530773
research-article2014
AJMXXX10.1177/1062860614530773American Journal of Medical QualityStein et al
Article
Patients’ Perceptions of Care Are Associated With Quality of Hospital Care: A Survey of 4605 Hospitals
American Journal of Medical Quality 2015, Vol. 30(4) 382–388 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1062860614530773 ajmq.sagepub.com
Spencer M. Stein, BA1, Michael Day, MD, MPhil1, Raj Karia, MPH1, Lorraine Hutzler, BA1, and Joseph A. Bosco III, MD1
Abstract Favorable patient experience and low complication rates have been proposed as essential components of patientcentered medical care. Patients’ perception of care is a key performance metric and is used to determine payments to hospitals. It is unclear if there is a correlation between technical quality of care and patient satisfaction. The study authors correlated patient perceptions of care measured by the Hospital Consumer Assessment of Healthcare Providers and Systems scores with accepted quality of care indicators. The Hospital Compare database (4605 hospitals) was used to examine complication rates and patient-reported experience for hospitals across the nation in 2011. The majority of the correlations demonstrated an inverse relationship between patient experience and complication rates. This negative correlation suggests that reducing these complications can lead to a better hospital experience. Overall, these results suggest that patient experience is generally correlated with the quality of care provided. Keywords patient satisfaction, quality, HCAHPS, value-based purchasing All stakeholders of medical care including physicians, patients, policy makers, and payors understand the increasing importance of measuring quality of care and patient experience. Despite minimal high-quality evidence that financial incentives improve quality of care,1-3 the Deficit Reduction Act of 2005 and the Patient Protection and Affordable Care Act have mandated that the Centers for Medicare & Medicaid Services (CMS) implement payment for performance initiatives. These initiatives include a hospital-acquired condition (HAC) reduction program and a value-based purchasing (VBP) program. VBP provides financial incentives for hospitals based on the patient experience,4 the premise being that patient experience is a key component of quality of care. Prior studies have investigated the correlation between quality of care and patient experience with varied results. However, none has specifically studied HACs and patient satisfaction on a national level. Since its implementation in 2012, CMS has included self-reported patient experience in the VBP model. CMS employs the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey to measure patient experience. HCAHPS is the first national, standardized, publically reported information on patient satisfaction.5,6 It includes questions on 10 areas of health care interaction such as communication,
responsiveness of staff, and overall hospital rating.7 Prior studies have noted an association between technical quality of care measures and global score, communication with doctors, and responsiveness of staff.8-10 One way to measure technical quality of care is by complication rate. The Deficit Reduction Act of 2005 required CMS to establish a list of HACs, or conditions that are (a) high cost and/or high volume, (b) result in assignment of a case to a diagnosis-related group that has a higher payment when listed as a secondary diagnosis, and (c) “could reasonably have been prevented through the application of evidence-based guidelines.”11 Since 2008, hospitals have not received additional compensation from CMS for treating these conditions. In April 2013, CMS laid out its new Hospital-Acquired Condition Reduction Program for fiscal year 2015 implementation. Under this proposed rule, hospitals in the highest quartile of reported HACs or Patient Safety Indicators (PSIs) will receive a 1% penalty in payment (Table 1).12 PSIs were developed by the Agency for Healthcare Research and 1
NYU Hospital for Joint Diseases, New York, NY
Corresponding Author: Lorraine Hutzler, BA, NYU Hospital for Joint Diseases, 301 East 17th Street, Suite 1402, New York, NY 10003. Email: [email protected]
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Stein et al Table 1. Proposed Hospital-Acquired Condition Reduction Program Measures.a Domain 1
1 2 3 4
Domain 2
5 6 1
2
Pressure ulcer rate Volume of foreign object left in body Iatrogenic pneumothorax rate Postoperative physiological and metabolic derangement rate Postoperative PE or DVT rate Accidental puncture or laceration rate Central line–associated bloodstream infection Catheter-associated urinary tract infection
Abbreviations: PE, pulmonary embolism; DVT, deep vein thrombosis; CMS, Centers for Medicare & Medicaid Services; HAC, hospitalacquired condition. a CMS will calculate a composite score from the averages of Domain 1 and Domain 2 to rank hospitals into quartiles. Hospitals in the highest quartiles of HACs will receive a 1% reduction in pay.
