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Scholarly Works (10 results)

  • Thesis
  • Peer Reviewed
UCLA Electronic Theses and Dissertations (2016)

Racial/ethnic disparities in patient experiences are widely reported. Asian Americans (Asians) consistently report worse care experiences in the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) surveys than non-Hispanic whites (Whites). However, little is known whether these race/ethnic differences in reports and ratings are due to differences in care experiences or differential response tendencies.

This dissertation consists of three studies. The first study compares reports and ratings of care between Asians and Whites using ordinary least squares analyses. The second study evaluates whether the hypothesized factor structure underlying the scoring of the CAHPS survey is confirmed in the survey dataset using categorical confirmatory factor analytic models. The third paper evaluates measurement invariance between Asians and Whites using a multiple group confirmatory factor analysis. The dissertation uses the Clinician & Group CAHPS Adult Visit Surveys 1.0 data collected in 2011.

In the first study, Asians reported worse care experiences on access to care, office staff courtesy and helpfulness, rated their doctor lower and were less likely to recommend their doctor to family and friends than Whites. On physician communication, no significant difference was noted between Asians and Whites. The reported differences in care experiences between Asians and Whites are likely due to real racial/ethnic differences in care received rather than lack of measurement invariance. The study findings have several important policy implications and provide directions for future research. Quality improvement initiatives in primary care need to be tailored towards reducing racial/ethnic differences in care. Further research will be needed to understand what are the underlying reasons for differential care for Asians and Whites in ambulatory care.

    Cover page: Differences in perceptions of health care between Asian Americans and non-Hispanic whites on the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Clinician and Group Adult Visit Survey 1.0.
    • Thesis
    • Peer Reviewed
    UCLA Electronic Theses and Dissertations (2018)

    This dissertation contributes to the scholarship on health outcomes among individuals with spinal cord injury (SCI). SCI is a dramatic, life-changing trauma that requires long-term and evolving care. Life with SCI entails learning to self-care, acquiring the right wheelchair, home adaptations, and learning to move inside and outside the home. Improving health outcomes measurement of this subgroup may benefit them by making SCI care more patient-centered, i.e. reflective of patients’ preferences and values. Three studies were conducted: (1) an assessment of associations between health-related quality of life (HRQOL) and evaluative well-being (EWB) measures collected in the United States (U.S.) Patient Reported Outcomes Measurement Information System (PROMIS�) project (Chapter 2); (2) a comparison of perceptions of quality of life (QOL) among adults with SCI in the U.S. versus the United Kingdom (UK) (Chapters 3 and 4); and (3) development and psychometric evaluation of a Fatigability Index for full-time wheelchair users with SCI (Chapter 5). The first study provides further evidence that there is an empirical overlap between HRQOL and EWB. The second study found that for adults living with SCI, good QOL is essential for successful rehabilitation. Differences between interviewees from the US and the UK in perceived medical care and functional adjustment suggest that factors affecting QOL may relate to broader health system characteristics. Also, understanding what HRQOL and subjective well-being (SWB) measures are valued by adults living with SCI can lead to selection of informative instruments, which could help clinicians to complement and tailor established care and rehabilitation protocols for individual needs. Specifically, measuring and managing fatigue in the context of SCI is important. The third study developed an instrument assessing physical and mental fatigability in adults with SCI. The instrument covers a comprehensive list of health problems and activities associated with fatigue. The psychometric evaluation shows high measurement precision in discriminating among individuals with a relatively wide range of fatigability. The resulting patient chart, the Fatigability Vector, highlights causes of fatigue and areas requiring immediate intervention.

      Cover page: Assessing Health-Related Quality of Life and Subjective Well-Being in Adults with Spinal Cord Injury
      • Thesis
      • Peer Reviewed
      UCLA Electronic Theses and Dissertations (2016)

      ABSTRACT OF THE DISSERTATION

      Trust in the Medical Profession

      and Health-Related Quality of Life

      in Patients with Hypertension

      by

      Lilia Susana Meltzer

      Doctor of Philosophy in Nursing

      University of California, Los Angeles, 2016

      Professor Ronald D. Hays, Co-Chair

      Professor Felicia S. Hodge, Co-Chair

      Hypertension is a precursor to cardiovascular disease and a major contributor to disability from stroke and coronary heart disease. Prevalence of hypertension among US adults has remained unchanged (30%) from 1999 to 2016, and analyzed national data indicate that 90% of adults with uncontrolled hypertension have a usual source of health care and insurance. Under-resourced race/ethnic minorities are disproportionately affected by hypertension and its adverse cardiovascular outlook, particularly stroke. Hispanics have less awareness of hypertension, receive less management of the disease, are less likely to take prescribed medicines, and have lower blood pressure control than non-Hispanics (Whites, African Americans, and Asians). Hispanics comprise 16% of the US population and have a high poverty rate (26%), similar to African Americans.

