Understanding Variations in Patient Care from the Patient’s Viewpoint Integrated Patient Care...

Understanding Variations in Patient Care from the Patient’s Viewpoint

Integrated Patient Care Expert Advisory Panel

Boston, MA ● February 13, 2015

Financial support for this research was provided by The Commonwealth Fund and Kaiser Permanente Community Benefit; the Lucian Leape Foundation provided financial support for the

advisory panel. Thanks to Ariadne Labs for hosting the inaugural advisory panel meeting.

Agenda• Welcome • PPIC survey development• Survey findings• Lunch• Patient / provider-manager panel discussion• Dissemination plans and opportunities• Related research and future opportunities• Summary & next steps

Aim to understand and critically assess survey development and initial results and explore new opportunities

Meet the project team• Harvard: Sara Singer, Ashley Fryer,

Michaela Kerrissey, Maryaline Catillon, Juliana Stone

• UC Berkeley: Steve Shortell, Patty Ramsay

• Weill Cornell: Larry Casalino

• RAND: Mark Friedberg, Maria Orlando Edelen, Sam Hirshman

• Penn State: Jonathan Clark

Introductions of panel and guests

• Your background

• Activities related to integrating care or studying its impact in which you or your organization is involved



PPIC national sample overview

• Original sample: 12,364 Medicare beneficiaries• Number of medical groups represented: 150• Number excluded*: 412• Surveys received: 3226• Response rate: 27%• Percent respondents who verified their association with

the medical group: 84%

A response rate of 27% was slightly lower than hoped, but on par with similar surveys and sufficient for analysis

Psychometric analysis of PPIC 2.1 responses

• We analyzed 3226 PPIC 2.1 responses– 1066 randomly drawn and reserved for CFA– Remaining 2160 responses entered into EFA

• We withheld items with low covariance coverage (i.e., those answered infrequently) from EFA

• Before conducting EFA, we adjusted each item score for “response tendency” (i.e., general optimism or pessimism)– Using residuals after accounting for LOT-R scores

EFA yielded a 5-factor solution Staff awareness of information

about the patient 3 items, Cronbach alpha = 0.80

Provider communication with the patient 12 items, Cronbach alpha = 0.86

Provider knowledge about the patient 5 items, Cronbach alpha = 0.70

Integration post visit 3 items, Cronbach alpha = 0.67

Integration with specialists 2 items, correlation = 0.61

Staff awareness of information about the patient (3 items)

• In reference to staff in the index provider’s office:– In the last 6 months, how often did these other staff

seem up-to-date about the care you were receiving from this provider?

– In the last 6 months, how often did these other staff talk to you about the care you received from this provider?

– In the last 6 months, how often did these other staff seem to know the important information about your medical history?

Provider communication with the patient (12 items)

• In the last 6 months, how often did this provider or someone in his or her office…– Talk with you about what to do if you have a bad reaction to your medicine?

– Talk with you about how you were supposed to take your medicine?

– [conditional on needing services at home] Help you get these services at home to take care of your health?

– Help you identify the most important things for you to do for your health?

– [conditional on presence of things that make it hard to take care of your health] Ask you about these things that make it hard for you to take care of your health? And Help you come up with a plan to help you deal with the things that make it hard for you to take care of your health?

– Give you instructions about how to take care of your health? And In the last 6 months, how often did the instructions you received help you take care of your health?

– Contact you between visits to see how you were doing?

Provider communication with the patient (12 items), continued

• In the last 6 months:– Did this provider talk with you about setting goals for your health? And Did

the care you received from this provider help you meet your goals?

– [conditional on receiving a prescription from a specialist] In general, how often does the provider named in Question 1 talk with you about the medicines prescribed by these specialists?

– Before your most recent visit with this provider, did you get a reminder from this provider's office about the appointment? And Before your most recent visit with this provider, did you get instructions telling you what to expect or how to prepare for the visit?

– How often did this provider ask about things in your work or life at home that affect your health?

– [conditional on missing an appointment] When you missed an appointment with this provider, how often did someone from his or her office contact you to make a new appointment?

Provider knowledge about the patient(5 items)

• How would you rate this provider’s knowledge of your values and beliefs that are important to your health care?

• In general, how often does the provider named in Question 1 seem informed and up-to-date about the care you get from specialists?

• In general, how often do you have to remind the provider named in Question 1 about care you receive from specialists?

