The Association Between Care Experiences and Parent Ratings of Care for Different Racial, Ethnic, and Language Groups in a Medicaid Population

Patient and parent assessments of health care have become increasingly recognized as important dimensions of health care quality (Committee on Quality of Health Care in America, Institute of Medicine 2001). The Consumer Assessment of Healthcare Providers and Systems (CAHPS) includes a family of standardized surveys used throughout the United States to evaluate patient experiences with health plans, providers, hospitals, and other health care entities (AHRQ 2007). CAHPS surveys elucidate how best to meet the needs of patients (Crofton, Lubalin, and Darby 1999). For adults, poor patient evaluations of care are associated with higher utilization of services (Zastowny, Roghmann, and Cafferata 1989), less compliance with medical regimens, poorer medical outcomes (Hall and Dornan 1990; David and Rhee 1998; Alazri and Neal 2003;), and increased frequency of changing providers (Newcomer, Preston, and Harrington 1996; Allen and Rogers 1997; Kerr et al. 1998; Schlesinger, Druss, and Thomas 1999; Haviland, Pincus, and Morales 2003; Lied et al. 2003;). In pediatric populations, high parent-reported quality of care has been associated with less nonurgent emergency department utilization (Brousseau et al. 2007, 2009). Prior studies have found specific associations between care experiences assessed using CAHPS composite measures and CAHPS global ratings (Morales et al. 2001, 2003; Hargraves, Hays, and Cleary 2003; Elliott et al. 2009). There is also evidence that some care experiences may be more important in predicting ratings of care than others (Morales et al. 2001; Hargraves, Hays, and Cleary 2003; Elliott et al. 2009;). Further, certain patient-specific characteristics, such as visit type and patient demographics, may influence the weight given to various care experiences (Morales et al. 2001; Mosen et al. 2004; Elliott et al. 2009;). Together, these studies indicate the potential utility in tailoring quality improvement interventions for patients with different characteristics and provide the rationale for the approach used here. This is the first detailed large-scale examination of the association between care experiences (as measured by CAHPS composites), and global ratings of care for children of different racial, ethnic, and language groups. It provides understanding of whether the same underlying experiences can be targeted in quality improvement efforts to improve overall experiences, and it informs the extent to which such efforts must be tailored for different subgroups. These prior studies, as well as many others examining CAHPS scores, have focused on the frequency of positive assessments of care. However, recent studies demonstrate the importance and utility of problem-oriented reporting, focusing on the frequency of negative ratings (Elliott et al. 2007), given that patients assign greater weight to negative information when forming impressions, or making judgments and choices (Ito et al. 1998; Scanlon et al. 2002;). Dissatisfaction with care, as demonstrated by poor ratings of care, has been associated with frequently changing doctors and disenrollment from health plans (Newcomer, Preston, and Harrington 1996; Kerr et al. 1998;) as well as malpractice suits (Fullam et al. 2009). In this study, we use a problem-oriented approach to examine the relationship between parent experiences of care as measured by CAHPS composites and negative ratings of that care for different racial/ethnic/language subgroups in order to better understand whether future interventions to improve pediatric care experiences and ratings should be differentially tailored for these groups. Because we were most interested in studying differences between whites and other racial/ethnic groups, we chose to conduct this study with a population of children insured by Medicaid to ensure adequate sample sizes for our subgroups of interest.