September 11, 2012 Naomi Dyer, PhD, Joann Sorra , PhD, Scott Smith, PhD, Westat

1. Psychometric Properties of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Clinician and Group Adult Visit Survey September 11, 2012 Naomi Dyer, PhD, Joann Sorra, PhD, Scott Smith, PhD, Westat Paul Cleary, PhD, Yale Ron Hays, PhD, RAND

2. Background • CAHPS is a multiyear initiative of AHRQ to support and promote the assessment of consumers’ experiences with health care • Numerous CAHPS surveys have been created for different health care settings such as : • Health Plan • Surgical Care • Home Health Care • Hospital • In-center Hemodialysis • Nursing Home • Clinician & Group

3. Background • Westat, under contract with AHRQ, houses the database for Clinician and Group CAHPS (CG-CAHPS) and reports on these data

4. Background • There are several CG-CAHPS Surveys: • CG-CAHPS 12-month Survey (Adult and Child) • CG-CAHPS 12 month Survey with Patient-Centered Medical Home • CG-CAHPS Visit Survey (Adult and Child) • CG-CAHPS Database is the newest component of the CAHPS Databases • The CG-CAHPS Adult Visit Survey database received the most data in 2011

5. Background • The CG-CAHPS Visit surveys were created to allow patients to report on and evaluate their experiences during their most recent outpatient medical visit • The 12 month versions ask about their experiences in the previous year • Surveys and related material available at: http://cahps.ahrq.gov/clinician_group/

6. Survey Development • Goal: Develop a survey to assess patients' experiences with medical groups and clinicians. • Development of the Visit Survey began in 2008 • Field testing in 2009 to compare with the 12-month survey version • Results led to the Access to Care items in the survey reverting to a 12-month reference period rather than visit-specific

7. CG-CAHPS Composites • 3 composites 1. Access to Care (5 items) 2. Doctor Communication (6 items) 3. Courteous/Helpful Staff (2 items) • 2 overall rating items 1. Overall Doctor Rating (11-point scale; 0 = “Worst doctor possible”, 10 = “Best doctor possible”) 2. Recommend the Doctor’s Office to family and friends (3-point scale; “No” to “Yes, definitely”) • Various socio-demographics including overall health, age, gender, and education

8. Access to Care Composite • All 5 items reference a 12-month period • 4-point scale (1 = Never, 2 = Sometimes, 3 = Usually, 4 =Always)

9. Access to Care Composite • In the last 12 months, • How often did you get an appointment for care you needed right away as soon as you needed? • How often did you get an appointment for routine care as soon as you needed? • When you phoned this doctor’s office during regular office hours, how often did you get an answer to your medical question that same day? • When you phoned this doctor’s office after regular office hours, how often did you get an answer to your medical question as soon as you needed? • How often did you see this doctor within 15 minutes of your appointment time?

10. Doctor Communication Composite • All six items reference the most recent office visit • 3-point scale (1 = Yes, definitely; 2 = Yes, somewhat; 3 = No) • During your most recent visit, did this doctor… • Explain things in a way that was easy to understand? • Listen carefully to you? • Give you easy to understand information about your health questions or concerns? • Seem to know the important information about your medical history? • Show respect for what you had to say?

11. Courteous/Helpful Staff Composite • Both items reference the office visit • 3-point scale (1 = Yes, definitely; 2 = Yes, somewhat; 3 = No) • During your most recent visit, were clerks and receptionists at this doctor’s office… • As helpful as you thought they should be? • Treat you with courtesy and respect?

12. CG-CAHPS Analysis Dataset • Adult Visit Survey Data from the CG-CAHPS Comparative Database • 103,442 responses • 469 practice sites • There were 5 screener questions that determined if the composite item was to be answered by respondents • 4 screener questions for Access to Care • 1 screen question Doctor Communication • Only non-missing data for the composite items were included in the analysis

13. CG-CAHPS Analysis Dataset • 93% of respondents did not phone their doctor after regular hours • Because of the high percentage of skips, “How often did you get an appointment for care you needed right away as soon as you needed?” was dropped from analysis • Remaining 4 Access to Care composite items had responses between 46% to 98% of respondents • Final CG-CAHPS Analysis Dataset • 450 practice sites • 21,318 responses

14. Characteristics of Analysis Dataset • All respondents received paper/mail surveys • 89% of sites were Family Practice or Internal Medicine • 69% of sites were owned by a hospital or integrated delivery system • 67% of respondents were female; • 81% were 45 years or older

15. Psychometric Analyses and Criterion • Individual and Multilevel Confirmatory Factor Analysis (CFA) • Factor loadings above 0.40 • Acceptable model fit indices • CFI > 0.95 • RMSEA < 0.06 • SRMR < 0.08 (Individual, Between- and Within-) • Individual Internal Consistency Reliability Analysis • Cronbach’s α ≥ 0.70

16. Psychometric Analyses and Criterion • Practice Site Reliability Analysis • Reliability ≥ 0.70 • Examined reliability by practice size categories • 1 clinician • 2 to 3 clinicians • 4-9 clinicians • 10-13 clinicians • 14-19 clinicians • 20 or more clinicians • Correlation analysis among the composites and global ratings • Individual and practice site levels

17. Individual Level CFA Results • All items within composites had individual factor loadings above 0.40 with average loadings of • Access to Care: 0.68 • Doctor Communication: 0.76 • Courteous/Helpful Staff: 0.86 • All model fit indices met criteria • CFI: 0.97 • RMSEA: 0.05 • SRMR: 0.04

18. Multilevel CFA Results • All items at practice site level had factor loadings above 0.40 • Between site factor loadings range: 0.59 to 0.99 • Within site factor loadings rage: 0.45 to 0.99 • All model fit indices met criteria except between-practice site SRMR • CFI: 0.97 • RMSEA: 0.03 • Between SRMR: 0.10 • Within SRMR: 0.05

19. Internal Consistency Reliability • All items at individual level had Cronbach’s alpha above 0.70 • Access to Care α = 0.77 • Doctor Communication α = 0.89 • Courteous/Helpful Staff α= 0.85

20. Practice Site Reliability • Practice site reliability estimate were acceptable for all site with at least 4 clinicians • For a site with 1 clinician • Only Access to Care had reliability above 0.70 • For a site with 2-3 clinicians • Access to Care and Courteous/Helpful Staff had reliability above 0.70 • The average number of respondents for 1 clinician and 2-3 clinicians was less than 100 • Smaller sites need more respondents per practice to increase reliability to acceptable levels

21. Individual Correlations • Strongest correlation was between Doctor Communication and Overall Global Rating Items • All correlations were significant (p < 0.05)

22. Practice Site Level Correlations • Strongest correlation was between Doctor Communication and Recommend Doctor’s Office • All correlations were significant (p < 0.05)

23. Summary • Overall, both the individual level and multilevel confirmatory factor analysis results provided support for the survey’s three composites • The CG-CAHPS composites have acceptable individual-level internal consistency reliability • The reliability remains acceptable across sites with four to twenty or more clinicians

24. Email: naomidyer@westat.com