Health Services Research

Objective. To provide practical strategies for conducting and evaluating analyses of qualitative data applicable for health services researchers.

Data Sources and Design. We draw on extant qualitative methodological literature to describe practical approaches to qualitative data analysis. Approaches to data analysis vary by discipline and analytic tradition; however, we focus on qualitative data analysis that has as a goal the generation of taxonomy, themes, and theory germane to health services research.

Principle Findings. We describe an approach to qualitative data analysis that applies the principles of inductive reasoning while also employing predetermined code types to guide data analysis and interpretation. These code types (conceptual, relationship, perspective, participant characteristics, and setting codes) define a structure that is appropriate for generation of taxonomy, themes, and theory. Conceptual codes and subcodes facilitate the development of taxonomies. Relationship and perspective codes facilitate the development of themes and theory. Intersectional analyses with data coded for participant characteristics and setting codes can facilitate comparative analyses.

Conclusions. Qualitative inquiry can improve the description and explanation of complex, real‐world phenomena pertinent to health services research. Greater understanding of the processes of qualitative data analysis can be helpful for health services researchers as they use these methods themselves or collaborate with qualitative researchers from a wide range of disciplines.

Mixed methods research offers powerful tools for investigating complex processes and systems in health and health care. This article describes integration principles and practices at three levels in mixed methods research and provides illustrative examples. Integration at the study design level occurs through three basic mixed method designs—exploratory sequential, explanatory sequential, and convergent—and through four advanced frameworks—multistage, intervention, case study, and participatory. Integration at the methods level occurs through four approaches. In connecting, one database links to the other through sampling. With building, one database informs the data collection approach of the other. When merging, the two databases are brought together for analysis. With embedding, data collection and analysis link at multiple points. Integration at the interpretation and reporting level occurs through narrative, data transformation, and joint display. The fit of integration describes the extent the qualitative and quantitative findings cohere. Understanding these principles and practices of integration can help health services researchers leverage the strengths of mixed methods.

Objective. To determine if professional medical interpreters have a positive impact on clinical care for limited English proficiency (LEP) patients.

Data Sources. A systematic literature search, limited to the English language, in PubMed and PsycINFO for publications between 1966 and September 2005, and a search of the Cochrane Library.

Study Design. Any peer‐reviewed article which compared at least two language groups, and contained data about professional medical interpreters and addressed communication (errors and comprehension), utilization, clinical outcomes, or satisfaction were included. Of 3,698 references, 28 were found by multiple reviewers to meet inclusion criteria and, of these, 21 assessed professional interpreters separately from ad hoc interpreters. Data were abstracted from each article by two reviewers. Data were collected on the study design, size, comparison groups, analytic technique, interpreter training, and method of determining the participants' need for an interpreter. Each study was evaluated for the effect of interpreter use on four clinical topics that were most likely to either impact or reflect disparities in health and health care.

Principal Findings. In all four areas examined, use of professional interpreters is associated with improved clinical care more than is use of ad hoc interpreters, and professional interpreters appear to raise the quality of clinical care for LEP patients to approach or equal that for patients without language barriers.

Conclusions. Published studies report positive benefits of professional interpreters on communication (errors and comprehension), utilization, clinical outcomes and satisfaction with care.

Objective.To assess the contribution of primary care systems to a variety of health outcomes in 18 wealthy Organization for Economic Cooperation and Development (OECD) countries over three decades.

Data Sources/Study Setting.Data were primarily derived from OECDHealth Data 2001and from published literature. The unit of analysis is each of 18 wealthy OECD countries from 1970 to 1998 (totaln=504).

Study Design.Pooled, cross‐sectional, time‐series analysis of secondary data using fixed effects regression.

Data Collection/Extraction Methods.Secondary analysis of public‐use datasets. Primary care system characteristics were assessed using a common set of indicators derived from secondary datasets, published literature, technical documents, and consultation with in‐country experts.

Principal Findings.The strength of a country's primary care system was negatively associated with (a) all‐cause mortality, (b) all‐cause premature mortality, and (c) cause‐specific premature mortality from asthma and bronchitis, emphysema and pneumonia, cardiovascular disease, and heart disease (p<0.05 in fixed effects, multivariate regression analyses). This relationship was significant, albeit reduced in magnitude, even while controlling for macro‐level (GDP per capita, total physicians per one thousand population, percent of elderly) and micro‐level (average number of ambulatory care visits, per capita income, alcohol and tobacco consumption) determinants of population health.

