COMPARING HEALTH CARE OUTCOMES FOR CHILDREN ENROLLED IN THE FLORIDA HEALTHY KIDS PROGRAM AND CARED FOR BY PEDIATRICIANS VS. FAMILY PRACTITIONERS A REPORT PREPARED FOR THE HEALTHY KIDS BOARD OF DIRECTORS Christine A. Bono, PhD Program Associate Elizabeth Shenkman, PhD Principal Investigator October 24, 2003 Tab P Page 1 of 18
INTRODUCTION The purpose of this study was to assess health care outcomes of children cared for by pediatricians versus family practitioners. Information about health care delivered by different types of providers is essential. This information assists the Florida Healthy Kids Corporation and their participating health plans in working with their health care providers and health plans to develop the most effective health care provider networks for children. The following outcomes were assessed and are described for children seen by pediatricians or family practitioners: 1) children s health status; 2) children s functional status; 3) presence of a usual source of care; 4) compliance with preventive care guidelines; 5) family satisfaction with care as measured by the Consumer Assessment of Health Plans Survey (CAHPS); 6) incidence of ambulatory care sensitive conditions. Telephone interviews were conducted with a random sample of parents/guardians of children continuously enrolled in the Florida Health Healthy Kids from September 2001 to August 2002. Each telephone interview took approximately 35-45 minutes. A total of 622 interviews were completed with 407 families indicating that their child s primary provider was a pediatrician; 160 families indicating that their child s provider was a family practitioner; and the remaining 55 families indicating that their child s provider was neither a pediatrician nor a family practitioner (e.g., internal medicine physician, specialist, etc.) Since the differences between pediatricians and family practitioners are the focus of this report, the results will not be discussed for these 55 families; however, their results will be included in the tables for the reader. The Family Caregiver Survey was administered to each of these 622 families and is described below. The children s survey information also was linked to claims and encounter 1
data, providing a perspective, other than parent-report, with respect to health care use. Information gathered by both means will be presented in this report. SAMPLE AND INSTRUMENT The Family Caregiver Survey contains several sections including: a household enumeration that addresses the health and health insurance status of all household members; a section regarding general satisfaction among parents of enrollees; and a section on family demographics. In addition, the survey contains several standardized questionnaire components including: the Child Health Questionnaire Parent Form (CHQ-28); the Consumer Assessment of Health Plans Survey (CAHPS); and the Child and Adolescent Health Measurement Initiative: Children with Special Health Care Needs (CSHCN) Screener. RESPONDENT AND CHILD DEMOGRAPHIC CHARACTERISTICS The demographic characteristics of children and respondents, both overall and by provider type can be found in Table 1 of this report. Children among both groups of providers were similar with respect to gender, and health status. Respondents among both groups of providers were similar with respect to marital status, educational level, mean household size, and federal poverty level. Despite these similarities, several significant demographic differences were found between provider types. A significantly higher percentage of white, non-hispanic children were found among the family practitioner group when compared to the pediatrician group (69% vs. 57% respectively; χ 2 =14.76, p<0.01). Furthermore, a significantly higher percentage of Hispanic children were found among the pediatrician group than the family practitioner group (31% vs. 16%; respectively). Children who saw pediatricians were on average 12 years of age while the children seeing family practitioners were slightly older (14 years of age; t=-4.14, p<0.01). Finally, a 2
significantly higher percentage of two parent households were found among the pediatrician group when compared to the family practitioner group (65% vs. 56% respectively; χ 2 =3.99, p<0.05). CHILD S HEALTH STATUS There was no significant difference in the child s health status by provider type. Approximately 42% of parents in the pediatrician group and 40% of parents in the family practitioner group reported that their child s overall health was excellent (See Table 1). Thirty-two percent of the pediatric parents and 33% of the family practitioner parents stated that their child was in very good health. Twenty-two percent of the pediatric parents and 24% of the family practitioner parents stated that their child was in good health. Approximately 3% of the pediatric parents and 4% of the family practitioner parents stated that their child was in fair health. Less than 0.5% of pediatric parents stated that their child was in poor health, in comparison, none of the family practitioner parents indicated that their child was in poor health. Overall, the majority of children were very healthy by parent self-report regardless of whether they saw a pediatrician or family practitioner. CHILD S FUNCTIONAL STATUS The functional status of these children was assessed using the Child Health Questionnaire Parent Form (CHQ-28). This instrument was constructed to measure the physical and psychosocial well being of children five years of age and older. The CHQ-28 consists of 28 questions yielding 14 unique components (i.e., physical functioning, role/social functioning - emotional/behavioral, role/social functioning - physical, bodily pain, general behavior, mental health, self-esteem, general health perceptions, parental impact - time, parental impact - emotional, family activities, family cohesion, single item general health, a single item global 3
