Development of a New Patient-Based Measure of Pediatric Ambulatory Care
ABSTRACT In 1995, the Agency for Health Care Policy and Research initiated the Consumer Assessments of Healthcare Providers and Systems (CAHPS) project to develop and evaluate survey protocols for collecting reliable and valid assessments of health care from consumers. CAHPS surveys are used throughout the United States for evaluating ambulatory and hospital care experiences, including a version for assessing pediatric ambulatory care; however, pediatric experts thought that the existing pediatric instruments did not adequately assess developmental and preventive care. The objective of this study was to develop and test an Ambulatory Pediatric CAHPS survey that focuses on clinicians and groups and includes measures of developmental and preventive care.
To develop the survey, we conducted 2 focus groups and conducted 9 cognitive interviews. We conducted a telephone pretest with 20 parents and coded potential problems with the interview (behavioral coding). We conducted a dual-language field test of the instrument with 670 parents who reported about their children's ambulatory care. We used data from that survey to assess the reliability and validity of the measures.
Questions about developmental monitoring and preventive care were developed and tested. Two scales that were based on those new questions had good internal consistency (coefficient alpha) and inter-physician reliability. A consortium of CAHPS investigators and federal sponsors have approved the resulting instrument as a national measure of pediatric care.
A new instrument for assessing ambulatory pediatric care by clinicians and groups that includes questions about developmental and preventive care is now available for use.
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ABSTRACT: Patient-centered medical homes have not been shown to reduce adverse outcomes or costs in adults or children with chronic illness. To assess whether an enhanced medical home providing comprehensive care prevents serious illness (death, intensive care unit [ICU] admission, or hospital stay >7 days) and/or reduces costs among children with chronic illness. Randomized clinical trial of high-risk children with chronic illness (≥3 emergency department visits, ≥2 hospitalizations, or ≥1 pediatric ICU admissions during previous year, and >50% estimated risk for hospitalization) treated at a high-risk clinic at the University of Texas, Houston, and randomized to comprehensive care (n = 105) or usual care (n = 96). Enrollment was between March 2011 and February 2013 (when predefined stopping rules for benefit were met) and outcome evaluations continued through August 31, 2013. Comprehensive care included treatment from primary care clinicians and specialists in the same clinic with multiple features to promote prompt effective care. Usual care was provided locally in private offices or faculty-supervised clinics without modification. Primary outcome: children with a serious illness (death, ICU admission, or hospital stay >7 days), costs (health system perspective). Secondary outcomes: individual serious illnesses, medical services, Medicaid payments, and medical school revenues and costs. In an intent-to-treat analysis, comprehensive care decreased both the rate of children with a serious illness (10 per 100 child-years vs 22 for usual care; rate ratio [RR], 0.45 [95% CI, 0.28-0.73]), and total hospital and clinic costs ($16,523 vs $26,781 per child-year, respectively; cost ratio, 0.58 [95% CI, 0.38-0.88]). In analyses of net monetary benefit, the probability that comprehensive care was cost neutral or cost saving was 97%. Comprehensive care reduced (per 100 child-years) serious illnesses (16 vs 44 for usual care; RR, 0.33 [95% CI, 0.17-0.66]), emergency department visits (90 vs 190; RR, 0.48 [95% CI, 0.34-0.67]), hospitalizations (69 vs 131; RR, 0.51 [95% CI, 0.33-0.77]), pediatric ICU admissions (9 vs 26; RR, 0.35 [95% CI, 0.18-0.70]), and number of days in a hospital (276 vs 635; RR, 0.36 [95% CI, 0.19-0.67]). Medicaid payments were reduced by $6243 (95% CI, $1302-$11,678) per child-year. Medical school losses (costs minus revenues) increased by $6018 (95% CI, $5506-$6629) per child-year. Among high-risk children with chronic illness, an enhanced medical home that provided comprehensive care to promote prompt effective care vs usual care reduced serious illnesses and costs. These findings from a single site of selected patients with a limited number of clinicians require study in larger, broader populations before conclusions about generalizability to other settings can be reached. clinicaltrials.gov Identifier: NCT02128776.JAMA The Journal of the American Medical Association 12/2014; 312(24):2640-8. DOI:10.1001/jama.2014.16419 · 30.39 Impact Factor
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ABSTRACT: Surveys are increasingly used to assess patient experiences with health care. Comparisons of hospital scores based on patient experience surveys should be adjusted for patient characteristics that might affect survey results. Such characteristics are commonly drawn from patient surveys that collect little, if any, clinical information. Consequently some hospitals, especially those treating particularly complex patients, have been concerned that standard adjustment methods do not adequately reflect the challenges of treating their patients.Medical Care 07/2014; 52(7):619-25. DOI:10.1097/MLR.0000000000000144 · 2.94 Impact Factor
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ABSTRACT: : Consumer assessment of health care is an important metric for evaluating quality of care. These assessments can help purchasers, health plans, and providers deliver care that fits patients' needs. : To examine differences in reports and ratings of care delivered to adults and children and whether they vary by site. : This observational study compares adult and child experiences with care at a large west coast medical center and affiliated clinics and a large mid-western health plan using Consumer Assessment of Healthcare Providers and Systems Clinician & Group 1.0 Survey data. : Office staff helpfulness and courtesy was perceived more positively for adult than pediatric care in the west coast site. In contrast, more positive perceptions of pediatric care were observed in both sites for coordination of care, shared decision making, overall rating of the doctor, and willingness to recommend the doctor to family and friends. In addition, pediatric care was perceived more positively in the mid-west site for access to care, provider communication, and office staff helpfulness and courtesy. The differences between pediatric care and adult care were larger in the mid-western site than the west coast site. : There are significant differences in the perception of care for children and adults with care provided to children tending to be perceived more positively. Further research is needed to identify the reasons for these differences and provide more definitive information at sites throughout the United States.Medical care 11/2012; 50 Suppl(11):S35-9. DOI:10.1097/MLR.0b013e3182610a88 · 2.94 Impact Factor