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Table

Bivariate Comparison of Depressed and Nondepressed
Beneficiaries  on Measures of Patient Experience

                                          M (SD)

                              Depressed       Nondepressed    t

Ease of getting needed care   XX.XX (XX.XX)   XX.XX (XX.XX)   XX.XX *
([dagger])

Getting appointments with      X.XX (X.XX)     X.XX (X.XX)     X.XX *
specialists

Getting needed care, tests,    X.XX (X.XX)     X.XX (X.XX)    XX.XX *
and treatment

Getting care quickly          XX.XX (XX.XX)   XX.XX (XX.XX)   XX.XX *
([dagger])

Getting care when sick or      X.XX (X.XX)     X.XX (X.XX)     X.XX *
injured

Getting routine care at        X.XX (X.XX)     X.XX (X.XX)    XX.XX *
doctor's office or clinic

Quality of doctor             XX.XX (XX.XX)   XX.XX (XX.XX)   XX.XX *
communication

Provides easy-to-understand    X.XX (X.XX)     X.XX (X.XX)    XX.XX *
explanations

Listens carefully              X.XX (X.XX)     X.XX (X.XX)    XX.XX *

Shows respect                  X.XX (X.XX)     X.XX (X.XX)     X.XX *

Spends enough time             X.XX (X.XX)     X.XX (X.XX)    XX.XX *

Global rating of personal     XX.XX (XX.XX)   XX.XX (XX.XX)   XX.XX *
physician or nurse

Global rating of              XX.XX (XX.XX)   XX.XX (XX.XX)   XX.XX *
specialists

Global rating of care receivedXX.XX (XX.XX)   XX.XX (XX.XX)   XX.XX *

Global rating of Medicare     XX.XX (XX.XX)   XX.XX (XX.XX)    X.XX *

* p <.XXX.

([dagger]) Means provided for the composite measure as well as
its underlying items. Ratings on the  composites are presented on
a X-XXX scale. Ratings on the underlying items are presented on
their original X-X scale.

Full article

Depression is a common disabling condition that exacts a high toll on individuals and society (Rice and Miller 1998; Pincus and Pettit 2001; Kessler et al. 2005). Despite the availability of effective psychotherapeutic and pharmacological treatments (Von Korff et al. 1997; Schulberg et al. 1998), less than one-third of adults with depression in the United States receive appropriate treatment (Wang, Berglund, and Kessler 2000; Young et al. 2001). Patients with depressive symptoms also tend to receive poorer care for their comorbid chronic conditions than do patients without depressive symptoms who have the same chronic conditions (e.g., Ciechanowski, Katon, and Russo 2000; Ciechanowski et al. 2003; Katon et al. 2005). Additional research is needed to understand how the health care experiences of patients with and without depressive symptoms may differ, and to suggest ways in which the health care experience of patients with depression may be improved. This study compared the health care experiences of Medicare beneficiaries with and without symptoms of depression and investigated the role of patient confidence in shaping these experiences.

Eighty-three percent of Medicare beneficiaries are aged XX and older (Kaiser Family Foundation 2010); the rest are primarily younger adults qualified for Medicare via chronic physical disability. The prevalence of depression among the elderly is estimated at X-XX percent depending on definition (i.e., minor versus major depression), setting (e.g., community-based versus medical inpatient population), and diagnostic criteria (e.g., DSM versus other; McCall et al. 2002). Depression among older adults is a public health concern due to its association with decreased functional ability (Kivela and Pahkala 2001), poorer adherence to medical treatment (DiMatteo, Lepper, and Croghan 2000), and increased risk of mortality (Penninx et al. 1999; Schulz, Drayer, and Rollman 2002; Gallo et al. 2005). People with physical disabilities are also at increased risk for depression (Turner and Noh 1988; Turner and McLean 1989; Geerlings et al. 2000; Yang and George 2005; Schieman and Plickert 2007), partly because of mobility impairment (Briesacher et al. 2002) and partly because of other adversities, such as social stigma (Bruce 1999; Graney 2000; Mickelson 2001).

Quality of care for depressed patients is enhanced by good patient-provider communication (Carney et al. 1999; Bultman and Svarstad 2000; Bull et al. 2002; Deveugele, Derese, and De Maeseneer 2002). Depressed patients who report more physician information sharing and more involvement in treatment decisions are more likely to receive guideline-concordant care (Clever et al. 2006). Good patient-provider communication results in a lower symptom burden for patients (Greenfield, Kaplan, and Ware 1985; Little et al. 2001), greater satisfaction with treatment (Stewart 1984; Brody et al. 1989; Little et al. 2001), and improved treatment adherence (Stewart 1984; Lin et al. 1995; Bull et al. 2002).