health) i. This instrument also yields a summary health score and a summary psychosocial score. Higher average scores are more favorable than lower average scores. Higher scores indicate a healthier state. The average scores and standard deviations for each of the components and summary scores of the CHQ-28 for the Florida Healthy Kids sample (overall and by provider type) and the United States population sample are presented in Table 2 of this report. Among children whose provider was a pediatrician, average scores on all but one of the CHQ components were higher among children enrolled in the Florida Healthy Kids Program, than among the U.S. population. Children enrolled in the Florida Healthy Kids Program who were seen by pediatricians scored slightly lower than the U.S average on the behavioral component of the CHQ-28. Among children whose provider was a family practitioner, average scores on all of the CHQ components were higher among children enrolled in the Florida Healthy Kids Program, than among the U.S. population. Therefore, children enrolled in the Florida Healthy Kids Program are perceived by their parents to be healthier than the average child in the United States. Furthermore, CHQ scores of children seen by pediatricians were not significantly different from CHQ scores of children seen by family practitioners. THE CSHCN SCREENER As part of this survey, we screened the children in two ways to determine if they may have a special health care need. First, we simply asked parents if their children had a condition or health care need requiring ongoing medical care or supervision. Second, we administered the CSHCN Screener. The results for each of these are described below. Twenty-four percent of parents in the pediatrician group indicated that their child had special health care need and 26% of parents in the family practitioner group indicated that their 4
child head a special health care need based on the single item. The second screen involved the CSHCN Screener, which has been approved as the standard screening tool for special needs by the National Committee for Quality Assurance (NCQA) The Child and Adolescent Health Measurement Initiative (CAHMI) is a collaborative effort to create comprehensive measures of care for children and adolescents. The Foundation for Accountability (FACCT) has developed a series of screening questions designed to reflect consensus definitions of children with chronic conditions ii. The intent of the tool is to be sensitive enough to capture children with a wide range of childhood chronic conditions and specific enough to not include children with non-chronic or very mild health problems. There are three components or domains within the screening questions: 1) functioning, 2) need and use for compensatory mechanisms, and 3) utilization of services. A scoring algorithm has been written which places children into these three domains. There was a significant difference between provider types regarding whether or not children met the CSHCN Screener criteria (χ 2 =6.94, p<0.01). Approximately 22% of the children in the pediatrician group and 33% of the children in the family practitioner group fell into a least one of the three domains; and therefore can be said to have met the CSHCN Screener criteria to be classified as a child with a chronic condition (See Table 3). In addition, there was a significant difference between provider types regarding how many of the CSHCN Screener domains were met (χ 2 =15.37, p<0.01). Approximately 12% of children in the pediatrician group and 21% of children in the family practitioner group were classified into only one of the three domains; 7% of children in the pediatrician group and 8% of children in the family practitioner group were classified into two of the three domains; and 4% of children in both groups were classified into all three domains. It is not known why a higher percentage of 5
children with a special health care need are seen by family practitioners, however it is important to note that this is parent self-report rather than physician report. Assessments of the presence of special health care needs using diagnostic information found in claims and encounter data will be presented later in this report. The above information is important for program planning purposes. Although children with the most severe health care needs are referred to Children s Medical Services, the Florida Healthy Kids Program does have a significant percentage of children with mild to moderate chronic conditions. Since many program enrollees have some type of special health care need, albeit mild or moderate, quality assurance and evaluation must continue to focus on these children to ensure that they continue to receive the excellent access to care they have been receiving. USUAL SOURCE