CAHPS Surveys: Sorting Fact from Fiction

Rebecca Anhang-Price
Policy Researcher; Associate Director, Health Services Delivery Systems
RAND

Can patients really report on the quality of the care they receive? Do patients' expectations affect how they respond to CAHPS survey questions about their providers? Is there a tradeoff between positive patient experiences and favorable clinical outcomes? In this podcast, Rebecca Anhang-Price from the RAND Corporation talks about some common concerns and misconceptions related to CAHPS surveys.

• Listen to the Interview (MP3, 8 min 15 sec)

Learn more:

• "Should Health Care Providers be Accountable for Patients' Care Experiences?" in the Journal of General Internal Medicine.
• "Examining the Role of Patient Experience Surveys in Measuring Health Care Quality" in Medical Care Research and Review.

Transcript

Jeff Brady: The Agency for Healthcare Research and Quality welcomes you to our series of podcasts on topics related to CAHPS surveys. I'm Rear Admiral Jeff Brady, Assistant Surgeon General, U.S. Public Health Service, and director of AHRQ's Center for Quality Improvement and Patient Safety. We are pleased to sponsor this podcast series as part of our mission to develop and disseminate scientific knowledge, tools, and data to improve the health care system and help patients make informed health care decisions. I'd like to introduce Dale Shaller, who will moderate this podcast and introduce you to our guest.

Dale Shaller [Moderator]: Thank you Dr. Brady, and welcome everyone to our podcast on "CAHPS Surveys: Sorting Fact from Fiction." My name is Dale Shaller and I'm a member of the CAHPS research team that's based at Yale University, and I'm pleased to serve as the moderator of our podcast series on CAHPS. Today I'm joined by Rebecca Anhang-Price, a CAHPS team member and a policy researcher at the RAND Corporation and Rebecca and I will be talking about some common concerns and misconceptions related to CAHPS surveys. So Rebecca, welcome!

Rebecca Anhang-Price: Thanks, Dale, great to be here!

Dale Shaller: Well let's start off with the big picture. Results from CAHPS surveys, as you know, are increasingly being reported to the public. They're also being used in pay-for-performance programs. Some people express concern about using information from CAHPS surveys to measure health care quality. Why should CAHPS results be used in public performance reports and payment programs?

Rebecca Anhang-Price: It's a great question! I think the main answer is that patient experiences are an essential element in any assessment of health care quality. They're intrinsically important – that means they matter to patients. Patient experience surveys give patients a voice to describe those experiences. And good patient experiences go hand in hand with better clinical outcomes. Because of that, measures of patient experience help health care providers improve care and help patients choose between health care providers. They can also help health care purchasers identify good value.

Dale Shaller: Well Rebecca, do patients really have the expertise that they need to answer questions about the quality of their health care?

Rebecca Anhang-Price: Well Dale, CAHPS surveys ask patients to report on what happened to them in the health care setting. That includes things like their interactions with their health care providers, like how respectful and responsive their providers were to their needs, whether they received understandable information, and got timely answers to medical questions, and got appointments for care when they needed them. Patients are the best and only source of that kind of information. What CAHPS surveys don't do is ask about the technical quality of care, since that information is better obtained from other sources. Measures from CAHPS surveys are meant to complement technical measures of health care quality, to provide an overall assessment of the quality of care.

Dale Shaller: Okay, but it does seem that what patients might expect to happen could affect how they respond to the survey. So for example, if a patient expects to get a prescription or some other treatment or maybe a diagnostic test, wouldn't they maybe give their doctor a poor rating if the doctor didn't do what they expected them to do? And wouldn’t those kinds of situations encourage doctors to do what patients ask for in order to improve their scores instead of providing the most appropriate care?

Rebecca Anhang-Price: Well research suggests that patients value how well their providers communicate more than whether their providers offer a specific treatment. And there are a lot of proven strategies that health care providers can use to ensure that patients have a positive experience even when they don't get exactly what they ask for. These strategies are things like involving patients in decision making, discussing the context for the patients' requests, proposing alternatives, and offering the possibility that a request will be fulfilled later if the patient's condition warrants it later. To our knowledge, there’s no published evidence indicating that health care providers get higher CAHPS scores by providing inappropriate or unnecessary care.

Dale Shaller: Okay, I see that and that's helpful, but if doctors and hospitals spend a lot of their time and effort to improve patient experience scores, like CAHPS, wouldn't that distract them from providing high quality clinical care? So in other words, is there a tradeoff between providing really great patient experiences and getting superb clinical outcomes?

Rebecca Anhang-Price: There's a lot of evidence showing that it's possible for health care providers to simultaneously offer better patient experiences and better clinical quality. In fact, we believe that good clinical care depends on both superior technical quality and great patient experiences. Dozens of studies have found either a positive relationship or no relationship between CAHPS scores and ratings of clinical quality, and that suggests that there is no tradeoff between those two.

Dale Shaller: Well I know that some people are concerned that it's just not fair to compare CAHPS scores across different health care providers or health plans. And it does seem like there are factors beyond their control – like say, the age or education of their patients– that could affect how their patients respond to the surveys.

Rebecca Anhang-Price: It's true that factors like how old or how sick patients are can affect CAHPS scores. But those differences can be accounted for by a statistical technique called case-mix adjustment, which makes it possible to estimate how health care providers would score if they all served patients with similar characteristics. Case-mix adjustment aims to level the playing field. And it reduces the likelihood that providers will avoid taking patients who they think will report poor experiences because of factors that aren't in providers' control.

Dale Shaller: Well another issue that I know comes up quite often has to do with concerns about the length of many of the CAHPS surveys. It does seem like the surveys to some people are really too long and that that discourages patients from responding.

Rebecca Anhang-Price: Actually, the evidence shows that survey length has very little effect on response rates. And we're learning that the design and wording of the questions appear to matter more than the number of questions.

Dale Shaller: I see, well Rebecca, I know that the CAHPS program is celebrating its 20th anniversary this year, so congratulations! How's the program trying to keep pace with all of the changes that are taking place in the health care system?

Rebecca Anhang-Price: Well, over the past 20 years, CAHPS surveys have grown and changed to meet the needs of health care providers, of patients and families, and others who use the surveys. For example, the CAHPS team is exploring strategies for reaching patients in new ways, going beyond traditional mail and telephone surveys. More Americans are using electronic means to communicate, so the CAHPS team is looking into how to leverage that while maintaining high standards of survey science and patient privacy protection. Our 20 years of experience have led to a scientifically sound survey process and some of the best outcome measures around. We are continuing to enhance CAHPS surveys to meet users’ needs all the time.

Dale Shaller: Well Rebecca, thanks again so much, for speaking with me today to help address some of the common questions that we hear from users of CAHPS surveys about how to gather and use information on patient experience.

Rebecca Anhang-Price: Thanks so much for having me!

Jeff Brady: Thank you for listening to this podcast from the Agency for Healthcare Research and Quality. You can download and listen to a variety of podcasts about CAHPS on our Web site at www.ahrq.gov/cahps. That's www.a h r q.gov slash [/] c-a-h-p-s [www.ahrq.gov/cahps]. The Agency also offers free technical assistance for CAHPS surveys at 1-800-492-9261 or by e-mail at cahps1@westat.com. That's CAHPS, the number 1, at [@] w-e-s-t-a-t.com [cahps1@westat.com].