Paul D. Cleary

Prior studies have found that critical access hospitals (CAHs), which serve patients who would otherwise have limited access to hospitals, provide lower-quality clinical care than inpatient prospective payment system (IPPS) hospitals; evidence is limited about the patient experiences they provide. Using linear mixed-effects regression models, we compared patient-mix–adjusted Hospital Consumer Assessment of Hospitals, Providers, and Systems (HCAHPS) survey scores for CAHs and IPPS hospitals and evaluated how much of the observed differences were associated with size, location, and other hospital characteristics. CAH patients were older, more often in the medical service line, had lower educational attainment, and worse self-rated health than their IPPS counterparts. Accounting for such differences, CAH patients had better experiences (+8 points on the 0–100 HCAHPS summary score, where differences >5 are considered large by patient experience heuristics), especially for staff responsiveness, cleanliness, quietness, and discharge information. CAHs do not outperform similarly small IPPS hospitals, which often have different missions (eg, for-profit surgical specialty hospitals). For-profit and teaching status, while uncommon among CAHs, predicted lower CAH HCAHPS performance. Despite the limited services provided by CAHs, their small scale may facilitate positive experiences for patients in areas with limited hospital choices. For-profit and teaching CAHs may benefit from quality-improvement efforts.

Objective: To examine the psychometric characteristics of a survey about the experiences of people seeking mental health care and substance use services, the CAHPS Outpatient Mental Health (MH) survey.Study Settings and Design: Field tests were conducted in two Northeastern states—one among a state's Medicaid enrollees and the other in family medicine practices where psychologists and social workers were collocated with primary care providers. The survey asked about psychiatric medicines and counseling services received in the last 6 months.Data Sources and Analytic Sample: In each study, questionnaires were mailed to sampled patients with an option to complete a web survey. Study 1 included 5508 Medicaid enrollees 21 years and older from four health plans. Study 2 included 3328 patients 18 years and older who visited one of four family medicine practices. Samples included patients with mental health or substance use disorders or both.Principal Findings: Response rates were 9.98% (n = 470) and 13.00% (n = 416) for the Medicaid and family medicine surveys, respectively. About 20% of respondents reported difficulty getting appointments with mental health medicine prescribers. From 10% to 30% of respondents had difficulties finding a counselor, and 15% reported problems making appointments with counselors. Many respondents reported no mental health care in the last 6 months. Composite measures for communication with counselors had excellent internal consistency, but the measure for access to counseling services was modest (0.68 and 0.52 for the two studies). Inter‐unit reliability (IUR) was modest for the survey (IUR for all measures was lower than 0.60; highest for rating of counselors).Conclusions: Both studies had uniformly good distributions of responses to specific questions, although communication and respect questions about counselors were positively skewed. The survey performs better for respondents with any mental health condition and less well for those with only substance use disorders.

Background: The lifetime risk of mental health disorders is almost 50% and, in any year, about 25% of the population have a psychiatric disorder. Many of those people are cared for in primary care settings. Research Objective: Measure access to mental health services, such as getting counselling or prescription mental health medications, using new patient survey questions that can be added to Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys. Study Design: Surveys were conducted with a stratified probability sample of patients receiving primary care services in a single state in 2018–2019. Medicaid and privately insured patients were surveyed by mail or telephone, respectively. Results: Approximately 14% of sampled patients responded to a survey. More than 10% of privately insured respondents and about 20% of Medicaid respondents got or tried to get appointments for mental health care. About 15% of privately insured respondents and 11% of Medicaid respondents reported problems getting appointments with counselors. Only 8%–9% of respondents seeking mental health medicines reported problems getting appointments for prescriptions. A composite measure combining access to counselors and prescribers of mental health medicines evidenced adequate internal consistency reliability. Group level reliability estimates were low. Conclusions: Many respondents got or tried to get mental health services and a substantial number reported problems getting appointments or getting mental health prescriptions. The tested questions can be combined into an Access to Mental Health Care measure, which can be included in patient experience surveys for ambulatory care to monitor access to behavioral health care.

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.

The Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS^®) surveys collect standardized information about patient experiences of care from nationally representative samples of people with Medicare to support consumers’ enrollment choices and enable the Centers for Medicare & Medicaid Services to monitor care quality and incentivize high quality patient-centered care. Since 2007, protocols for data collection, analysis, and reporting have evolved to address expanded Medicare coverage options and a shift from a single survey vendor to a model in which health plans hire approved vendors to administer the survey. During that time, response rates for all types of surveys have declined; increasing effort has gone toward increasing survey participation, especially among people whose preferred language is not English. In this paper, we describe the history, goals, and current use of the Medicare CAHPS surveys. We also summarize key methodological issues, such as sample design, field implementation and data cleaning, adjustment, scoring, and report production. Additionally, we discuss issues that may arise more generally in managing a large, annual national survey that has direct impact on policy, and consider how a long-running survey of this nature may need to evolve to reflect changes in health care delivery and promote standardization in survey administration while maintaining survey content.

The most widely used surveys for assessing patient health care experiences in the U.S. are the Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys. Studies examining the associations of language and ethnicity with responses to CAHPS surveys have yielded inconsistent findings. More research is needed to assess the effect of responding to CAHPS surveys in Spanish. Subjects were patients who had received care at a study community health center in Connecticut within 6 or 12 months of being sent a CAHPS survey that asks about care experiences. The survey included four multi-item measures of care plus an overall rating of the provider. Sampled patients were mailed dual language (English and Spanish) cover letters and questionnaires. Those who did not respond after follow-up mailings were contacted by bilingual interviewers to complete the survey by telephone. We tested three hypotheses for any observed differences by ethnicity and language: 1. Spanish speakers are more likely than others to choose extreme response options. 2. The semantic meaning of the Spanish translation is not the same as the English version of the questions, resulting in Spanish speakers giving different answers because of meaning differences. 3. Spanish speakers have different expectations regarding their health care than those who answer in English. Analyses compared the answers on the survey measures for three groups: non-Hispanics answering in English, Hispanics answering in English, and Hispanics answering in Spanish. The overall response rate was 45%. After adjusting for differences in demographic characteristics and self-rated health, those answering in Spanish gave significantly more positive reports than the other two groups on three of the five measures, and higher than the non-Hispanic respondents on a fourth. Those answering in Spanish gave more positive reports of their medical experiences than Hispanics and non-Hispanics answering in English. Whether these results reflect different response tendencies, different standards for care, or better care experiences is a key issue in whether CAHPS responses in Spanish need adjustment to make them comparable to responses in English.

Background: Describe and evaluate an implementation science network focused on HIV prevention and treatment in New England. Methods: In 2014, we established a partnership among university researchers and community stakeholders to stimulate and support HIV-related implementation research. We solicited information from Network members through surveys, interviews at Network events, and dialog with participants. In 2017, we conducted a sociocentric network assessment of collaborations on research projects, grants, manuscripts, and consultations. Results: We identified 988 connections made through the Network that resulted in 185 manuscripts published and 15 grants funded. Our experience indicated that eight factors were instrumental in building and sustaining the Network: (1) acknowledging different perspectives, (2) balancing content and expertise, (3) encouraging consistent engagement, (4) providing seed funding, (5) membership flexibility, (6) maintenance of Network interactions, (7) supporting local HIV prevention and treatment efforts, and (8) maintaining productive relationships with health departments and community-based organizations. Conclusions: Developing and maintaining a regional network on implementation science for HIV prevention and treatment is feasible and can facilitate new and productive partnerships among researchers and community organizations and members.

Background There is great interest in identifying factors that are related to positive patient experiences such as physician communication style. Documented gender-specific physician communication and patient behavior differences raise the question of whether gender concordant relationships (i.e., both the provider and patient share the same gender) might affect patient experiences. Objective Assess whether patient experiences are more positive in gender concordant primary care relationships. Design Statewide telephone surveys. Linear mixed regression models to estimate the association of CAHPS scores with patient gender and gender concordance. Subjects Two probability samples of primary care Medicaid patients in Connecticut in 2017 (5/17–7/17) and 2019 (7/19–10/19). Main Measures Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) survey augmented with questions about aspects of care most salient to PCMH-designated organizations and two questions to assess access to mental health services. Key Results There were no significant effects of gender concordance and differences in experiences by patient gender were modest. Conclusions This study did not support the suggestion that patient and physician gender and gender concordance have an important effect on patient experiences.