individuals with high SES in the same contract. Black and Hispanic enrollees had simulated star ratings that were 0.3 stars (95% CI, 0.2-0.4 stars) and 0.1 stars (95% CI, -0.04 to 0.2 stars) lower than White enrollees within the same contracts. Black enrollees had a 0.4-star lower rating (95% CI, 0.1-0.7 stars) in 4.5- to 5-star contracts and a no statistical difference in 2.0- to 2.5-star-rated contracts (difference, 0.3 stars; 95% CI, -0.02 to 0.7 stars). Hispanic enrollees had a 0.6-star lower simulated rating (95% CI, 0.2-1.0 stars) in 4.5- to 5-star contracts and no statistical difference in 2- to 2.5-star contracts (difference, -0.01 stars; 95% CI, -0.5 to 0.4 stars). There was low correlation between simulated ratings for enrollees of low SES and high SES (difference, 0.2 stars; 95% CI, 0.03-0.4 stars) and between simulated ratings for White and Black enrollees (difference, 0.4 stars; 95% CI, 0.3-0.5 stars) and White and Hispanic enrollees (difference, 0.3 stars; 95% CI, 0.2-0.4 stars). As the proportion of Black and Hispanic enrollees increased in a contract, racial/ethnic disparities in ratings decreased.

Conclusions and Relevance

In this cross-sectional study, simulated MA star ratings were only weakly correlated with those for enrollees of low SES in the same contract, and contracts with higher star ratings had larger disparities in quality. Measures of equity in MA plans' quality of care may be needed.

Are Spanish-Speaking Families Less Satisfied with Care in Pediatric Otolaryngology?

OBJECTIVES/HYPOTHESIS

Language barriers may impact family experience, which is a key measure of healthcare quality. We compared family satisfaction between Spanish-speaking families (SSF) and English-speaking families (ESF) in pediatric otolaryngology.

STUDY DESIGN

Retrospective cohort study.

METHODS

Responses from the Family Experience Survey (FES), a hospital quality benchmarking survey, were analyzed from 2017 to 2019 at one academic pediatric otolaryngology practice. Question responses were compared between SSF versus ESF using mixed effect logistic regression models, adjusting for patient age, medical complexity, and insurance.

RESULTS

A total of 4,964 FES survey responses were included (14% SSF). In multivariate analysis adjusting for age, medical complexity, and insurance, SSF were 1.7 times more likely than ESF to rate their provider with the highest rating (i.e. 9-10/10; 95% confidence interval [CI] 1.24-2.22). However, SSF were less likely than ESF to provide the highest rating on many individual aspects of care, including whether providers explained things intelligibly (odds ratio [OR] 0.43, 95% CI 0.25-0.74), listened carefully (OR 0.36, 95% CI 0.28-0.47), knew their medical child's history (OR 0.53, 95% CI 0.44-0.64), provided understandable information (OR 0.36, 95% CI 0.16-0.83), spent sufficient time with them (OR 0.38, 95% CI 0.31-0.48), allowed them to discuss their questions (OR 0.57, 95% CI 0.47-0.70), or had enough input in their children's' care (OR 0.46, 95% CI 0.26-0.80).

CONCLUSIONS

In a large cohort of pediatric otolaryngology patients, SSF rated many individual aspects of their child's care less positively compared to ESF, despite rating their provider highly. Further research is needed to explore the reasons for these differences and how they can be improved.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E2393-E2401, 2021.

Examining Racial Disparities in Diabetes Readmissions in the United States Military Health System

INTRODUCTION

Diabetes is one of the most common chronic conditions in the United States and has a cost burden over $120 billion per year. Readmissions following hospitalization for diabetes are common, particularly in minority patients, who experience greater rates of complications and lower quality healthcare compared to white patients. This study examines disparities in diabetes-related readmissions in the Military Health System, a universally insured, population of 9.5 million beneficiaries, who may receive care from military (direct care) or civilian (purchased care) facilities.

METHODS

The study identified a population of 7,605 adult diabetic patients admitted to the hospital in 2014. Diagnostic codes were used to identify hospital readmissions, and logistic regression was used to analyze associations among race, beneficiary status, patient or sponsor's rank, and readmissions at 30, 60, and 90 days.