• In the last 6 months, how often did this provider seem to know the important information about your medical history?

• In the last 6 months, how often did you have to repeat information that you had already provided during the same visit?

Integration post visit(3 items)

• [conditional on having had a test] In the last 6 months:– When this provider or someone in his or her office

ordered a blood test, x-ray, or other test for you, how often did this provider or someone from his or her office follow up to give you those results?

– How often did you have to request your test results before you got them?

– How often were your test results presented in a way that was easy to understand?

Integration with specialists(2 items)

• [conditional on having seen a specialist] In the last 6 months:– When you see this specialist, does he or she seem

to know enough information about your medical history?

– When you see this specialist, how often does this specialist seem to know all your test results from other providers?

Integration following a hospital stay(4 items)

• This scale included items not entered into factor analysis because few patients had hospital stays (low covariance coverage)

• [conditional on having had a hospital stay] After your most recent hospital stay:– Did the provider named in Question 1 or someone in his or her office

contact you to see how you were doing?

– Did the provider named in Question 1 or someone in his or her office contact you to check if you were able to follow instructions about any medicines you were prescribed?

– Were you given instructions about caring for yourself at home? And, were the instructions you were given easy to understand?

– After your most recent hospital stay, did the provider named in Question 1 seem to know important information about this hospital stay?

Orphan items

• Three items failed to load with any factor• In the last 6 months:

– If you had any trouble taking care of your health at home, would you know who to ask for help?

– There are many reasons why people may not always be able to take their medicines as prescribed. How often were you able to take your medicine as prescribed?

– How often did this provider cancel or change the date of an appointment?

Psychometric summary

• Final model demonstrates satisfactory goodness of fit according to standard measures

• And sufficient discriminant validity (factor correlations ranging from .214 to .458 versus internal consistencies > 0.61)

Measure Exploratory sample

Confirmatory sample

Target

Χ2 (df) 574.147 (248) 657.488 (262) N/ARMSEA 0.027 0.040 <0.08CFI 0.962 0.912 >0.93SRMR 0.037 0.072 <0.08

Coordinated within care team

Coordinated across care teams

Information flow to your primary provider

Information flow to other providers in your primary provider’s office

Information flow to your specialist

Information flow post hospitalization

Coordination with home and community resources

Continuous familiarity with patient over time

Proactive action before visits

Post-visit information flow to the patient

Responsive independent of visits

Patient Centeredness

Shared responsibility

Continuity: familiarity with patient over time

Continuity: proactive and responsive action

between visits

Patient centeredness


Coordination between care teams and

community resources

PPIC 1.0 PPIC 2.0

Staff awareness of information about the

patient

Integration with specialists

Provider knowledge about the patient

Integration post visit

Provider communication with the patient

Integration following a hospital stay

PPIC 2.1


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PPIC 2.1PPIC 2.0


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PPIC 2.1PPIC 2.0


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PPIC 2.1PPIC 2.0


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PPIC 2.1PPIC 2.0


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PPIC 2.1PPIC 2.0

PPIC journey

• Psychometrically-derived factors are generally consistent with the 11 functional domains of integrated care we hypothesized based on PPIC 2.0

• Psychometric analysis also suggests that patients may not differentiate between knowledge and communication about medical and patient-centered issues– Items about provider knowledge of/communication

about patients’ medical care loaded onto the same factors as items about provider knowledge of/communication about patients’ values and beliefs

Panel member reflections

• Any questions or clarifications?

• What is striking to you about these findings?

• Is there value in providing results according to functional domains in addition to psychometrically-derived factors?



Analysis update

• Sample characteristics

• Levels of patient-perceived integration

• Relationship with organizational characteristics

1

2

3

Sample overview (reprise)

• Original sample: 12,364 Medicare beneficiaries• Number of medical groups represented: 150• Number excluded*: 412• Surveys received: 3226• Response rate: 27%• Percent respondents who verified their association with

the medical group: 84%

1 Sample Characteristics

A response rate of 27% was slightly lower than hoped, but on par with similar surveys and sufficient for analysis

Respondent demographics1 Sample Characteristics

Alone in house

Income

Race

Education

Gender

Age

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Percent of respondents by demographic category

Respondents tended to be older, female, with at least some college, white, low income, not living alone