      This study examined associations of trust in the medical profession with health-related quality of life (HRQOL) in adults with hypertension and the extent to which the effect of trust was mediated by improving medication adherence and enhancing resilience. In addition, it evaluated whether the effects of trust vary by ethnicity (Hispanic vs. non-Hispanic). The hypothesized relationships were derived from the Vulnerable Populations Conceptual Model’s (VPCM) domains of resource availability, relative risk, and health status; the VPCM is a population-based model with focus on the social conditions that influence the differential vulnerability to adverse health outcomes of minority groups. It was posited that among adults under medical treatment for hypertension, having trust in the medical profession is related to greater medication adherence and resilience and, in turn, better HRQOL.

      A cross-sectional survey was conducted with 201 adults (101 Hispanics and 100 non-Hispanics), recruited from a medical practice consisting of five cardiologists. The study included the Patient-Reported Outcomes Measurement Information System (PROMIS�) Global Health Items; Trust in Doctors Generally Scale; Connor-Davidson Resilience Scale-25; and Morisky Medication Adherence Scale-8. Structural equation modeling was used to evaluate the hypothesized associations (direct and indirect effects) among variables.

      The proposed model fit the data well and most of the hypothesized associations were supported. The model explained 37% of the variance in global mental health and 15% of the variance in global physical health. A simultaneous group analysis indicated that ethnicity (i.e., non-Hispanic vs. Hispanic) did not moderate the associations between trust, resilience, medication adherence, and HRQOL. Two alternative theoretically plausible models proposing different directional relationships were tested and these also fit the data well indicating that causality cannot be inferred when cross-sectional designs are used. Findings suggest that trust in the medical profession serves as a protective mechanism for improving health outcomes in adults with hypertension by promoting medication adherence and enhancing resilience regardless of Hispanic ethnicity.

        Cover page: Trust in the Medical Profession and Health-Related Quality of Life in Patients with Hypertension
        • Article
        • Peer Reviewed
        UCLA Previously Published Works (2024)
        PURPOSE: The Patient-Reported Outcomes Measurement and Information System (PROMIS®): includes the PROMIS-29 physical and mental health summary and the PROMIS global physical and mental health scores. It is unknown how these scores coincide with one another. This study examines whether the scores yield similar or different information. METHODS: The PROMIS-29 and the PROMIS global health items were administered to 5804 adults from Amazons Mechanical Turk (MTurk) in 2021-2022 and to 4060 adults in the Ipsos KnowledgePanel (KP) in 2022. RESULTS: The median age of those in MTurk (KP) was 36 (54) and 53% (50%) were male. Mean T-scores on the PROMIS-29 and PROMIS global physical health scales were similar, but PROMIS global mental health was 3-4 points lower than the PROMIS-29 mental health summary score. Product-moment correlations ranged from 0.69 to 0.81 between the PROMIS-29 physical health and PROMIS global physical health scales and 0.56-0.69 between the mental health scales. Multi-trait multimethod analyses indicated that only a small proportion of the correlations between the two methods of measuring mental health were significantly more highly correlated with one another than correlations between physical and mental health. CONCLUSIONS: PROMIS-29 and PROMIS global mental health scales provide different information and, therefore, study conclusions may vary depending on which measure is used. Interpretation of results needs to consider that the PROMIS-29 mental health scale is a weighted combination of specific domains while the PROMIS global mental health scale is based on general mental health perceptions. Further comparisons of methods of assessing mental health are needed.
          Cover page: Comparison of patient-reported outcomes measurement information system (PROMIS®)-29 and PROMIS global physical and mental health scores.
          • Article
          • Peer Reviewed
          UCLA Previously Published Works (2014)
          BACKGROUND: There are validated measures assessing insomnia and disturbed sleep, but few psychometrically sound instruments to assess perceptions of the restorative or inadequate properties of sleep are available. STUDY OBJECTIVES: To develop and evaluate a new instrument, the Restorative Sleep Questionnaire (RSQ). DESIGN AND SETTING: Focus groups were conducted using participants with and without nonrestorative sleep complaints. Questions were designed to elicit the feelings and experiences people have about their sleep and their view of daytime consequences of sleep. Expert panels confirmed the importance of nonrestorative sleep (NRS) as a frequently encountered problem either with or without other sleep complaints. The resulting RSQ was administered in three studies: (1) a telephone interview with healthy controls and individuals with sleep problems; (2) a randomized clinical trial of patients with primary insomnia assessed by polysomnography (PSG); (3) a PSG study of subjects with NRS complaints. MEASUREMENT AND RESULTS: Across all studies, the new measures were shown to be significantly correlated with health-related quality of life (HRQL) domains hypothesized to be related to NRS. The RSQ had good psychometric properties (α > 0.90; rtest-retest > 0.80), and factor analysis confirmed the unidimensionality of the measure. The RSQ was able to distinguish between healthy controls, patients with primary insomnia, and insomnia patients with isolated NRS complaints but without PSG defined sleep onset, duration, or maintenance problems. Normal sleepers reported sleep that was about a standard deviation more restorative than that of those with NRS on the RSQ. CONCLUSIONS: The results of the study provide support for the reliability and validity of the RSQ as a measure of NRS in subjects with and without self-reported or PSG confirmed sleep initiation and maintenance difficulties. CLINICALTRIALSGOV IDENTIFIERS: NCT00655369; NCT00705601.
            Cover page: Development and evaluation of a measure to assess restorative sleep.
            • Article
            • Peer Reviewed
            UCLA Previously Published Works (2020)