RESULTS

A total of 239 direct care patients and 545 purchased care patients were included in our analyses. After adjusting for age and sex, we found no significant difference in readmission rates for black versus white patients; however, we found a statistically significant increase in the likelihood for readmission of Native American/Alaskan Native patients compared to white patients, which persisted in direct care at 60 days (adjusted odds ratio [AOR] 11.51, 95% CI 1.11-119.41) and 90 days (AOR 18.42, 95% CI 1.78-190.73), and in purchased care at 90 days (AOR 4.54, 95% CI 1.31-15.74).

CONCLUSION

Our findings suggest that universal access to healthcare alleviates disparities for black patients, while Native America/Alaskan Native populations may still be at risk of disparities associated with readmissions among diabetic patients in both the closed direct care system and the civilian fee for service purchased care system.

The role of county-level socioeconomic status on brand-name prescriptions in Medicare part D: A cross-sectional Study

The objective of this study was to examine the association between county-level socioeconomic factors and brand-name drug prescription drug patterns among medical specialties with overall high brand-name outpatient prescription use.This cross-sectional study used data from 2 publicly available datasets. The 2015 Medicare Part D PUF data quantifies the prescription rates at the county-level and data from the US Census Bureau provides information on socioeconomic status at the county-level.We analyzed 3,821,523 brand-name claims and 14,088,613 generic claims reported by health providers from 40 specialties as provided by the 2015 Medicare Part D dataset. Internal Medicine, Family Practice, General Practice, Cardiology, and Ophthalmology accounted for 71% of the total amount of brand-name drugs filled under Medicare Part D in 2015. As the presence of individuals with an income ≥$100,000 increased in a given county, the likelihood of receiving a brand-name prescription claim increased.A county-level association exists involving socioeconomic factors and outpatient brand-name drug prescription patterns. Future interventions should consider these factors in order to reduce percentage of brand-name drugs filled and decrease health care expenditures.

Patient Experience in Primary Care: A Systematic Review of CG-CAHPS Surveys

The National Academy of Medicine's (NAM) vision for 21st-century health care underscored the need for increased patient engagement and charged health-care researchers to develop tools to evaluate patient experience. The most widely studied patient experience tools are the Consumer Assessments of Healthcare Providers and Systems (CAHPS) surveys. The Clinician and Group (CG)-CAHPS survey is the preferred patient experience survey for primary care, and thus a systematic review of patient reports from the CG-CAHPS empirical literature is ideal to appreciate the voice of health-care consumers. This systematic review revealed patient subjective reports regarding the acceptability of health-care delivery models, the effectiveness of interventions, the timeliness of care in different practice climates, and their responses to quality improvement initiatives. The synthesized results inform clinicians, organizations, and the health-care system where to prioritize and how to adapt services to efficiently provide equitable care, achieving the NAM's vision for a patient-centered US health-care system.

Imputation of race/ethnicity to enable measurement of HEDIS performance by race/ethnicity

OBJECTIVE

To improve an existing method, Medicare Bayesian Improved Surname Geocoding (MBISG) 1.0 that augments the Centers for Medicare & Medicaid Services' (CMS) administrative measure of race/ethnicity with surname and geographic data to estimate race/ethnicity.

DATA SOURCES/STUDY SETTING

Data from 284 627 respondents to the 2014 Medicare CAHPS survey.

STUDY DESIGN

We compared performance (cross-validated Pearson correlation of estimates and self-reported race/ethnicity) for several alternative models predicting self-reported race/ethnicity in cross-sectional observational data to assess accuracy of estimates, resulting in MBISG 2.0. MBISG 2.0 adds to MBISG 1.0 first name, demographic, and coverage predictors of race/ethnicity and uses a more flexible data aggregation framework.

DATA COLLECTION/EXTRACTION METHODS

We linked survey-reported race/ethnicity to CMS administrative and US census data.

PRINCIPAL FINDINGS

MBISG 2.0 removed 25-39 percent of the remaining MBISG 1.0 error for Hispanics, Whites, and Asian/Pacific Islanders (API), and 9 percent for Blacks, resulting in correlations of 0.88 to 0.95 with self-reported race/ethnicity for these groups.

