Telephone Follow-up Of Nonrespondents Research Articles

Sex differences in Medicare beneficiaries' experiences by low-income status.

Medicare beneficiaries dually eligible for Medicaid are a low-income group who are often in poor health. Little research has examined sex differences in patient experience by dual/low-income subsidy (LIS) status. Cross-sectional comparison by sex and low-income status. We used linear regression to compare 6 case mix-adjusted patient experience measures (on a 0-100 scale) by sex within non-dual/LIS and dual/LIS beneficiary groups among 549,603 respondents 65 years and older to the 2016-2017 Medicare Consumer Assessment of Healthcare Providers and Systems surveys of beneficiary experience with Medicare (mail with telephone follow-up of nonrespondents, 42% response rate). Dual/LIS male beneficiaries reported worse patient experiences on all 6 measures than female beneficiaries, with scores 1 to 2 percentage points lower for 3 measures and less than 1 percentage point lower for the other 3 measures. For 4 of the 6 measures, sex differences among dual/LIS beneficiaries were significantly larger than those among non-dual/LIS beneficiaries. In all 4 instances, the gaps between men and women among dual/LIS beneficiaries favored women; P < .05 for all differences discussed. Low-income male Medicare beneficiaries are more likely to report poor patient experiences, possibly because of lower health literacy, less patient activation, and smaller social networks, along with provider responses to these characteristics. Efforts to address these patient-level factors should happen in parallel with structural-level approaches to train and prepare providers to ensure attentive, respectful patient-centered care for all patients. Additionally, targeted use of ombudsmen and interventions may help reduce inequities.

Do dual eligible beneficiaries experience better health care in special needs plans?

Dual Eligible Special Needs Plans (D-SNPs) were intended to provide better care for beneficiaries eligible for both Medicare and Medicaid through better coordination of these two programs. 671913 dual eligible (DE) respondents to the 2009-2019 Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. We compared the 2015-2019 experiences of DE beneficiaries in D-SNPs relative to fee-for-service Medicare (FFS) and non-SNP Medicare Advantage (MA) using propensity-score weighted linear regression. Comparisons were made to 2009-2014. 12 patient experience measures were considered. Annual mail survey with telephone follow-up of non-respondents. More than 65% of DE beneficiaries enrolled in FFS. Of 12 measures, D-SNP performance was higher than non-SNP MA on two (P<.05), lower than non-SNP MA on two (P<.05), and higher than FFS on four (P<.01). DE beneficiaries did not report better coordination of care in D-SNPs. D-SNP performance was often worse than other coverage types in prior periods. Relative to FFS Medicare, DE beneficiaries report higher immunization rates in D-SNPs, but slight or no better performance on other dimensions of patient experience. New requirements in 2021 may help D-SNPs attain their goal of better care coordination.

Using predicted Spanish preference to target bilingual mailings in a mail survey with telephone follow-up.

Spanish-preferring Medicare beneficiaries are underrepresented in national patient experience surveys. We test a method for improving their representation via higher response rates. 2009-2010 Medicare CAHPS surveys; Medicare population. We used surname and address to predict Spanish-language preference for a national sample of 177139 beneficiaries. We randomized half of the 10000 non-Puerto Rico beneficiaries with the highest predicted probabilities of Spanish preference (>10 percent) to bilingual mailings (intervention) and half to standard English-only mailings (control). Medicare CAHPS Survey data were collected through mail surveys with telephone follow-up of nonrespondents. Mail response rate was higher for intervention (28.7 percent) than control (23.9 percent) (P<0.0001); phone response rates among mail nonrespondents were similar in intervention and control arms (15.8 percent vs 15.7 percent, P=0.90). Targeted bilingual mailings induced 6.5 percent of those who would not have responded to respond by mail and 54.0 percent of those who would have responded in English to respond in Spanish. Beneficiaries with greater Spanish probabilities showed greater increases in response rates, a higher proportion of responses in Spanish, and lower control response rates among. Targeted bilingual mailing of mixed-mode surveys using commonly available surname and address information can efficiently increase representation of this underrepresented group.