            Background

            Many therapeutic options are available to glaucoma patients. One recent therapeutic option is minimally invasive glaucoma surgical (MIGS) devices. It is unclear how patients view different treatments and which patient-reported outcomes would be most relevant in patients with mild to moderate glaucoma. We developed a questionnaire for patients eligible for MIGS devices and a patient preference study to examine the value patients place on certain outcomes associated with glaucoma and its therapies.

            Objectives

            To summarize the progress to date.

            Methods

            Questionnaire development: We drafted the questionnaire items based on input from one physician and four patient focus groups, and a review of the literature. We tested item clarity with six cognitive interviews. These items were further refined. Patient preference study: We identified important benefit and risk outcomes qualitatively using semi-structured, one-on-one interviews with patients who were eligible for MIGS devices. We then prioritized these outcomes quantitatively using best-worst scaling methods.

            Results

            Questionnaire testing: Three concepts were deemed relevant for the questionnaire: functional limitations, symptoms, and psychosocial factors. We will evaluate the reliability and validity of the 52-item draft questionnaire in an upcoming field test. Patient preference study: We identified 13 outcomes that participants perceived as important. Outcomes with the largest relative importance weights were "adequate IOP control" and "drive a car during the day."

            Conclusions

            Patients have the potential to steer clinical research towards outcomes that are important to them. Incorporating patients' perspectives into the MIGS device development and evaluation process may expedite innovation and availability of these devices.
              Cover page: Patient-reported outcomes measures and patient preferences for minimally invasive glaucoma surgical devices
              • Article
              • Peer Reviewed
              UCLA Previously Published Works (2018)

              Objectives

              The purpose of this article is to report on the Center of Excellence for Research on Complementary and Alternative Medicine at RAND Corporation. The overall project examined the appropriateness of chiropractic spinal manipulation and mobilization for chronic low back pain and chronic cervical pain using the RAND and University of California Los Angeles Appropriateness Method, including patient preferences and costs, to acknowledge the importance of patient-centered care in clinical decision-making.

              Methods

              This article is a narrative summary of the overall project and its inter-related components (ie, 4 Research Project Grants and 2 centers), including the Data Collection Core, whose activities and learning will be the subject of a following series of methods articles.

              Results

              The project team faced many challenges in accomplishing data collection goals. The processes we developed to overcome barriers may be of use to other researchers and for practitioners who may want to participate in such studies in complementary and integrative health, which previously was known as complementary and alternative medicine.