OF CARE Information regarding children s usual source of care can be found in Table 4 of this report. All parents, regardless of provider type, reported that they had a particular doctor s office, clinic, health center, or other place where they could take their child if he/she was sick. Respondents were then asked what type of facility this was. Seventy-seven percent of parent in the pediatric group and 67% of parents in the family practitioner group indicated that their child s usual source of care was a doctor s office. Interestingly, 10% of parents in the family practitioner group indicated that their child s usual source of care was a community health center and an additional 8% of parents in this group indicated that their child s usual source of care was a walk in clinic or urgent care center. Approximately 95% of parents in the pediatrician group and 97% of parents in the family practitioner group reported that they were very satisfied to satisfied with their child s 6
primary provider. Seventy-nine of parents in the pediatric group and 71% of parents in the family practitioner group indicated that they were able to choose their child s primary care provider. It is important to note that all families are given the opportunity to choose their child s provider. If they do not do so within a certain time period and after reminders, a provider is assigned. Families are free to change from this provider should they wish to do so. Almost 88% of parents in the pediatrician group and 85% of parents in the family practitioner group reported that it was not at all difficult or not too difficult to obtain a personal doctor they were happy with for their child. Approximately 96% of parents in the pediatrician group and 97% of parents in the family practitioner group stated that they were sent information about their child s health plan and a list of participating providers. Being able to choose their child s provider, being able to locate a provider with whom they are happy with and being sent information regarding their providers are important factors that may contribute to the high satisfaction rate among parents of enrollees. Overall, the findings regarding family satisfaction with their child s providers were positive, regardless of whether they saw a pediatrician or family practitioner. IMMUNIZATIONS During the interview parents were asked about their child s immunizations (see Table 5). There were no significant differences between children seen by pediatricians and children seen by family practitioners with respect to DTP, Polio, MMR, Hepatitis B, HIB, Varicella, and Pneumoccous compliance. Overall, the majority of children were in compliance with these vaccines regardless of whether they saw a pediatrician or family practitioner. 7
CONSUMER ASSESSMENT OF HEALTH PLANS SURVEY (CAHPS) The Consumer Assessment of Health Plans Survey (CAHPS) questions are used to assess family satisfaction iii. The CAHPS instrument has undergone extensive testing and development with funding from the Agency for Health Care Policy and Research and is recommended by federal agencies for the assessment of family satisfaction. The CAHPS Survey contains several sections regarding the following issues: the child s personal doctor or nurse; the ability to obtain health care from a specialist; calling the child s doctor s office; the child s health care in the last 12 months; the child s health plan; and parent and child hospital stays and prescription medication(s) used. The CAHPS was scored as recommended by the developers into the following categories: Getting Needed Care (possible score range of 1 to 3) Getting Care Quickly (possible score range of 1 to 4) Doctor Communication (possible score range of 1 to 4) Office Staff Helpfulness (possible score range of 1 to 4) Health Plan Customer Service (possible score range of 1 to 3) Table 6 contains the mean scores, adjusted for child health and sociodemographic characteristics, overall and by provider type. All of the mean scores were near the high end of the range, indicating satisfaction in all areas of care (e.g., getting needed care, getting care quickly, etc.). No significant differences in any of the CAHPS clusters were noted between these two types of providers after adjusting for child health and sociodemographic characteristics. The CAHPS clusters are scored only for those enrollees who had the particular health care experience. For example, if the respondent indicates that their child went to the doctor in the past 12 months, then he or she is asked a series of questions about satisfaction with the provider. However, those questions are not asked of respondents whose children did not go to the doctor. To better assess the health care experiences of all enrollees, regardless of their 8
