During September and December 2022, there were 295 MHD patients at the dialysis center of Chiang Mai University Hospital. As depicted in Fig. 1, 106 patients were excluded. One hundred eighty-nine patients were included in the analysis. The survey response rate was 80.43%. Patient characteristics are shown in Table 1. The mean age was 58.28 ± 14.87 years. The majority of patients were aged between 55 and 74 years (55.56%). The median dialysis vintage was 39 months (IQR; 18,72). Among the 189 patients included in the analysis, 143 (75.66%) completed the questionnaire themselves. Our “Thai CAHPS-ICH” survey is provided in the supplementary appendix.
Table 1 Patient characteristics at baseline
Characteristics
|
N (%) (Total=189)
|
Age (years old)
18 – 34
35 – 54
55 – 74
75 or more
|
12 (6.35)
53 (28.04)
105 (55.56)
19 (10.05)
|
Sex
Male
Female
|
107 (56.61)
82 (43.39)
|
BMI (kg/m2)
<18.5
18.5 – 22.9
23 – 25
>25
|
23 (12.17)
72 (38.10)
37 (19.58)
57 (30.16)
|
Hemodialysis Vintage
3 months – less than 1 year
1 – less than 5 years
5 years or more
|
31 (16.40)
100 (52.91)
58 (30.69)
|
Education
Elementary School
Junior high school
Senior high school
Bachelor
Master’s degree or more
|
56/187 (29.95)
17/187 (9.09)
30/187 (16.04)
63/187 (33.69)
21/187 (11.23)
|
Survey response
Self-complete
Reading the question
Writing down the given answer
Translating the question into local language
|
143 (75.66)
43 (22.75)
25 (13.23)
4 (2.12)
|
The ceiling and floor effects are shown in Table 2. All the 10-point global rating scales (Q8, Q32, and Q35) exhibited significant ceiling effects (ranging from 39.89 to 48.91%). Ceiling effects were also observed in most composites of the NCC and QoC domains, with exceptions noted for “Q24 staff manage problem” (12.07%) and “Q43 satisfied with way problems handled” (1.14%). None of the questions demonstrated significant floor effects (0–13.89%).
Table 2
Ceiling and floor of the Thai CAHPS-ICH
Thai CAHPS-ICH
|
Baseline
|
1 month
|
%Ceiling effect
|
%Floor effect
|
%Ceiling effect
|
%Floor effect
|
Q3 Doctor listens carefully
|
59.57
|
1.06
|
52.69
|
0.60
|
Q4 Doctor explains things
|
38.67
|
2.76
|
42.17
|
1.81
|
Q5 Doctor shows respect
|
47.49
|
0
|
44.85
|
0.61
|
Q6 Doctor spends enough time
|
42.54
|
0.55
|
48.19
|
0
|
Q7 Doctor cared about you
|
48.62
|
1.10
|
46.99
|
0.60
|
Q8 Nephrologists’ communication and caring
|
39.89
|
0
|
43.71
|
0
|
Q10 Staff listen carefully
|
64.84
|
0
|
59.52
|
0
|
Q11 Staff explain in a way that is easy to understand
|
55.25
|
0
|
54.76
|
0
|
Q12 Staff show respect
|
51.65
|
0
|
55.36
|
0
|
Q13 Staff spend enough time
|
57.07
|
0
|
52.69
|
0.60
|
Q14 Staff cared about you
|
57.84
|
0
|
55.95
|
0
|
Q15 Staff makes you comfortable
|
61.41
|
0.54
|
62.50
|
2.38
|
Q21 Staff insert needle without pain
|
34.07
|
1.65
|
36.42
|
0
|
Q22 Staff check you closely
|
57.61
|
0.54
|
52.07
|
1.18
|
Q24 Staff manage problems
|
12.07
|
0
|
17.18
|
0.61
|
Q25 Staff professional
|
64.77
|
0
|
56.36
|
1.82
|
Q27 Staff explain tests
|
32.42
|
4.95
|
31.52
|
4.24
|
Q32 Quality of Dialysis Center Care and Operations
|
46.70
|
0
|
46.43
|
0
|
Q33 On machine within 15 min
|
32.78
|
13.89
|
35.33
|
10.78
|
Q34 Center clean
|
67.21
|
0.55
|
65.87
|
0
|
Q35 Providing Information to Patients
|
48.91
|
0
|
50.90
|
0
|
Q43 Satisfied with way problems handled
|
1.14
|
0
|
1.23
|
1.23
|
Table 3 displays the results of the validity assessment, presenting the correlations between survey domains and global rating scales. The NCC domain demonstrated a strong association with the global rating scale of nephrologists (r = 0.60). Similarly, the QoC scale exhibited a strong association with the global rating scales of staff and center (r = 0.65 and r = 0.58, respectively). Additionally, a moderate association was observed between the PI scale and center global rating scale (r = 0.31).