Younger than 75 Older than 75

Male Female

No more than high schoolOlder than 75

Less than $40K/year

Older than 75White

At least some college

Alone

Non white

More than $40K/year

Not alone

Types of services received1 Sample Characteristics

0400800

120016002000 1904

1011556 345

Obtained sufficient responses from patients receiving relevant types of care

Number of respondents by type of service received

Respondent health status

• Average of ~7 chronic conditions

• 93% had at least two chronic conditions


Number of respondents with each chronic condition

Majority of respondents could be considered high need

Health status overview

IHD

Diabetes

Depression

CHF

Asthma

0

500

1000

1500

2000

Organizational characteristics

Care Management Processes

Technology Sophistication

Ownership

Type

Size

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


Large Small

Multi-specialty Primary care

Hospital owned Not hospital owned

High Low

High Low

Though there is some imbalance, the distribution appears adequate for analysis

Distribution of respondents across medical group characteristics

Percentage of responses in top box

Q21 Q22 Q23 Q4/5 Q8 Q11 Q18/19 Q29/30 Q31 Q33 Q34/36 Q39 Q41 Q42 Q490%

10%

20%

30%

40%

50%

60%

70%

80%

Q25 Q26 Q27 Q9 Q10 Q17 Q46 Q47 Q50 Q52 Q54 Q56 Q57/58 Q590%

10%

20%

30%

40%

50%

60%

70%

80%




Integration following hospital stay

Staff awareness about patient

Provider communication with patient

2 Levels of patient perceived integration



10%

20%

30%

40%

50%

60%

70%

80%

Q25 Q26 Q27 Q9 Q10 Q17 Q46 Q47 Q50 Q52 Q54 Q56 Q57/58 Q590%

10%

20%

30%

40%

50%

60%

70%

80%








Question 42: 7% said their provider or someone in the office always contacts them between visits to see how they are doing.

Question 49: 34% said their provider always talked with them about medicines prescribed by their specialists.

Question 29/30: 30% said their provider or someone in the office always asked about things that make it hard to take care of their health and helped them come up with a plan.



10%

20%

30%

40%

50%

60%

70%

80%

Q25 Q26 Q27 Q9 Q10 Q17 Q46 Q47 Q50 Q52 Q54 Q56 Q57/58 Q590%

10%

20%

30%

40%

50%

60%

70%

80%








Question 22: 33% said other staff always talked to them about the care they received from their provider.

Question 23: 50% said other staff always seemed to know important information about their medical history.



10%

20%

30%

40%

50%

60%

70%

80%

Q25 Q26 Q27 Q9 Q10 Q17 Q46 Q47 Q50 Q52 Q54 Q56 Q57/58 Q590%

10%

20%

30%

40%

50%

60%

70%

80%








All 3 integration post visit items had top box percentages over 70%, and the highest was:Question 26: 79% said they never had to request their test results before they got them.

Question 47: 58% said they never had to remind their provider about the care they received from specialists.



10%

20%

30%

40%

50%

60%

70%

80%

Q25 Q26 Q27 Q9 Q10 Q17 Q46 Q47 Q50 Q52 Q54 Q56 Q57/58 Q590%

10%

20%

30%

40%

50%

60%

70%

80%








Question 52: 45% said their specialists always seemed to know their test results from other providers.

Question 56: 41% said after their most recent hospital stay, their provider or someone in the office contacted them to check if they were able to follow instructions about any medicines that were prescribed.

Summary of findings on levels of patient-perceived integration

• Substantial variation in top box percentages across questions

• Some notably low levels of perceived integration in certain areas

• Several questions in “provider communication with patient” dimension had particularly low levels


Regressions exploring the relationship with medical group characteristics

3 Relationship with organizational characteristics

• We first analyzed a set of basic models for each psychometric dimension with only one medical group explanatory variable in each (30 models total)

• We then analyzed a set of complete models with all explanatory variables and multiple control variables (and standard errors clustered by practice)

• The complete models indicated some unexpected negative relationships with patient-perceived integration for CMPs. This led us to wonder whether the effect of CMPs depended on other variables.

Step 1

Step 2

Step 3

Addition of interaction terms

What did we do?

• Ran additional models for each integration dimension with interaction terms added for CMP capability with each of the other organizational characteristics

What did we find?

