Possibilities for Shortening the CAHPS Clinician and Group Survey

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Peer Reviewed
Title:
Possibilities for Shortening the CAHPS Clinician and Group Survey
Journal Issue:
MEDICAL CARE, 54(1)
Author:
Stucky, BD
Hays, RD
Edelen, MO
Gurvey, J
Brown, JA
Publication Date:
01-01-2016
Series:
UCLA Previously Published Works
Permalink:
http://escholarship.org/uc/item/0mk8b98c
DOI:
https://doi.org/10.1097/MLR.0000000000000452
Keywords:
CAHPS, patient experiences survey, short form
Local Identifier:
1560580
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BRIEF REPORT

Possibilities for Shortening the CAHPS Clinician and
Group Survey
Brian D. Stucky, PhD,* Ron D. Hays, PhD,*w Maria O. Edelen, PhD,* Jill Gurvey, MPH,*
and Julie A. Brown, BA*

Background: The Consumer Assessment of Healthcare Providers
and Systems (CAHPS) Clinician and Group adult survey (CGCAHPS) includes 34 items used to monitor the quality of ambulatory care from the patient’s perspective. CG-CAHPS includes items
assessing access to care, provider communication, and courtesy and
respect of office staff. Stakeholders have expressed concerns about
the length of the CG-CAHPS survey.
Objectives: This paper explores the impact on reliability and validity of the CAHPS domain scores of reducing the numbers of items
used to assess the 3 core CG-CAHPS domains (Provider Communication, Access to Care, and Courteous and Helpful Office Staff).
Research Design: CG-CAHPS data reported here consist of
136,725 patients across 4 datasets including ambulatory clinics,
patient-centered medical homes, and Accountable Care Organizations. Analyses are conducted in parallel across the 4 settings to
allow evaluations across data source.
Analyses: Multiple regression and ANOVA techniques were used
to evaluate reliability for shorter sets of items. Site-level correlations with the overall rating of the provider were compared to
evaluate the impact on validity. The change in practices’ rankordering as a function of domain revision is also reported.
Results: Findings suggest that the Provider Communication (6
items) and Access (5 items) domains can be reduced to as few as 2
items each and Office Staff (2 items) can be reduced to a single item
without a substantial loss in reliability or content.
Conclusions: The performance of several of the reduced-length
options for CG-CAHPS domains closely matches the full versions
and may be useful in health care settings where the full-length
survey is impractical due to time or cost constraints.
Key Words: CAHPS, patient experiences survey, short form
(Med Care 2016;54: 32–37)
From the *RAND Corporation, Santa Monica; and wDepartment of Medicine, UCLA, Los Angeles, CA.
Supported by the Agency for Healthcare Research and Quality’s Award
Number 2U18HS016980.
The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research
and Quality.
The authors declare no conflict of interest.
Reprints: Brian D. Stucky, PhD, RAND Corporation, 1776 Main Street,
Santa Monica, CA 90407-2138. E-mail: [email protected].
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0025-7079/16/5401-0032

32 | www.lww-medicalcare.com

T

he Consumer Assessment of Healthcare Providers and
Systems (CAHPS) surveys are used by health plans to
assess quality and for quality improvement initiatives, and by
consumers and patients to assist in selecting among health
care professionals, group practices, and health plans.1 The
CAHPS Clinician and Group (CG-CAHPS) survey is reported on the Centers for Medicare & Medicaid Services
Physician Compare Web site, and a variant of CG-CAHPS is
being used to evaluate Accountable Care Organizations
(ACOs) participating in the Medicare Shared Savings Program. CG-CAHPS surveys have been administered to over
1.5 million patients from over 5000 US medical practices,2
making it among the most frequently adopted survey for
assessing patient experiences with care received from providers and staff in primary, specialty, and ambulatory care
settings.
The full-length CG-CAHPS survey is perceived to be
lengthy by some health care organizations (sponsors) who
administer the instrument. The adult, 12-month CG-CAHPS
survey includes 34 questions on a 5-page survey that assesses
domains such as Provider Communication, Access to Care,
and Courteous and Helpful Office Staff and can be completed in approximately 15 minutes. A shortened version of
the CG-CAHPS survey would reduce patient and administrator burden,3 potentially increase response rates,4 and
may enhance its use and impact on the delivery of health
care.
We report findings from 4 separate implementations of
the CG-CAHPS survey to explore the effects of shortening it
on the reliability and validity of measurement. The CGCAHPS survey is standardized to ensure comparability
across providers and groups. Because of this, it is important
to ensure that any potential revision maintains the content of
the domains and does not adversely affect the statistical
properties of the measure.

