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BackgroundData 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.ObjectiveReview evidence on survey administration strategies to improve response rates and representativeness of patient surveys.Research designSystematic review adhering to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines.Study selectionForty peer-reviewed randomized experiments of administration protocols for patient experience surveys.ResultsMail 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%).ConclusionsSequential 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.

Patient-centered medical home takes years to attain. Fifteen-to-eighteen percent of US primary care practices in 2008-2017 sought or maintained patient-centered medical home recognition. We conducted interviews with a stratified-random sample of 105 of these practices to determine why patient experience surveys were chosen. Fifty-one were using a Consumer Assessment of Healthcare Providers and Systems survey and 53 administering another patient survey. The 3 most common reasons were (1) to compare performance against other practices, which requires systematically collected data across large numbers of practices (ie, the Consumer Assessment of Healthcare Providers and Systems survey), (2) participation in an external patient-centered medical home program, and (3) survey administration cost. Leaders invested in a second patient survey for quality improvement needs.

BACKGROUND: Patient surveys are the primary tool to measure patient experiences of care. Caution must be taken when analyzing these data, as responses can be influenced by factors that do not reflect the quality of care received. OBJECTIVES: To provide a practical overview of adjusting patient experience survey results to address bias related to patient case-mix, extreme response tendency, and mode of survey administration. RESEARCH DESIGN: We discuss options for adjustment for biases in how people respond to patient experience surveys. RESULTS: Case-mix adjustment (CMA) aims to compare provider performance that would have been observed if all providers had treated the same set of patients by removing the effects of patient characteristics that vary across providers. Extreme response tendency can bias the measurement of the disparities in patient experiences even after typical CMAs, since differences in patients’ use of extreme response option may affect “top box” or linear mean scores when patient experience scores have a skewed distribution. Survey mode may affect scores for the provider entity being evaluated (e.g., hospital) more than CMA if survey mode differs at the provider level and case mix at the patient level. CONCLUSIONS: It is best practice to evaluate known source of bias when analyzing patient experience surveys. Failure to adjust for patient case-mix, extreme response tendency, and survey mode in patient experience surveys may lead to erroneous comparisons of providers.

Author(s): Xenakis, Lea; Quigley, Denise D; Qureshi, Nabeel; AlMasarweh, Luma; Pham, Chau; Hays, Ron D | Abstract: Background and objectivesDelivering care as a patient-centered medical home (PCMH) is being widely adopted across the United States by primary care practices to better meet patient needs. A key PCMH element is measuring patient experience for practice improvement. The National Committee for Quality Assurance (NCQA) PCMH recognition program requires practices to both measure patient experience and engage in continuous practice/quality improvement to attain PCMH recognition and then throughout full PCMH transformation. The NCQA recommends but does not require that practices administer the Consumer Assessment of Healthcare Providers and Systems (CAHPS) clinician and group patient experience survey (CG-CAHPS) plus 14 CAHPS PCMH items, known as the CAHPS PCMH survey. We examine aspects of patient experience measured by practices with a varying number of years on their journey of PCMH transformation.MethodsWe randomly selected practices from the 2008-2017 NCQA directory of practices that had applied for PCMH recognition based on region, physician count, number of years and level of PCMH recognition, and use of the CG-CAHPS PCMH survey. We collected characteristics of the practices from practice leader(s) knowledgeable about the practice's PCMH history and patient experience data. We confirmed the patient experience surveys used during their PCMH history and requested copies of their non-CAHPS survey(s). For practices not administering the recommended CG-CAHPS survey (53/105 practices), we obtained and coded the content of their non-CAHPS surveys (68%; 36/53). We mapped the patient experience domains and specific measures to the CG-CAHPS survey (versions 2.0 and 3.0), CAHPS PCMH item set (versions 2.0 and 3.0), and the available CG-CAHPS supplemental items.ResultsWhether or not practices administered the CG-CAHPS items, most of them addressed topics contained in the CG-CAHPS survey such as Access to care, Provider communication, Office staff helpfulness/courteousness, Care coordination, and Shared decision-making. The most common CAHPS measures included were Office staff helpfulness/courteousness and Provider communication. Common non-CAHPS measures included were Ease of scheduling, Being informed about delays, and Provider helpfulness/courteousness.ConclusionNCQA PCMH practices included CAHPS items on their patient experience surveys even if they did not administer the full CG-CAHPS survey or the recommended CAHPS PCMH survey. To enhance the usefulness of patient experience surveys for practices undergoing PCMH changes, additional CAHPS measures could be developed related to key areas of PCMH change, including expanded access to care (ie, after-hours and weekend visits, ease of scheduling, being informed about delays), use of shared decision-making, and improvements in provider communication (ie, the provider is courteous, communication by other clinical staff members with the patient). These additional measures would assist practice leaders in capturing the breadth and depth of their PCMH transformation and its influence on providing more patient-centered care. Developing such items would help standardize the measurement of changes related to patient experience during PCMH transformation. Research is needed to determine whether a CAHPS survey is the best source of this information.

ObjectiveThe aim of this study was to understand variation in intraoperative and postoperative utilization for common general surgery procedures.Summary background dataReducing surgical costs is paramount to the viability of hospitals.MethodsRetrospective analysis of electronic health record data for 7762 operations from 2 health systems. Adult patients undergoing laparoscopic cholecystectomy, appendectomy, and inguinal/femoral hernia repair between November 1, 2013 and November 30, 2017 were reviewed for 3 utilization measures: intraoperative disposable supply costs, procedure time, and postoperative length of stay (LOS). Crossed hierarchical regression models were fit to understand case-mixed adjusted variation in utilization across surgeons and locations and to rank surgeons.ResultsThe number of surgeons performing each type of operation ranged from 20 to 63. The variation explained by surgeons ranged from 8.9% to 38.2% for supply costs, from 15.1% to 54.6% for procedure time, and from 1.3% to 7.0% for postoperative LOS. The variation explained by location ranged from 12.1% to 26.3% for supply costs, from 0.2% to 2.5% for procedure time, and from 0.0% to 31.8% for postoperative LOS. There was a positive correlation (ρ = 0.49, P = 0.03) between surgeons' higher supply costs and longer procedure times for hernia repair, but there was no correlation between other utilization measures for hernia repair and no correlation between any of the utilization measures for laparoscopic appendectomy or cholecystectomy.ConclusionsSurgeons are significant drivers of variation in surgical supply costs and procedure time, but much less so for postoperative LOS. Intraoperative and postoperative utilization profiles can be generated for individual surgeons and may be an important tool for reducing surgical costs.