Table 3
Correlations between Scales and Global Rating Scales
Scale domains
|
Doctor
rating scale
|
Staff
rating scale
|
Center
rating scale
|
Nephrologists’ Communication and Caring (NCC)
|
0.60
|
0.45
|
0.38
|
Quality of Dialysis Center Care and Operations (QoC)
|
0.37
|
0.65
|
0.58
|
Providing Information to Patients (PI)
|
0.17
|
0.26
|
0.31
|
All correlations are significant at P < 0.05
|
The correlations between each multi-item scale and all three global rating scales are outlined in Table 4. Five out of six items from the NCC domain demonstrated a strong correlation with the doctor global rating scale (r = 0.51–0.58). Additionally, ten out of 17 items in the QoC domain were associated with the staff and center rating scales (r = 0.45–0.59 and r = 0.34–0.55, respectively). However, no correlation was detected between the PI domain and any of the global rating scales.
Table 4
Item-scale correlations of the Thai CAHPS-ICH composites
Items
|
Scales
|
Doctor rating
|
Staff rating
|
Center rating
|
Q3 Doctor listens carefully (n = 176)
Q4 Doctor explains things (n = 175)
Q5 Doctor shows respect (n = 173)
Q6 Doctor spends enough time (n = 175)
Q7 Doctor cared about you (n = 175)
Q9 Doctor seemed informed (n = 163)
|
0.51a
0.58a
0.55a
0.54a
0.55a
-0.03
|
0.42a
0.42a
0.44a
0.37a
0.48a
-0.07
|
0.38a
0.43a
0.41a
0.42a
0.55a
<-0.001
|
Q10 Staff listen carefully (n = 174)
Q11 Staff explain in a way that is easy to understand (n = 174)
Q12 Staff show respect (n = 172)
Q13 Staff spend enough time (n = 173)
Q14 Staff cared about you (n = 174)
Q15 Staff makes you comfortable (n = 173)
Q16 Staff keep information private (n = 168)
Q17 Comfortable asking staff (n = 173)
Q21 Staff insert needle without pain (n = 171)
Q22 Staff check you closely (n = 173)
Q24 Staff manage problems (n = 168)
Q25 Staff professional (n = 170)
Q26 Staff discuss diet (n = 174)
Q27 Staff explain tests (n = 176)
Q33 On machine within 15 min (n = 174)
Q34 Center clean (n = 175)
Q43 Satisfied with way problems handled (n = 167)
|
0.28a
0.33a
0.39a
0.38a
0.34a
0.37a
0.02
-0.08
0.07
0.33a
-0.04
0.33a
-0.24a
0.34a
0.22a
0.33a
-0.15a
|
0.48a
0.50a
0.59a
0.51a
0.57a
0.54a
-0.08
-0.03
0.16a
0.54a
-0.04
0.47a
-0.25a
0.49a
0.25a
0.46a
-0.27a
|
0.37a
0.44a
0.48a
0.39a
0.42a
0.46a
-0.04
0.02
0.15
0.47a
-0.06
0.34a
-0.14
0.37a
0.25a
0.55a
-0.22a
|
Q19 Know how to care of access site (n = 173)
Q28 Staff give information on patient rights (n = 169)
Q29 Staff review patient rights (n = 167)
Q30 Staff told you what to do if health problem at home
(n = 176)
Q31 Staff told you how to get off machine if emergency (n = 173)
Q36 Doctor/staff talk about which treatment is right for you
(n = 165)
Q38 Doctor/staff explain why not eligible for transplant (n = 171)
Q39 Doctor/staff talk about peritoneal dialysis (n = 168)
