Less Use of Extreme Response Options by Asians to Standardized Care Scenarios May Explain Some Racial/Ethnic Differences in CAHPS Scores.

BACKGROUND: Asian Americans (hereafter "Asians") generally report worse experiences with care than non-Latino whites (hereafter "whites"), which may reflect differential use of response scales. Past studies indicate that Asians exhibit lower Extreme Response Tendency (ERT)-they less frequently use responses at extreme ends of the scale than whites. OBJECTIVE: To explore whether lower ERT is observed for Asians than whites in response to standardized vignettes depicting patient experiences of care and whether ERT might in part explain Asians reporting worse care than whites. PROCEDURE: A representative US sample (n=575 Asian; n=505 white) was presented with 5 written vignettes describing doctor-patient encounters with differing levels of physician responsiveness. Respondents evaluated the encounters using modified CAHPS communication questions. RESULTS: Case-mix-adjusted repeated-measures multivariate models show that Asians provided more positive responses than whites to several vignettes with less-responsive physicians but less positive responses than whites for the vignette with the most physician responsiveness (P<0.01 for each). While all respondents provided more positive ratings for vignettes with greater physician responsiveness, the increase was 15% less for Asian than white respondents. CONCLUSIONS: Asians exhibit lower ERT than whites in response to standardized scenarios. Because CAHPS reponses are predominantly near the positive end of the scale and the most responsive scenario is most typical of the score observed in real-world settings, lower ERT in Asians may partially explain observations of lower observed mean CAHPS scores for Asians in real-world settings. Case-mix adjustment for Asian race/ethnicity or its correlates may improve quality of care measurement.

Current and Projected Characteristics and Unique Health Care Needs of the Patient Population Served by the Department of Veterans Affairs.

The Veterans Access, Choice, and Accountability Act of 2014 addressed the need for access to timely, high-quality health care for veterans. Section 201 of the legislation called for an independent assessment of various aspects of veterans' health care. The RAND Corporation was tasked with an assessment of the current and projected demographics and health care needs of patients served by the Department of Veterans Affairs (VA). The number of U.S. veterans will continue to decline over the next decade, and the demographic mix and geographic locations of these veterans will change. While the number of veterans using VA health care has increased over time, demand will level off in the coming years. Veterans have more favorable economic circumstances than non-veterans, but they are also older and more likely to be diagnosed with many health conditions. Not all veterans are eligible for or use VA health care. Whether and to what extent an eligible veteran uses VA health care depends on a number of factors, including access to other sources of health care. Veterans who rely on VA health care are older and less healthy than veterans who do not, and the prevalence of costly conditions in this population is projected to increase. Potential changes to VA policy and the context for VA health care, including effects of the Affordable Care Act, could affect demand. Analysis of a range of data sources provided insight into how the veteran population is likely to change in the next decade.

Pre-Deployment Stress, Mental Health, and Help-Seeking Behaviors Among Marines.

The Marine Corps Operational Stress Control and Readiness (OSCAR) program is designed to provide mental health support to marines by embedding mental health personnel within Marine Corps units and increasing the capability of officers and senior noncommissioned officers to improve the early recognition and intervention of marines exhibiting signs of stress. The Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury have asked RAND to evaluate the OSCAR program. As part of this evaluation, RAND conducted a large survey of marines who were preparing for a deployment to Iraq or Afghanistan in 2010 or 2011. This article describes the methods and findings from this survey. The results are among the first to shed light on the pre-deployment mental health status of marines, as well as the social resources they draw on when coping with stress and their attitudes about seeking help for stress-related problems. The 2,620 marines in the survey sample had high rates of positive screens for current major depressive disorder (12.5 percent) and high-risk drinking (25.7 percent) and reported having experienced more potentially traumatic events over their lifetime than adult males in the general population. Marines in the sample also reported relying on peers for support with stress and perceiving moderate levels of support from the Marine Corps for addressing stress problems.

Use of CAHPS patient experience surveys to assess the impact of health care innovations.