Experiences of Care Among Medicare Beneficiaries With ESRD: Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey Results

Patients with end-stage renal disease (ESRD) have special health needs; little is known about their care experiences. Secondary analysis of 2009-2010 Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) data, using representative random samples of Medicare beneficiaries. Description of Medicare beneficiaries with ESRD and investigation of differences in patient experiences by sociodemographic characteristics and coverage type. Data were collected from 823,564 Medicare beneficiaries (3,794 with ESRD) as part of the Medicare CAHPS survey, administered by mail with telephone follow-up of nonrespondents. ESRD status, age, education, self-reported general and mental health status, race/ethnicity, sex, Medicare coverage type, state of residence, and other demographic measures. 6 composite measures of patient experience in 4 care domains (access to care, physician communication, customer service, and access to prescription drugs and drug information) and 4 ratings (overall care, personal physician, specialist physician, and prescription drug plan). Patients with ESRD reported better care experiences than non-ESRD beneficiaries for 7 of 10 measures (P < 0.05) after adjustment for patient characteristics, geography, and coverage type, although to only a small extent (adjusted mean difference, <3 points [scale, 0-100]). Black patients with ESRD and less educated patients were more likely than other patients with ESRD to report poor experiences. Inability to distinguish patient experiences of care for different treatment modalities. On average, beneficiaries with ESRD report patient experiences that are at least as positive as non-ESRD beneficiaries. However, black and less educated patients with ESRD reported worse experiences than other ESRD patients. Stratified reporting of patient experience by race/ethnicity or education in patients with ESRD can be used to monitor this disparity. Physician choice and confidence and trust in physicians may be particularly important for patients with ESRD.

Management of neonatal abstinence syndrome: a national survey and review of practice

Aim:To ascertain the present management of neonatal abstinence syndrome (NAS) in neonatal units in the United Kingdom (UK) and Ireland.Methods:Postal questionnaire to 235 neonatal units, with telephone follow-up of non-respondents.Results:The...

Differences Between Painless and Painful Constipation Among Community Women

In the Rome II criteria, patients with both constipation and abdominal pain (AP) (i.e., "painful constipation" (PC)), who do not satisfy criteria for irritable bowel syndrome (IBS) are included in the same functional constipation (FC) category as patients with constipation without AP (i.e., "painless constipation" (PLC)). What differences, if any, exist between FC without (i.e., PLC) and with AP (i.e., PC) are unclear. To compare clinical features among PLC, PC, constipation-predominant IBS (C-IBS), and non-C-IBS, a validated questionnaire was mailed (with telephone follow-up of nonresponders) to an age-stratified random sample of 5,200 adult women in Olmsted County, Minnesota. Altogether, 2,800 women (53%) responded. The age-adjusted prevalence of PLC (7.1 per 100; 95% confidence interval (95% CI), 6.2-8.0) was higher compared to PC (0.9 per 100; 95% CI, 0.6-1.2). Compared to PLC, patients with PC reported worse general health (i.e., excellent or very good = 37.5% vs 51.2%), more somatic symptoms (mean score = 1.3 vs 0.9), and urinary urgency (% often = 58% vs 32%), and had a higher prevalence of hysterectomy. Bowel symptoms significantly impacted > or =1 domain of quality of life (QOL) in 18% of PC versus 9% of PLC. In a logistic discriminant model, age, general health, impact of bowel symptoms on QOL, somatic symptoms, and urinary urgency independently discriminated between bowel subtypes. Patients with PC more closely resemble those with C-IBS than PLC. Consideration should be given to separating PC from PLC in the Rome criteria and in therapeutic trials.

Variation in institutional review board responses to a standard protocol for a multicenter clinical trial.

Multicenter clinical trials require approval by multiple local institutional review boards (IRBs). The Multicenter Airway Research Collaboration mailed a clinical trial protocol to its U.S. investigators and 44 IRBs ultimately reviewed it. To describe IRB responses to one standard protocol and thereby gain insight into the advantages and disadvantages of local IRB review. Two surveys were mailed to participants, with telephone follow-up of nonrespondents. Survey 1 was mailed to 82 investigators across North AMERICA: Survey 2 was mailed to investigators from 44 medical centers in 17 U.S. states. Survey 1 asked about each investigator's local IRB (e.g., frequency of meetings, membership), whereas survey 2 asked about IRB queries and concerns related to the submitted clinical trial. Both surveys had 100% response rate. Investigators submitted applications a median of 58 days (interquartile range [IQR], 40--83) after receipt of the protocol, and IRB approval took an additional 38 days (IQR, 26--62). Although eight applications were approved with little or no changes, IRBs requested an average of 3.5 changes per site. Changes involved study logistics and supervision for 45%, the research process for 43%, and the consent form for 91%. Despite these numerous requests, all eventually approved the basic protocol, including inclusion criteria, intervention, and data collection. The IRBs showed extreme variability in their initial responses to a standard protocol, but ultimately all gave approval. Almost all IRBs changed the consent form. A national, multicenter IRB process might streamline ethical review and warrants further consideration.