• Introduction of interaction between CMP and hospital ownership resulted in a decrease in the negative relationship of CMP with integration for non hospital-owned practices


Preliminary models include the five organizational factors, controls, and an interaction term for CMP/hospital ownership

Preliminary models3 Relationship with organizational characteristics

Notes:^ p<.1; * p<.05; **p<.01; ***p<.001Control variables not shownStandard errors are heteroskedasticity robust and clustered by practice

Preliminary models3 Relationship with organizational characteristics

Notes:^ p<.1; * p<.05; **p<.01; ***p<.001Control variables not shownStandard errors are heteroskedasticity robust and clustered by practice

Key findings on the relationship with organizational characteristics

• Patients receiving care from multispecialty and hospital-owned groups more often perceived slightly higher levels of integration than those from primary care and non hospital-owned practices

• The integrative value of CMPs depends on the organizational context in which the activities are carried out, with a more positive relationship observed among non-hospital affiliated practices


Panel member reflections

• Any questions or clarifications?

• What is striking to you about these findings?





[Slide for internal use only]Care integration at Atrius Health

• Patient: The people gathered here today are interested in patients’ experiences related to their health care. Can you tell us about the care you receive from your providers? How many caregivers are involved in your care?

• Provider: I’d like you to begin by considering your role as a physician at Atrius. We’re interested in understanding care integration from providers’ perspectives. What keeps you up at night?

• Manager: How are you changing practice structures and processes to provide reliably safe care for your high need, high cost patients and for patients like Mr. Gibson?

• Provider: What have these changes meant for you as a physician who cares for patients?

• Patient: Have you noticed any difference in the care you receive? What support do you still need to feel like your care is well-integrated? If you could change one thing about the care you receive, what would it be?



Dissemination plans and opportunities

• Papers planned

• Website

• Papers in progress

1

2

3

Papers planned

• A paper about the psychometric journey of the PPIC survey and what it taught us about how patients think

• Capstone paper tentatively titled “The Patient Perceptions of Integrated Care survey: Establishing a National Evidence Base”– Proposed presentations at Academy of Management

and Academy Health

1

Suggested journals, framing, emphasis?

Website under construction

• integratedpatientcare.org

• Website for information about and access to the PPIC survey and related research

2

What information is most useful and important?

http://www.integratedpatientcare.org/

Papers in progress

• “Achieving Care Integration from the Patients’ Perspective: Results from a Care Management Program” comparing perceptions of CMP patients to patients receiving standard care (Fryer et al.)

• “Patient Perceptions of Integrated Care and their Relationship to Utilization of Health Services” showing perceptions of more integrated care relate to lower utilization, especially in outpatient settings, but for some factors the inverse was true (Fryer et al.)

• “Translating the PPIC to measure integrated care in the Netherlands: Combining equivalence and contextualization approaches for optimal results” (Tietschert et al.)

3Papers based on pilot data

Your suggestions

• What additional key questions can our data help answer?– Are there disparities in perceived integration based on

demographic characteristics like income, education and race?

– Are some patients more likely not to respond to this survey, and are there items to which patients are less likely to respond?

• What key audiences should we aim to reach and how best can we reach them?



Related and future research

• Proposed new research

• Related research

• Opportunities under development

1

2

3

Proposed new research

• Qualitative investigation of 12 physician organizations in order to gain a more in-depth understanding of how physician organizations achieve care integration for patients with high costs and high needs

• Quantitative study combining data on patient-perceived integration with data on Medicare claims in order to examine the relationship between patient-perceived integration and clinical outcomes of care. – Collaboration with Steve Shortell and Patty Ramsay of UC

Berkeley, Larry Casalino of Weill Cornell, and Loren Baker of Stanford

1

Both proposals were submitted to CMWF

Related research:VA integrated care study

• “Achieving Integrated Care for Patients with Multiple Chronic Conditions” is an Investigator Initiative Research grant that will – Study the relationship of patient experience of integrated care

in a stratified random sample of VA medical centers– Compare patient experience to provider perceptions of

relational coordination, to alterable organizational characteristics

– Conduct qualitative assessment in select facilities to identify behavioral and process mechanisms underlying organizational characteristics

• Supported by the VA HSR&D, Mark Meterko PI

2

Related research:VA integrated maternity care study

• “Patterns and Experiences of VA Maternity Care Coordination for Women Veterans” is an IIR that will – Investigate prevailing approaches for pregnancy and

maternity care delivery, including facilitators to maternity care coordination through provider interviews