Quality (AHRQ) and represent “serious” but potentially preventable complications. Both HCAHPS scores and HACs/PSIs are publically reported on the Hospital Compare Web site (Hospitalcompare.hhs.gov).7 It remains unclear whether there is an association between developing a HAC and patients’ ratings of their hospital experience. Establishing a correlation between a lower rate of HACs and higher HCAHPS scores would validate CMS’s strategy and help guide efforts to optimize both quality of care and patient experience. To the authors’ knowledge, 2 studies have found associations suggesting HACs may correlate with HCAHPS scores. Isaac et al9 found varying degrees of correlation between PSIs, or “serious but preventable conditions,” and HCAHPS questions using 2005-2006 data. More recently, Saman et al10 reported a significant correlation between slower responsiveness of staff and higher rates of central line–associated bloodstream infections, a hospitalacquired infection. However, Day et al13 reported no significant difference in HCAHPS scores among a cohort of patients with and without HACs. Others have failed to find a correlation between patient satisfaction and technical quality of care measures.14-16 These mixed results raise questions about the validity of using patient satisfaction as a proxy for quality of care. The goal of this study is to determine if a correlation exists between 4 HCAHPS measures and 13 publically reported HACs using a large national database of 4500 hospitals. Based on a literature review, the study authors chose to focus the investigation on the following survey responses: (a) hospital overall rating 9 or 10, (b) definitely would recommend the hospital, (c) doctors always communicated well, and (d) patients always received help as soon as they wanted. The hypothesis was that there will be an inverse relationship between quality of
care as measured by complication rate and patient experience as measured by HCAHPS scores. This investigation aimed to establish a correlation between the quality of care received and how patients perceive that care using the updated Hospital Compare database of over 4500 hospitals.
Methods Data Sources The study authors used publically available and downloadable HCAHPS, HACs, and PSI data available from CMS on its Hospital Compare Web site from 2011.7
Patient Experience HCAHPS is the first national, standardized, publically reported information on patient satisfaction.5,6 It was developed by CMS and AHRQ and is administered to a random sample of patients, not limited to Medicare beneficiaries. Patients receive the survey throughout the year, via mail, phone, mail with phone follow-up, or interactive voice recognition, between 48 hours and 6 weeks after discharge. It includes 32 questions in total: 21 on patient experience, 4 screening questions, and 7 demographic items. The patient experience questions fall into 10 domains (Table 2): 6 composite topics (nurse communication, doctor communication, responsiveness of hospital staff, pain management, communication about medicines, discharge information), 2 individual topics (cleanliness and quietness of hospital environment), and 2 global questions (overall rating of hospital and willingness to recommend hospital). HCAHPS scores are adjusted for demographic data and are reported quarterly on a hospital level. Responses are presented as percent of patients and are grouped into thirds; for example, doctors always, sometimes, or never communicated well. The highest possible response in each category is known as the “top box” response. “Top box” responses for the 10 domains are reported online at hospitalcompare.hhs.gov. The study authors used Hospital Compare databases for 2011, which includes HCAHPS results for discharges from January 2011 to December 2011. Four “top box” HCAHPS responses were examined: (a) hospital overall rating of 9 or 10, (b) patients would definitely recommend the hospital, (c) doctors always communicated well, and (d) patients always received help as soon as they wanted. The study authors chose to look at physician communication in additional to global rating because prior reports have noted patients value communication.17,18 The authors also chose to study the responsiveness of hospital staff because a prior study linked this to central line infections.10
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Table 2. The 10 Domains of HCAHPS Questions.a Composite topics How often did doctors communicate well with patients? How often did nurses communicate well with patients? How often did patients receive help quickly from hospital staff? How often did staff explain about medicines before giving them to patients How often was patients’ pain well controlled? Were patients given information about what to do during their recovery at home? Individual topics How often was the area around the patients’ rooms kept quiet at night? How often were the patients’ room and bathrooms kept clean? Global topics How do patients rate the hospital overall? Would patients recommend the hospital to family and friends? Abbreviation: HCAHPS, Hospital Consumer Assessment of Healthcare Providers and Services. a Percentage of patients reporting “top box,” or highest possible response for each category, is publically available from the Hospital Compare Web site. The download includes percentage of patients for “top box,” as well as lower answer responses. Adapted from: Centers for Medicare and Medicaid Services: Hospital Compare: Downloads. http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/HospitalQualityInits/HospitalCompare.html. Accessed May 7, 2013.