METHODS
Data Collection and Procedures
Survey data were collected using a combination mail
and telephone modes of administration. Data reported here
consisted of responses from 136,725 participants obtained
from 4 separate CG-CAHPS collection efforts. (1) The
physician group setting consists of 53 ambulatory clinic locations, and 62 individual physicians, from which 63,441
respondents (response rate = 37%) were sampled from May
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Medical Care



Volume 54, Number 1, January 2016

Shortening the CG-CAHPS Survey

2005 to January 2009.5 (2) The safety net setting includes
data from 7192 participants (response rate approximately =
11%) who visited 28 practices in southern California from
August 2012 to March 2014. (3) The third setting reported
here includes responses from 2740 participants visiting 6
health maintenance organizations that implement the patientcentered medical home (PCMH) model of care delivery
(response rate = 37%).6 (4) The sample reported here consists
of 63,415 beneficiaries (response rate = 54%) from 152
ACOs who were sampled from January 2013 to March 2013.
ACOs are collections of doctors, hospitals, and health care
providers that have organized with an emphasis on performance measurement within populations they serve.

Demographics
The majority of the study participants were white
(78%), female (59%), had completed at least some college
(67%), and self-reported good, very good, or excellent
general health (73%). Table 1 presents demographic

comparisons across settings. The safety net sample had
substantially more nonwhites (49%) and less than high
school–educated (31%) respondents than the other samples.
The ACO sample had by far the oldest respondents (47%,
75 y or older).

Measures
The CG-CAHPS Adult Survey includes 13 items that
form 3 composites: Communication (6 items), Access (5
items), and Office Staff (2 items).7–9 The survey also includes a single item asking respondents to provide an overall
rating of their provider on a 0–10 scale (Table 2).
Most of the data reported here were collected using the
CAHPS survey version 2.0,10 which utilizes a 12-month recall
period and 4-point response options for all response items
(Never, Sometimes, Usually, and Always). The ACO survey
uses a 6-month recall period. The physician group sample was
administered the C-G CAHPS 1.0 survey.11 This version of the
survey includes minor wording differences for the Access

TABLE 1. Beneficiary Demographic Characteristics and Health Status Across 4 CG-CAHPS Samples

Characteristics
Age (y)
18–24
25–34
35–44
45–54
55–64
65–74
Z75
Missing
Sex
Male
Female
Missing
Race/ethnicity
White
Nonwhite
Missing
Education
Less than high school
High school graduate
Some college
4 y degree or more
Missing
General health status
Excellent
Very good
Good
Fair
Poor
Missing
Mental health status
Excellent
Very good
Good
Fair
Poor
Missing

Physician Group
(% Nonmissing)
(N = 63,441)

Safety Net
(% Nonmissing)
(N = 7192)

PCMH
(% Nonmissing)
(N = 2740)

ACO
(% Nonmissing)
(N = 63,415)