              Conclusion

              For this large, complex, successful project, we gathered online survey data, collected charts, and abstracted chart data from thousands of chiropractic patients. The present article delineates the challenges and lessons that were learned during this project so that others may gain from the authors' experience. This information may be of use to future research that collects data from independent practitioners and their patients because it provides what is needed to be successful in such studies and may encourage participation.
                Cover page: Researching the Appropriateness of Care in the Complementary and Integrative Health Professions: Part I.
                • Article
                • Peer Reviewed
                UCLA Previously Published Works (2020)
                BACKGROUND: Patient activation is associated with better outcomes in chronic conditions. OBJECTIVE: We evaluated the psychometric properties of the 12-item Altarum Consumer Engagement™ Measure (ACE-12) in patients with prediabetes. PARTICIPANTS: ACE-12 was administered to patients in the Prediabetes Informed Decisions and Education Study. MAIN MEASURES: We conducted an exploratory factor analysis followed by confirmatory factor analytic models. We evaluated item response categories using item characteristic curves. Construct validity was assessed by examining correlations of the ACE-12 scales with education, depressive symptoms, self-rated health, hemoglobin A1c, body mass index, and weight loss. KEY RESULTS: Participants (n = 515) had a median age of 58; 56% were female; 17% Hispanic; 54% were non-White. The scree plot and Tucker and Lewis reliability coefficient (0.95) suggested three factors similar to the original scales. One item loaded on the navigation rather than the informed choice scale. Ordinal alpha coefficients for the original scales were commitment (0.75); informed choice (0.71); and navigation (0.54). ICCs indicated that one or more of the response categories for 5 of the 12 items were never most likely to be selected. Patients with lower education were less activated on the commitment (r = - 0.124, p = 0.004), choice (r = - 0.085, p = 0.009), and overall score (r = - 0.042, p = 0.011). Patients with depressive symptoms had lower commitment (r = - 0.313, p ≤ 0.001) and overall scores (r = - 0.172, p = 0.012). Patients with poorer health scored lower on the Commitment (r = - 0.308, p ≤ 0.001), Navigation (r = - 0.137, p ≤ 0.001), and overall score (r = - 0.279, p ≤ 0.001). CONCLUSION: The analyses provide some support for the psychometric properties of the ACE-12 in prediabetic patients. Future research evaluating this tool among patients with other chronic conditions are needed to determine whether Q1 (I spend a lot of time learning about health) should remain in the informed choice or be included in the navigation scale. Additional items may be needed to yield acceptable reliability for the navigation scale.
                  Cover page: Psychometric Properties of the Altarum Consumer Engagement (ACE) Measure of Activation in Patients with Prediabetes.
                  • Article
                  • Peer Reviewed
                  UCLA Previously Published Works (2007)

                  Objective

                  The validity of quality of care measurement has important implications for practicing clinicians, their patients, and all involved with health care delivery. We used empirical data from managed care patients enrolled in west coast physician organizations to test the hypothesis that observed changes in health-related quality of life across a 2.5-year window reflecting process of care.

                  Data sources/study setting

                  Patient self-report data as well as clinically detailed medical record review regarding 963 patients with chronic disease associated with managed care from three west coast states.

                  Study design

                  Prospective cohort study of change in health-related quality of life scores across 30 months as measured by change in SF-12 physical component scores.

                  Data collection/extraction methods

                  Patient self-report and medical record abstraction.

                  Principal findings

                  We found a positive relationship between better process scores and higher burden of illness (p<.05). After adjustment for burden of illness, using an instrumental variables approach revealed better process is associated with smaller declines in SF-12 scores across a 30-month observation window (p=.014). The application of the best quartile of process of care to patients currently receiving poor process is associated with a 4.24 increment in delta SF-12-physical component summary scores.

                  Conclusions

                  The use of instrumental variables allowed us to demonstrate a significant relationship between better ambulatory process of care and better health-related quality of life. This finding underscores the importance of efforts to improve the process of care.
                    Cover page: Does Ambulatory Process of Care Predict Health‐Related Quality of Life Outcomes for Patients with Chronic Disease?
                    • Article
                    • Peer Reviewed
                    UCLA Previously Published Works (2019)
                    BACKGROUND: Parents play an important role in their childrens oral health behaviors, provide oral health access, initiate prevention, and coping strategies for health care. AIM: This paper develops a short form (SF) to assist parents to evaluate their childrens oral health status using Patient-Reported Outcome Measurement Information System (PROMIS) framework that conceptualized health as physical, mental, and social components. DESIGN: Surveys of parents were conducted at dental clinics in Los Angeles County, together with an on-site clinical examination by dentists to determine clinical outcomes, Childrens Oral Health Status Index (COHSI), and referral recommendations (RRs). Graded response models in item response theory were used to create the SF. A toolkit including SF, demographic information, and algorithms was developed to predict the COHSI and RRs. RESULTS: The final SF questionnaire consists of eight items. The square root mean squared error for the prediction of COHSI is 7.6. The sensitivity and specificity of using SF to predict immediate treatment needs (binary RRs) are 85% and 31%. CONCLUSIONS: The parent SF is an additional component of the oral health evaluation toolkit that can be used for oral health screening, surveillance program, policy planning, and research of school-aged children and adolescents from guardian perspectives.
                      Cover page: Development of a parents short form survey of their childrens oral health.
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