BACKGROUND: The Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys are the standard for collecting information about patient experience of care in the United States. However, despite their widespread use, including in pay-for-performance and public reporting efforts and various provisions of the Affordable Care Act, knowledge about the use of CAHPS in assessing the impact of quality improvement efforts is limited. A study was conducted to examine the use of patient experience surveys in assessing the impact of innovations implemented in health care settings. METHODS: Innovation profiles identified on the Agency for Healthcare Research and Quality (AHRQ) Health Care Innovations Exchange website that included patient experience (including patient satisfaction) as an outcome (N = 201), were analyzed with a variety of qualitative analysis methods. RESULTS: Fewer than half of the innovations used a patient experience measure, most commonly employing global measures such as an overall rating. Most innovations assessed patient experience at a single time point, with only one third using techniques such as pre-post comparisons, time trends, or comparisons to control groups. Ten domains of measures addressed reports of patient experience, all of which could be assessed by existing CAHPS instruments. Similarly, CAHPS measures are available to assess all of the organizational processes that are addressed by innovations in the profiles and for which patients are the best source of information. While 120 of the innovations that use patient experience measures report using surveys to collect these data, only 6 reported using a CAHPS measure. CONCLUSIONS: Although innovations targeting quality improvement are often evaluated using surveys, there is considerable untapped potential for using CAHPS measures or surveys to assess their effectiveness.

The Development and Application of the RAND Program Classification Tool.

As a result of extended military engagements in Iraq and Afghanistan during the past decade, the U.S. Department of Defense (DoD) has implemented numerous programs to support servicemembers and family members who experience difficulty handling stress, face mental health challenges, or are affected by a traumatic brain injury (TBI). As these efforts have proliferated, it has become more challenging to monitor these programs and to avoid duplication. To support DoD in this area, RAND compiled a comprehensive catalog of DoD-funded programs that address psychological health and TBI. In creating the catalog of programs, RAND recognized the need to consistently describe and compare multiple programs according to a set of core program characteristics, driven largely by the lack of a single, clear, widely accepted operational definition of what constitutes a program. To do this, RAND developed the RAND Program Classification Tool (R-PCT) to allow users to describe and compare programs, particularly those related to psychological health and TBI, along eight key dimensions that that define a program. The tool consists of a set of questions and responses for consistently describing various aspects of programs, along with detailed guidance regarding how to select the appropriate responses. The purpose of this article is to describe the R-PCT, to help potential users understand how it was developed, and to explain how the tool can be used.

The RAND Online Measure Repository for Evaluating Psychological Health and Traumatic Brain Injury Programs.

Since 2001, U.S. military forces have been engaged in extended conflicts in Iraq and Afghanistan. While most military personnel cope well across the deployment cycle, the operational tempo may raise the risk of mental health problems, such as post-traumatic stress disorder (PTSD) and major depression, and consequences from traumatic brain injury (TBI). To support servicemembers and their families as they cope with these challenges, the U.S. Department of Defense has implemented numerous programs addressing biological, social, spiritual, and holistic influences on psychological health along the resilience, prevention, and treatment continuum that focus on a variety of clinical and nonclinical concerns. As these efforts have proliferated, evaluating their effectiveness has become increasingly important. To support the design and implementation of program evaluation, RAND developed the RAND Online Measure Repository (ROMR) which indexes and describes measures related to psychological health and TBI. The ROMR is a publicly accessible, online, searchable database containing 171 measures related to psychological health and TBI. This article describes the rationale for developing the ROMR, the content included in the ROMR, and its potential in both civilian and military populations. The ROMR includes information about measure domains, psychometrics, number of items, and costs, which can inform the selection of measures for program evaluations. Included measures address domains of primary importance to psychological health (PTSD, depression, anxiety, suicidal ideation, and resiliency) and TBI (cognition, executive functioning, and memory). Also identified are measures relevant to military units, such as unit cohesion and force readiness.

A Systematic Process to Facilitate Evidence-Informed Decisionmaking Regarding Program Expansion.

While the Department of Defense supports more than 200 psychological health and traumatic brain injury programs, it lacks an approach and process to systematically develop, track, and assess the performance of this portfolio of programs. Further, there is not yet a uniform approach to decisionmaking around program support and expansion of particularly promising, evidence-based programs. This lack of centralized oversight may result in the proliferation of untested programs that are developed without an evidence base; an inefficient use of resources; and added cost and administrative inefficiencies. RAND researchers developed a potential model and tools to support a centralized, systematic, and ongoing process to help in making decisions around continued program support, and by which expansion can be facilitated. This study includes two tools. The first is a Program Abstraction Form, which collects relevant background information from programs and asks explicitly about program effectiveness and the design of the program evaluation used to assess program effectiveness, as a poor evaluation design may lead to incorrect conclusions about the effectiveness of the program. The second is the RAND Program Expansion Tool, which provides a standardized summary of the quality and outcome of a program evaluation. The focus of these tools is on decisionmaking around program expansion, and does not preclude or address initial funding decisions of particularly promising new programs that may not yet have a solid evidence base.

