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Community health centers (CHCs) are responsible for providing care for more than fifteen million Americans, many of whom are members of groups who have been documented to receive low-quality care. This study examines the quality of care for patients with chronic disease in a nationally representative sample of federally funded CHCs. Fewer than half of eligible patients received appropriate care for the majority of indicators measured, and uninsured patients received poorer care than insured patients. Although the quality of chronic disease care in CHCs compares favorably with that of care received in other settings, gaps in quality were observed for the uninsured. [ABSTRACT FROM AUTHOR]

Before the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, Medicare reimbursed physicians for chemotherapy drugs at rates that greatly exceeded physicians' costs for those drugs. We examined the effect of physician reimbursement on chemotherapy treatment of Medicare beneficiaries older than age sixty-five with metastatic lung, breast, colorectal, or other gastrointestinal cancers between 1995 and 1998 (9,357 patients). A physician's decision to administer chemotherapy to metastatic cancer patients was not measurably affected by higher reimbursement. Providers who were more generously reimbursed, however, prescribed more-costly chemotherapy regimens to metastatic breast, colorectal, and lung cancer patients. [ABSTRACT FROM AUTHOR]

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. Drop-out, often accompanied by treatment non-compliance, is common in psychiatric trials. Methodologists have criticized the use of a traditional intention-to-treat (ITT) approach in such cases, and have proposed alternative methods. We set out to describe and assess methods for estimation of a treatment effect when the trial is 'broken'.Method. We describe a stratified method of moments (SMOM) estimator that assesses treatment effects on subjects who are willing to comply with all the treatments under study. A simulation study and a re-analysis of data from an antipsychotics trial are used to compare SMOM to ITT, as-treated, and adequate estimators.Results. The new estimator retains good statistical properties under different levels of non-compliance and drop-out mechanisms. The re-analysis indicates that SMOM yields more precise results.Conclusions. Although the traditional ITT approach provides a valid method to estimate treatment effects, it can be biased in the presence of treatment non-compliance and drop-out. It is critical that researchers move beyond traditional approaches when trials are broken. A key first step is to consider non-compliance and drop-out as two independent phenomena, tracking and reporting rates separately. [ABSTRACT FROM AUTHOR]