The 5 following PSIs were excluded because CMS did not report data for these in 2011: postoperative respiratory failure, serious complications, death after abdominal aortic aneurysm repair, postoperative hip fracture rate, and death after certain conditions.19
Statistical Analysis To compare patient experience with quality of care, hospitals were divided into quartiles based on their performance on each of the 4 HCHAPS responses. Then, averages for each of the 13 quality of care indicators were averaged across those quartiles. Finally, a Cochran– Armitage test for trend was applied to evaluate the association between the presence of HACs and the patient experience as reported by HCAHPS scores.
Results Of the 4605 hospitals reporting HCAHPS data in 2011, a total 3275 (71.1%) reported rates of HACs and 2871 (62%) reported rates of PSI (Table 3). Overall, there were 31 trends out of a total of 52 relationships examined (60%). Of 31 trends, 23 (74%) demonstrated an inverse relationship (ie, higher complication rate was associated with lower patient experience). These relationships are detailed in the following sections by HCAHPS question.
Overall Rating of 9 or 10 Out of 10
Quality of Care HACs are a measure of how often certain potentially preventable events occur among Medicare beneficiaries. CMS includes only Medicare beneficiaries enrolled in a traditional fee-for-service plan who were discharged from a hospital paid through the Inpatient Prospective Payment System. Rates are given per 1000 patients and are not adjusted for demographic data. The Hospital Compare database for 2011 includes HACS for 20 months from July 2009 to April 2011. The reported HACs are (a) foreign object retained after surgery, (b) air embolism, (c) blood incompatibility, (d) pressure ulcers stage III and IV, (e) falls and trauma, (f) vascular catheter-associated infection (VCAI), (g) catheter-associated urinary tract infections (CAUTI), and (h) manifestations of poor glycemic control. In 2011, the number of hospitals that reported PSIs ranged from 2005 to 3261. These are calculated among Medicare beneficiaries per 1000 patients in a similar fashion to HACs. The PSIs considered in this study were (a) postoperative mortality from serious treatable complications, (b) iatrogenic pneumothorax, (c) postoperative pulmonary embolism or deep venous thrombosis rate (VTE), (d) postoperative wound dehiscence, and (e) accidental puncture or laceration.
Of the 8 HACs investigated for the top box response to the overall rating of the hospital question, 5 were statistically significantly associated (P < .05). Hospitals with high rates of serious pressure ulcers, VCAI, and manifestations of poor glycemic control demonstrated lower overall ratings of 9 or 10. However, hospitals with higher rates of air embolism and CAUTI demonstrated higher overall ratings of 9 or 10. Four of the 5 PSIs investigated were associated with overall hospital rating. Hospitals with higher postoperative deaths from serious treatable complications after surgery, VTE, and postoperative wound dehiscence had lower overall ratings of 9 or 10, while hospitals with higher rates of accidental puncture or laceration had higher percentages of overall hospital ratings. Rates of iatrogenic pneumothorax were not significantly associated with overall hospital rating. (See online Appendix A at http://ajm.sagepub.com/content/by/supplemental-data.)
Would Definitely Recommend the Hospital Two of the 8 HACs were significantly associated with likeliness to recommend the hospital, one positively and one negatively. Hospitals with higher rates of serious pressure ulcers were less likely to have patients report
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Table 3. Summary of the Significant Associations Between Hospital-Acquired Conditions/Patient Safety Indicators and Hospital Consumer Assessment of Healthcare Providers and Systems Responses.