Conclusions.(1) Strong primary care system and practice characteristics such as geographic regulation, longitudinality, coordination, and community orientation were associated with improved population health. (2) Despite health reform efforts, few OECD countries have improved essential features of their primary care systems as assessed by the scale used here. (3) The proposed scale can also be used to monitor health reform efforts intended to improve primary care.

Mục tiêu. Mục tiêu của nghiên cứu này là đánh giá tính hợp lệ của dữ liệu xuất viện bệnh viện hành chính trong phiên bản Phân Loại Bệnh Quốc Tế Thứ 10 (ICD‐10) và để xác định xem có sự cải thiện nào trong tính hợp lệ của mã hóa các tình trạng lâm sàng so với dữ liệu ICD‐9 Sửa Đổi Lâm Sàng (ICD‐9‐CM) hay không.

Phương pháp. Chúng tôi đã xem xét 4.008 hồ sơ bệnh án được lựa chọn ngẫu nhiên của những bệnh nhân nhập viện từ ngày 1 tháng 1 đến ngày 30 tháng 6 năm 2003 tại bốn bệnh viện giảng dạy ở Alberta, Canada để xác định sự hiện diện hoặc không có 32 tình trạng lâm sàng và để đánh giá độ đồng thuận giữa dữ liệu ICD‐10 và dữ liệu hồ sơ. Chúng tôi sau đó mã hóa lại các hồ sơ tương tự bằng ICD‐9‐CM và xác định độ đồng thuận giữa dữ liệu ICD‐9‐CM và dữ liệu hồ sơ trong việc ghi nhận những tình trạng tương tự. Độ chính xác của dữ liệu ICD‐10 so với dữ liệu hồ sơ được so sánh với độ chính xác của dữ liệu ICD‐9‐CM so với dữ liệu hồ sơ.

Kết quả. Giá trị độ nhạy dao động từ 9.3 đến 83.1 phần trăm cho ICD‐9‐CM và từ 12.7 đến 80.8 phần trăm cho dữ liệu ICD‐10. Giá trị tiên đoán dương dao động từ 23.1 đến 100 phần trăm cho ICD‐9‐CM và từ 32.0 đến 100 phần trăm cho dữ liệu ICD‐10. Giá trị độ đặc hiệu và giá trị tiên đoán âm luôn ở mức cao đối với cả hai cơ sở dữ liệu ICD‐9‐CM và ICD‐10. Trong số 32 tình trạng được đánh giá, dữ liệu ICD‐10 có độ nhạy cao hơn đáng kể cho một tình trạng và thấp hơn cho bảy tình trạng so với dữ liệu ICD‐9‐CM. Hai cơ sở dữ liệu có giá trị độ nhạy tương tự nhau đối với 24 tình trạng còn lại.

Kết luận. Tính hợp lệ của dữ liệu hành chính ICD‐9‐CM và ICD‐10 trong việc ghi nhận tình trạng lâm sàng là tương tự nhau, mặc dù tính hợp lệ khác nhau giữa các phiên bản mã hóa đối với một số tình trạng. Việc triển khai mã hóa ICD‐10 chưa cải thiện đáng kể chất lượng dữ liệu hành chính so với ICD‐9‐CM. Những đánh giá trong tương lai như nghiên cứu này là cần thiết vì tính hợp lệ của dữ liệu ICD‐10 có thể được cải thiện khi các mã hóa viên có thêm kinh nghiệm với hệ thống mã hóa mới.

Purpose. We report the validation of an instrument to measure mistrust of health care organizations and examine the relationship between mistrust and health care service underutilization.

Methods. We conducted a telephone survey of a random sample of households in Baltimore City, MD. We surveyed 401 persons and followed up with 327 persons (81.5 percent) 3 weeks after the baseline interview. We conducted tests of the validity and reliability of the Medical Mistrust Index (MMI) and then conducted multivariate modeling to examine the relationship between mistrust and five measures of underutilization of health services.

