A Perspective on America's Health: Kids, Parents, andB eyond: An interview with University of Michigan's Dr. Matthew Davis

As director of the C.S. Mott Children's Hospital National Poll on Children's Health (NCPH), Dr. Matthew Davis is investigating public opinion, perceptions and priorities regarding major health care issues and trends that affect the youngest Americans. Since April 2007, he and his team have released seven reports based on data from KnowledgePanel®; Dr. Davis' mandate is to cover the most recent and highly relevant topics in the national conversation. Survey topics have ranged from the phenomenon of retail clinic use, to Americans' views on the State Children's Health Insurance Program (SCHIP) and state mandates for kids attending school to get the HPV vaccine. Our interview with Dr. Davis follows.

What is the main objective of the C.S. Mott Children's Hospital National Poll on Children's Health?

There are several health policy polls conducted on a routine basis and done very well; they help inform the public about how fellow Americans are thinking, and what their opinions are about various issues of health and health policy. However, these polls rarely focus on issues related to children. Contrast that with the fact that many issues related to children are of national interest, in terms of making an investment in future generations. Many Americans want to have a sense of how best to take care of children.

One of my frustrations as a health services researcher is that much of the data published are a year, or two, or even three years out of date by the time they see the light of day. We want to bring real-time information from a national sample of households into the public dialogue about issues of national importance regarding children's health and health policy. As a source of information, Knowledge Networks gives me the opportunity to do this.

What did you find that was most revealing about retail heath clinics?

When we asked Americans about their views of retail clinics, there were only about 300 such clinics in existence. So it was a surprise to us that about 10% of the sample said that they had used a retail clinic; that was true for adults and for children. With only 300 retail clinics nationwide at the time, that's a remarkably high percentage. Moreover, we found that the expected use of retail clinics in the future was higher than the current usage, meaning that Americans expect to use these clinics in the future, even if they hadn't used them in the past. Our findings were consistent with other research on this topic: people who have used retail clinics are generally very happy with the care they've received. Whether it was timely or convenient, or they were pleased with the quality, users of retail clinics were planning on returning for more care. What was very important about our approach is that we asked about children; to our knowledge, no other group of researchers has previously or since looked at the issue of retail clinic use by children.

Do you plan to repeat any survey topics over time?

We conduct our surveys every three to four months. On every survey, we have "standard questions" about the health status and insurance coverage of the responding adult and his/her oldest child. We ask these questions to get a sense of how similar our samples are from one poll to the next, and to track trends over time. We also have "recurring questions" – questions administered to the sample at about the same calendar time each year. We posed the questions about the top ten health concerns about America's children back in March 2007. In March 2008, we plan to ask those same questions again and get a sense of how things may have changed. Finally, we have new questions each poll on various different topics that allows us to be flexible and nimble when it comes to covering the most recent and important news or policy items.

What led you to choose KnowledgePanelSM?

In the increasingly congested world of Web-enabled panels, KnowledgePanel really stands out in terms of how it's put together. The vast majority of Web-enabled panels are opt-in panels that are available for anybody, including you and me, to sign up online and participate in. I'm a member of some of those panels myself. But KnowledgePanel – because it's recruited through random digit dialing methods that are the gold standard of the survey research field – is a very different type of data source. I recognized that early on as an investigator working with KnowledgePanel. I determined from my previous experiments that there were characteristics of the panel, regarding health and health care, that were very, very similar to gold standard measures from government surveys. I realized that KnowledgePanel offered us an opportunity to do truly national representative work in real time in a way that is very hard to accomplish with any other mode of survey.

What types of information do you feel are lacking for the health care industry?

I think there are three types of information that are really lacking in the health care industry right now. The first type of information has to do with people's willingness and desire to be part of decision-making around their own health and health care. We're still in our infancy in our ability to understand how decisions are made as a partnership between patients and physicians; there needs to be innovation in this area. This is especially important as we grow more and more interested, in this country, in having patients serve as their own advocates and, as some would say – as consumers – seeking more information about quality, and to some extent about cost.