598 (2)
2394 (8)
3166 (10)
4727 (15)
6607 (21)
7029 (22)
7028 (22)
31892

635 (9)
1234 (17)
1169 (16)
1621 (23)
1880 (26)
471 (7)
182 (3)
0

82 (3)
144(5)
310 (11)
484 (18)
701 (26)
641 (24)
359 (13)
11

32 (0)
308 (0)
804 (1)
2222 (4)
4358 (7)
24,909 (40)
29,176 (47)
1606

25,362 (41)
37,095 (59)
984

2373 (33)
4818 (67)
1

1048 (38)
1692 (62)
—

27,098 (43)
36,317 (57)
—

46,206 (75)
15,026 (25)
2209

3051 (51)
2945 (49)
1196

1890 (71)
760 (29)
90

49,016 (85)
8590 (15)
5809

2910 (5)
6792 (11)
16,948 (27)
35,420 (57)
1371

2064 (31)
1557 (23)
2087 (31)
1039 (15)
445

234 (9)
583 (22)
1152 (43)
735 (27)
36

9128 (15)
20,266 (33)
16,186 (26)
15,756 (26)
2079

8077 (13)
18,569 (30)
20,219 (33)
11,515 (19)
3624 (6)
1437

900 (13)
1744 (25)
2378 (34)
1678 (24)
383 (5)
109

301 (11)
897 (33)
1063 (39)
377 (14)
72 (3)
30

4207 (7)
15,301 (25)
22,919 (37)
14,589 (24)
4313 (7)
2086

19,335 (31)
20,334 (33)
15,276 (25)
6026 (10)
1181 (2)
1289

1873 (26)
1980 (28)
1874 (27
1061 (15)
284 (4)
120

703 (26)
950 (35)
737 (27)
280 (10)
280 (2)
24

12,766 (21)
19,197 (31)
19,127 (31)
8542 (14)
1814 (3)
1969

ACO indicates Accountable Care Organization; CG-CAHPS, Consumer Assessment of Healthcare Providers and Systems Clinician and Group adult survey; PCMH, patientcentered medical home.

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33

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Volume 54, Number 1, January 2016

TABLE 2. Items and Abbreviations From CG-CAHPS Core Domains
Scales and Items

Item Abbreviation

How Well Your Providers Communicate
How often did this provider show respect for what you had to say?
How often did this provider listen carefully to you?
How often did this provider give you easy to understand information about these health questions or concerns?
How often did this provider explain things in a way that was easy to understand?
How often did this provider spend enough time with you?
How often did this provider seem to know the important information about your medical history?
Getting Timely Care, Appointments, and Information
When you phoned this provider’s office during regular office hours, how often did you get an answer to your medical
question that same day?
When you phoned this provider’s office after regular office hours, how often did you get an answer to your medical
question as soon as you needed?
How often did you see this provider within 15 min of your appointment time?
When you phoned this provider’s office to get an appointment for care you needed right away, how often did you get
an appointment as soon as you needed?
When you made an appointment for a check-up or routine care with this provider, how often did you get an appointment
as soon as you needed?
Helpful, Courteous, and Respectful Office Staff
How often were clerks and receptionists at this provider’s office as helpful as you thought they should be?
How often did clerks and receptionists at this provider’s office treat you with courtesy and respect?
Provider Rating
Using any number from 0 to 10, where 0 is the worst provider possible and 10 is the best provider possible, what number
would you use to rate this provider?

Respect
Listen
Information
Understand
Spend enough time
Medical history
During office hours
After office hours
Timely
Urgent care
Routine care
Helpful office staff
Courtesy and respectful
Provider Rating

CG-CAHPS indicates Consumer Assessment of Healthcare Providers and Systems Clinician and Group adult survey.

items, uses items that refer to the “doctor” rather than
“provider,” and has a 6-point response scale (Never, Almost
never, Sometimes, Usually, Almost always, and Always). To
maintain consistency with CAHPS 2.0, we recoded “Almost
never” as “Never” and “Almost always” as “Always.” The
safety net sample was administered the visit version of the
survey that had a 3-point response scale (“no,” “yes, somewhat,” and “yes, definitely”) for the Communication and Office
Staff items; we dichotomized these into “yes” or “no” response.