Results. Using principle components analysis, we reduced the 17‐item MMI to 7 items with a single dimension. Test–retest reliability was moderately strong, ranging from Pearson correlation of 0.346–0.697. In multivariate modeling, the MMI was predictive of four of five measures of underutilization of health services: failure to take medical advice (b=1.56, p<.01), failure to keep a follow‐up appointment (b=1.11, p=.01), postponing receiving needed care (b=0.939, p=.01), and failure to fill a prescription (b=1.48, p=.002). MMI was not significantly associated with failure to get needed medical care (b=0.815, p=.06).

Conclusions. The MMI is a robust predictor of underutilization of health services. Greater attention should be devoted to building greater trust among patients.

Objective. To develop and test a multi‐item measure for general trust in physicians, in contrast with trust in a specific physician.

Data Sources. Random national telephone survey of 502 adult subjects with a regular physician and source of payment.

Study Design. Based on a multidimensional conceptual model, a large pool of candidate items was generated, tested, and revised using focus groups, expert reviewers, and pilot testing. The scale was analyzed for its factor structure, internal consistency, construct validity, and other psychometric properties.

Principal Findings. The resulting 11‐item scale measuring trust in physicians generally is consistent with most aspects of the conceptual model except that it does not include the dimension of confidentiality. This scale has a single‐factor structure, good internal consistency (alpha=.89), and good response variability (range=11–54; mean=33.5; SD=6.9). This scale is related to satisfaction with care, trust in one's physician, following doctors' recommendations, having no prior disputes with physicians, not having sought second opinions, and not having changed doctors. No association was found with race/ethnicity. While general trust and interpersonal trust are qualitatively similar, they are only moderately correlated with each other and general trust is substantially lower.

Conclusions. Emerging research on patients' trust has focused on interpersonal trust in a specific, known physician. Trust in physicians in general is also important and differs significantly from interpersonal physician trust. General physician trust potentially has a strong influence on important behaviors and attitudes, and on the formation of interpersonal physician trust.

Objective. To update research on Medicare payments in the last year of life.

Data Sources. Continuous Medicare History Sample, containing annual summaries of claims data on a 5 percent sample from 1978 to 2006.

Study Design. Analyses were based on elderly beneficiaries in fee for service. For each year, Medicare payments were assigned either to decedents (persons in their last year) or to survivors (all others).

Results. The share of Medicare payments going to persons in their last year of life declined slightly from 28.3 percent in 1978 to 25.1 percent in 2006. After adjustment for age, sex, and death rates, there was no significant trend.

Conclusions. Despite changes in the delivery of medical care over the last generation, the share of Medicare expenditures going to beneficiaries in their last year has not changed substantially.

Objective. To describe initial testing of the Assessment of Chronic Illness Care (ACIC), a practical quality‐improvement tool to help organizations evaluate the strengths and weaknesses of their delivery of care for chronic illness in six areas: community linkages, self‐management support, decision support, delivery system design, information systems, and organization of care.

Data Sources. (1) Pre‐post, self‐report ACIC data from organizational teams enrolled in 13‐month quality‐improvement collaboratives focused on care for chronic illness; (2) independent faculty ratings of team progress at the end of collaborative.

Study design. Teams completed the ACIC at the beginning and end of the collaborative using a consensus format that produced average ratings of their system's approach to delivering care for the targeted chronic condition. Average ACIC subscale scores (ranging from 0 to 11, with 11 representing optimal care) for teams across all four collaboratives were obtained to indicate how teams rated their care for chronic illness before beginning improvement work. Paired t‐tests were used to evaluate the sensitivity of the ACIC to detect system improvements for teams in two (of four) collaboratives focused on care for diabetes and congestive heart failure (CHF). Pearson correlations between the ACIC subscale scores and a faculty rating of team performance were also obtained.

Results. Average baseline scores across all teams enrolled at the beginning of the collaboratives ranged from 4.36 (information systems) to 6.42 (organization of care), indicating basic to good care for chronic illness. All six ACIC subscale scores were responsive to system improvements diabetes and CHF teams made over the course of the collaboratives. The most substantial improvements were seen in decision support, delivery system design, and information systems. CHF teams had particularly high scores in self‐management support at the completion of the collaborative. Pearson correlations between the ACIC subscales and the faculty rating ranged from .28 to .52.

Conclusion. These results and feedback from teams suggest that the ACIC is responsive to health care quality‐improvement efforts and may be a useful tool to guide quality improvement in chronic illness care and to track progress over time.