Survey response style and differential use of CAHPS rating scales by Hispanics

Med Care. 2008 Sep;46(9):963-8. doi: 10.1097/MLR.0b013e3181791924.


Background: Previous Consumer Assessments Of Healthcare Providers And Systems (CAHPS) studies have shown that Hispanics report care that is similar to or less positive than for non-Hispanic whites, yet have more positive ratings of care.

Objective: To examine differential use of the 0-10 rating scales in the CAHPS health plan survey by Hispanic ethnicity and insurance status (Medicaid vs. commercial managed care).

Data: CAHPS 2.0H adult Medicaid and commercial data submitted to the National Committee for Quality Assurance.

Measures: The dependent variables are the CAHPS 2.0 ratings of care: personal doctor or nurse, specialists, and health care received. Ratings were categorized into 4 levels: 0-4, 5-8, 9, and 10. The independent variable is a 4-level categorical variable: Hispanic Medicaid, Hispanic commercial, (non-Hispanic) white Medicaid, and (non-Hispanic) white commercial. Six potential confounders were controlled: gender, age, education, self-rated health, survey mode, and survey language.

Analysis: Multinomial logistic regression was used to test for differences in extreme response styles.

Results: Hispanics exhibited a greater tendency toward extreme responding in the CAHPS ratings than non-Hispanic whites-in particular, they were more likely than whites in commercial plans to endorse a "10," and often, scores of 4 or less, relative to an omitted category of "5" to "8."

Conclusions: The observed higher Hispanic ratings may be partially attributed to differences in response style rather than superior care. This suggests caution in the use of central tendency measures and the proportion of 10 ratings when examining racial/ethnic differences in CAHPS ratings of care. It is advisable to consider pooling responses at the top end (eg, 9 and 10) and lower end (eg, 0-6) of the response scale when making racial/ethnic comparisons.

Publication types

  • Comparative Study
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Bias
  • Cross-Cultural Comparison
  • European Continental Ancestry Group / psychology*
  • European Continental Ancestry Group / statistics & numerical data
  • Female
  • Health Services Research / statistics & numerical data
  • Health Status
  • Hispanic Americans / psychology*
  • Hispanic Americans / statistics & numerical data
  • Humans
  • Male
  • Managed Care Programs / statistics & numerical data*
  • Medicaid / statistics & numerical data*
  • Middle Aged
  • Patient Satisfaction / statistics & numerical data*
  • Quality of Health Care / statistics & numerical data*
  • Regression Analysis
  • United States