HCAHPS Response HAC
Pressure ulcers stage III and IV
Falls and trauma Vascular catheterassociated infection
Catheter-associated urinary tract infection
Manifestation of poor glycemic control
PSI
Postoperative death due to treatable complications
Overall rating of 9 or 10 Definitely recommend the hospital Doctors always communicated well Always received timely help No significant associations Overall rating of 9 or 10 Doctors always communicated well Always received timely help Overall rating of 9 or 10 Definitely recommend the hospital Doctors always communicated well Always received timely help Overall rating of 9 or 10 Doctors always communicated well Always received timely help Overall rating of 9 or 10
Definitely recommend the hospital Always received timely help Iatrogenic pneumothorax Definitely recommend the hospital Doctors always communicated well Always received timely help Venous thromboembolism Overall rating of 9 or 10 Definitely recommend the hospital Doctors always communicated well Always received timely help Postoperative wound Overall rating of 9 or 10 dehiscence Definitely recommend the hospital Accidental puncture or Overall rating of 9 or 10 laceration Definitely recommend the hospital
Number of Responding Hospitals 3273
3273 3273
3273
3273
2005
3261
3104
2728
3255
Respondent Percentage 71.1
71.1 71.1
71.1
71.1
43.5
70.8
67.4
59.2
70.7
Direction of Trend
P Value for Trend
Negative
0
Negative
0
Negative
0
Negative Negative
0 0
Negative
0
Negative Positive
0 .005
Positive
0
Negative
.021
Negative Negative
.001 .024
Negative
0
Negative Negative
0 0
Negative
0
Negative Positive
.004 .008
Negative
.009
Negative Negative Negative
.01 0 .001
Negative
0
Negative Negative
0 0
Negative
0
Positive
0
Positive
0
Abbreviations: HCAHPS, Hospital Consumer Assessment of Healthcare Providers and Systems; HAC, hospital-acquired condition; PSI, Patient Safety Indicator.
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they were willing to recommend the hospital. Hospitals with higher rates of CAUTI were more likely to have patients recommend the hospital. No significant trend was established between air embolism, falls and trauma, VCAI, manifestations of poor glycemic control, and willingness to recommend the hospital. All 5 PSIs were significantly associated with likeliness to recommend the hospital, 3 negatively and 2 positively. Hospitals with higher rates of postoperative death related to serious treatable complications, VTE, and postoperative wound dehiscence were less likely to have patients report they were willing to recommend the hospital. Hospitals with higher rates of iatrogenic pneumothorax and accidental punctures or lacerations were more likely to have patients report they were willing to recommend the hospital. (See online Appendix B at http://ajm. sagepub.com/content/by/supplemental-data.)
Doctors Always Communicated Well Four of the 8 HACs demonstrated significant negative trends with physician communication. Hospitals with higher rates of pressure ulcers, VCAI, CAUTI, and manifestations of poor glycemic control were significantly less likely to have patients report that doctors always communicated well. There was no statistical trend between physician communication and rates of postoperative foreign object retention, air embolism, blood incompatibility, or falls and trauma. Two of the 5 PSIs demonstrated significant negative trends with physician communication. Physicians at hospitals with higher rates of iatrogenic pneumothorax and VTE were less likely to be rated as “always communicated well.” There was no significant trend between physician communication and postoperative death from serious treatable complications, postoperative wound dehiscence, or accidental puncture or laceration. (See online Appendix C at http://ajm.sagepub.com/content/by/ supplemental-data.)
Patients Always Received Help as Soon as They Wanted (Timely Responsiveness of Staff) Four of the 8 HACs were statistically negatively associated with the timely responsiveness of staff. Hospitals with higher rates of pressure ulcers, VCAI, CAUTI, and manifestations of poor glycemic control were less likely to obtain a top box rating for the timely responsiveness of their staff. Three of the 5 PSIs were statistically negatively associated with the timely responsiveness of staff. Hospitals with higher rates of postoperative death from serious treatable complications, iatrogenic pneumothorax, and
VTE were less likely to receive a top box rating for timely responsiveness of staff. Postoperative wound dehiscence and accidental puncture or laceration were not significantly associated with responsiveness of staff. (See online Appendix D at http://ajm.sagepub.com/content/by/ supplemental-data.)