– Explore pregnant Veteran’s experience of integrated maternity care

– Develop recommendations for VHA research, practice and policy

• Supported by the VA HSR&D, Kristin Mattocks, PI

2

Related research:Pediatric Integrated Care Survey (PICS)

• “Advancing care integration in child health” is developing and validating a survey measure of patient- and family-centered care integration with support from the Lucille Packard Children’s Foundation– Rich Antonelli PI and Sonia Ziniel Co-PI

2

Related research:Additional applications of PPIC survey

What Where WhoEvaluation of the NHS Scotland Reid and Hartung

Evaluation of integrated care The Netherlands Ruwaard and Tietschert

Evaluation of the Programs for All-inclusive Care for the Elderly (PACE)

US Bonner (Northeastern)

Development of a provider perceptions of integrated care survey

New Zealand Derrett (U of Otago)

2

Opportunities under development

• Medicare Current Beneficiary Survey (MCBS) includes PPIC as of 2014, presenting an opportunity to study:– Level of expenditures,– Type of health insurance coverage,– Health status, and– Demographic category

• Exploring with Commonwealth Fund Scorecard team the potential for contributing measures of integration among high-cost, high-need beneficiaries

• Does fielding of the Qualified Health Plan (QHP) enrollee survey of experience with Healthcare.gov Marketplace plans offer an opportunity for comparative research?

3

Your suggestions

• What are the most important questions we can address through planned research?

• Toward what additional research opportunities should we strive?

Agenda• Welcome • PPIC survey development• Survey findings• Lunch• Patient / provider-manager panel discussion• Dissemination plans and opportunities• Related research and future opportunities• Summary and next steps

Have we achieved today’s aims?

• To understand and critically assess survey development and initial results

• To explore new opportunities

67

Thank you!

Please send us your comments and suggestions:

[email protected]@hsph.harvard.edu

Back up slides

MCBS, CWF Scorecards, and QHP enrollee survey

Content and methodology

Medicare Current Beneficiary Survey

MCBS Overview

Nationally representative survey of Medicare beneficiaries:- expenditures and sources of payment for all

services, including copayments, deductibles, and non-covered services;

- health insurance coverage and related coverages to sources of payment;

- changes in health status and effects of program changes.

MCBS: initial content

• Demographics • Health status and

functioning • Cost of care • Preventive services• Access to, satisfaction

with, and usual source of care

• Health insurance • Household or facility

characteristics

• Survey weights• Community/ Institutional

timeline • Event specific information:

– Inpatient/Outpatient– Provider – Drug – LTC – SNF – Dental

(source: CMS)

New / Health Reform-related Content

• Care coordination• Patient activation• Electronic health record

use by provider of care• Satisfaction, access to

care, and usual source of care

• Knowledge and use of preventive services

• Mobility and Use of Transportation Services

• Premiums • Out of pocket spending • Enhanced race/ethnicity

reporting • Self-reported health

outcomes (e.g., ADLs, health status, etc.)

MCBS MethodologyData Years Available 1991-present

Periodicity Annual

Mode of Collection Computer-assisted personal interviews (CAPI) in households and facilities. Proxy respondents may be used for institutionalized persons in poor health.

Population Covered Nationally representative sample of aged, institutionalized, and disabled Medicare beneficiaries.

Methodology The overlapping panel design of the survey allows each sample person to be interviewed three times a year for 4 years, whether he or she resides in the community or a facility or moves between the 2 settings, with oversampling among disabled persons under age 65 and among persons 80 years of age and older.

Response Rates and Sample Size

16,000 beneficiaries. Each fall 1/3 of the sample is retired and new sample persons are included in the survey. response rates for initial interviews: mid- to high-80s; subsequent rounds in 95%.

MCBS Data Files

Access to Care

• Point in time • Always enrolled • No survey-reported cost and

utilization included • No imputation • Sample size =15,500

Cost and Use

• Entire calendar year • Ever enrolled • Include costs and utilization

and event-level info. • Imputation • Sample size = 12,000

(source: CMS)

Commonwealth Fund Scorecards

CWF Scorecards 42 key indicators in 4 dimensions + 19 equity indicators

Access and Affordability (6 indicators) rates of insurance coverage individuals’ out-of-pocket expenses cost-related barriers to receiving care

Prevention and Treatment (16 indicators) measures of receiving preventive care and the quality of care in ambulatory, hospital, and LTC and postacute settings.