children s use of health care services, individual CAHPS items were further assessed and results are presented below. Child s Personal Doctor or Nurse Approximately 88% of parents in the pediatrician group and 86% of parents in the family practitioner group indicated that they have one person they consider as their child s personal doctor or nurse. Thus there was no significant difference in whether or not parents had a personal doctor or nurse for their child by provider type. Calling Doctor s Office Approximately 47% of parents in the pediatrician group and 42% of parents in the family practitioner group indicated that they had called their child s doctor s office or clinic during regular office hours to get help or advice regarding their child during the last 12 months. Again, there was no significant difference among provider type regarding whether or not parents had called their child s doctor s office for advice. Child s Health Care in the Last 12 Months Approximately 70% of parents in the pediatric group and 64% of parents in the family practitioner group indicated that they have made an appointment for their child with a doctor or other health care provided for regular or routine health care within the last 12 months. In addition, 93% of parents in the pediatric group and 90% of parents in the family practitioner group reported that they have taken their child to a doctor s office or clinic during the last 12 months. Finally, there was no significant difference among provider type regarding whether or not parents made an appointment for their child with a doctor. 9
INFORMATION OBTAINED BY LINKING SURVEY DATA TO CLAIMS AND ENCOUNTER DATA In addition to the survey information gathered, claims and encounter data was also examined for these 622 families for the time period of October 1, 2001 to September 30, 2002. Information regarding the mean number of inpatient, outpatient, and emergency room (ER) visits, as well as cost information can be found in Table 7 on this report. Preventive care visit information and data regarding ER visits due to ambulatory care sensitive conditions can also be found in this table. Children of 604 of these 622 families, or 97%, contained a variable adequate for linking the survey data with the claims and encounter data. The information below is based on those 604 children. Users and Non-Users of Health Care There was no significant difference between provider types with respect to whether or not enrollees utilized health care during the time period above. Claims and encounter data show that 86% of children whose primary source of care was a pediatrician used health care at least once during the above time period compared to 82% of children whose primary source of care was a family practitioner. Overall, a high percentage of enrollees are using health care services regardless of whether they saw a pediatrician or family practitioner. If children are enrolled in a health care program and not using health care services, this could be an indication of problems with access to care. Throughout the past five years, about 25 percent to 30 percent of those enrolled in the Healthy Kids Program for at least six months do not use health care. It is interesting to note that among this population of children, the percentage of non-users was quite low (14% among children seeing pediatricians and 18% among children seeing family practitioners) indicating that access to care was not a problem among this population. 10
However, there was a significant difference between provider types with respect to whether or not enrollees had at least one preventive care visit during this time period (χ 2 =6.22, p<0.01). Approximately 39% of children whose primary source of care was a pediatrician practitioner had at least one preventive care visit during this time period while only 28% of children whose primary source of care was a family practitioner had a preventive care visit. Clinical Risk Groups (CRGs) The Clinical Risk Group classification system was developed by the National Association of Children s Hospitals and Related Institutions (NACHRI) in conjunction with 3M. The system relies on administrative data and assigns an individual child to a health status category and a severity level within that category. There are nine health status categories, including seven that indicate a child has a special health care need. The nine categories are as follows: 1) healthy; 2) significant acute; 3) single minor acute; 4) multiple minor chronic; 5) single dominate/moderate chronic; 6) pair dominate/moderate chronic; 7) triplet dominant/moderate chronic; 8) malignancies; and 9) catastrophic. A brief description and example of each of these nine categories are presented below: 1) Healthy - routine care, minor health occurrences; 2) Significant acute - acute illnesses that could be precursors to or place the person at risk for developing a chronic disease. Examples: head injury with coma, prematurity, and meningitis; 3) Minor Chronic Conditions - can usually be managed effectively throughout an individual's life with typically few complications. Examples: attention deficit/hyperactive disorders ADHD), minor eye problems (excluding near-sightedness and other refractory disorders), hearing loss, migraine headache, some dermatological conditions, and depression; 4) Moderate Chronic Conditions - those illnesses that are variable in their severity and progression, but can be complicated and require extensive care and sometimes contribute to debility and death. Examples: asthma, epilepsy, and major depressive disorders; 11