Analytic Approach
The purpose of this study was to determine (1) the
minimum length (or number of items) of each domain while
maintaining core domain content and site-level reliability
and (2) to provide some options for short-item subsets that
perform well

in comparison to the original domains. We
evaluated nk combinations of items in a given subset length,
where n is the total number of items per domain and k is the
number of items in a given subset (ie, the length of the
subset). For example, in the 6-item Communication domain
there are 62 possible item subsets because there are n–1
possible lengths of each domain.
A 2-step process was used to evaluate each item
combination. The first step in the process was conducted to
identify how short the domains could reasonably be without
impacting reliability or unduly limiting the content of the
domains. Step 1: first, for all possible combinations for the
Communication, Access, and Office Staff domains, we regressed the CAHPS full-length domain score on each combination of item subsets across samples, which provided an
R2 for each item subset.12 We then estimated the practicelevel reliability of each item subset considered using ANOVA to partition between versus within practice variance.
The results of step 1 provided recommendations for the

34 | www.lww-medicalcare.com

minimum length of each domain based on the variance accounted for in the full-length version, the site-level reliability, and the content represented by the subset.
The second step in the analysis was conducted on the
item combinations for the minimum domain lengths obtained
in step 1 to provide the analytic properties of some shortened
domains. Step 2: because the number of participants assigned
to each practice or group varied across samples, we used
intraclass correlations to estimate sample sizes needed to
obtain practice-level reliabilities of 0.70, 0.80, and 0.90 for
each recommended subset. We estimated practice-level
correlations between the CAHPS single-item overall rating
of the provider with CAHPS composite scores estimated
from the full-length and recommended shortened item sets.
Finally, we compared the percentile rank of the ACO practice scores using scores estimated from the original and the
various recommended reduced domains. The difference in
the percentile rank is an index of how much a revision to a
domain affects the rank-ordering of the practices; as a
summary of the difference, we also report the average of the
absolute value of the difference and the range of differences
across practices.

RESULTS
Identifying Reduced-length Measures
Table 3 presents the results for only the most informative item combination from each reduced-length option. Results for both Communication and Access indicate
that reduced domains with as few as 2 items remain closely
related to the full-length domains. Note that because Office
Staff contains only 2 items, it is not evaluated in this step.
For 2-item combinations, the percentage of variance accounted for across samples ranges from 81% to 92% and
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Volume 54, Number 1, January 2016

Shortening the CG-CAHPS Survey

TABLE 3. Summary of the Percentage of Variance Accounted for in the Original Domains by the Reduced Domains Across Item
Combinations
Variance Accounted for in the Original Domain (%)
Domain and Length of Item
Subsets
Provider Communication
(original domain)
5 items (Understand, Listen,
Information, Medical history,
Spend enough time)
4 items (Understand, Listen,
Medical history, Spend enough
time)
3 items (Understand, Medical
history, Spend enough time)
2 items (Understand, Spend
enough time)
1 item (Spend enough time)
Access (original domain)
4 items (Urgent care, Routine care,
During office hours, Timely)
3 items (Urgent care, Routine care,
Timely)
2 items (Routine care, Timely)
1 item (Timely)

ACO PCMH

Physician
Group:
Physician

Physician
Group:
Practice

Site-level Reliability

Safety
Net ACO PCMH

Physician
Group:
Physician

Physician
Group:
Practice

Safety
Net

—

—

—

—

—

0.80

0.80

0.95

0.97

0.87

99

99

99

99

99

0.80

0.82

0.95

0.97

0.87

97

98

98

98

96

0.80

0.81

0.95

0.97

0.87

93

94

96

96

91

0.79

0.86

0.95

0.97

0.87

86

86

92

92

81

0.79

0.87

0.95

0.96

0.85

67
—
99

70
—
98

80
—
99

80
—
99

62
—
97

0.75
0.77
0.88

0.81
0.88
0.92

0.95
0.95
0.95

0.97
0.96
0.96

0.84
0.84
0.89

94

94

95

95

91

0.90

0.86

0.94

0.96

0.91

88
66

88
64

90
73

90
73

86
59

0.94
0.96

0.87
0.71

0.97
0.98

0.98
0.99

0.91
0.87

Results presented here were selected from the item subset among all possible combinations within a given length that resulted in the highest site-level reliability. The items
representing the highest site-level reliability for a given length are provided in parenthesis. Complete item text can be found in Table 2.
ACO indicates Accountable Care Organization; PCMH, patient-centered medical home.