As patient-oriented care has expanded in health care, the use of patient-reported outcomes (PROs) to evaluate patients’ health has increased as well. A PRO is defined by the US Food and Drug Administration as “any report coming from patients about a health condition and its treatment, without

Patient-reported outcome measures (PROMs), including patient-reported outcomes (PROs), are one of two primary sources of data about patients on dialysis ([1][1]); the other is biologically based patient data. The Food and Drug Administration definition of a PRO is “any report coming from patients

B RIEF R EPORT Possibilities for Shortening the CAHPS Clinician and Group Survey Brian D. Stucky, PhD,* Ron D. Hays, PhD,* w Maria O. Edelen, PhD,* Jill Gurvey, MPH,* and Julie A. Brown, BA* Background: The Consumer Assessment of Healthcare Providers and Systems (CAHPS) Clinician and Group adult survey (CG- CAHPS) includes 34 items used to monitor the quality of ambula- tory care from the patient’s perspective. CG-CAHPS includes items assessing access to care, provider communication, and courtesy and respect of office staff. Stakeholders have expressed concerns about the length of the CG-CAHPS survey. Objectives: This paper explores the impact on reliability and val- idity of the CAHPS domain scores of reducing the numbers of items used to assess the 3 core CG-CAHPS domains (Provider Commu- nication, Access to Care, and Courteous and Helpful Office Staff). Research Design: CG-CAHPS data reported here consist of 136,725 patients across 4 datasets including ambulatory clinics, patient-centered medical homes, and Accountable Care Organ- izations. Analyses are conducted in parallel across the 4 settings to allow evaluations across data source. Analyses: Multiple regression and ANOVA techniques were used to evaluate reliability for shorter sets of items. Site-level correla- tions with the overall rating of the provider were compared to evaluate the impact on validity. The change in practices’ rank- ordering as a function of domain revision is also reported. Results: Findings suggest that the Provider Communication (6 items) and Access (5 items) domains can be reduced to as few as 2 items each and Office Staff (2 items) can be reduced to a single item without a substantial loss in reliability or content. Conclusions: The performance of several of the reduced-length options for CG-CAHPS domains closely matches the full versions and may be useful in health care settings where the full-length survey is impractical due to time or cost constraints. Key Words: CAHPS, patient experiences survey, short form (Med Care 2016;54: 32–37) From the *RAND Corporation, Santa Monica; and wDepartment of Medi- cine, UCLA, Los Angeles, CA. Supported by the Agency for Healthcare Research and Quality’s Award Number 2U18HS016980. The content is solely the responsibility of the authors and does not neces- sarily represent the official views of the Agency for Healthcare Research and Quality. The authors declare no conflict of interest. Reprints: Brian D. Stucky, PhD, RAND Corporation, 1776 Main Street, Santa Monica, CA 90407-2138. E-mail: bstucky@rand.org. Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0025-7079/16/5401-0032 32 | www.lww-medicalcare.com T he Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys are used by health plans to assess quality and for quality improvement initiatives, and by consumers and patients to assist in selecting among health care professionals, group practices, and health plans. 1 The CAHPS Clinician and Group (CG-CAHPS) survey is re- ported on the Centers for Medicare & Medicaid Services Physician Compare Web site, and a variant of CG-CAHPS is being used to evaluate Accountable Care Organizations (ACOs) participating in the Medicare Shared Savings Pro- gram. CG-CAHPS surveys have been administered to over 1.5 million patients from over 5000 US medical practices, 2 making it among the most frequently adopted survey for assessing patient experiences with care received from pro- viders and staff in primary, specialty, and ambulatory care settings. The full-length CG-CAHPS survey is perceived to be lengthy by some health care organizations (sponsors) who administer the instrument. The adult, 12-month CG-CAHPS survey includes 34 questions on a 5-page survey that assesses domains such as Provider Communication, Access to Care, and Courteous and Helpful Office Staff and can be com- pleted in approximately 15 minutes. A shortened version of the CG-CAHPS survey would reduce patient and admin- istrator burden, 3 potentially increase response rates, 4 and may enhance its use and impact on the delivery of health care. We report findings from 4 separate implementations of the CG-CAHPS survey to explore the effects of shortening it on the reliability and validity of measurement. The CG- CAHPS survey is standardized to ensure comparability across providers and groups. Because of this, it is important to ensure that any potential revision maintains the content of the domains and does not adversely affect the statistical properties of the measure. METHODS Data Collection and Procedures Survey data were collected using a combination mail and telephone modes of administration. Data reported here consisted of responses from 136,725 participants obtained from 4 separate CG-CAHPS collection efforts. (1) The physician group setting consists of 53 ambulatory clinic lo- cations, and 62 individual physicians, from which 63,441 respondents (response rate = 37%) were sampled from May Medical Care Volume 54, Number 1, January 2016 Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.

Background: Nonadherence to blood pressure lowering medication is a main contributor to poor hypertension control. While trust in the medical profession has been found to be associated with health behaviors such as treatment adherence, it has rarely been examined in Hispanics with hypertension and its relationship with health-related quality of life (HRQOL) is unknown. Objective: We evaluated a priori hypotheses positing that trust in the medical profession would be associated with greater medication adherence, resilience, and, in turn, better HRQOL in patients with hypertension. The three specific aims of this study were to: 1) examine the overall association (total effect) of trust in the medical profession and HRQOL (self-reported physical and mental health); 2) assess whether the association of trust with HRQOL is mediated by medication adherence and resilience; and 3) evaluate whether these associations vary by ethnicity (Hispanic vs. non-Hispanic). Methods: A cross-sectional survey that included the PROMIS® global physical and mental health scales and Morisky Medication Adherence Scale-8 was conducted with 201 adults (101 Hispanics and 100 non-Hispanics) under treatment for hypertension at a practice with seven cardiologists. A structural equation model was estimated to examine hypothesized associations (direct and indirect effects) among variables. Model fit was assessed via the chi-square statistic and three fit indices (Root Mean Square Error of Approximation; Comparative Fit Index; Non-Normed Fit Index). Results: The proposed model fit the data well and explained 37% of the variance in mental health and 15% of the variance in physical health. Trust was positively associated with physical health (β = 0.32, P < 0.001) and mental health (β = 0.43, P < 0.001). Trust was also positively associated with resilience (β = 0.18, P < 0.05), and medication adherence (β = 0.25, P < 0.05). Resilience was not significantly associated with physical health, but it was positively associated with mental health (β = 0.34, P < 0.001). Medication adherence was not significantly associated with either physical or mental health. Additionally, resilience partially mediated the relationship between trust and physical and mental health. And medication adherence partially mediated the relationship between trust and mental health, but did not significantly mediate the relationship between trust and physical health. A simultaneous group analysis indicated that Hispanic ethnicity did not moderate the associations between trust, medication adherence, resilience, and HRQOL. Conclusions: Findings suggest that trust in the medical profession serves as a protective mechanism for improving health in patients with hypertension by enhancing medication adherence, resilience, and global health irrespective of Hispanic ethnicity.

To examine racial/ethnic differences in Medicare beneficiary experiences with Medicare Part D prescription drug (PD) coverage.2008 Consumer Assessment of Health Care Providers and Systems survey of U.S. Medicare beneficiaries.Surveys were administered by mail with phone follow-up to a nationally representative sample (61% response rate). This study examines 201,496 beneficiaries of age 65 and older with PD coverage [6% Hispanic, 7% non-Hispanic Black, 3% non-Hispanic Asian or Pacific Islander (API)]. Key variables are self-reported race/ethnicity and Consumer Assessment of Health Care Providers and Systems getting information and needed PDs measures.We generated weighted case-mix adjusted means for 4 racial/ethnic groups and for Hispanics separately by English-language or Spanish-language preference status. We calculated within-plan disparities using a linear mixed-effect model, with fixed effects for race/ethnicity, coverage type and case-mix variables, and random effects for contract and contract by race/ethnicity interactions.Disparities for Hispanic, Black, and API beneficiaries on obtaining needed PDs and information regarding coverage range from -2 to -11 points (0-100 scale) relative to non-Hispanic Whites, with the greatest disparities observed for Spanish-preferring Hispanics and API beneficiaries, especially those with low income. There is wide variation in disparities across contracts, and contracts with the largest disparities for Hispanics have higher proportions of beneficiaries with lower education and income.Quality improvement efforts may be needed to reduce racial/ethnic disparities in beneficiary experience with PD coverage. Cultural, language, and health literacy barriers in navigating Medicare's Part D program may partially explain the observed disparities.