Selective decontamination of the digestive tract — current national practice

The use of selective decontamination of the digestive tract (SDD) in the intensive care setting was first reported in 19841 and, since then, has been the subject of many further studies. Two large meta-analyses have been conducted2 3 and have suggested that, used alone, the topical element of SDD reduces the incidence of nosocomial respiratory tract infections (NRTIs), but has no impact on mortality. When the systemic element is added, however, not only are NRTIs prevented, but mortality is also reduced. It was estimated that either six2, or five3 patients had to be treated to prevent one NRTI and 23 to prevent one death. This would appear to be a worthwhile effect and one which, in terms of supporting evidence, compares favourably with some interventions used commonly in clinical practice. Despite this, there is an impression that SDD is very little used in this country and this study sought to explore this. In September 1998, a questionnaire was sent to the directors of all general intensive care units (ICUs) in the UK and Ireland (n = 289). In addition to basic information about the unit, it asked whether SDD was in routine use, if so whether both topical and systemic elements were used, and whether it was used on all or selected cases. If SDD was not routinely used, it asked for the reasons. A telephone follow-up of non-responders was undertaken. Responses were obtained from 222 ICUs (77%). Of these, 66 were in teaching and 156 in non-teaching hospitals. A total of 213 units (96%) never used SDD. The nine units that did use it (six teaching, three non-teaching) did so only in selected cases. The commonest reason for selective use was major trauma, but liver failure, liver transplants, long-stay patients, burns and oesophageal perforation were also cited. Of the nine units using SDD, all but one used combined topical and systemic antibiotics. A lack of evidence of efficacy was the commonest reason for non-use (184 units) but concerns were also expressed about costs and cost-effectiveness (47 units) and the development of resistant organisms (35 units). Unusually for intensive care practice, SDD represents a treatment for which there is reasonable evidence of efficacy and yet one which, paradoxically, is rarely used. It is particularly interesting that the lack of such evidence is most commonly cited as the reason for non-use. The potential for producing resistant organisms and the issue of cost-effectiveness are, as yet, unquantified and may prove to be more valid reasons.

C ANCELLATION OF R ESPONDING ALS U NITS BY BLS P ROVIDERS : A N ATIONAL S URVEY

Objective. In many emergency medical services (EMS) systems, personnel without advanced life support (ALS) training are authorized to cancel responding ALS units before the ALS personnel arrive and examine the patient. This study was conducted to examine these cancellations in major U.S. cities. Methods. A survey was mailed to the physician medical directors of the EMS services of the 125 largest U.S. cities, with telephone follow-up of nonresponders. The survey requested information on system structure, and on policies governing cancellation of responding ALS units by non-ALS personnel. Results. Ninety-four cities responded (75%), from 35 states. Nineteen systems (20%) are all-ALS with no basic life support (BLS) tier, and these were eliminated. Of the remaining 75 systems, eight (11%) use BLS ambulances (BLS-A), 35 (47%) use BLS first responders (BLS-FR), and 32 (43%) use both. Of these 75 systems, 60 (80%) allow cancellation of responding ALS units by BLS personnel. Only 24 of these (40%) have written protocols for such cancellations, and only 12 of those (50%) involve specific medical criteria, with two (8%) relying on the best judgment of the BLS personnel with no medical criteria, and another eight (33%) allowing cancellation only for logistic reasons. Of the 60 systems that permit cancellation, 13 (22%) perform some type of medical oversight review of all such calls, 26 (43%) review some such calls (median 10%, range 2–80% for the 19 systems specifying a percentage), 15 (25%) do not review any, and six did not specify. Conclusions. Fewer than half of the surveyed EMS systems that permit non-ALS personnel to cancel responding ALS units use written protocols to guide these decisions, and only half of those protocols utilize specific medical criteria. Medical oversight review of these calls is highly variable, with many systems reviewing few or none of these cancellations.

Occupational factors and reproductive outcomes among a cohort of female veterinarians

Objective To estimate absolute and relative risks of preterm delivery (PTD) and small-for-gestational-age (SGA) births among a cohort of female veterinarians in relation to selected occupational factors, including clinical practice type (CPT). Design Retrospective cohort survey. Sample Population 2,997 female graduates from US veterinary colleges between 1970 and 1980. Procedure Relevant health and occupational data were collected through a self-administered mail questionnaire with telephone follow-up of nonrespondents. Absolute and relative risks of PTD and SGA births were estimated in relation to maternal CPT at the time of conception and exposure to 13 occupational factors. Attempts were made to control confounding by use of multiple logistic regression analyses. Results Absolute and relative risks of PTD were highest for veterinarians employed in exclusively equine clinical practice. Although several increased, none of the CPT-specific relative risk estimates were significantly different from the null value of 1. Exposure-specific analyses indicated that occupational involvement with solvents among exclusively small animal practitioners was associated with the highest relative risk of PTD. A small number of SGA births limited information that could be obtained from these analyses. Overall absolute risks of PTD and SGA births among cohort members were much lower in comparison with the general female population. Clinical Implications Given the large number of women currently practicing and entering the profession of veterinary medicine, clinical tasks associated with potential reproductive hazards should be approached with heightened awareness and increased caution, especially activities that may involve exposure to solvents. (J Am Vet Med Assoc 1998;213:61-67)

