Is There A Relationship between
Hospital Encounters for Ambulatory
Care Sensitive Conditions and
Beneficiaries’ Experience and
Satisfaction with Health Care?
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
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.
Research Objective

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.
Ambulatory Care Sensitive
Conditions Studied

Cellulitis

Asthma

Congestive Heart
Failure

Chronic Obstructive
Pulmonary Disease

Dehydration


Bacterial Pneumonia

Septicemia
Acute Diabetic Events
among Medicare
beneficiaries with
diabetes

Ischemic Stroke


Urinary Tract Infection
Lower Limb Peripheral
Vascular Disease
among Medicare
beneficiaries with
diabetes
Measures of Patient Satisfaction:
MFFS Consumer Assessment of
Health Plans Survey (CAHPS)

Experience with Care
 Getting Needed Care
 Getting Care Quickly
 Good Communication with Provider

Satisfaction with Care
 Rate Medicare
 Rate Personal Doctor
 Rate Care
 Rate Specialist

Customer Service
 Respectful Treatment
 Medicare Customer Service
Analytic File

103,551 MFFS beneficiary respondents
 Claims data
 CAHPS survey data
 Medicare enrollment and eligibility data
Analysis File Construction:
Claims-Based Measure of Quality - ACSC

Incidence of hospital encounters for ACSC
 1999-2001 MFFS claims data for the
2000 CAHPS survey sample
 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.*
 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
Analysis File Construction:
Beneficiary Satisfaction with Care –
CAHPS Indicators

Survey data from MFFS beneficiaries (2000 survey)

Estimated weighted and case-mix adjusted means
for 9 CAHPS measures

Case-mix adjustment variables
 Education
 Proxy assistance
 Proxy respondent
 Self-reported health
 Self-reported mental health
 Claims-based measure of health status – HCC
score
Claims-based measure of
health status – HCC score

Hierarchical Condition Categories (HCC)

Aggregate ICD-9-CM diagnostic codes into 184
clinically meaningful diagnostic categories

Organized into multiple body system or disease type
hierarchies that distinguish disease severity of
related diagnoses.

For this analysis, the claims-based health status
measure used was equal to the beneficiary’s HCC
risk score divided by the national mean of HCC of all
Medicare beneficiaries in 2000, resulting in:
 a range of 0.13 to 12.29, and
 a mean of 1.53,
 with higher scores indicating greater disease
severity.
Analysis

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

Compared means by ACSC for 9 CAHPS
indicators

Used two sample t-tests for differences in
means for all pairwise comparisons (p<0.05
with Bonferroni corrections)
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
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
2.13
0.82
HCC score*
*p<0.001
CAHPS Ratings and
Composites
Indicator
Experience with Care
Needed Care
Care Quickly
Good Communication
Satisfaction with Care
Rate Medicare
Rate Care
Rate Specialist
Rate Personal Doctor
Customer Service
Respectful Treatment
Medicare Customer Service
Range
Mean Score
1-3
1-4
1-4
2.81
3.41
3.57
0-10
0-10
0-10
0-10
8.70
8.80
8.84
8.86
1-4
1-4
3.73
2.51
Results: Comparison of Average
CAHPS scores for MFFS
Beneficiaries By ACSC indicator
Indicator
ACSC
No ACSC
p-value
Experience with Care
Needed Care
Care Quickly
Good Communication
2.80
3.41
3.57
2.81
3.40
3.57
P<.01
NS
NS
Satisfaction with Care
Rate Medicare
Rate Care
Rate Specialist
Rate Personal Doctor
8.68
8.79
8.83
8.85
8.70
8.81
8.85
8.86
NS
NS
NS
NS
Customer Service
Respectful Treatment
Medicare Customer Service
3.73
2.52
3.73
2.51
NS
NS
Is There a Relationship
between ACSCs and CAHPS®
Measures of Quality?

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.

Overall, there were virtually no differences
in mean CAHPS scores between
beneficiaries who did or did not experience
an ACSC encounter.
Implications

Health care quality is a multi-dimensional
concept.

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.

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.