Adapting a patient satisfaction instrument for low literate and Spanish-speaking populations: comparison of three formats.

OBJECTIVE: To compare responses to print versions of the Consumer Assessment of Healthcare Providers and Systems 2.0 survey (CAHPS) to those for an illustration enhanced format and a telephone based interactive voice response format. METHODS: First, 2015 adult patients awaiting primary care visits completed: demographic information, Test of Functional Health Literacy (S-TOFHLA), CAHPS in one of three formats: print, illustrated, or interactive voice. A second sample of 4800 active patients was randomized to receive alternative formats. RESULTS: Response rates for the illustrated (31.3%) and print (30.4%) formats were significantly higher than for the interactive voice format (18.1%). The results of the illustrated format were comparable to the traditional text version, but required about 2 min more to complete by both low and high literacy groups. There were almost no invalid responses for the interactive voice format, but the format was associated with lower CAHPS satisfaction scores. CONCLUSION: Despite extensive efforts to produce formats tailored to individuals with limited literacy, surprisingly we found no consistent advantages to either alternative format. In fact, the interactive voice format yielded lower satisfaction scores and lower response rates. PRACTICE IMPLICATIONS: Practitioners need to ensure the health instruments they use are aligned with literacy skills and delivery preferences of their consumers. The lack of benefit of the illustrated form does not support investment of resources in these formats to measure satisfaction. The interactive voice response deserves more study--do lower scores register limited access to or use of telephones, irritation or true signal?

Effect of race on patient expectations regarding their primary care physicians.

BACKGROUND: Fulfilment of patients' expectations has been associated with greater patient satisfaction with care and greater adherence to medical advice. However, little is know about how race influences patient expectations. OBJECTIVE: To determine the association between patient race and patient expectations of their primary care physician. METHODS: The design was a cross-sectional study. Setting and participants were sample of 709 primary care patients from four clinic sites at the Philadelphia Veterans Affairs Medical Center and the University of Pennsylvania Health System. The measures were an expectations instrument asking patients to rate the necessity of the physician performing 13 activities during the index visit, self-reported race, demographics, the Rapid Estimate of Adult Literacy in Medicine, the Charlson Comorbidity Index and SF-12. RESULTS: After adjusting for age, sex, education, clinic site, comorbidity, health literacy and health status, African Americans were more likely to report it was absolutely necessary for the physician to refer them to a specialist [AOR 1.55 (95% confidence interval, CI, 1.09-2.21), P = 0.01], order tests [AOR 1.59 (95% CI 1.11-2.27), P = 0.01] and conduct each of the six physical exam components. CONCLUSIONS: African American race is associated with greater expectations of the primary care physicians. More research is needed to confirm the differential expectations by race and determine the reasons for the differential expectations.

Racial/ethnic differences in physician distrust in the United States.

OBJECTIVES: We examined the racial/ethnic and geographic variation in distrust of physicians in the United States. METHODS: We obtained data from the Community Tracking Study, analyzing 20 sites where at least 5% of the population was Hispanic and 5% was Black. RESULTS: In univariate analyses, Blacks and Hispanics reported higher levels of physician distrust than did Whites. Multivariate analyses, however, suggested a complex interaction among sociodemographic variables, city of residence, race/ethnicity, and distrust of physician. In general, lower socioeconomic status (defined as lower income, lower education, and no health insurance) was associated with higher levels of distrust, with men generally reporting more distrust than women. But the strength of these effects was modified by race/ethnicity. We present examples of individual cities in which Blacks reported consistently higher mean levels of distrust than did Whites, consistently lower mean levels of distrust than did Whites, or a mixed relationship dependent on socioeconomic status. In the same cities, Hispanics reported either consistently higher mean levels of distrust relative to Whites or a mixed relationship. CONCLUSIONS: Racial/ethnic differences in physician distrust are less uniform than previously hypothesized, with substantial geographic and individual variation present.