Q40 Involved in choosing treatment (n = 168)
|
-0.06
-0.25a
-0.30a
-0.13
-0.03
-0.10
-0.14
-0.20a
-0.08
|
-0.20a
-0.30a
-0.31a
-0.24a
-0.11
-0.04
-0.14
-0.20a
-0.07
|
-0.21a
-0.22a
-0.32a
-0.15a
-0.15a
-0.06
-0.13
-0.21a
-0.01
|
ap < 0.05
|
For internal consistency reliability, the composites of the Nephrologists’ Communication (6 items) and Quality of Dialysis Center Care and Operations (17 items) domains exhibited good and acceptable reliability (α = 0.86 and 0.78, respectively). However, the PI composite did not demonstrate internal consistency (α = 0.53). (Table 5)
Table 5
Internal Consistency Reliability
Domains
|
Cronbach’s alpha (α)
|
Nephrologists’ Communication and Caring (6 items)
Quality of Dialysis Center Care and Operations (17 items)
Providing Information to Patients (9 items)
|
0.86
0.78
0.53
|
Most of the multi-item scales exhibited test-retest repeatability (intraclass correlation coefficient; ICC, 0.55–0.85). However, one multi-item scale (Q43 Satisfied with way problems handled) did not demonstrate this reliability (ICC = 0.19). Test-retest reliability was observed for 4 out of the 13 yes/no questions, all of which are in the PI domain (Q29, Q30, Q31, and Q38) as shown in Table 6.
Table 6
Items
|
ICC
|
95%CI
|
P value
|
Q3 Doctor listens carefully
|
0.66
|
0.54–0.75
|
< 0.001
|
Q4 Doctor explains things
|
0.68
|
0.67–0.77
|
< 0.001
|
Q5 Doctor shows respect
|
0.66
|
0.53–0.75
|
< 0.001
|
Q6 Doctor spends enough time
|
0.59
|
0.43–0.70
|
< 0.001
|
Q7 Doctor cared about you
|
0.56
|
0.40–0.68
|
< 0.001
|
Q8 Nephrologists’ communication and caring2
|
0.64
|
0.51–0.73
|
< 0.001
|
Q9 Doctor seemed informed1
|
0.48
|
0.28–0.62
|
< 0.001
|
Q10 Staff listen carefully
|
0.70
|
0.59–0.78
|
< 0.001
|
Q11 Staff explain in a way that is easy to understand
|
0.65
|
0.52–0.74
|
< 0.001
|
Q12 Staff show respect
|
0.70
|
0.60–0.78
|
< 0.001
|
Q13 Staff spend enough time
|
0.66
|
0.53–0.75
|
< 0.001
|
Q14 Staff cared about you
|
0.62
|
0.49–0.72
|
< 0.001
|
Q15 Staff makes you comfortable
|
0.63
|
0.49–0.72
|
< 0.001
|
Q16 Staff keep information private1
|
0.22
|
-0.07–0.43
|
0.061
|
Q17 Comfortable asking staff1
|
-0.06
|
-0.44–0.22
|
0.638
|
Q21 Staff insert needle without pain
|
0.85
|
0.79–0.89
|
< 0.001
|
Q22 Staff check you closely
|
0.57
|
0.42–0.68
|
< 0.001
|
Q24 Staff manage problems
|
0.50
|
0.31–0.63
|
< 0.001
|
Q25 Staff professional
|
0.61
|
0.47–0.72
|
< 0.001
|
Q26 Staff discuss diet1
|
0.30
|
0.05–0.49
|
0.012
|
Q27 Staff explain tests
|
0.61
|
0.47–0.71
|
< 0.001
|
Q32 Quality of Dialysis Center Care and Operations2
|
0.70
|
0.60–0.78
|
< 0.001
|
Q33 On machine within 15 min
|
0.65
|
0.52–0.74
|
< 0.001
|
Q34 Center clean
|
0.54
|
0.37–0.66
|
< 0.001
|
Q35 Providing Information to Patients2
|
0.79
|
0.72–0.85
|
< 0.001
|