The complexity of health information frequently exceeds patients' skills to understand and use it. Improvement in hospital communication has the potential to improve the quality of care.To develop a set of items to supplement the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospital Survey (HCAHPS) to assess how well hospitals communicate health information to inpatients.We conducted an environmental scan and obtained input from stakeholders to identify domains and survey items, and cognitively tested the item set in English and Spanish. We administered the items to a random sample of adult hospital patients using mail and telephone data collection. We estimate item-scale correlations for hypothesized multi-item composites, internal consistency reliability for composites, correlations among composites, and regressed global rating of the hospital and a would you recommend the hospital items on HCAHPS existing core and the new composites to evaluate the unique contribution of each to these "bottom-line" measures.A total of 1013 surveys were obtained (55% response rate). With some exceptions, correlations between items and scales were consistent with the hypothesized item clusters. Three composites were identified: (1) communication about tests; (2) communication about how to care for self and medicines; and (3) communication about forms.This study provides support for the measurement properties of the HCAHPS Item Set for Addressing Health Literacy. It can serve as both a measure of whether healthcare providers in a hospital setting have communicated effectively with their patients and as a tool for quality improvement.

The complexity of health information often exceeds patients' skills to understand and use it.To develop survey items assessing how well healthcare providers communicate health information.Domains and items for the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Item Set for Addressing Health Literacy were identified through an environmental scan and input from stakeholders. The draft item set was translated into Spanish and pretested in both English and Spanish. The revised item set was field tested with a randomly selected sample of adult patients from 2 sites using mail and telephonic data collection. Item-scale correlations, confirmatory factor analysis, and internal consistency reliability estimates were estimated to assess how well the survey items performed and identify composite measures. Finally, we regressed the CAHPS global rating of the provider item on the CAHPS core communication composite and the new health literacy composites.A total of 601 completed surveys were obtained (52% response rate). Two composite measures were identified: (1) Communication to Improve Health Literacy (16 items); and (2) How Well Providers Communicate About Medicines (6 items). These 2 composites were significantly uniquely associated with the global rating of the provider (communication to improve health literacy: P0.001, b=0.28; and communication about medicines composite: P=0.02, b=0.04). The 2 composites and the CAHPS core communication composite accounted for 51% of the variance in the global rating of the provider. A 5-item subset of the Communication to Improve Health Literacy composite accounted for 90% of the variance of the original 16-item composite.This study provides support for reliability and validity of the CAHPS Item Set for Addressing Health Literacy. These items can serve to assess whether healthcare providers have communicated effectively with their patients and as a tool for quality improvement.

The objectives of the present study were to evaluate whether investigator bias influenced the Convergence Insufficiency Symptom Survey (CISS) scores of children with normal binocular vision (NBV) in our original validation study, reevaluate the usefulness of the cutoff score of 16, and reexamine the validity of the CISS.Six clinical sites participating in the Convergence Insufficiency Treatment Trial (CITT) enrolled 46 children 9 to18 years with NBV. Examiners masked to the child's binocular vision status administered the CISS. The mean CISS score was compared with that from the children with NBV in the original, unmasked CISS study and also to that of the 221 symptomatic convergence insufficiency (CI) children enrolled in the CITT.The mean (+/-standard deviation) CISS score for 46 subjects with NBV was 10.4 (+/-8.1). This was comparable with our prior unmasked NBV study (mean = 8.1 (+/-6.2); p = 0.11) but was significantly different from that of the CITT CI group (mean = 29.8 +/- 9.0; p0.001). Eighty-three percent of these NBV subjects scored16 on the CISS, which is not statistically different from the 87.5% found in the original unmasked study (p = 0.49).Examiner bias did not affect the CISS scores for subjects with NBV in our prior study. The CISS continues to be a valid instrument for quantifying symptoms in 9 to18-year-old children. These results also confirm the validity of a cut-point ofor = 16 in distinguishing children with symptomatic CI from those with NBV.

Objective: Illustrate an accessible method of bridging data from earlier surveys to the CAHPS® Hospital Survey to support hospitals' internal quality improvement efforts. Data Sources/Study Setting: Survey of patients with more than 300,000 annual hospitalizations in a large urban hospital. Study Design and Data: Six pairs of parallel items from the CAHPS and Picker Hospital Surveys were administered to the same 734 patients. We assessed item comparability and applied bridging adjustments to convert old items to predicted scores on the new CAHPS items. Principle Findings: Differences in wording, response options, and cut points for "problem scores" yielded large differences in problem score rates between the Picker and CAHPS Hospital Surveys, requiring bridging formulas. Tetrachoric correlations for 5 of 6 pairs indicated high correspondence (r = 0.71-0.97, P < 0.001) in the underlying constructs assessed by the 2 surveys, validating the use of bridging. Bridged scores contain less information per observation than directly measured new scores, but with sufficient sample sizes they can be used to detect trends across the transition. Conclusions: Hospitals can use the methodology described here to trend their scores from a previous survey to the CAHPS Hospital Survey with sufficient precision to support ongoing quality improvement efforts. Hospitals should administer an instrument containing pairs of old and new items to enough patients to yield at least 625 completes to measure bridging parameters precisely. Where correspondence is high, old items can and should be replaced by CAHPS items. Important old items with weaker associations with new items may be retained.

It is unknown if different national surveys that vary in mode of administration yield similar national averages for health-related quality of life (HRQoL).Examine HRQoL scores from 4 surveys representative of the noninstitutionalized US adult population for patterns related to age, gender, and mode of administration.We use data from the Joint Canada/United States Survey of Health (JCUSH; telephone survey), 2002 Medical Expenditure Panel Survey (MEPS; mail survey), National Health Measurement Study (NHMS; telephone survey), and US Valuation of the EuroQol EQ-5D Health States Survey (USVEQ; self-administered with interviewer present). We compare estimates from the EQ-5D, Visual Analog Scale, Health Utilities Index Mark 3, and general self-rated health stratified by age and gender. Scores were also regressed on age and gender within each survey and in a pooled analysis.We used 4939 subjects from JCUSH, 23,006 from MEPS, 3844 from NHMS, and 3878 from USVEQ. The majority of age and gender strata had instrument completion rates above 85%. Age- and gender-stratified estimates of HRQoL scores tended to be consistent when mode of administration (self- or interviewer-administered) was the same. Telephone administration yielded more positive HRQoL estimates than self-administration in older age groups. Older age groups and females reported lower HRQoL than younger age groups and males regardless of mode of administration.When choosing survey-collected HRQoL scores for comparative purposes, analysts need to take mode of administration into account.