CONCLUSIONS

MBISG 2.0 represents a substantial improvement over MBISG 1.0 and the use of CMS administrative data on race/ethnicity alone. MBISG 2.0 is used in CMS' public reporting of Medicare Advantage contract HEDIS measures stratified by race/ethnicity for Hispanics, Whites, API, and Blacks.

Speaking Up and Walking Out: Are Vulnerable Patients Less Likely to Disagree With or Change Doctors?

BACKGROUND

Disparities in clinical process-of-care and patient experiences are well documented for Medicare beneficiaries with ≥1 social risk factors. If such patients are less willing to express disagreement with their doctors or change doctors when dissatisfied, these behaviors may play a role in observed disparities.

OBJECTIVE

To investigate the association between social risk factors and self-reported likelihood of disagreeing with or changing doctors if dissatisfied among the Medicare fee-for-service population.

SUBJECTS

Fee-for-service beneficiaries (N=96,317) who responded to the 2014 Medicare Consumer Assessment of Healthcare Providers and Systems survey. Subgroups were defined based on age, education, income, and race/ethnicity.

METHODS

Respondents reported how likely they would be to express disagreement with their doctors and change doctors if dissatisfied (1=very unlikely to 4=very likely; rescaled to 0-100 points). We fit mixed-effect linear regression models predicting these outcomes from social risk factors, controlling for health status and geographic location.

RESULTS

Beneficiaries who were older, less educated, and had lower incomes were least inclined to express disagreement or change doctors (P<0.001). Compared with non-Hispanic whites, Asian/Pacific Islander (-9.5) and Hispanic (-3.6) beneficiaries said they would be less likely, and black (+2.8) beneficiaries more likely, to express disagreement. Asian/Pacific Islander (-8.7), Hispanic (-5.9), and American Indian/Alaska Native (-3.8) beneficiaries were less inclined than non-Hispanic whites to change doctors (P<0.01).

DISCUSSION

Reduction in health care disparities may be achieved if doctors and advocates encourage vulnerable patients to express their concerns and perspectives and if communities and caregivers provide support for changing providers when care is poor.

Improving patient experience in primary care: a multimethod programme of research on the measurement and improvement of patient experience

Background

There has been an increased focus towards improving quality of care within the NHS in the last 15 years; as part of this, there has been an emphasis on the importance of patient feedback within policy, through National Service Frameworks and the Quality and Outcomes Framework. The development and administration of large-scale national patient surveys to gather representative data on patient experience, such as the national GP Patient Survey in primary care, has been one such initiative. However, it remains unclear how the survey is used by patients and what impact the data may have on practice.

Objectives

Our research aimed to gain insight into how different patients use surveys to record experiences of general practice; how primary care staff respond to feedback; and how to engage primary care staff in responding to feedback.

Methods

We used methods including quantitative survey analyses, focus groups, interviews, an exploratory trial and an experimental vignette study.

Results

(1)Understanding patient experience data. Patients readily criticised their care when reviewing consultations on video, although they were reluctant to be critical when completing questionnaires. When trained raters judged communication during a consultation to be poor, a substantial proportion of patients rated the doctor as ‘good’ or ‘very good’. Absolute scores on questionnaire surveys should be treated with caution; they may present an overoptimistic view of general practitioner (GP) care. However, relative rankings to identify GPs who are better or poorer at communicating may be acceptable, as long as statistically reliable figures are obtained. Most patients have a particular GP whom they prefer to see; however, up to 40% of people who have such a preference are unable regularly to see the doctor of their choice. Users of out-of-hours care reported worse experiences when the service was run by a commercial provider than when it was run by a not-for profit or NHS provider. (2)Understanding patient experience in minority ethnic groups. Asian respondents to the GP Patient Survey tend to be registered with practices with generally low scores, explaining about half of the difference in the poorer reported experiences of South Asian patients than white British patients. We found no evidence that South Asian patients used response scales differently. When viewing the same consultation in an experimental vignette study, South Asian respondents gave higher scores than white British respondents. This suggests that the low scores given by South Asian respondents in patient experience surveys reflect care that is genuinely worse than that experienced by their white British counterparts. We also found that service users of mixed or Asian ethnicity reported lower scores than white respondents when rating out-of-hours services. (3)Using patient experience data. We found that measuring GP–patient communication at practice level masks variation between how good individual doctors are within a practice. In general practices and in out-of-hours centres, staff were sceptical about the value of patient surveys and their ability to support service reconfiguration and quality improvement. In both settings, surveys were deemed necessary but not sufficient. Staff expressed a preference for free-text comments, as these provided more tangible, actionable data. An exploratory trial of real-time feedback (RTF) found that only 2.5% of consulting patients left feedback using touch screens in the waiting room, although more did so when reminded by staff. The representativeness of responding patients remains to be evaluated. Staff were broadly positive about using RTF, and practices valued the ability to include their own questions. Staff benefited from having a facilitated session and protected time to discuss patient feedback.