86% to 90%, for Communication and Access, respectively.
In addition, the most informative 2-item combinations are
highly reliable across samples and are similar to the reliability of the original domains (0.79–0.96 and 0.87–0.98, for
Communication and Access, respectively). Note that the
variance in the original Communication and Access domains
is substantially reduced in both 1-item options.
Having identified 2 items as the minimum length for
the Communication and Access domains, we reviewed all
possible combinations of 2-item subsets with each domain
to consider content along with reliability. Among all

combinations, Table 4 includes the 2-item subsets that have
both the highest reliabilities and the content essential to
represent the Communication and Access domains. For the
Communication domain, the spend enough time item
performs well when paired with either understand or listen
items and results in 2-item composites that provide nearly
equivalent site-level measurement precision as the 6-item
full-length composite. For the Access domain, the timely
item performs well when paired with either routine care or
during office hours items and results in 2-item composites
that in some settings are more reliable than the 5-item

TABLE 4. Reliabilities of the Recommended Minimum Communication, Access, and Courteous and Helpful Office Staff Reduced
Domains
Site-level Sample Size Associated With
Reliability at 0.70

Site-level Reliability

Domain and Item Subsets
Provider Communication (Original domain)
Understand, Spend enough time
Listen, Spend enough time
Access (Original domain)
Routine care, Timely
During office hours, Timely
Courteous and Helpful Office Staff
(Original domain)
Helpful office staff
Courteous and respectful

Physician
Group:
ACO PCMH Physician

Physician
Group:
Practice

Physician
Safety
Group:
Net ACO PCMH Physician

Physician
Group:
Practice

Safety
Net

0.80
0.79
0.78
0.77
0.94
0.91
0.87

0.80
0.87
0.70
0.88
0.87
0.89
0.85

0.95
0.95
0.95
0.95
0.97
0.97
0.95

0.97
0.96
0.97
0.96
0.98
0.98
0.97

0.87
0.85
0.86
0.84
0.91
0.82
0.55

210
221
235
250
53
79
127

265
155
447
141
156
126
189

111
116
111
117
68
65
190

90
97
91
102
61
55
194

78
90
82
93
51
109
405

0.85
0.84

0.83
0.82

0.95
0.93

0.96
0.96

0.39
0.66

141
152

219
236

168
193

150
212

791
254

ACO indicates Accountable Care Organization; PCMH, patient-centered medical home.

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Stucky et al

original measure. The single-item versions of Office Staff are
somewhat more inconsistent and the degree to which the
single-item versions impact reliability is less clear.



Volume 54, Number 1, January 2016

differences = 3% and 6%, ranges = 0%–13% and 0%–22%
for helpful office staff and courtesy and respectful,
respectively).

Preliminary Validity of Reduced-length
Measures

DISCUSSION

Table 5 presents the correlations for the recommended 2-item combination options of Communication
and Access and the single-item versions of Office Staff
with the original full-length versions of the domains and
with the Provider Rating item. The recommended minimum-length domain options yield scores that are closely
related to their original full-length versions. Across samples and item subsets, the Pearson correlations range from
0.92–0.98, 0.80–0.96, and 0.97–1.00, for Communication,
Access, and Office Staff, respectively. Compared with the
original domains, there is only a slight reduction in correlations between the reduced domains and the Provider
Rating, though there is little reduction for Office Staff.
Note that the PCMH correlation results are based on very
few sites (n = 6) and are thus excluded.
Finally, we evaluated the difference in the ACO
sample percentiles between site-level scores from the
original and reduced domains. The average difference can
be interpreted as the absolute value of the expected change
in the percentile for a given ACO when reporting a reduced domain. For the Communication domain, the 2
options (understand and spend enough time; listen and
spend enough time) both result in an average absolute
percentile difference of 6% with a range across sites of
0%–39% and 0%–31% for both options, respectively. The
average percentile differences and ranges are somewhat
larger in magnitude for the Access revision options
(average percentile differences = 13% and 15%, ranges =
0%–68% and 0%–72% for routine care and timely, and
during office hours and timely, respectively). The average
percentile differences and ranges is similarly small for
the Office Staff single-item options (average percentile