A Program Manager's Guide for Program Improvement in Ongoing Psychological Health and Traumatic Brain Injury Programs.

Between 2001 and 2011, the U.S. Department of Defense has implemented numerous programs to support service members and their families in coping with the stressors from a decade of the longstanding conflicts in Iraq and Afghanistan. These programs, which address both psychological health and traumatic brain injury (TBI), number in the hundreds and vary in their size, scope, and target population. To ensure that resources are wisely invested and maximize the benefits of such programs, RAND developed a tool to help assess program performance, consider options for improvement, implement solutions, then assess whether the changes worked, with the intention of helping those responsible for managing or implementing programs to conduct assessments of how well the program is performing and to implement solutions for improving performance. Specifically, the tool is intended to provide practical guidance in program improvement and continuous quality improvement for all programs.

An Evaluation of the Implementation and Perceived Utility of the Airman Resilience Training Program.

Since 2001, the U.S. Military has been functioning at an operational tempo that is historically high for the all-volunteer force in which service members are deploying for extended periods on a repeated basis. Even with the drawdown of troops from Iraq in 2011, some service members are returning from deployment experiencing difficulties handling stress, mental health problems, or deficits caused by a traumatic brain injury (TBI). In response to these challenges, the U.S. Department of Defense (DoD) has implemented numerous programs to support service members and their families in these areas. In 2009, the Assistant Secretary of Defense for Health Affairs asked the RAND National Defense Research Institute to develop a comprehensive catalog of existing programs sponsored or funded by DoD to support psychological health and care for TBI, to create tools to support ongoing assessment and evaluation of the DoD portfolio of programs, and to conduct evaluations of a subset of these programs. This article describes RAND's assessment of an Air Force program, Airman Resilience Training (ART), which is a psychoeducational program designed to improve airmen's reactions to stress during and after deployment and to increase the use of mental health services when needed. ART was initiated in November 2010, replacing a previous program named Landing Gear, which had been in place since April 2008. The RAND study took place from August 2011 through November 2011. This study will be of particular interest to officials within the Air Force who are responsible for the psychological health and well-being of airmen, as well as to others within the military who are developing programs for service members to help them cope with stress while in combat situations and after returning from deployment.

Emergency Department Patient Experience of Care Survey: Development and Field Test.

The Centers for Medicare & Medicaid Services (CMS) have implemented Consumer Assessment of Healthcare Providers and Systems (CAHPS®) surveys to assess patient experience in a number of settings. Following CAHPS principles, RAND researchers designed and field tested an Emergency Department Patient Experience of Care Survey that consists of three survey instruments for use with adult patients who have visited the emergency department (ED). One instrument is for use with those patients who are discharged to the community following their ED visit; the other two are for use with those patients who are admitted to the hospital from the ED (one for use on its own and one to supplement an existing inpatient survey). The authors conducted a field test of these instruments in 12 hospitals in late 2013 and early 2014 and analyzed the resulting data from 4,101 ED patients. The analyses identified four composite measures (measures composed of responses to multiple survey questions) and ten measures that are each composed of a single survey question. As of September 2014, CMS plans to conduct additional testing on these instruments.

Racial/Ethnic differences in Medicare experiences and immunization: the role of disease burden.

BACKGROUND: Although Medicare provides beneficiaries with primary access to the health care system, racial/ethnic disparities in health care experiences and preventive care are well documented in the Medicare population. OBJECTIVE: To investigate disease burden and its possible impact on racial/ethnic health disparities for measures of secondary and tertiary access to health care, such as access to health plan information, obtaining recommended care in a timely manner, and immunization. SUBJECTS: A total of 355,874 beneficiaries over the age of 64 years who responded to the 2008 Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. METHODS: We fit a series of linear, case-mix adjusted models predicting Medicare CAHPS measures of patient experience and immunization from race/ethnicity, a 0 to 6 count of disease burden, and their interaction. RESULTS: Disparities between non-Hispanic whites and other racial/ethnic groups are largest among beneficiaries with no major health conditions. Disparities between whites and other racial/ethnic groups on getting care quickly and immunization are mitigated at higher levels of disease burden. Disparities persist at higher levels of disease burden for getting information from one's health plan. DISCUSSION: Whites have better overall access to care than other beneficiaries with Medicare in the absence of major health conditions. Disparities in getting care quickly and immunizations are smaller among beneficiaries with greater disease burden, perhaps as a function of integration into the health care system gained through management of health issues. These results underscore the importance of outreach to minorities with low utilization and few or no major health conditions.