Conclusions

Our findings demonstrate the importance of patient experience feedback as a means of informing NHS care, and confirm that surveys are a valuable resource for monitoring national trends in quality of care. However, surveys may be insufficient in themselves to fully capture patient feedback, and in practice GPs rarely used the results of surveys for quality improvement. The impact of patient surveys appears to be limited and effort should be invested in making the results of surveys more meaningful to practice staff. There were several limitations of this programme of research. Practice recruitment for our in-hours studies took place in two broad geographical areas, which may not be fully representative of practices nationally. Our focus was on patient experience in primary care; secondary care settings may face different challenges in implementing quality improvement initiatives driven by patient feedback. Recommendations for future research include consideration of alternative feedback methods to better support patients to identify poor care; investigation into the factors driving poorer experiences of communication in South Asian patient groups; further investigation of how best to deliver patient feedback to clinicians to engage them and to foster quality improvement; and further research to support the development and implementation of interventions aiming to improve care when deficiencies in patient experience of care are identified.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Racial/Ethnic Differences in Primary Care Experiences in Patient-Centered Medical Homes among Veterans with Mental Health and Substance Use Disorders

BACKGROUND

Patient-Centered Medical Homes (PCMH) may be effective in managing care for racial/ethnic minorities with mental health and/or substance use disorders (MHSUDs). How such patients experience care in PCMH settings is relatively unknown.

OBJECTIVE

We aimed to examine racial/ethnic differences in experiences with primary care in PCMH settings among Veterans with MHSUDs.

DESIGN

We used multinomial regression methods to estimate racial/ethnic differences in PCMH experiences reported on a 2013 national survey of Veterans Affairs patients.

PARTICPANTS

Veterans with past-year MHSUD diagnoses (n = 65,930; 67 % White, 20 % Black, 11 % Hispanic, 1 % American Indian/Alaska Native[AI/AN], and 1 % Asian/Pacific Island[A/PI]).

MAIN MEASURES

Positive and negative experiences from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) PCMH Survey.

RESULTS

Veterans with MHSUDs reported the lowest frequency of positive experiences with access (22 %) and the highest frequency of negative experiences with self-management support (30 %) and comprehensiveness (16 %). Racial/ethnic differences (as compared to Whites) were observed in all seven healthcare domains (p values < 0.05). With access, Blacks and Hispanics reported more negative (Risk Differences [RDs] = 2 .0;3.6) and fewer positive (RDs = -2 .3;-2.3) experiences, while AI/ANs reported more negative experiences (RD = 5.7). In communication, Blacks reported fewer negative experiences (RD = -1.3); AI/ANs reported more negative (RD = 3.6) experiences; and AI/ANs and APIs reported fewer positive (RD = -6.5, -6.7) experiences. With office staff, Hispanics reported fewer positive experiences (RDs = -3.0); AI/ANs and A/PIs reported more negative experiences (RDs =  3.4; 3.7). For comprehensiveness, Blacks reported more positive experiences (RD = 3.6), and Hispanics reported more negative experiences (RD = 2.7). Both Blacks and Hispanics reported more positive (RDs = 2.3; 4.2) and fewer negative (RDs = -1.8; -1.9) provider ratings, and more positive experiences with decision making (RDs = 2.4; 3.0). Blacks reported more positive (RD = 3.9) and fewer negative (RD = -5.1) experiences with self-management support.

