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Objectives: To estimate the associations among hospital-level scores from the Consumer Assessments of Healthcare Providers and Systems (CAHPS) Hospital pilot survey within and across different services (surgery, obstetrics, medical), and to evaluate differences between hospital- and patient-level analyses.Data Source: CAHPS Hospital pilot survey data provided by the Centers for Medicare and Medicaid Services.Study Design: Responses to 33 questionnaire items were analyzed using patient- and hospital-level exploratory factor analytic (EFA) methods to identify both a patient-level and hospital-level composite structures for the CAHPS Hospital survey. The latter EFA was corrected for patient-level sampling variability using a hierarchical model. We compared results of these analyses with each other and to separate EFAs conducted at the service level. To quantify the similarity of assessments across services, we compared correlations of different composites within the same service with those of the same composite across different services.Data Collection: Cross-sectional data were collected during the summer of 2003 via mail and telephone from 19,720 patients discharged from November 2002 through January 2003 from 132 hospitals in three states.Principal Findings: Six factors provided the best description of inter-item covariation at the patient level. Analyses that assessed variability across both services and hospitals suggested that three dimensions provide a parsimonious summary of inter-item covariation at the hospital level. Hospital-level factor structures also differed across services; as much variation in quality reports was explained by service as by composite.Conclusions: Variability of CAHPS scores across hospitals can be reported parsimoniously using a limited number of composites. There is at least as much distinct information in composite scores from different services as in different composite scores within each service. Because items cluster slightly differently in the different services, service-specific composites may be more informative when comparing patients in a given service across hospitals. When studying individual-level variability, a more differentiated structure is probably more appropriate. [ABSTRACT FROM AUTHOR]

Objective: To identify a parsimonious subset of reliable, valid, and consumer-salient items from 33 questions asking for patient reports about hospital care quality.Data Source: CAHPS Hospital Survey pilot data were collected during the summer of 2003 using mail and telephone from 19,720 patients who had been treated in 132 hospitals in three states and discharged from November 2002 to January 2003.Methods: Standard psychometric methods were used to assess the reliability (internal consistency reliability and hospital-level reliability) and construct validity (exploratory and confirmatory factor analyses, strength of relationship to overall rating of hospital) of the 33 report items. The best subset of items from among the 33 was selected based on their statistical properties in conjunction with the importance assigned to each item by participants in 14 focus groups.Principal Findings: Confirmatory factor analysis (CFA) indicated that a subset of 16 questions proposed to measure seven aspects of hospital care (communication with nurses, communication with doctors, responsiveness to patient needs, physical environment, pain control, communication about medication, and discharge information) demonstrated excellent fit to the data. Scales in each of these areas had acceptable levels of reliability to discriminate among hospitals and internal consistency reliability estimates comparable with previously developed CAHPS instruments.Conclusion: Although half the length of the original, the shorter CAHPS hospital survey demonstrates promising measurement properties, identifies variations in care among hospitals, and deals with aspects of the hospital stay that are important to patients' evaluations of care quality. [ABSTRACT FROM AUTHOR]

Background Transcarotid artery revascularization (TCAR) was approved by the Food and Drug Administration in 2015 for patients with carotid artery stenosis. However, no randomized trial to evaluate TCAR has been performed to date, and previous reports have important limitations. Accordingly, we measured stroke or death after TCAR compared with carotid endarterectomy (CEA) and transfemoral carotid artery stenting (TF-CAS). Methods and Results We used the Vascular Quality Initiative registry to study patients who underwent TCAR, CEA, or TF-CAS from September 2016 to June 2021. Our primary outcomes were perioperative and 1-year stroke or death. We used logistic regression for risk adjustment for perioperative outcomes and Cox regression for risk adjustment for 1-year outcomes. We used a 2-stage residual inclusion instrumental variable (IV) method to adjust for selection bias and other unmeasured confounding. Our instrument was a center's preference to perform TCAR versus CEA or TF-CAS. We performed a subgroup analysis stratified by presenting neurologic symptoms. We studied 21 234 patients who underwent TCAR, 82 737 who underwent CEA, and 14 595 who underwent TF-CAS across 662 centers. The perioperative rate of stroke or death was 2.0% for TCAR, 1.7% for CEA, and 3.7% for TF-CAS ( P <0.001). Compared with TCAR, the IV-adjusted odds ratio of perioperative stroke or death for CEA was 0.74 (95% CI, 0.55-0.99) and for TF-CAS was 1.66 (95% CI, 0.99-2.79). Results were similar among both symptomatic and asymptomatic patients. The 1-year rate of stroke or death was 6.4% for TCAR, 5.2% for CEA, and 9.7% for TF-CAS ( P <0.001). Compared with TCAR, the IV-adjusted hazard ratio of 1 year stroke or death for CEA was 0.97 (95% CI, 0.80-1.17), and for TF-CAS was 1.45 (95% CI, 1.04-2.02). IV analysis further demonstrated that symptomatic patients with carotid stenosis had the lowest 1-year likelihood of stroke or death with TCAR (compared with TCAR, symptomatic IV-adjusted hazard ratio for CEA: 1.30 [95% CI, 1.04-1.64], and TF-CAS: 1.86 [95% CI, 1.27-2.71]). Conclusions Perioperative stroke or death was greater following TCAR when compared with CEA. However, at 1 year there was no statistically significant difference in stroke or death between the 2 procedures. TCAR performed favorably compared with TF-CAS at both time points. Although CEA remains the gold standard procedure for patients with carotid stenosis, TCAR appears to be a safe alternative to CEA and TF-CAS when used selectively and may be useful when treating symptomatic patients.

Background The long-term effectiveness of atherectomy treatment for peripheral arterial disease is unknown. We studied 5-year clinical outcomes by endovascular treatment type among patients with peripheral arterial disease. Methods and Results We queried the Medicare-linked VQI (Vascular Quality Initiative) registry for endovascular interventions from 2010 to 2015. The exposure was treatment type: atherectomy (with or without percutaneous transluminal angioplasty [ PTA] ), stent (with or without PTA ), or PTA alone. The outcomes were major amputation, any amputation, and major adverse limb event (major amputation or any reintervention). We used the center-specific proportions of atherectomy procedures performed in the 12 months before a patient's procedure as the instruments to perform an instrumental-variable Cox model analysis. Among 16 838 eligible patients (median follow-up: 1.3-1.5 years), 11% underwent atherectomy, 40% received PTA alone, and 49% underwent stenting. Patients receiving atherectomy commonly underwent femoropopliteal artery treatment (atherectomy: 65%; PTA : 49%; stenting: 43%; P<0.001) and had worse disease severity (Trans-Atlantic Inter-Society Consensus score [TASC] B and greater; atherectomy: 77%; PTA : 68%; stenting: 67%; P<0.001). The 5-year rate of major adverse limb events was 38% in patients receiving atherectomy versus 33% for PTA and 32% for stenting (log rank P<0.001). Controlling for unmeasured confounding using instrumental-variable analysis, patients treated with atherectomy experienced outcomes similar to those of patients treated with PTA , except for a higher risk of any amputation (hazard ratio: 1.51; 95% CI , 1.08-2.13). However, compared with stenting, atherectomy patients had a higher risk of major amputation (hazard ratio: 3.66; 95% CI , 1.72-7.81), any amputation (hazard ratio: 2.73; 95% CI , 1.60-4.76), and major adverse limb event (hazard ratio: 1.61; 95% CI , 1.10-2.38). Conclusions Atherectomy is used to treat severe femoropopliteal and tibial peripheral arterial disease even though long-term adverse outcomes occur more frequently after this treatment modality.