Q43 Satisfied with way problems handled
|
0.19
|
-0.12–0.41
|
0.105
|
Q19 Know how to care of access site1
|
0.28
|
0.02–0.47
|
0.020
|
Q28 Staff give information on patient rights1
|
0.13
|
-0.19–0.37
|
0.190
|
Q29 Staff review patient rights1
|
0.68
|
0.55–0.77
|
< 0.001
|
Q30 Staff told you what to do if health problem at home1
|
0.58
|
0.42–0.69
|
< 0.001
|
Q31 Staff told you how to get off machine if emergency1
|
0.57
|
0.41–0.69
|
< 0.001
|
Q36 Doctor/staff talk about which treatment is right for you1
|
0.34
|
0.09–0.52
|
0.006
|
Q38 Doctor/staff explain why not eligible for transplant1
|
0.70
|
0.59–0.79
|
< 0.001
|
Q39 Doctor/staff talk about peritoneal dialysis1
|
0.47
|
0.27–0.61
|
< 0.001
|
Q40 Involved in choosing treatment1
|
0.44
|
0.23–0.59
|
< 0.001
|
1Yes/No question
2Global rating scale
|
We compared the results of our “Thai CAHPS-ICH” survey and the original ICH-CAHPS® survey in Table 7. The response rate in our study was higher than that of the original survey (80.43% vs. 46%). Both surveys demonstrated internal consistency in the NCC and QoC domains (⍺ = 0.86 and 0.78 in the Thai CAHPS-ICH survey, and ⍺ = 0.81 and 0.90 in the ICH-CAHPS® survey, respectively). However, neither survey showed internal consistency in the PI domain (⍺ = 0.53 in the Thai CAHPS-ICH survey and ⍺ = 0.55 in the ICH-CAHPS® survey). Regarding validity, both surveys exhibited correlations between the NCC domain and the doctor rating scale (r = 0.60 and 0.78 in the Thai CAHPS-ICH and original ICH-CAHPS® surveys, respectively), between the QoC domain and the staff rating scale (r = 0.65 and 0.75 in the Thai CAHPS-ICH and original ICH-CAHPS® surveys, respectively), and between the QoC and the center rating scale (r = 0.58 and 0.69 in the Thai CAHPS-ICH and original ICH-CAHPS® surveys, respectively). However, both surveys showed less strong correlations between the PI domain and all global rating scales.
Table 7
Comparison between the Thai CAHPS-ICH and original ICH-CAHPS®(5, 17)
Contents
|
Thai CAHPS-ICH
|
Original ICH-CAHPS®
|
Study design (n)
|
Single center study in Chiang Mai (n = 189)
|
Multicenter study in US (n = 819)
|
Data collection
|
Questionnaire form
|
Telephone or mailed survey
|
Response rate
|
80.43%
|
46%
|
Reliability
|
⍺1 = 0.86 (NCC),
0.78 (QoC),
0.53 (PI)
|
⍺1 = 0.81 (NCC),
0.90 (QoC),
0.55 (PI)
|
Validity(r)2
|
- 0.60 between NCC and Doctor GRS
- 0.65 between QoC and Staff GRS
- 0.58 between QoC and Center GRS
- < 0.5 between PI domain and all GRS
|
- 0.78 between NCC and Doctor GRS
- 0.75 between QoC and Staff GRS
- 0.69 between QoC and Center GRS
- < 0.5 between PI domain and all GRS
|
1Cronbachs’ alpha coefficient
2Correlation coefficient (r) of value ≥ 0.3 and ≥ 0.4 were considered association for Thai CAHPS-ICH and for Original ICH-CAHPS respectively.
|