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Article Excerpt
Like in many advanced countries, current health care reforms which emphasize accountability, transparency, choice, and performance improvement encourage Dutch patients to become critical consumers (Ministry of Health, Welfare and Sport 2002; Ministerie van Volksgezondheid, Welzijn en Sport 2004; ten Asbroek et al. 2004). Health care seekers need all the help they can get to identify appropriate and high quality health care providers, insurers, and institutions (Iezzoni 2002). Surveys which assess patients' health care experiences are increasingly being used by consumers and insurers to choose and contract high performers, as well as to hold them accountable. Several Dutch instruments have been previously developed to capture generic, group-specific (e.g., elderly), or disease-specific (e.g., HIV) health care experiences, satisfaction, opinions, and preferences (Sixma et al. 1998, 2000; Sixma, Spreeuwenberg, and van der Pasch 1998; Hendriks et al. 2000, 2002; Jansen, Hutten, and Spreeuwenberg 2002; Hekkink et al. 2003). The growing role of cross-national learning and comparisons of health systems performance (Arah et al. 2003) imply that there are opportunities for standardization of survey instruments and for international comparisons.
After an extensive literature review, the United States Consumer Assessment of Health Plans Survey (CAHPS[R]) instruments were selected for adaptation and use in Dutch pilot studies. The Dutch health care system is seeking a family of related and standardized instruments such as the CAHPS[R] products for multiple (choice, purchasing, and performance improvement) purposes. The CAHPS[R] products are well-established in the American context (Hays et al. 1999; Spranca et al. 2000; Goldstein and Fyock 2001; Morales et al. 2001; Farley et al. 2002; Hargraves, Hays, and Cleary 2003; CAHPS[R] Survey Users Network [SUN] 2004; Solomon et al. 2005). Funded by the Centers for Medicare and Medicaid Services in partnership with the Agency for Healthcare Research and Quality in the United States (U.S.), the Hospital CAHPS[R] (H-CHAPS) instrument was recently developed and field tested to provide comparative information on hospitals and to aid informed choices by patients (CAHPS Survey Users Network 2004; Centers for Medicare and Medicaid Services 2004). During the pilot study in the U.S. in 2003, we received and adapted the pilot version of the H-CAHPS for use in Dutch hospitals. This study is part of concerted efforts, initially spearheaded by a large Dutch health insurer, to import a family of CAHPS[R] instruments, including ambulatory care (such as the health plan) surveys and facility surveys (such as the H-CAHPS), for measuring health care experiences from the perspective of Dutch patients and consumers, and to use the resulting information for their health care purchasing purposes. (1) The aim of this study is to report on the reliability and validity of the H-CAHPS in Dutch hospitals.
METHODS
H-CAHPS Instrument and the Dutch Translation
We used the 2003 U.S. pilot version of the H-CAHPS: a 66-item instrument which contained 33 core items on patient experiences, three global ratings (of nurses, doctor, and the hospital), one item on the likelihood to recommend hospital to friends and family, and several items on patient characteristics. Twenty-seven of the core items on patient experiences were evaluated on a 1-to-4 response scale, where 1 referred to "never," 2 "sometimes," 3 "usually," and 4 "always." The remaining six core items had a dichotomous (yes-no) response scale. The global ratings had a 0-10 response scale with only the endpoints labeled (e.g., was "worst hospital possible" and 10 was "best hospital possible"). The one question on patient's likelihood to recommend the hospital to friends and family had the following response scale: 1 "definitely no," 2 "probably no," 3 "probably yes," and 4 "definitely yes." The instrument asked respondents to think about their last stay at the specified and confirmed hospital. The development of the H-CAHPS through extensive systematic literature review, consumer focus groups, public response to Federal Register notice, stakeholder input, cognitive testing, and a 3-state pilot test in New York, Arizona, and Maryland is detailed elsewhere (The CAHPS[R] II Investigators and the Agency for Healthcare Research and Quality 2003).
Mindful of the difficulties and equivalence issues involved in transplanting survey instruments from one culture to another (Weidmer, Brown, and Garcia 1999; Streiner and Norman 2003), we had H-CAHPS translated into Dutch by two independent professional translators, and subsequently backtranslated into English by two other independent translators who had never seen the original U.S. version. A panel of seven researchers experienced in patient surveys or survey instrument development was asked to choose a mix of the two versions that came closest to the original U.S. instrument and used clear, comprehensible language. A few adaptations were also made to fit the Dutch context as follows: the two U.S. questions on Hispanic descent and race were replaced by three items on birth place of respondent, mother, and father; and three additional items on getting verbal information on activity limitations (Q47), getting help when home (Q50), and taking new medication at home (Q53). The new Dutch instrument totaled 70 items which included 35 core items.
The Pilot Survey and Subjects
The study sites were two multispecialty city hospitals with 555 and 386 beds, and 15,761 and 12,606 admissions, respectively, in...
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