Patients with depressive symptoms often report poor doctor-patient communication. In recent studies of adults with diabetes (Swenson et al. 2008) and chronic coronary disease (Schenker et al. 2009), depressive symptoms were associated with reports of suboptimal clinician-patient communication across multiple domains, particularly patient-centered communication (e.g., elicitation of patient problems, concerns, and expectations; explanation of condition; and responsiveness to patient preferences).

The association between depression and poor patient-provider communication may extend to other aspects of care, as depressed patients are often disengaged, unassertive, and poorly informed, and therefore may be unlikely to negotiate care or to expect or demand timely and proper care (Rogers, May, and Oliver 2001; Gasket al. 2003; Savard 2004). However, studies comparing experiences of care reported by depressed and nondepressed patients have so far limited their scope to patient-provider communication, omitting other specific aspects of care and overall evaluations of care. Moreover, little is known about factors that mediate the association between depressive symptoms and poorer experiences of care.

One mediating mechanism may be patients' confidence in their ability to actively participate in their health care. To participate, patients must be able to monitor and accurately report on changes in their health condition and feel confident in their ability to do so (Lorig 1996). Confident patients ask more questions, have a greater sense of control over their health, and adhere better to treatment (DiMatteo 1998; Hibbard et al. 1999). Because depression generally entails feelings of pessimism and inefficacy, it is reasonable to assume that patients with depressive symptoms lack confidence in their ability to take an active role in their care. If so, they are likely to also be less satisfied with their care and--according to the chronic care model (Wagner, Austin, and Von Korff 1996)--to actually experience poorer care.

CURRENT STUDY

In this study, we examined the association between depressive symptoms and severn aspects of patient experience, including doctor communication, access to care, timeliness of care, and overall ratings of care, including specialty care. Our primary aim was to determine whether beneficiaries with and without depressive symptoms evaluate their experiences with care differently. Our secondary aim was to understand the reason for any differential evaluations of care. We addressed this secondary aim in several ways. First, we investigated whether differences between depressed and nondepressed beneficiaries remain after controlling for global self-rated mental health, which is highly predictive of patients' ratings of care and therefore commonly included in models for case mix adjustment of patient reports and ratings of health care (O'Malley et al. 2005; Elliott et al. 2009). Second, we investigated whether accounting for beneficiaries' confidence in their ability to help manage their own care helps explain associations between depression and ratings of patient experience.

A key challenge in investigating associations between depression and ratings of care is distinguishing true differences in care between depressed and nondepressed patients from differences in scale use (Atkinson and Caldwell 1997; Schenker et al. 2009). An analysis of differential item functioning (DIF; Zumbo 1999) can help make this distinction. A DIF analysis evaluates whether subgroups of respondents (e.g., those with and without depressive symptoms) who have equivalent levels of some underlying construct (e.g., patient experiences) respond similarly to individual items that measure that construct. To investigate the possibility of differential scale use by depressed and nondepressed beneficiaries and to further illuminate our findings, we subjected a subset of our outcome measures to a DIF analysis.

We hypothesized that Medicare beneficiaries with depressive symptoms would report poorer experiences with care than would beneficiaries without depressive symptoms. Given that there are plausible reasons to expect patient behaviors associated with depression to adversely affect the process of care, we hypothesized that findings from our DIF analysis would support an interpretation of these differences as reflecting real differences in care (as opposed to differences in scale use). We expected that Medicare beneficiaries with depressive symptoms would have less confidence in their ability to manage their own care than would beneficiaries without depressive symptoms and that less confidence would be associated with poorer experiences of care.

METHODOLOGY

Data

We tested our hypotheses using data from the 2009 CAHPS Medicare X.X Fee-for-Service (FFS) Survey, which was fielded to a national probability sample of XXX,XXX FFS Medicare beneficiaries. FFS beneficiaries, those not enrolled in Medicare Advantage, the managed care version of Medicare, represent XX percent of all Medicare beneficiaries (Kaiser Family Foundation 2009). Different versions of the survey were completed by FFS beneficiaries with (N = XXX,XXX) and without (N = XX,XXX) prescription drug coverage. Because the survey completed by beneficiaries with prescription drug coverage (about half of all FFS beneficiaries) did not include a measure of depressive symptoms, only data from beneficiaries without prescription drug coverage were included in this analysis. Surveys were distributed by mail, with follow-up of nonrespondents by phone. The overall response rate for the 2009 CAHPS Medicare FFS survey was XX percent among eligibles (and XX percent among FFS beneficiaries without prescription drug coverage), with XX percent of completions by phone. Unit response to the survey followed patterns typical for other health surveys (Elliott et al. 2005), including higher response rates with age through age XX, higher response rates for non-Hispanic Whites than for other racial/ethnic groups, and lower response rates for beneficiaries dually eligible for Medicaid. Poststratification weights, using respondents' states of residence as strata, accounted for sample design and nonresponse.