Potentially Avoidable Hospital Use and Cost (9 indicators)

avoidable hospital useestimates of per-person spending among Medicare beneficiaries cost of employer-sponsored insurance

Healthy Lives (11 indicators) premature death health risk behaviors

Equity (19 indicators) differences in performance associated with patients’ income level or race or ethnicity on the 4 other dimensions

CWF Scorecard Methodology

Performance Metrics Same indicators over time. But since the 2009 Scorecard, several indicators have been dropped. Several new indicators have been added, including measures of premature death, out-of-pocket spending on medical care relative to income, and potentially avoidable emergency department use.

Measuring Change over Time Time series for 34 of 42 indicators.

Data Sources Indicators draw from publicly available data sources, including government-sponsored surveys, registries, publicly reported quality indicators, vital statistics, mortality data, and administrative databases.

CWF Scorecard Data Sources• BRFSS• CAHPS (via AHRQ

NationalHealthcare Quality Report)

• CCW (via CMS Geographic Variation Public Use File)

• CDC NVSS: Mortality Restricted Use File, WISQARS, WONDER

• CMS Hospital Compare• CPS ASEC• HCAHPS (via CMS Hospital

Compare)

• HCUP (via AHRQ National Healthcare Quality Report)

• MDS (via CMS Nursing Home Compare)

• Medicare Claims (via CMS Home Health Compare)

• MedPAR, MDS• MEPS• NIS• NSCH• OASIS (via CMS Home

HealthCompare)• 5% Medicare enrolled in Part D • 5% Medicare SAF

Qualified Health Plan Enrollee Experience Survey

QHP enrollee survey overview

The QHP Enrollee Survey is a consumer experience survey that assesses enrollee experience with the QHPs offered through the Marketplaces.

The QHP Enrollee Survey will be fielded nationally for the first time in early 2015 and will be administered by CMS-approved survey vendors using a standardized protocol to facilitate QHP comparison both within and across Marketplaces.

QHP enrollee survey content

The QHP Enrollee Survey expands on the CAHPS Health Plan Survey 5.0 incorporating:

- existing CAHPS supplemental items

- new survey items

• Access to care• Access to information• Care coordination• Cost• Cultural competence• Doctor communication• Health promotion• Plan administration• Prevention• Shared decision-making• Specialized services

QHP enrollee survey methodologySampling At the product level (HMO, PPO, etc.) offered by a particular

issuer in a particular state. QHPs with at least 500 enrollees are required to conduct the survey.

Eligible Members Adults (18+) enrolled at least 6 months with no more than one 30-day break in enrollment. Disenrollees will be included.

Sample Size HHS will require a sample size of 1,000 members per sampling unit, anticipating a response rate of 30% and 300 completed surveys.

Survey Tool The survey tool is based on Medicaid CAHPS 5.0 with an array of additional and supplemental questions. There are currently a total of 76 questions for the beta test phase.

Methodology HHS anticipates a mixed mode methodology with mail, phone and web protocols.

Timeline CMS will not publically report the results of the 2015 survey administration; however, State Exchanges may have the option to publicly report the 2015 results. CMS will begin to publicly report results using the scores from 2016.

Back up: Regression variablesDependent variables(psychometric dimensions)

1. Staff awareness of information about the patient

2. Provider communication with patient3. Integration post visit4. Provider knowledge about patient5. Integration with specialists6. Integration following hospital stay

Explanatory variables (organizational characteristics)

1. Size (large v. small)2. Type (multispecialty v. primary care)3. Ownership (hospital v. not)4. Tech sophistication (high v. low)5. Care management processes (high v.

low)

Control variables

Provider characteristics Primary care provider (v specialist) Individual characteristics Age 75 or older (v younger) Gender Male (v female) Education No college (v more) Ethnicity Hispanic (v non-hispanic) Race non-white (v white) Income less than $40K (v more) No. people in household 1 (v not living alone) Individual health and psychological characteristics Number of chronic conditions Depression Expectation of health in next 6 months Fair or Poor (v better) Problems with care scale of 0-12** Assistance needed scale of 0-12*** One or more friends or relatives helped with any of the tasks in Q69 Yes (v no) Q70 Life orientation test-revised on scale of 0-24****


patient

















PPIC 2.1PPIC 2.0

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