Number two, the health care system really lacks information about what their patients do or do not understand about their own health care. Too often, patients leave their visits without a good understanding of what's supposed to happen in their own health or health care next; we know this from other research. We need to understand better how to improve that transfer of information and how to assure that better information transfer is linked to better health outcomes for patients.

Third, everyone agrees that our health care system in the U.S. is broken, but there is little consensus about how it should be fixed. Despite the fact that several surveys have asked the American people, "Do you think there should be health coverage for everybody?," and a lot of people say, "Yes," there is precious little information about how Americans would be willing to change their own behavior or their own payment of taxes versus health plan premiums in order to accomplish coverage for more, if not all, Americans. There needs to be much better information about that in order to inform our national and state policies going forward when it comes to health care reform.

I'd call it "household economics." I think that too little of the debate about health care reform is translated into what it would mean for the average American family. If they didn't have to pay health care premiums, but they did have to pay a national health plan premium, what would that look like? If they didn't have to have a deductible for their health plan, but they had a higher co-pay, what would that look like? If everyone had to be on a generic medication, if there were a generic alternative other than being allowed to take the brand name without any other explanation, how would that be for families? These are some of the critical questions that need to be asked and could be asked in a very productive, scientific, rigorous way to try to inform policy makers going forward.

What is your colleagues' and policymakers' take on the use of online surveys?

Some of my colleagues in health and health care research are skeptical of research completed with online surveys – to the point of disregarding the findings. However, by showing how data from KnowledgePanel® are very similar to gold standard findings from other survey modes, I think we're able to establish that KnowledgePanel does give representative data that can reliably inform decision-makers.

In my view, policy makers are more willing to accept data from a lot of different sources and are not necessarily so attuned to the methods by which data are gathered. Policy makers are instead much more interested in the timeliness of data and in the relevance of the research questions – two requirements difficult to accomplish through more traditional survey research, which takes months or even years to mature. With KnowledgePanel, we're able to bring information to policy makers and other decision-makers in a much shorter timeframe to approximate the decision-making timeframe that policy makers consider relevant and real world.

An example is that earlier this year, we asked questions about different types of families in the U.S. with regard to their income, and whether Americans thought that children and the adult in those families should have government-sponsored health insurance. We designed those questions specifically in anticipation of the congressional debate about re-authorization of the State Child Health Insurance Program, or SCHIP. We also designed the questions specifically to deal with what we thought would be – and it turns out we were right about this – the tipping points in that legislation regarding particular income levels. We were able to bring to the congressional level information about what the public would prefer with regard to coverage for children versus coverage for adults through a program like SCHIP. We know that members of Congress on Capital Hill are using our data to inform their strategy in re-developing the bill, and in continuing the House versus White House debate.

Does the online approach provide any additional advantages for your work?

One opportunity of online research that isn't available through pen and paper techniques is the ability to randomly assign respondents to certain bits of information, and to understand the respondents' ways of thinking or their opinions with that randomization process. For example, on our first poll we asked questions about how people thought DNA information should best be used in the clinical setting. We wondered whether people had much of an opinion just off the cuff – versus whether they would have an opinion after they had gone through some thought experiments about different scenarios in which they or their children might be offered genetic testing. So we randomly asked our KnowledgePanel sample. Half of them got the question prior to the scenarios, and half of them got their general attitude questions after the scenarios. We were able to demonstrate that there did not seem to be much of a difference in people's attitudes, whether they had the chance to think about the scenarios or not.

What issues can impede research accuracy?

That's always a question to ask yourself when you're doing survey work. As with any panel, there are questions about fatigue of panelists. There are also questions about the ability to recruit people to the panel and whether there could possibly be some disparity in recruitment vis-a-vis factors such as age, gender, income status, race/ethnicity. With KnowledgePanel®, I've always been impressed with the high representation of individuals from lower income and racial/ethnic minority backgrounds. That's extremely valuable to us in the health domain, when we know that individuals of low income and individuals of racial/ethnic minority backgrounds are disproportionately likely to have worse health and worse access to health care in the U.S.

Matthew Davis, M.D., M.A.P.P., is associate professor of pediatrics, internal medicine, and public policy at the University of Michigan Medical School and Gerald R. Ford School of Public Policy.

Photo courtesy of University of Michigan Health System.