Background: The construction and evaluation of item banks to measure unidimensional constructs of health-related quality of life (HRQOL) is a fundamental objective of the Patient-Reported Outcomes Measurement Information System (PROMIS) project. Objectives: Item banks will be used as the foundation for developing short-form instruments and enabling computerized adaptive testing. The PROMIS Steering Committee selected 5 HRQOL domains for initial focus: physical functioning, fatigue, pain, emotional distress, and social role participation. This report provides an overview of the methods used in the PROMIS item analyses and proposed calibration of item banks. Analyses: Analyses include evaluation of data quality (eg, logic and range checking, spread of response distribution within an item), descriptive statistics (eg, frequencies, means), item response theory model assumptions (unidimensionality, local independence, monotonicity), model fit, differential item functioning, and item calibration for banking. Recommendations: Summarized are key analytic issues; recommendations are provided for future evaluations of item banks in HRQOL assessment.

Adherence to antiretroviral medications is critical to achieving HIV viral suppression. Studies have been limited to cross-sectional analyses using measures that reflect only the percentage of prescribed doses taken (percent adherence), however. The contribution of dose timing and other factors to achieving virologic suppression has received less scrutiny.In a longitudinal study, we collected detailed adherence information using multiple tools along with demographic, clinical, social-behavioral, and virologic measures. Subjects were followed for 48 weeks. Percent adherence, dose-timing, genotypic sensitivity, and virologic outcomes were collected every 4 weeks. Repeated measures mixed effects models (RMMEMs) were used to model the relation between virologic outcomes and adherence as well as genotypic sensitivity and others.Of the 141 subjects, mean percent adherence was 73% with a downward trend. Viral load (VL) dropped significantly (P = 0.01) over time. RMMEMs revealed that higher genotypic sensitivity, higher percent adherence, lower baseline VL, longer inclusion in the study, earlier HIV stage, and smaller dose-timing error were significantly associated with lower VL. In multivariate modeling, a 0.50 increase in the genotypic sensitivity score, a 10% increase in adherence, and a decrease of 3 hours of dose-timing error were associated with a decrease in log10 HIV RNA at 48 weeks of 0.69, 0.54, and 0.48, respectively (P0.05 for each).Long-term viral suppression requires consistent and high percent adherence accompanied by optimal interdose intervals. Efforts to improve viral outcomes should address not only missed doses but excessive variation in dose timing and prevention of adherence decline over time. Preventing the development and transmission of resistant variants is also critically important.

To compare nurse practitioner/physician management of hospital care, multidisciplinary team-based planning, expedited discharge, and assessment after discharge to usual management.In the context of managed care, the goal of academic medical centers is to provide quality care at the lowest cost and minimize length of stay (LOS) while not compromising quality.Comparative, 2-group, quasiexperimental design was used; 1,207 general medicine patients (n=581 in the experimental group and n=626 in the control group) were enrolled. The control unit provided usual care. The care management in the experimental unit had 3 different components: an advanced practice nurse who followed the patients during hospitalization and 30 days after discharge, a hospitalist medical director and another hospitalist, and daily multidisciplinary rounds. LOS, hospital costs, mortality, and readmission 4 months after discharge were measured.Average LOS was significantly lower for patients in the experimental group than the control group (5 vs. 6 days, P.0001). The "backfill profit" to the hospital was US$1591 per patient in the experimental group (SE, US$639). There were no significant group differences in mortality or readmissions.Collaborative physician/nurse practitioner multidisciplinary care management of hospitalized medical patients reduced LOS and improved hospital profit without altering readmissions or mortality.

Little is known about the health burden of chronic viral hepatitis in HIV-infected patients. We compared health-related quality of life (HRQOL) of patients with HIV and hepatitis C virus (HCV) or HIV and hepatitis B virus (HBV) coinfection to those with HIV monoinfection.Using a nationally representative sample of 1,874 adults with HIV who completed a baseline and two follow-up interviews, we identified those with HIV monoinfection (n = 1,493), HIV-HCV coinfection (n = 279), and HIV-HBV coinfection (n = 122). We measured baseline and change over time scores for physical and mental health (PHS, MHS), overall quality of life (QOL), overall health, and disability days. To identify the independent effect of coinfection, we adjusted for demographic and clinical predictors of HRQOL using multivariable regression.Despite significant differences in socio-demographic characteristics between groups, there were no differences in the baseline scores for PHS, MHS, overall QOL, overall health, or disability days between groups. The HRQOL did not decline significantly over time for the HIV patients with or without HCV or HBV coinfection. All groups reported similar longitudinal changes in the HRQOL scores for all measures.We found no significant differences in disease burden as assessed by a generic HRQOL instrument between patients with HIV monoinfection and HIV-HCV or HIV-HBV coinfection. These data are relevant in counseling coinfected patients regarding the impact of coinfection on HRQOL, and are important in designing clinical trials and conducting cost-effectiveness analyses including this vulnerable cohort.

Goals: To compare the impact of irritable bowel syndrome (IBS) on health related quality of life (HRQOI) for non-white and white IBS patients. Background: There are no reported data evaluating the HRQOL of non-white persons with IBS. Study: SF-36 scores are compared between non-white IBS patients (n = 166), white IBS patients (n = 707), the general US population, and patients with selected chronic diseases. Results: Of the n = 166 non-white IBS patients included for analysis, 66 (40%) described themselves as African-American, 56 (34%) as Hispanic, 25 (15%) as Asian-American, 2 (1%) as Native American and the remaining 17 (10%) as other. Compared with white IBS patients, non-white IBS patients reported similar decrements in their HRQOL after controlling for age, gender, income and education level. On all 8 SF-36 scales, non-white IBS patients had significantly worse HRQOL compared with the general US population, (P < 0.001). Compared with GERD patients, non-white IBS patients scored significantly lower on all SF-36 scales (P < 0.001) except physical functioning. Similarly, non-white IBS patients had significantly worse HRQOL on selected SF-36 scales compared with diabetes mellitus and ESRD patients. Non-white IBS patients had significantly better emotional well-being than depressed patients, (P < 0.001). Conclusions: Non-white IBS patients experience impairment in vitality, role limitations-physical, and bodily pain. Yet overall, non-white IBS patients report similar HRQOL to white IBS patients. These data provide the first detailed evaluation of the impact of IBS on HRQOL in non-white IBS patients.