Reporting CAHPS and HEDIS data by race/ethnicity for Medicare beneficiaries.

OBJECTIVE: To produce reliable and informative health plan performance data by race/ethnicity for the Medicare beneficiary population and to consider appropriate presentation strategies. DATA SOURCES: Patient experience data from the 2008-2009 Medicare Advantage (MA) and fee-for-service (FFS) CAHPS surveys and 2008-2009 HEDIS data (MA beneficiaries only). STUDY DESIGN: Mixed effects linear (and binomial) regression models estimated the reliability and statistical informativeness of CAHPS (HEDIS) measures. PRINCIPAL FINDINGS: Seven CAHPS and seven HEDIS measures were reliable and informative for four racial/ethnic subgroups-Whites, Blacks, Hispanics, and Asian/Pacific Islanders-at sample sizes of 100 beneficiaries (200 for prescription drug plans). Although many plans lacked adequate sample size for reporting group-specific data, reportable plans contained a large majority of beneficiaries from each of the four racial/ethnic groups. CONCLUSIONS: Statistically reliable and valid information on health plan performance can be reported by race/ethnicity. Many beneficiaries may have difficulty understanding such reports, however, even with careful guidance. Thus, it is recommended that health plan performance data by subgroups be reported as supplemental data and only for plans meeting sample size requirements.

CMS Innovation Center Health Care Innovation Awards: Evaluation Plan.

The Center for Medicare and Medicaid Innovation within the Centers for Medicare & Medicaid Services (CMS) has funded 108 Health Care Innovation Awards, funded through the Affordable Care Act, for applicants who proposed compelling new models of service delivery or payment improvements that promise to deliver better health, better health care, and lower costs through improved quality of care for Medicare, Medicaid, and Children's Health Insurance Program enrollees. CMS is also interested in learning how new models would affect subpopulations of beneficiaries (e.g., those eligible for Medicare and Medicaid and complex patients) who have unique characteristics or health care needs that could be related to poor outcomes. In addition, the initiative seeks to identify new models of workforce development and deployment, as well as models that can be rapidly deployed and have the promise of sustainability. This article describes a strategy for evaluating the results. The goal for the evaluation design process is to create standardized approaches for answering key questions that can be customized to similar groups of awardees and that allow for rapid and comparable assessment across awardees. The evaluation plan envisions that data collection and analysis will be carried out on three levels: at the level of the individual awardee, at the level of the awardee grouping, and as a summary evaluation that includes all awardees. Key dimensions for the evaluation framework include implementation effectiveness, program effectiveness, workforce issues, impact on priority populations, and context. The ultimate goal is to identify strategies that can be employed widely to lower cost while improving care.

Pay-for-performance programs to reduce racial/ethnic disparities: what might different designs achieve?

Pay-for-performance (P4P) programs may have unintended effects on racial/ethnic disparities. We used patient-level quality scores from the Hospital Quality Alliance and ranked hospitals by overall quality and by racial/ethnic disparities. We then modeled the effects of different P4P designs on national disparity scores. The models using overall quality to rank hospitals resulted in modest reductions in national disparity scores, although these were smaller than the reductions that were found from programs using disparities to rank hospitals. These results suggest that many hospitals treat Whites and minorities equitably. Nevertheless, in order to maximize both improvements in quality and reductions in national disparities, P4P programs should consider an approach that considers both overall quality and reductions in disparities when setting incentives.

Programs Addressing Psychological Health and Traumatic Brain Injury Among U.S. Military Servicemembers and Their Families.

Over the last decade, U.S. military forces have been engaged in extended conflicts that are characterized by increased operational tempo, most notably in Iraq and Afghanistan. While most military personnel cope well across the deployment cycle, many will experience difficulties handling stress at some point; will face psychological health challenges, such as post-traumatic stress disorder or major depression; or will be affected by the short- and long-term psychological and cognitive consequences of a traumatic brain injury (TBI). Over the past several years, the Department of Defense (DoD) has implemented numerous programs that address various components of psychological health along the resilience, prevention, and treatment continuum and focus on a variety of clinical and nonclinical concerns. This article provides detail from an evaluation of 211 programs currently sponsored or funded by DoD to address psychological health and TBI, along with descriptions of how programs relate to other available resources and care settings. It also provides recommendations for clarifying the role of programs, examining gaps in routine service delivery that could be filled by programs, and reducing implementation barriers. Barriers include inadequate funding and resources, concerns about the stigma associated with receiving psychological health services, and inability to have servicemembers spend adequate time in programs. The authors found that there is significant duplication of effort, both within and across branches of service. As each program develops its methods independently, it is difficult to determine which approaches work and which are ineffective. Recommendations include strategic planning, centralized coordination, and information-sharing across branches of service, combined with rigorous evaluation. Programs should be evaluated and tracked in a database, and evidence-based interventions should be used to support program efforts.

