Less Use of Extreme Response Options by Asians to Standardized Care Scenarios May Explain Some Racial/Ethnic Differences in CAHPS Scores

O RIGINAL A RTICLE Less Use of Extreme Response Options by Asians to Standardized Care Scenarios May Explain Some Racial/Ethnic Differences in CAHPS Scores Lauren A. Mayer, PhD,* Marc N. Elliott, PhD, w Ann Haas, MPH, MS,* Ron D. Hays, PhD, z and Robin M. Weinick, PhD y Background: Asian Americans (hereafter “Asians”) generally re- port worse experiences with care than non-Latino whites (hereafter “whites”), which may reflect differential use of response scales. Past studies indicate that Asians exhibit lower Extreme Response Ten- dency (ERT)—they less frequently use responses at extreme ends of the scale than whites. Objective: To explore whether lower ERT is observed for Asians than whites in response to standardized vignettes depicting patient experiences of care and whether ERT might in part explain Asians reporting worse care than whites. Procedure: A representative US sample (n = 575 Asian; n = 505 white) was presented with 5 written vignettes describing doctor- patient encounters with differing levels of physician responsiveness. Respondents evaluated the encounters using modified CAHPS communication questions. Results: Case-mix–adjusted repeated-measures multivariate models show that Asians provided more positive responses than whites to several vignettes with less-responsive physicians but less positive responses than whites for the vignette with the most physician responsiveness (P < 0.01 for each). While all respondents provided more positive ratings for vignettes with greater physician re- sponsiveness, the increase was 15% less for Asian than white respondents. Conclusions: Asians exhibit lower ERT than whites in response to standardized scenarios. Because CAHPS reponses are predom- inantly near the positive end of the scale and the most responsive scenario is most typical of the score observed in real-world settings, lower ERT in Asians may partially explain observations of lower From the *RAND Corporation, Pittsburgh, PA; wRAND Corporation, Santa Monica; zUCLA Division of General Internal Medicine & Health Services Research, Los Angeles, CA; and yRTI International, Wash- ington, DC. Supported through a cooperative agreement from the Agency for Healthcare Research and Quality (U18 HS016980). The authors declare no conflict of interest. Reprints: Lauren A. Mayer, PhD, RAND Corporation, 4570 Fifth Avenue, Suite 600, Pittsburgh, PA 15213-1516. E-mail: lauren@rand.org. Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Website, www.lww- medicalcare.com. Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0025-7079/16/5401-0038 38 | www.lww-medicalcare.com observed mean CAHPS scores for Asians in real-world settings. Case-mix adjustment for Asian race/ethnicity or its correlates may improve quality of care measurement. Key Words: racial/ethnic disparities, CAHPS, patient experience, extreme response tendency (Med Care 2016;54: 38–44) S urveys of patient experience with health care provide valuable information about different groups of patients, allowing comparisons by race/ethnicity, age, sex, or other characteristics. Many studies that analyze these measures in the United States report different patient experiences by race/ ethnicity. 1–9 African Americans and Latino Americans have been found to report different experiences with care than non-Latino US whites (hereafter “whites”). 1–5,10 However, the largest and most consistent pattern of observed effects are for Asian American respondents (hereafter “Asians”), who tend to report the worst experiences with care in Con- sumer Assessment of Healthcare Providers and Systems (CAHPS s ) surveys 2,3,5,6 and other patient experience sur- veys, 7,8,11 despite evidence that Asians receive equal or better care in terms of clinical process. 12 Few studies have explored whether the differences being reported for Asian populations are a result of differences in the care provided, differences in use of survey response scales, or a combina- tion of these 2 factors. 13 Some studies suggest that compared with whites, 4,9,14–16 Latinos and perhaps African Americans are more likely to use responses at the extreme ends of the scale, a measurement properly known as Extreme Response Tendency (ERT). 17–19 In contrast, Asians show less ERT than whites, 20–23 and lower ERT may explain why Asians report worse experiences with care than whites. Because of the skewness of CAHPS scores, in which most ratings fall in the most positive categories (eg, 9 or 10 on a 0–10 rating scale), 24 avoidance of the extremes (low ERT) by Asians could result in lower mean scores overall, as avoiding positive extremes lowers the mean, and the negative extreme is rare enough to have little consequence. 18,25 Much of the extant evidence on ERT comes from observational data. To more confidently assess whether certain patient groups use experience with care response scales differently, the care being rated needs to be held constant. In 1 study, Weinick et al 9 used standardized Medical Care Volume 54, Number 1, January 2016 Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.