5) Dominant Chronic Conditions - those illnesses that are serious, and often result in progressive deterioration, debility, death, and the need for more extensive medical care. Examples: diabetes, sickle cell anemia, chronic obstructive lung disease and schizophrenia; 6 & 7) Chronic Pairs and Triplets - those individuals who have multiple primary chronic illnesses in two (Pairs), or three or more body systems (Triplets); 8) Metastatic Malignancies - include acute leukemia under active treatment and other active malignant conditions that effect children; 9) Catastrophic Conditions - those illnesses that are severe, often progressive, and are either associated with long-term dependence on medical technology, or are life defining conditions that dominate the medical care required. Examples: cystic fibrosis, spina bifida, muscular dystrophy, respirator dependent pulmonary disease and end stage renal disease on dialysis. For the purposes of this report these nine categories were further collapsed into five categories (i.e., combining category 3 and 4; and category 5, 6 and 7; and category 8 and 9). The CRG system was applied to this population of children and the results can be found in Table 7 of this report. According to the CRGs, 71% of children seen by pediatricians and 78% of the children seen by family practitioners were classified as healthy. Almost 12% of the children seen by pediatricians and 9% of the children seen by family practitioners were classified as significant acute. An additional 10% of the children seen by pediatricians and 5% of the children seen by family practitioners were classified as single minor chronic. Despite these somewhat differing percentages there were no significant differences in CRG classification by provider type. Even though the results were not significantly different that with very small groups of children, as seen in this analysis, statistically non-significant differences in case mix can be practically significant. This statement may be supported when one looks at the children s health care costs when cared for by pediatricians versus family practitioners. 12
Ambulatory Care Sensitive Conditions (ACSCs) Inpatient and ER visits for ACSCs are potentially avoidable if there is good access to care in the outpatient setting. ACSCs include pneumonia, otitis media, cellulites, asthma, and others. The Institute on Medicine (IOM) has recommended examining the incidence of inpatient and ER use for such conditions as a measure of access to care. Overall, the percentage of ER visits due to an ACSC was very low among children seen by pediatricians and among children seen by family practitioners. Approximately, 5% of children seen by pediatricians and 4% of children seen by family practitioners had and ER visit due to an ACSC. There was no significant difference between provider types in whether or not enrollees had an ER visit due to an ACSC. Inpatient Stays/Inpatient Costs There was a significant difference between the provider types in both the average number of inpatient visits and the average inpatient costs. Children seen by pediatricians had on average 0.12 inpatient visits per year while children seen by family practitioners had on average 0.01 inpatient visits per year (t=3.59, p<0.01). The average inpatient stay cost among children seen by pediatricians was significantly higher than the average inpatient stay cost among children seen by family practitioners ($845.78/child/year vs. $26.50/child/year respectively; t=2.47, p<0.01). It should be noted that very few children experienced an inpatient stay during this time period, regardless of provider type; hence the above figures are based on very small numbers and may not provide stable estimates. Might be helpful to state the percent with inpatient stays for the two groups. Outpatient Visits/ Outpatient Costs There was a significant difference between provider type in both the average number of outpatient visits and the average outpatient costs. Children seen by pediatricians had 13
approximately six outpatient visits per year while children seen by family practitioners had approximately four outpatient visits per year (t=1.92, p<0.05). The average outpatient visit cost among children seen by pediatricians was significantly higher than the average outpatient visit cost among children seen by family practitioners ($845.44/child/year vs. $573.43/child/year respectively; t=2.39, p<0.01). Emergency Room Visits/Emergency Room Costs There was no significant difference between provider type in both the average number of ER visits and the average ER costs. Children seen by pediatricians had approximately 0.5 ER visits per year and children seen by family practitioners had approximately 0.4 ER visits per year. The average ER visit cost among children seen by pediatricians was $70.98 per child per year, while the average ER visit cost among children seen by family practitioners was $48.50 per child per year. Prescriptions/Prescriptions Costs There was no significant difference between provider types in both the average number of prescriptions filled and the average prescription costs. Children seen by pediatricians had approximately 3.12 prescriptions filled per year and children seen by family practitioners had approximately 3.07 prescriptions filled per year. The average yearly prescription cost among children seen by pediatricians was $379.83 while the average yearly prescription cost among children seen by family practitioners was $490.24. Total Visits/Total Costs There was a significant difference between provider type in both the average total number of visits (e.g. inpatient, outpatient, and ER combined) and the average total visit costs. Children seen by pediatricians had approximately six total visits per year while children seen by 14