Model for end-stage liver disease (MELD) score is now often used as an overall indicator of health status for patients with end-stage liver disease. However, there are no data evaluating the associations between MELD scores and patient reports of health-related quality of life (HRQOL).Two hundred-three patients with end-stage liver disease completed a disease-targeted HRQOL instrument (the LDQOL 1.0). Patients also rated the severity of their liver disease and reported number of disability days attributed to their liver disease in the preceding month. MELD and Child Turcott Pugh (CTP) scores were calculated for all patients. Associations of MELD and CTP scores with patient-derived outcomes were estimated.The mean MELD and CTP scores were 12 and 7, respectively, indicating mild severity of liver disease. HRQOL of patients was generally poor, with the mean SF-36 physical and mental component summary scores of 35 and 40. Seventy percent of patients rated their liver disease symptoms as moderate to severe. Similarly, 70% reported being disabled from their liver disease. MELD was associated with physical functioning scale and the physical component summary (PCS) score in patients with end-stage liver disease. In contrast, CTP score was significantly associated with physical functioning, role limitations due to physical health problems, PCS score, effects of liver disease, sexual functioning, and sexual problems. Both MELD and CTP scores correlated with self-rated severity of liver disease symptoms but not with self-reported disability days.Despite objectively mild liver disease, the subjective HRQOL of this cohort was severely impaired. CTP score was more closely associated with patient-reported estimates of HRQOL than the MELD score. CTP or disease-specific HRQOL instruments may compliment MELD by providing insights into outcomes of importance to patients with low risk of mortality.

Purpose The purpose of this study was to determine how many patients are needed to provide reliable patient ratings of care at the individual clinician level. Setting and Sources of Data The study was conducted in an academic medical center and was based on analysis of 34,985 patients who completed a 50-item survey rating the care received during a recent outpatient visit to a physician or midlevel provider. Study Design Analyses of patient satisfaction surveys was done to: 1) confirm the dimensions of satisfaction with outpatient care in an existing measure, and 2) determine the number of patients required to provide reliable estimates of clinician care for single items and an 11-item composite scale. Principal Findings Factor analysis showed that the survey measured 2 dimensions of satisfaction: 1) clinician care, and 2) features of visiting the office. The 11-item clinician care scale had high reliability (Cronbach’s alpha = 0.97). The number of patients needed to achieve reliability of 0.80 at the clinician level was 66 for the 11-item scale and ranged from 52 to 91 for individual items. For primary care physicians only, the comparable number of patients per clinician was 77 for the 11-item scale and ranged from 50 to 147 across items. Conclusions For the survey items that we analyzed, the answer to the question “How many patients are needed to obtain useful and reliable feedback?” is at least 50, but varies by item type (global vs. specific) and by number of items (composite scale or single-item rating) and by the conditions of use (for self-assessment and learning or reward and punishment).

The objective of this study was to compare physician-level survey instruments and estimate the number of patients needed per physician to provide reliable estimates of health care. The setting consisted of 3 health plans and 1 large physician group in the greater Cincinnati metro area. Surveys were mailed to patients of 100 primary care physicians. Patients were mailed either the Consumer Assessment of Health Plans Study (CAHPS) or DoctorGuide survey instrument. A total of 4245 CAHPS surveys and 5519 DoctorGuide surveys were returned. Internal consistency reliability estimates for the multi-item scales (access to care, communication, and preventive care) for both surveys were adequate. The number of patient responses needed to obtain a reliability of 0.70 at the physician level for the access to care, communication, and preventive care scales were 32, 43, and 38, respectively, for the CAHPS survey and 26, 25, and 47, respectively, for the DoctorGuide survey. These results indicate similar and parallel psychometric performance for the DoctorGuide and CAHPS survey instruments.

Examined is the relationship of patient-reported health-related quality of life (HRQOL) to the mode of survey administration in the Hemodialysis Study. In addition to self-administered surveys to assess HRQOL, interviewer-administered surveys were made available to include patients with poor vision, decreased manual dexterity, or strong preference. For examining the predictors of participation by self-administration of the survey, multiple logistic regression was performed. For examining the relationship of HRQOL results to mode of survey administration, adjusted differences between the self-administered and interviewer-administered groups were obtained from multiple linear regression models accounting for sociodemographic and case-mix factors. A total of 978 of the first 1000 subjects in the Hemodialysis Study completed the survey by interview (n = 427) or by self-administration (n = 551). The interviewer-administered group was older, was more likely black, had longer duration of ESRD, had a higher prevalence of diabetes, and had more severe comorbidity (all P < 0.01). After adjustment for these differences, patients in the interviewer-administered group had higher scores on scales that measured Role-Physical, Role-Emotional, and Effects of Kidney Disease (all P < 0.001). Dialysis studies that restrict HRQOL measurement to patients who are able to complete surveys without assistance will not accurately represent the health of the overall hemodialysis population. Clinical studies and clinical practices using HRQOL as an outcome should include interviewer administration or risk a selection bias against subjects with older age, minority status, and higher level of comorbidity. Future investigation should include research of survey modalities with a low response burden such as telephone interview, computer-assisted interview, and proxy administration.

The objectives of this study were to provide a national profile of socioeconomic circumstances of the middle-aged and older population living with HIV and to evaluate variations in social support and quality of life (QOL) across age and socioeconomic subgroups, controlling for indicators of disease progression. The design used was a cross-sectional analysis of nationally representative interview data on HIV-infected individuals collected in the HIV Cost and Services Utilization Study. Multiple measures of social support and QOL were used. Bivariate comparisons of outcomes across categories of age and exposure category were performed; multivariate analyses to isolate the effect of older age on outcomes within exposure categories were performed, controlling for socioeconomic and clinical co-variates. Study results indicate that older gay men with HIV/AIDS are a predominantly white population and more likely to have health insurance than their younger counterparts; 38% were employed and 48% reported incomes of more than $25,000. Older injection drug users (IDUs) with HIV/AIDS are a predominantly black population with a particularly high concentration of disadvantages; only 11% were employed and 74% reported incomes of less than $10,000. Older IDUs reported especially low levels of physical functioning and emotional support in comparison with their younger counterparts, whereas older gay men did not significantly differ from younger gay men in these respects. The authors conclude that characteristics and care needs of the older HIV-positive population are very diverse and vary sharply by exposure route. Interventions need to be tailored to the needs of these distinct subpopulations, with an emphasis on development of supportive care interventions for older IDUs.

Summary of background data and objectives Alternative health care was used by an estimated 42% of the U.S. population in 1997, and chiropractors accounted for 31% of the total estimated number of visits. Despite this high level of use, there is little empirical information about who uses chiropractic care or why. Methods The authors surveyed randomly sampled chiropractors (n = 131) at six study sites and systematically sampled chiropractic patients seeking care from participating chiropractors on 1 day (n = 1275). Surveys collected data about the patient's reason for seeking chiropractic care, health status, health attitude and beliefs, and satisfaction. In addition to descriptive statistics, the authors compared data between patients and chiropractors, and between patients and previously published data on health status from other populations, corrected for the clustering of patients within chiropractors. Results More than 70% of patients specified back and neck problems as their health problem for which they sought chiropractic care. Chiropractic patients had significantly worse health status on all SF-36 scales than an age- and gender-matched general population sample. Compared with medical back pain patients, chiropractic back pain patients had significantly worse mental health (6-8 point decrement). Roland-Morris scores for chiropractic back pain patients were similar to values reported for medical back pain patients. The health attitudes and beliefs of chiropractors and their patients were similar. Patients were very satisfied with their care. Conclusion These data support the theory that patients seek chiropractic care almost exclusively for musculoskeletal symptoms and that chiropractors and their patients share a similar belief system.