Health literacy weakly but consistently predicts primary care patient dissatisfaction.

OBJECTIVES: To study relationships between health literacy and multiple satisfaction domains. Health literacy is related to some domains of patient satisfaction such as communication and understanding, but little is known about relationships of health literacy with other satisfaction domains. Moreover, the importance of health literacy in predicting satisfaction compared with other patient sociodemographics is underexplored. DESIGN: Cross-sectional survey. SETTING: Primary care waiting areas with a Veterans Administration Medical Center and a university health system. PARTICIPANTS: One thousand five hundred and twenty-eight primary care patients. MAIN OUTCOME MEASURES: A brief demographics questionnaire, the Rapid Estimate of Adult Literacy in Medicine, the Veterans Affairs ambulatory care patient satisfaction survey, and an adaptation of the Charlson Comorbidity Index. RESULTS: In unadjusted regression analyses, lower health literacy level was a significant predictor of worse satisfaction in 7 of 10 domains (P < 0.01). When adjusting for patient sociodemographics, predicted relationships remained significant in six of the seven domains (P < 0.05), with each unit change in the 4-stage literacy classification associated with a 3-6 point decrease in dissatisfaction scores (0-100 scale). Health literacy did not predict overall dissatisfaction (P = 0.55). CONCLUSIONS: These results suggest that health literacy, as assessed through a pronunciation exercise that is closely related to more comprehensive measures of literacy, has a consistent, albeit weak relationship with patient satisfaction. Future work is needed to clarify if patients with lower literacy are really receiving different care than those with higher literacy and to pinpoint the sources of their more negative responses.

Assessing health literacy in African American and Caucasian adults: disparities in rapid estimate of adult literacy in medicine (REALM) scores.

BACKGROUND AND OBJECTIVES: The influence of literacy on health and health care is an important area of investigation. Studies with a literacy focus are most valuable when literacy is assessed with psychometrically sound instruments. METHODS: This study used a prospective cohort sample of 1,610 primary care patients. Patients provided sociodemographics and took the Rapid Estimate of Adult Literacy in Medicine (REALM), a 66-item word pronunciation literacy test. RESULTS: The sample was 65% African American; 66% were men; 51% had a high school education or less. REALM scores were significantly related to education, age, and race but not gender. When stratified by education, differences between African Americans and Caucasians remained significant. Using 19 different strategies to shorten the 66-item instrument, reliability coefficients above.80 were maintained. CONCLUSIONS: The REALM is a robust assessment of health literacy. However, the discordance in scores between African Americans and Caucasians with similar educational attainment needs to be further addressed. A much shorter instrument would still have internally consistent scores and potentially be more useful in clinical settings.

Residents as members of intern selection committees: can they partially replace faculty?

BACKGROUND: Faculty involvement in the residency selection process is important, but increasing pressures on available faculty resources have made their ability to participate more difficult. Residents may be acceptable substitutions for some faculty in the selection process. PURPOSE: To test 2 new interview models and explore whether residents could partially replace faculty by examining what role the interview itself plays in the overall assessment of an applicant, comparing faculty and resident ratings of the interview, and asking whether partially substituting residents for faculty had an impact on the match outcome. METHODS: Applicants to an internal medicine residency program were assigned to 1 of 3 interview models: faculty-faculty, resident-faculty, resident-faculty-faculty. The 12 interview days were randomly assigned to a model and all applicants on each day had the same model. Interviewers used an applicant assessment form to assign ratings to 6 components of the portfolio and a final score. RESULTS: For both residents and faculty, the final score was highly correlated with the formal interview component. Within-model analyses showed residents consistently gave more favorable scores than faculty interviewers. There was no impact of interview model on initial or final rank position. Similarly, there was no difference between models in their match "success" rates. CONCLUSIONS: Residents can be successfully substituted for some faculty in the residency selection process. The use of residents does not impact the match results. Developing a small, committed group of interviewers should benefit both programs and applicants.