family practitioners had approximately four total visits per year (t=1.06; p<0.05). The average total visit cost among children seen by pediatricians was significantly higher than the average outpatient visit cost among children seen by family practitioners ($2,142.03/child/year vs. $1,138.62/child/year respectively; t=2.63; p<0.01). Charges Summary Although not statistically significant, the small differences in CRGs between the two groups are likely contributing to the differing health care expenditures. In a small pool of children, very small changes in case-mix can have a strong impact on charges. Further analyses focused on refining the relationship between case-mix and health care expenditures are being conducted. 15
Summary and Recommendations Overall, the majority of children were very healthy by parent self-report regardless of whether they saw a pediatrician or family practitioner. There were no differences between children seeing pediatricians and children seeing family practitioners with respect to: CHQ scores whether or not parents had a particular doctor s office, clinic, health center, or other place where they could take their child if he/she was sick whether or not parents had called their child s doctor s office for advice whether or not parents made an appointment for their child with a doctor family satisfaction with their child s providers compliance with these vaccines CAHPS clusters scores whether or not enrollees utilized health care during the time period above whether or not a child had a special health care as defined in the claims and encounter data need by provider type whether or not enrollees had an ER visit due to an ACSC the average number of ER visits and the average ER costs the average number of prescriptions filled and the average prescription costs CRG classification by provider type however, the small differences in CRGs between the two groups are likely contributing to the differing health care expenditures. In a small pool of children, very small changes in case-mix can have a strong impact on charges There were significant differences between children seeing pediatricians and children seeing family practitioners with respect to: whether or not children met the CSHCN Screener criteria a greater percentage of children seen by family practitioners met the CSHCN Screener than children seen by pediatricians average number of inpatient visits and the average inpatient costs children seen by pediatricians had more inpatient visits and a higher average inpatient cost than children seen by family practitioners average number of outpatient visits and the average outpatient costs children seen by pediatricians had more outpatient visits and a higher average outpatient cost than children seen by family practitioners average total number of visits (e.g. inpatient, outpatient, and ER combined) and the average total visit costs children seen by pediatricians had more total visits and a higher average total cost than children seen by family practitioners 16
i For component description see: Jeanne M. Landgraf, Linda Abetz, and John E. Ware (1996). Child Health Questionnaire (CHQ): A Users Manual. First Edition. Boston, MA: The Health Institute, New England Medical Center. ii Living with Illness Screener and Supplemental Survey Module: Description and Summary of Development and Testing, Interim Report. Prepared by Christina Bethell and Debra Read, May, 1999. iii Shenkman E, Vogel B. Enrollment, Disenrollment, and Re-enrollment in the Florida Healthy Kids Program. Working Paper. Gainesville, Florida: Institute for Child Health Policy. June, 1999. 17
Table 2: CHQ Scores, Overall and by Provider Type. U.S. Overall N=622 Pediatrician N=407 Family Practitioner N=160 Other N=55 Mean Standard Deviation Mean Standard Deviation Mean Standard Deviation Mean Standard Deviation Mean Standard Deviation CHQ-PF28 single item general health -- -- 83.40 19.04 83.50 19.27 83.00 18.70 83.81 18.58 CHQ-PF28 single item global behavior -- -- 82.19 21.54 81.66 21.62 82.86 22.55 84.18 17.81 CHQ-PF28 single item family cohesion -- -- 78.30 21.03 78.81 20.51 77.62 21.87 76.45 22.64 CHQ-PF28 Physical Functioning (0-100) 90.85 16.38 95.41 14.62 95.71 14.19 95.52 14.42 92.92 18.06 CHQ-PF28 Role-Emotional/behavior (0-100) 90.40 19.51 96.72 14.73 96.38 15.64 98.11 11.40 95.15 16.25 CHQ-PF28 Role-Physical (0-100) 91.50 18.91 95.96 15.73 96.55 14.40 95.38 16.97 93.33 20.68 CHQ-PF28 Bodily Pain (0-100) 78.68 20.74 83.26 22.36 83.60 21.97 84.52 22.49 77.09 24.16 CHQ-PF28 Behavior (0-100) 72.31 17.14 72.23 19.70 71.19 20.04 74.49 19.25 73.34 18.10 CHQ-PF28 Mental Health (0-100) 77.26 13.69 80.32 15.87 80.25 15.86 80.45 16.02 80.45 15.81 CHQ-PF28 Self-Esteem (0-100) 79.26 17.83 84.34 16.97 85.10 15.93 83.35 18.47 81.59 19.63 CHQ-PF28 General Health (0-100) 66.70 19.20 72.30 19.54 71.88 20.02 71.88 18.96 76.66 17.23 CHQ-PF28 Parent Impact-Emotional (0-100) 73.98 22.45 81.54 23.41 81.55 23.11 81.72 23.88 80.90 24.63 CHQ-PF28 Parent Time Impact (0-100) 83.88 18.93 94.91 15.55 95.23 15.01 94.96 16.21 92.42 17.51 CHQ-PF28 Family Activities (0-100) -- -- 88.32 19.08 87.74 19.18 89.07 19.37 90.50 17.49 CHQ-PF28 Physical Summary Score 53.37 0.51 53.52 8.89 53.71 8.57 53.46 9.00 52.26 10.81 CHQ-PF28 Psychosocial Summary Score 51.12 0.51 52.82 9.14 52.71 9.10 53.23 9.34 52.52 8.97