Purpose: We estimated the association of sildenafil use with erectile function, relationship with sexual partner, functional status and emotional well-being in men with erectile dysfunction.Materials and Methods: Letters were mailed to eligible patients at a university hospital urology and internal medicine clinic, and university affiliated community primary care clinics by the primary care provider or urologist inviting them to participate in the study. Of the eligible sample 124 men (53%) completed and returned a survey, including 85 who reported current sildenafil use. Change scores in these patients were calculated using the International Index of Erectile Function, marital interaction scale from the Cancer Rehabilitation Evaluation System Short Form, 5-item emotional well-being scale of the RAND 36-Item Health Survey and 12-Item Short Form Health Survey.Results: Sildenafil users reported an 88% increase in erectile function scores, 60% increase in overall sexual satisfaction and 36% increase in inter...

Development and evaluation of the liver disease quality of life instrument in persons with advanced, chronic liver disease—the LDQOL 1.0

OBJECTIVES Consumer surveys are being used increasingly to assess the quality of care provided by health plans, physician groups, and clinicians. The purpose of the Consumer Assessment of Health Plans Study (CAHPS) is to develop an integrated and standardized set of surveys designed to collect reliable and valid information about health plan performance from consumers. This article reports psychometric results for the CAHPS 1.0 survey items in samples of individuals with Medicaid or private health insurance coverage. METHODS Reliability estimates for CAHPS 1.0 measures were estimated in a sample of 5,878 persons on Medicaid and 11,393 persons with private health insurance. Correlations of the CAHPS global rating of the health plan with willingness to recommend the plan and intention to re-enroll were estimated in a sample of 313 persons on Medicaid. The association of the rating of the health plan with ratings using a 5-point Excellent-to-Poor response scale also was investigated in the latter sample and in a sample of 539 persons with private health insurance. RESULTS The CAHPS measures appeared to have good reliability, particularly at the health-plan level. Responses from 300 consumers per health plan tend to yield estimates that are reliable enough for health plan comparisons, especially among the privately insured. The global health plan rating was significantly correlated with consumers' willingness to recommend the plan to family and friends and to their intention to re-enroll in the plan if given a choice. CONCLUSIONS The CAHPS 1.0 survey instrument appears to have excellent psychometric properties.

Objectives. It is important that health measures are both reliable and responsive to clinical change. The aim of this study was to assess the reliability and responsiveness of the physical, mental, and social health scales of the Duke Health Profile (DUKE). Methods. Impotent males self-administered the Duke Health Profile before and during treatment with alprostadil for erectile dysfunction during a 19-month period. Subjects were 490 patients in the United States and 583 patients in 12 other countries. Each of the three basic Duke Health Profile scales has only five items, and each is heterogeneous because each measures more than one health concept. Results. Cronbach's alpha reliability estimates were: physical health, 0.68 for United States and 0.64 for other countries; mental health, 0.62 and 0.52, respectively; and social health, 0.53 and 0.47, respectively. Alprostadil was expected to improve mental health primarily, and results of the study were consistent with this hypothesis. For example, at approximately 14 months from therapy onset, mental health improved for patients both in the United States (standardized response mean, SRM, = 0.17) and other countries (mean SRM = 0.30), whereas physical health worsened in the United States and was unchanged in other countries, and social health was unchanged in the United States and improved in other countries. Maximum responsiveness was shown for mental health in the other countries, where the mean standardized response means at four follow-ups during a 19-month period were 0.11, 0.21, 0.30, and 0.36. Conclusions. This study provides support for the responsiveness of the Duke Health Profile mental health scale.

Objectives. This study examined the prospective effect of reported access to medical care on health-related quality-of-life outcomes in patients with symptomatic human immunodeficiency virus (HIV) disease. Methods. A cohort study was designed with interviews at baseline, follow-up interviews at 3 months after baseline, mortality follow-up through 6 months after baseline, and medical record reviews for selected baseline clinical data. Participants were HIV-infected patients who were receiving ambulatory and/or hospital care at one county-run municipal and one Veterans Administration hospital in metropolitan Los Angeles and were interviewed about access to medical care (using a reliable 9-item scale assessing affordability, availability, and convenience of medical care). Access to care reported by this sample was compared with that of 2,471 patients with other chronic diseases from the Medical Outcomes Study. The main outcome measures were composite scores for physical and mental health-related quality of life 3 months after baseline, derived from a validated 56-item instrument, scored from 0 to 100, and controlling for baseline health-related quality of life. Results. Overall reported access to medical care in this sample was significantly poorer than that for patients with other chronic diseases (means scores were 63 and 73, respectively). The sample was categorized into tertiles of initial physical and mental health-related quality of life and into groups with initial high versus low access to care. Among those in the middle tertile of physical health-related quality of life at baseline, those with high access improved in physical health scores by 10.2 points relative to those with low access. Those in the low and middle tertiles of initial mental health improved in mental health to a significantly greater extent for those with high versus low access. There were nonsignificant trends toward similar effects for most other subgroups. The effects of access on health-related quality-of-life outcomes were generally robust in multivariate regression analyses that included CD4, hemoglobin, albumin, insurance status, and sociodemographic characteristics. Conclusions. Access to care at baseline predicted better physical and mental health outcomes at 3 months for those in the middle tertile of physical health and for those in the bottom and middle tertiles of mental health at baseline. Increasing access to care for poor public hospital patients with HIV infection may help to improve health-related quality-of-life outcomes among selected persons with advanced disease.

The objectives of this research were to: (1) evaluate the reliability and equivalence of the Arabic and English versions of the RAND-36 Health Survey (RAND-36) in a sample of Saudi Arabian citizens; and (2) assess the health status of a sample of Saudi Arabian citizens using both the Arabic and English versions.Both the Arabic and English versions of the survey were administered to a convenience sample of bilingual (English and Arabic) Saudi citizens (n = 415) at Saudi ARAMCO Company, Dhahran, Saudi Arabia. Internal consistency, equivalent-forms, and test-retest reliability were estimated for the eight multi-item scales in the Arabic and English versions. Mean scale scores were calculated for each version and compared with the general US populations.The median Cronbach's alphas for the Arabic RAND-36 in multiple subgroups exceeded 0.70 for every scale except one. Two of the English RAND-36 scales had median Cronbach's alphas that exceeded 0.70; the remainder exceeded 0.50. Two-week test-retest correlations were all statistically significant for both versions. Product-moment correlations to test the equivalence of the corresponding Arabic and English versions of the RAND-36 ranged from 0.73 to 0.92. Saudi citizens reported significantly higher vitality scores, but significantly lower physical functioning, social functioning, and general health perception scores than the general US population.The results provide support for the reliability and equivalence of the Arabic and English versions of the RAND-36. Additional studies need to be conducted in a representative sample of the general Saudi population to further assess the psychometric properties of the Arabic version.

Objectives The objectives of this investigation were to evaluate the dimensional structure of satisfaction with pharmacy services, to determine whether satisfaction is best viewed as a unidimensional or multidimensional construct, and to determine the degree of correspondence between a general satisfaction scale and satisfaction with specific aspects of pharmacy services. Methods Data was collected via telephone interviews of 509 patrons of traditional retail pharmacies and analyzed using structural equation modeling techniques. Results The hypothesized, multidimensional measurement model fit the observed data reasonably well. However, correlations between the latent dimensions of satisfaction with pharmacy services indicated that some dimensions were empirically indistinguishable. Conclusions Considering item content and theoretical considerations, modifications to the structure of previously used measures of satisfaction with pharmacy services were suggested. The data also support the hypothesis of a hierarchical model in which general satisfaction could be simultaneously represented as both an overall domain and as a set of distinct dimensions tapping unique aspects of satisfaction with pharmacy services. Depending on the purpose of the measurement, either or both levels of analysis may be useful.