Hazardous materials preparedness in the emergency department

Introduction. This study was conducted to examine the preparedness of emergency departments (EDs) to safely receive, decontaminate, and treat chemically contaminated patients.Methods. The safety officers of all 58 acute-care hospitals in the five-county Philadelphia metropolitan region were surveyed by mail, with a repeat mailing to nonresponders followed by telephone contact. The 16 survey questions addressed the ability of EDs to safely decontaminate and treat chemically contaminated patients.Results. Thirty-eight of 58 hospitals (66%) returned usable surveys. Of these, 24 (63%) have a written plan for decontamination and treatment of chemically contaminated patients in the ED, and 19 (50%) have a hospital-wide disaster plan that includes contingencies for decontamination and treatment of one or more chemically contaminated patients. Thirteen hospitals (34%) conducted a drill of either of these plans in 1994. Twenty (53%) EDs have a specific treatment area for chemically contaminated patients. A stock of supplies for protecting the ED from secondary contamination is maintained by 16 (42%). While 24 (63%) store personal protective equipment, most of these involve only gowns, gloves, and surgical masks; only 13 provide any type of respiratory protection. Nine respondents were certain that patients brought in by local EMS would have been adequately decontaminated in the field, eight stated that they believed or felt decontamination would be adequate, and 12 were concerned that field decontamination might not be adequate. Eighteen hospitals (47%) reported treating one or more chemically contaminated patients in 1994. The authors believe the return rate reflects reluctance to commit hospital policies to paper. This was confirmed during telephone follow-up of nonrespondents when, for example, one safety officer discussed hazardous materials (hazmat) principles for 40 minutes, but refused to complete the survey.Conclusions. Hospital hazmat preparedness in this area varies tremendously. A significant proportion of hospitals lack a written plan and equipment to allow the ED to safely and effectively handle the chemically contaminated patient. There is reluctance to discuss this topic.

The deliberate misdiagnosis of major depression in primary care.

Because the correct diagnosis of a psychiatric condition can jeopardize reimbursement and other benefits, physicians deliberately substitute alternative diagnoses. We estimated the prevalence of alternative coding for major depression by primary care physicians and the reasons for its occurrence. Cross-sectional mail survey with telephone follow-up of nonresponders. Primary care practices in communities across the nation. Physicians were eligible to participate if they were randomly selected from membership lists of two professional organizations of primary care clinicians. Four hundred forty-four physicians (70.0% of eligible physicians and 89.5% of eligible physicians we could locate) completed the survey by mail or telephone. Substitution of an alternative code for major depression within a 2-week period. Of our respondents, 50.3% (SE, +/- 2.5%) reported that they had substituted another diagnostic code during a 2-week period for one or more patients whom they recognized met the criteria for major depression in the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition. Thirty-one percent of depressed patients received alternative codes. The most common reasons for these substitutions involved physician uncertainty about the diagnosis and problems with reimbursement for services if a diagnosis of major depression was coded. The practice of deliberately substituting another diagnostic code for major depression is widespread among primary care providers. Physicians who employ deliberate misdiagnosis circumvent inequitable policies for particular patients, but the impact of substitution on the health care system as a whole deserves more careful consideration.

The Swedish Health-Related Quality of Life Survey (SWED-QUAL)

We present a Swedish Health-Related Quality of Life Survey (SWED-QUAL) that was adapted from measures used in the Medical Outcome Study (MOS). The development of these measures spans more than 20 years and their reliability and validity have been extensively tested. The SWED-QUAL consists of 61 items that form 11 multi-item scales tapping aspects of physical, mental, social and general health. The instrument was mailed in 1991 to a random stratified sample of 2,366 individuals from the Swedish general population aged 18-84 years and to a stratified random sample of 2,349 individuals who had been seriously injured in a traffic accident. The response rates were 61% and 59%, respectively. Telephone follow-up of non-responders indicate that most of those tended to have a better health-related quality of life than responders. The SWED-QUAL satisfied all of the psychometric criteria that were evaluated. Multitrait scaling provided strong support for item discrimination. Cronbach's alpha exceeded 0.78 for all scales. Scores tended to be lower among older than younger people, and among females compared to males. The good response rate indicates that the content of the SWED-QUAL is considered relevant by people at large, that the results from the general population sample could be used for comparisons with other samples and the instrument used for further studies of the effectiveness of a broad spectrum of medical interventions.