1. Is There A Relationship between Hospital Encounters for Ambulatory Care Sensitive Conditions and Beneficiaries Experience and Satisfaction with Health Care? P.O. Box 12194 · 3040 Cornwallis Road · Research Triangle Park, NC 27709 Phone: 919-485-2788 · Fax: 919-990-8454 · ebrody@rti.org · www.rti.org RTI International is a trade name of Research Triangle Institute. Presented at the AcademyHealth 2004 Annual Research Meeting, San Diego, CA, June 6–8, 2004 Presenting author: Erica Brody, MPH Co-authors: Shulamit Bernard, PhD, RN Lisa Carpenter, BS

2. Research Objective n To examine whether the incidence of hospital encounters for ambulatory care sensitive conditions are associated with self reports of poor access to care or dissatisfaction with health care services among Medicare Fee-for-Service (MFFS) beneficiaries.

3. Ambulatory Care Sensitive Conditions Studied n Cellulitis n Congestive Heart Failure n Dehydration n Bacterial Pneumonia n Septicemia n Ischemic Stroke n Urinary Tract Infection n Asthma n Chronic Obstructive Pulmonary Disease n Acute Diabetic Events among Medicare beneficiaries with diabetes n Lower Limb Peripheral Vascular Disease among Medicare beneficiaries with diabetes

4. Measures of Patient Satisfaction: MFFS Consumer Assessment of Health Plans Survey (CAHPS) n Experience with Care l Getting Needed Care l Getting Care Quickly l Good Communication with Provider n Satisfaction with Care l Rate Medicare l Rate Care n Customer Service l Respectful Treatment l Medicare Customer Service l Rate Personal Doctor l Rate Specialist

5. Analytic File n 103,551 MFFS beneficiary respondents l Claims data l CAHPS survey data l Medicare enrollment and eligibility data

6. Analysis File Construction: Claims-Based Measure of Quality - ACSC n Incidence of hospital encounters for ACSC l 1999-2001 MFFS claims data for the 2000 CAHPS survey sample l We used ICD codes from inpatient and emergency room data to identify an ACSC during the 12 months preceding the date of the survey response.* l In the event that the date of survey response was not available we used the mid-point of the survey period. *Note that the reference period for the CAHPS survey is 6 months

7. Analysis File Construction: Beneficiary Satisfaction with Care – CAHPS Indicators n Survey data from MFFS beneficiaries (2000 survey) n Estimated weighted and case-mix adjusted means for 9 CAHPS measures n Case-mix adjustment variables l Education l Proxy assistance l Proxy respondent l Self-reported health l Self-reported mental health l Claims-based measure of health status – HCC score

8. Claims-based measure of health status – HCC score n Hierarchical Condition Categories (HCC) n Aggregate ICD-9-CM diagnostic codes into 184 clinically meaningful diagnostic categories n Organized into multiple body system or disease type hierarchies that distinguish disease severity of related diagnoses. n For this analysis, the claims-based health status measure used was equal to the beneficiarys HCC risk score divided by the national mean of HCC of all Medicare beneficiaries in 2000, resulting in: l a range of 0.13 to 12.29, and l a mean of 1.53, l with higher scores indicating greater disease severity.

9. Analysis n Calculated case-mix adjusted mean CAHPS® ratings and composites stratified by whether or not beneficiaries had an ACSC using the CAHPS® 3.4 Survey and Reporting Kit macros n Compared means by ACSC for 9 CAHPS indicators n Used two sample t-tests for differences in means for all pairwise comparisons (p<0.05 with Bonferroni corrections)

10. Demographic Characteristics and Health Status of Study Population Variable MFFS Beneficiaries with an ACSC (n=6,351) MFFS Beneficiaries with No ACSC (n=97,200) Age* <64 65-69 70-74 75-79 80+ 12.9 12.5 19.5 20.3 34.9 10.3 21.9 24.8 20.5 22.5 Gender Male Female 44.2 55.8 43.2 56.8 Race*White Black Other 88.7 9.3 2.0 90.3 6.9 2.8 * p<0.001

11. Health Status of Study Population Variable MFFS Beneficiaries with an ACSC (n=6,351) MFFS Beneficiaries with No ACSC (n=97,200) Self-rated health* Excellent Very Good Good Fair Poor 1.4 7.3 21.9 39.6 29.9 6.5 22.2 33.8 27.9 9.5 Self-rated mental health* Excellent Very Good Good Fair Poor 11.4 23.6 28.9 24.0 12.1 22.3 31.7 27.0 14.8 4.3 HCC score*2.130.82 * p<0.001

12. CAHPS Ratings and Composites IndicatorRangeMean Score Experience with Care Needed Care1-32.81 Care Quickly1-43.41 Good Communication1-43.57 Satisfaction with Care Rate Medicare0-108.70 Rate Care0-108.80 Rate Specialist0-108.84 Rate Personal Doctor0-108.86 Customer Service Respectful Treatment1-43.73 Medicare Customer Service1-42.51

13. Results: Comparison of Average CAHPS scores for MFFS Beneficiaries By ACSC indicator IndicatorACSCNo ACSCp-value Experience with Care Needed Care2.802.81P<.01 Care Quickly3.413.40NS Good Communication3.57 NS Satisfaction with Care Rate Medicare8.688.70NS Rate Care8.798.81NS Rate Specialist8.838.85NS Rate Personal Doctor8.858.86NS Customer Service Respectful Treatment3.73 NS Medicare Customer Service2.522.51NS

14. Is There a Relationship between ACSCs and CAHPS ® Measures of Quality? n Although beneficiaries with an ACSC were modestly more likely to report problems getting needed care, and this difference was statistically significant, the mean difference in this CAHPS composite was very small. n Overall, there were virtually no differences in mean CAHPS scores between beneficiaries who did or did not experience an ACSC encounter.

15. Implications n Health care quality is a multi-dimensional concept. n We need both consumer measures of satisfaction and experience, as well as clinical measures of quality to have a full understanding of health care quality. n This analysis used a composite measure of ACSC. Additional research is needed to examine whether there is relationship between CAHPS measures and ACSC for specific conditions.