PURPOSE To assess the association between structural factors in the health care delivery system and self-reported utilization of ophthalmic services by patients with diabetes in the Medical Outcomes Study (MOS). METHODS Self-reported utilization of ophthalmic services within the 6 months preceding enrollment into the MOS among 522 of 567 individuals with diabetes in the MOS longitudinal panel was measured. Use of eye care services was regressed (logistic model) on patient demographics, geographic location, physician specialty, type of practice, and finance plan (prepaid or fee-for-service). RESULTS None of the variables was significantly associated with a higher or lower likelihood of having used ophthalmic services in the preceding 6 months. Thus, no difference between prepaid or fee-for-service plans or among solo practice, large multispecialty groups, or HMOs were identified. Having seen an internist, family practitioner, or diabetes specialist for diabetes care was not related to use of ophthalmic services. CONCLUSIONS Despite a presumed greater interest in preventive health, prepaid health plans were no more or less likely than the fee-for-service sector to have patients with diabetes reporting an eye examination within the prior 6 months. Thus, steps to improve the rate of eye examinations of diabetics may need to focus beyond the structural elements of the health care delivery system.

Previous studies have found that health-status measures may be unable to detect clinically important changes for patients whose baseline health is poor (the "floor phenomenon"). It is not known whether this inability to detect change is confined to patients in very poor baseline health or whether the sensitivity of health-status instruments varies across the entire range of health states. The goals of this study were to see how changes in physical health, mental health, and overall health (1) depend on baseline (usual) health and (2) compare with patients' global assessment of changes in their health.Stable, ambulatory patients presenting to the emergency department of a public hospital retrospectively rated their usual physical health (eight items), mental health (three items), and overall health (one item); their health on the day of study entry using these same items; and their global assessment of the change in their health compared with baseline. Complete information on these items was available for 1,005 patients. Baseline scores on the physical and mental health subscales and the overall health item were divided into five categories: 81 to 100 (best), 61 to 80, 41 to 60, 21 to 40, and 0 to 20 (worst).The mean difference in health from baseline to emergency department presentation decreased as the baseline health category worsened, as follows: physical health, -26.0, -35.9, -15.1, -9.5, +1.0; mental health, -23.0, -16.1, -9.6, 0.0, 6.6; overall health -64.0, -45.3, -28.4, -8.4, 10.4, respectively. However, patients' global assessment of health change showed the opposite trend; the proportion of patients rating their health as "much worse" than baseline increased as baseline health worsened. When only patients whose physical health score declined less than 10 points were analyzed, 14% of those in the best baseline health said their health was "much worse," whereas 74% of those with the worst baseline physical health said their health was "much worse" than baseline.These findings suggest that the sensitivity of health-status measures to change and the meaning of an incremental change in physical health or mental health vary depending on baseline health. This may result from noninterval properties of response options or from patients being at the lowest health state (the "floor") of individual questions. If health-status measures similar to this are to be used to compare the outcomes of treatment across diseases and for patients in a wide variety of baseline health states, weighting schemes may be needed to account for these effects.

To assess whether better access to community-based outpatient medical services was associated with fewer HIV-related hospitalizations, we studied 217 patients hospitalized at seven southern California hospitals. During hospital admission, patients completed an interview that included one item about the reported difficulty or ease of access to community-based medical services prior to their first hospitalization for HIV-related illness. After discharge, medical records were abstracted for data on prior hospitalizations. CD4 counts, and illness severity. About one-half of patients reported that medical services were readily accessible. Medical records revealed that since the time of HIV infection 49% had two or more total hospitalizations (mean = 2. SD = 2). In multiple logistic regression analysis, better reported access to services was significantly associated with not having been hospitalized (vs. having been hospitalized) over the same time period (OR = 0.73, 95% CI = 0.55-0.97), controlling for CD4 count, illness severity, duration of diagnosed HIV infection, having a regular source of care, type of hospital care, insurance coverage, and other patient characteristics. Improving access to community-based medical services for ambulatory HIV-infected patients may help to avert costly hospital care. Prospective studies are needed to assess whether a causal relationship between greater community-based access and reduced hospitalizations exists and, if so, whether community-based services may be cost-effective substitutes for hospital HIV care.

Despite growing interest in the accessibility of medical care and health-related quality of life for persons infected with human immunodeficiency virus, an association between these variables has not been documented. The authors conducted a cross-sectional study of access to care and its association with health-related quality of life among 205 persons of low income infected with the human immunodeficiency virus with constitutional symptoms and/or diarrhea at one public and one Veterans Administration hospital, using a 9-item measure of perceived access and a 55-item health-related quality of life instrument. Problems with access were widespread: 55% traveled for longer than 30 minutes to their usual source of care (compared with 9% to 12% of general populations in national surveys), 49% had problems meeting costs of care, and 48% had problems with clinic hours (compared with 23% in national surveys). In multivariate analyses, uninsured patients reported worse access than patients with Medicaid or Veterans Administration insurance, particularly for meeting the cost of care (P < 0.01). Adjusted health-related quality of life scores in this sample were far lower (by about 1 SD) than those of subjects in a large national acquired immune deficiency syndrome clinical trial. For 8 of 11 health-related quality of life subscales, worse perceived access was significantly (P < 0.05) associated with poorer health-related quality of life, even after controlling for T-4 lymphocyte count, symptoms and other factors. Access and health-related quality of life measures similar to those used in this study may prove useful in future evaluations of medical care systems serving poor, clinically ill populations infected with human immunodeficiency virus.

In the past decade physicians have identified the need to expand patient assessment to include global function and quality of life. During the same period, the busy clinic has evolved into the location where this assessment seems most appropriate. Integrating functional health assessment into a busy clinical practice is difficult because the necessary steps require time, thought, recording, and follow-up. Attention to the office ecosystem is very important before any patient care management method is introduced. The clinician must transform the results of health status screening into a specific functional diagnosis. The clinician has to understand the sensitivity, specificity, and predictive value of the measure for a preliminary diagnosis to be made. Often, additional measurements must be taken to establish a specific diagnosis. These steps encompass assessment linkage. Once the specific cause for the dysfunction is recognized, the clinician then has to determine the need for special resources. This is called the resource linkage. By following the steps outlined in this paper, the clinician should be able to overcome many obstacles for functional health status assessment in busy ambulatory settings.