This paper presents evidence supporting possible reductions in 3 core domains of the CG-CAHPS survey. Results
indicate that the measures can be shortened while maintaining
the general content measured by the original, full-length
scales. Because CAHPS instruments are routinely used by
consumers to evaluate health care options and by providers to
evaluate the care being given, it is critical that the measures
maintain standards of reliability at the site or program level.
Results presented here suggest the Communication and Access domains can be reduced to a minimum of 2 items each,
and Office Staff to a single item, without loss in reliability
and while maintaining the validity of the original domains.
Although the results presented here are promising,
potential users of these reduced domain options should be
aware of several limitations. The domain options presented
here were derived from analytic findings and substantive
judgment; obtaining feedback from patients may result in a
different set of options.13 In addition, the breadth of content
measured by the original domains is an important consideration. Reducing the scales to 2 items (or a single item in
the case of Office Staff) necessarily reduces the aspects of
patient experiences that each domain measures, though the
benefits of shorter length scales may offset this issue in
certain contexts. In addition, the intended use of reduced
scales, as with all CAHPS measures, is at the level of the
group/practice/site. Users intending to evaluate patient-level
scores should be aware that shorter scales will result in lower
participant-level reliability. In addition, we note that due to
the potential shift in site-level scores that may accompany a
substantial reduction in the number of items in a given domain, caution is needed in evaluating trends over time if one
switches from the standard CAHPS survey to a shorter

TABLE 5. Correlations Between the Recommended Communication, Access, and Courteous and Helpful Office Staff Reduced
Domains With the Original Domains and Overall Provider Rating
Site-level Correlations With the Original Domain
Domain and Item
Subsets
Provider Communication
Understand, Spend
enough time
Listen, Spend enough
time
Access
Routine care, Timely
During office hours,
Timely
Courteous and Helpful
Office Staff
Helpful office staff
Courteous and
respectful

ACO

Physician Group:
Physician

Physician Group:
Practice

—
0.97

—
0.97

—
0.98

—
0.98

0.97

0.99

0.98

—
0.80
0.84

—
0.82
0.86

—
0.98
0.97

Site-level Correlations With Overall Provider Rating

Safety
Net
ACO

Physician Group:
Physician

Physician Group:
Practice

Safety
Net

0.86
0.84

0.88
0.81

0.87
0.82

0.86
0.82

0.98

0.83

0.82

0.81

0.81

—
0.86
0.94

—
0.83
0.91

0.65
0.57
0.59

0.58
0.31
0.37

0.64
0.40
0.49

0.50
0.57
0.51

—

—

—

0.67

0.53

0.51

0.04

0.99
0.98

0.99
0.98

1.00
1.00

0.65
0.66

0.52
0.54

0.50
0.50

0.00
0.07

ACO indicates Accountable Care Organization.

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Volume 54, Number 1, January 2016

measure. The results presented here are indications of how
the reduced-length measures would theoretically perform as
reduced measures, but these estimates are based on prior
administrations that included the original full-length survey.
Future implementations of these measures are needed to
evaluate the generalizability of the reliability evidence presented here and to provide an assessment of the potential
impact of the revised measures across race, ethnic, and
cultural groups.14,15
The reduced domain options presented here are a response to a perceived need for shorter surveys many users of
CAHPS have expressed. The possible reductions to the survey include 7 core reporting items and 4 screeners associated
with the response items. This reduction of the CG-CAHPS
survey from 34 to 23 items is estimated to reduce response
burden by 25% and would translate to cost-savings associated with administering the survey through telephone or
mail. Finally, we note that the reduced domain options reported here are presented only as recommendations; based on
these findings, some users of the CAHPS survey may prefer
to maximize the reliability of the scales, whereas other users,
based on program needs, may select scale options that contain particularly relevant domain content.
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