CONCLUSIONS

In a national sample of Veterans with MHSUDs, potential deficiencies were observed in access, self-management support, and comprehensiveness. Racial/ethnic minorities reported worse experiences than Whites with access, comprehensiveness, communication, and office staff helpfulness/courtesy.

Understanding negative feedback from South Asian patients: an experimental vignette study

OBJECTIVES

In many countries, minority ethnic groups report poorer care in patient surveys. This could be because they get worse care or because they respond differently to such surveys. We conducted an experiment to determine whether South Asian people in England rate simulated GP consultations the same or differently from White British people. If these groups rate consultations similarly when viewing identical simulated consultations, it would be more likely that the lower scores reported by minority ethnic groups in real surveys reflect real differences in quality of care.

DESIGN

Experimental vignette study. Trained fieldworkers completed computer-assisted personal interviews during which participants rated 3 video recordings of simulated GP-patient consultations, using 5 communication items from the English GP Patient Survey. Consultations were shown in a random order, selected from a pool of 16.

SETTING

Geographically confined areas of ∼130 households (output areas) in England, selected using proportional systematic sampling.

PARTICIPANTS

564 White British and 564 Pakistani adults recruited using an in-home face-to-face approach.

MAIN OUTCOME MEASURE

Mean differences in communication score (on a scale of 0-100) between White British and Pakistani participants, estimated from linear regression.

RESULTS

Pakistani participants, on average, scored consultations 9.8 points higher than White British participants (95% CI 8.0 to 11.7, p<0.001) when viewing the same consultations. When adjusted for age, gender, deprivation, self-rated health and video, the difference increased to 11.0 points (95% CI 8.5 to 13.6, p<0.001). The largest differences were seen when participants were older (>55) and where communication was scripted to be poor.

CONCLUSIONS

Substantial differences in ratings were found between groups, with Pakistani respondents giving higher scores than White British respondents to videos showing the same care. Our findings suggest that the lower scores reported by Pakistani patients in national surveys represent genuinely worse experiences of communication compared to the White British majority.

Provision of Healthcare Services to Men Who Have Sex with Men in Nigeria: Students' Attitudes Following the Passage of the Same-Sex Marriage Prohibition Law

PURPOSE

After signing of the Same-Sex Marriage (Prohibition) Act 2013 in Nigeria, media reports portray widespread societal intolerance toward the lesbian, gay, and bisexual population. This study was conducted to assess the attitudes of university undergraduates in Lagos state, Nigeria, toward provision of healthcare services for men who have sex with men (MSM), because the 2014 same-sex marriage prohibition law stipulates a jail sentence for organizations providing services to MSM.

METHODS

A cross-sectional descriptive study was conducted by using self-administered questionnaires to collect information, including homophobic attitudes and views on access to healthcare, from 4000 undergraduates in 10 randomly selected faculties in two universities. During analysis, inter-university and inter-faculty comparison was carried out between medical and nonmedical students.

RESULTS

Outright denial of healthcare services to MSM was supported by 37.6% of the 3537 undergraduates who responded, whereas denial of HIV prevention services was supported by 32.5%. However, compared with 38.7% and 34.1% of undergraduates from other faculties, 23.7% and 18.2% of medical students agreed that healthcare providers should not provide services to MSM and that MSM should not have access to HIV prevention services, respectively (P = 0.000). Although a significant proportion of the medical students supported the statement that doctors and other healthcare workers should be compelled to give priority to other groups before MSM (29.4% of medical vs. 47.2% of students from other faculties), a statistically significant difference was observed between the two groups of students. The homophobic statement with the highest support was that doctors and healthcare workers should be compelled to report MSM who come to access treatment (48.1% of medical vs. 57.4% of students from other faculties).

CONCLUSION

A very high proportion of the undergraduate students had a negative attitude toward provision of healthcare services to MSM in Nigeria; the medical students were, however, less homophobic than their nonmedical counterparts. If attitudes translate to a lack of healthcare service provision to MSM, with the high burden of HIV among MSM in Nigeria, it is unlikely that the country will achieve the UNAIDS 90-90-90 target of 90% of the population knowing their HIV status, 90% of people living with HIV receiving sustained antiretroviral medication, and 90% of those receiving antiretroviral medication having viral suppression by 2020.