The goals of surgery in treating intractable epilepsy are to eliminate seizures and improve quality of life. This report describes the development of the Epilepsy Surgery Inventory (ESI)-55, a 55-item measure of health-related quality of life for epilepsy patients. The ESI-55 includes the following scales (number of items in parentheses): health perceptions (9), energy/fatigue (4), overall quality of life (2), social function (2), emotional well-being (5), cognitive function (5), physical function (10), pain (2), and three separate scales of role limitations due to emotional, physical, or memory problems (5 items each). Also included is one change in health item. The ESI-55 was completed by 89% of 224 adults who had undergone a protocol evaluation for epilepsy surgery since 1974. Alpha internal consistency reliability coefficients ranged from 0.76 to 0.88 except for social function (alpha = 0.68). Multitrait scaling analyses supported item discrimination across scales. Factor analysis confirmed previously identified mental and physical health factors, and yielded a third factor defined by cognitive function and role limitations scales. Construct validity was supported by correlations of the ESI-55 with a mood profile instrument. Analysis of ESI-55 scale scores by seizure classification showed that the 44 patients who were seizure-free following surgery scored higher than did 55 patients who continued to have seizures (P less than 0.05 for all comparisons); 43 patients having seizures without loss of consciousness scored in between. Results of this study indicate that the ESI-55 is reliable, valid, and sensitive to differences in seizure status.

Interest in health-related quality of life (HRQOL) is burgeoning and there has been a proliferation of self-report measures of HRQOL. However, only two instruments available for measuring HRQOL have been calibrated using empirically derived preferences; both are long and complex. This study tested a brief survey designed to concurrently assess HRQOL and preferences for different HRQOL states. Multitrait-multimethod (MTMM) analysis was used to evaluate the construct validity of the survey in a convenience sample of 116 persons. Two methods were used to assess six aspects of HRQOL: general health perceptions, meaningful activities, outlook on life, physical suffering, self-care activities, and social relationships. HRQOL preferences were assessed using two methods similar to those used for self-reports, as well as one additional method. The construct validity of self-reported HRQOL was supported. On the other hand, substantial method variance and little valid trait variance was observed for the HRQOL preferences. Results are discussed in terms of their implications for evaluating and measuring HRQOL and related preferences.

Because of the rapid changes that have occurred in the dental profession, the Dentist Satisfaction Survey (DSS) was developed to assess both facet and overall job satisfaction among dentists. The DSS was administered to a sample of 558 California general dentists. The results suggest that the DSS is a practical, reliable, and valid measure of dentists' job satisfaction. Internal consistency reliability coefficients for all facet subscales and the overall job satisfaction scale ranged from 0.60-0.92. The DSS discriminated between groups of dentists known to have different levels of job satisfaction; dentists identified by dental society presidents as being very dissatisfied scored significantly differently in the hypothesized direction on the DSS. A high correlation (r = 0.68) was found between judges' independent ratings of dentists' satisfaction based on their open-ended comments and DSS scores. While the majority of respondents were satisfied with most facets of their jobs, substantial variation was found among dentists in their levels of satisfaction.

ORIGINAL CONTRIBUTIONS nature publishing group FUNCTIONAL GI DISORDERS see related editorial on page x Development of the NIH Patient-Reported Outcomes Measurement Information System (PROMIS) Gastrointestinal Symptom Scales Brennan M.R. Spiegel , MD, MSHS, RFF, FACG, AGAF 1 , 2 , 3 , 4 , Ron D. Hays , PhD 4 , 5 , Roger Bolus , PhD 2 , Gil Y. Melmed , MD, MS 1 , Lin Chang , MD 5 , 6 , Cynthia Whitman , MPH 2 , Puja P. Khanna , MD, MPH 7 , Sylvia H. Paz , PhD 4 , Tonya Hays , MS 4 , Steve Reise , PhD 8 and Dinesh Khanna , MD, MSc 7 OBJECTIVES: The National Institutes of Health (NIH) Patient-Reported Outcomes Measurement Information System (PROMIS ® ) is a standardized set of patient-reported outcomes (PROs) that cover physical, mental, and social health. The aim of this study was to develop the NIH PROMIS gastrointestinal (GI) symptom measures. METHODS: We fi rst conducted a systematic literature review to develop a broad conceptual model of GI symp- toms. We complemented the review with 12 focus groups including 102 GI patients. We developed PROMIS items based on the literature and input from the focus groups followed by cognitive de- briefi ng in 28 patients. We administered the items to diverse GI patients (irritable bowel syndrome (IBS), infl ammatory bowel disease (IBD), systemic sclerosis (SSc), and other common GI disorders) and a census-based US general population (GP) control sample. We created scales based on con- fi rmatory factor analyses and item response theory modeling, and evaluated the scales for reliability and validity. RESULTS: A total of 102 items were developed and administered to 865 patients with GI conditions and 1,177 GP participants. Factor analyses provided support for eight scales: gastroesophageal refl ux (13 items), disrupted swallowing (7 items), diarrhea (5 items), bowel incontinence / soilage (4 items), nausea and vomiting (4 items), constipation (9 items), belly pain (6 items), and gas / bloat / fl atulence (12 items). The scales correlated signifi cantly with both generic and disease-targeted legacy instru- ments, and demonstrate evidence of reliability. CONCLUSIONS: Using the NIH PROMIS framework, we developed eight GI symptom scales that can now be used for clinical care and research across the full range of GI disorders. SUPPLEMENTARY MATERIAL is linked to the online version of the paper at http://www.nature.com/ajg Am J Gastroenterol 2014; 109:1804–1814; doi: 10.1038/ajg.2014.237; published online 9 September 2014 INTRODUCTION Patients typically seek health care because they experience symp- toms. Th is is especially true in gastroenterology where most digestive disorders initially present with symptoms rather than biochemical abnormalities alone. To fully describe the illness experience of gastrointestinal (GI) patients, providers must elicit, measure, and interpret patient symptoms as part of their clinical evaluation ( 1,2 ). Department of Gastroenterology, Cedars-Sinai Medical Center , Los Angeles , California , USA ; 2 Cedars-Sinai Center for Outcomes Research and Education , Los Angeles , California , USA ; 3 Department of Gastroenterology, VA Greater Los Angeles Healthcare System , Los Angeles , California , USA ; 4 Department of Health Policy and Management, UCLA Fielding School of Public Health , Los Angeles , California , USA ; 5 Department of Medicine, David Geffen School of Medicine at UCLA , Los Angeles , California , USA ; 6 Gail and Gerald Oppenheimer Family Center for Neurobiology of Stress, David Geffen School of Medicine at UCLA , Los Angeles , California , USA ; 7 Division of Rheumatology, University of Michigan , Ann Arbor , Michigan , USA ; 8 Department of Psychology, UCLA , Los Angeles , California , USA . Correspondence: Brennan M.R. Spiegel, MD, MSHS, RFF, FACG, AGAF , Department of Gastroenterology and Health Services, Cedars-Sinai Medical Center, Pacifi c Theatre Building, 116 N. Robertson Blvd, 4th Floor , Los Angeles , California 90048 , USA or Dinesh Khanna, MD, MSc, University of Michigan Scleroderma Program, Division of Rheumatology / Department of Internal Medicine, 300 North Ingalls Street, Suite 7C27, Ann Arbor, Michigan 48109, USA. E-mail: bspiegel@ucla.edu or khannad@med.umich.edu Received 24 December 2013; accepted 24 June 2014 The American Journal of GASTROENTEROLOGY VOLUME 109 | NOVEMBER 2014 www.amjgastro.com