Measures

Ratings of Health Care Experiences. The dependent measures were respondents' reports of their health care experiences in the past X months. We analyzed four global ratings (personal physician or nurse, specialists, all health care received, and all experiences with Medicare) and three composite measures of reported care: ease of getting needed care, getting care quickly, and how well doctors communicate. Global ratings were on XX-point scales, verbally anchored only at X (worst possible) and XX (best possible). To measure ease of getting needed care ([alpha] = X.XX), we asked respondents how often (X = "never" to X = "always") it was easy to get (a) appointments with specialists and (b) the care, tests, or treatment they thought they needed through their health plan. Getting care quickly ([alpha] = X.XX) used a similar response scale with respect to (a) receiving care as soon as needed when sick or injured and (b) getting an appointment for care at a doctor's office or clinic as soon as they thought they needed it when they were not sick or injured. Doctor communication ([alpha] = X.XX) similarly addressed how often patients' personal physician or nurse (a) explained things in a way that was easy to understand, (b) listened to them carefully, (c) spent enough time with them, and (d) showed respect for what they had to say. To facilitate comparisons across measures of health care experiences, we transformed scores linearly to a X-XXX possible range.

Depression. We measured depression symptoms with the PHQ-X, a X-item depression screener (Kroenke, Spitzer, and Williams 2003). Respondents used a X-point response scale (X = "not at all," X = "several days," X = "more than half the days," X = "nearly every day") to report how often in the past X weeks they had been bothered by "having little interest or pleasure in doing things" and by "feeling down, depressed, or hopeless." Alpha reliability for these two items in our sample was X.XX. Following instructions in Kroenke, Spitzer, and Williams (2003), we summed responses to these two items and categorized respondents whose sum was X or higher as screening positive for depressive symptoms (hereafter referred to as "depressed") and respondents whose sum was below X as screening negative for depressive symptoms (hereafter referred to as "not depressed"). Compared with a structured clinical interview, the PHQ-X has high sensitivity (X.X-X.X) and moderate to high specificity (X.X-X.X) for detecting major depression among general primary care samples (Kroenke, Spitzer, and Williams 2003; Arroll et al. 2010) and samples of older patients (Li et al. 2007; Thombs, Ziegelstein, and Whooley 2008; Watson et al. 2009). Moreover, among older patients, the PHQ-X performs similarly to the lengthier PHQ-X as a "first step" screener for depression (Thombs, Ziegelstein, and Whooley 2008).

Self-rated Mental Health. Respondents rated their general mental health as "poor," "fair," "good," "very good," or "excellent." Global self-rated mental health has been found to be moderately correlated (|X.XX| < r < |X.XX|) with other measures of mental health, including the PHQ-X screener for depression, in a nationally representative sample (Fleishman and Zuvekas 2007). In our data, the polychoric correlation between self-rated mental health and depression as measured by the PHQ-X is -X.XX.

Patient Confidence. We measured patients' confidence in their ability to manage their own care with a single item from Heller et al. (2009): "How confident are you that you can identify when it is necessary for you to get medical care (X = "not at all confident" to X = "very confident")?"

Control Variables. Potential confounders that were controlled for in all multivariate models include gender, age (younger than XX years, XX-XX, XX-XX, XX-XX, XX-XX, XX-XX, and XX years or older), education (no high school, some high school, high school graduate or GED, some college, X-year college graduate, and > X years of college), self-rated physical health (poor, fair, good, very good, and excellent), receipt of a low-income subsidy (an indicator of being below XXX percent of the federal poverty level), dual eligibility for Medicaid (a subset of the previous category), and whether the beneficiary received assistance in completing the survey or had a proxy respondent (two separate indicators). (X) We also included dummy indicators of state of residence.

Missing Data and Imputation

Listwise deletion of cases missing at least one predictor would omit XX percent of cases from the study. To avoid the resultant bias and loss of precision, we imputed values for the independent, but not dependent, variables used in our analyses. Seven percent of respondents did not complete one or both depression items, and X percent omitted the patient confidence item. Missing data on the control variables ranged from X percent to XX percent (see Table X for more specific information on missing data). Only beneficiaries who reported applicable experiences were asked to complete some dependent measures, such as the rating of specialists. Of those eligible to respond, rates of missingness on our dependent measures (i.e., the four global ratings and three composites) were X-XX percent.

We first imputed missing values for control variables and self-rated mental health status, using the mean within the beneficiary's area of residence (XXX such areas). To preserve correlational relationships among key predictors, we used least-squares regression imputation for depression and patient confidence. Regression imputation employed all predictors in our multivariate analyses, including nonmissing values of the depression indicator to predict patient confidence, and nonmissing values of the two depression items to predict the depression indicator. These commonly used imputation approaches efficiently handle missing data, produce more reliable estimates than those obtained with listwise deletion, and reasonably approximate other commonly employed imputation approaches when rates of missingness are low and missing values are spread uniformly across the data (Schafer and Graham 2002). (X)

Analytic Approach
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