Behavioral Health in the District of Columbia: Assessing Need and Evaluating the Public System of Care.

This article shares findings from a study of the public behavioral health care system in the District of Columbia, including the prevalence of mental health disorders and substance use, the organization and financing of public behavioral health services, utilization of public behavioral health services, and priorities for improvement. The authors' analyses found that prevalence of mental health conditions resembles patterns nationally, among both adults and youth. Substance use disorders are more prevalent among adults and comparatively lower for the youth population, compared to national patterns. Potentially 60 percent of adults and 72 percent of adolescents enrolled in Medicaid managed care may have unmet need for depression services. Based on claims data, 45 percent of children and 41 percent of adults enrolled in Mental Health Rehabilitation Services programs have gaps in care that exceed six months during a 12-month period. Participants in focus groups and stakeholder interviews highlighted such challenges as gaps in care and difficulties in coordination of care for particular populations and services. High-level priorities include reducing unmet need for public mental health care, tracking and coordinating care, improving the availability and accessibility of substance use treatment services, and upgrading the data infrastructure.

Quality improvement efforts under health reform: how to ensure that they help reduce disparities--not increase them.

Despite persistent evidence of continued racial and ethnic disparities in health care, little explicit attention has been paid to how quality improvement activities might affect disparities. As the nation focuses on the practical realities of implementing health care reform and concurrent quality improvement provisions under the Affordable Care Act of 2010, it is important to recognize that overall improvements in the US health care system might not automatically benefit all segments of the population equally. In this article we highlight challenges to ensuring that quality improvement efforts reduce racial and ethnic disparities. These include making certain that quality improvement efforts measure disparities and improvements in them, notwithstanding providers' reputational concerns; that such efforts not create perverse incentives for providers to avoid serving minority patients; that they be applied to institutions where minority patients are most likely to receive care; and that they fully engage minority patients despite language or other barriers. To assist in these efforts, we argue for the development of disparities impact assessments to measure the effect that the Affordable Care Act's quality provisions will have on reducing disparities.

Health information management and perceptions of the quality of care for children with tracheotomy: a qualitative study.

BACKGROUND: Children with tracheotomy receive health care from an array of providers within various hospital and community health system sectors. Previous studies have highlighted substandard health information exchange between families and these sectors. The aim of this study was to investigate the perceptions and experiences of parents and providers with regard to health information management, care plan development and coordination for children with tracheotomy, and strategies to improve health information management for these children. METHODS: Individual and group interviews were performed with eight parents and fifteen healthcare (primary and specialty care, nursing, therapist, equipment) providers of children with tracheotomy. The primary tracheotomy-associated diagnoses for the children were neuromuscular impairment (n = 3), airway anomaly (n = 2) and chronic lung disease (n = 3). Two independent reviewers conducted deep reading and line-by-line coding of all transcribed interviews to discover themes associated with the objectives. RESULTS: Children with tracheotomy in this study had healthcare providers with poorly defined roles and responsibilities who did not actively communicate with one another. Providers were often unsure where to find documentation relating to a child's tracheotomy equipment settings and home nursing orders, and perceived that these situations contributed to medical errors and delayed equipment needs. Parents created a home record that was shared with multiple providers to track the care that their children received but many considered this a burden better suited to providers. Providers benefited from the parent records, but questioned their accuracy regarding critical tracheotomy care plan information such as ventilator settings. Parents and providers endorsed potential improvement in this environment such as a comprehensive internet-based health record that could be shared among parents and providers, and between various clinical sites. CONCLUSIONS: Participants described disorganized tracheotomy care and health information mismanagement that could help guide future investigations into the impact of improved health information systems for children with tracheotomy. Strategies with the potential to improve tracheotomy care delivery could include defined roles and responsibilities for tracheotomy providers, and improved organization and parent support for maintenance of home-based tracheotomy records with web-based software applications, personal health record platforms and health record data authentication techniques.