Discussion Measuring quality of medical care is an essential aspect of patient-centered care. There is general agreement that objective measures of care, such as HACs and PSIs, should be optimized to improve overall care quality. To accomplish this goal, professional guidelines have been established, such as the American College of Chest Physicians guidelines to prevent VTE.20 However, patient experience is more subjective, less quantifiable, and may be more difficult to improve. Nevertheless, CMS now publically reports patients’ perception of their hospital care and incorporates patient satisfaction scores, along with technical quality of care indicators, in its pay-forperformance initiatives. This present report established a trend between how patients rate their care and the quality of hospital care received utilizing the Hospital Compare Web site of over 4500 hospitals. To date, there have been mixed results of investigations that aim to correlate patients’ experience with objective quality of care metrics. Two reports studied HCAHPS and quality of care as measured by complication rates on a national level and found significant trends.9,10 Additionally, Jha et al8 reported a significant correlation between hospital overall rating and (a) nurse-to-patient ratios and (b) process of care measures for acute myocardial infection, heart failure, pneumonia, and surgical processes. Other studies have noted that patients value communication as reflective of their overall experience and the technical quality of care.15,18,21-23 These results suggest HACs and patient satisfaction are associated and related metrics. There also have been numerous reports with contradictory results.15,16 For example, Day et al13 reported no significant difference in HCAHPS scores among a single, hospital-based cohort of patients with and without HACs. Additionally, Lyu et al14 found no correlation between HCAHPS global score and surgical process of care measures. Fenton et al21 reported that the most satisfied patients had more inpatient hospitalizations, higher total health expenditures, and a 26% greater mortality risk than less satisfied patients. Deyo22 suggested that physicians’ decisions may be influenced by what will satisfy patients and may result in lower quality of care. Taken together, these results suggest measuring patient satisfaction is a poor indicator of quality of care.
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Stein et al The present report investigated a trend between patient experience and quality of care using publicly available data from 4605 hospitals in 2011. It focused on 4 HCAHPS questions to gauge patient experience and rates of 8 HACs and 5 PSIs to measure quality of care. Those chosen were overall hospital rating, willingness to recommend the hospital, communication with doctors, and responsiveness of staff, as others have demonstrated that these are representative of the HCAHPS questionnaire and are associated with technical quality of care.8,10,15,17,18,22 Most of the relationships investigated demonstrated an association between higher patient satisfaction scores and better quality of medical care. Of the 52 possible relationships studied, 29 (56%) demonstrated a significant trend (P < .05). Of these, 23 (79%) demonstrated an inverse trend (higher HCAHPS scores and lower HACs or PSIs), as was hypothesized. Hospitals with higher rates of pressure ulcers, VCAIs, manifestation of poor glycemic control, postoperative death related to treatable conditions, VTEs, and wound dehiscence had lower HCAHPS scores for least 2 questions. Two metrics had mixed results: CAUTI and iatrogenic pneumothorax demonstrated an inverse correlation with communication and timely help, but an unexpected positive trend in overall rating metrics. Only the rate of falls and trauma demonstrated no trends with patient satisfaction (Table 3). One goal of this report is to establish methods to improve patients’ experience. The inverse associations between rates of pressure ulcers, VCAI, manifestation of poor glycemic control, treatable postoperative mortality, VTE, wound dehiscence, and HCAHPS responses suggests that minimizing the rates of these indicators could improve the perception of care. The study authors also noted unexpected positive associations between quality of care and patients’ experience. However, the low rates of occurrence are considered to be limitations of those analyses. Still, Shahian et al23 reported similar associations when they noted that academic hospitals have lower HCAHPS scores as well as lower rates of hospital-acquired infections and pressure ulcers when compared with nonacademic hospitals. The relationship between higher rates of HACs and PSIs and higher HCAHPS scores could be attributed to the response to adverse events, termed “service recovery.” This method of interacting with consumers, borrowed from the business world, is rooted in addressing the negative experience, apologizing to the patient, and making extra efforts to ensure the patient is satisfied with the remainder of their care. That all positive associations were between overall perception measures and quality measures supports the notion that service recovery can be an effective model to ensure patients remain satisfied despite the occurrence of complications.
This study has several limitations. Overall hospital data were used to compare HACs and HCAHPs, but this limited the examination of individual patient responses. This may introduce selection bias if those without HACs or PSIs rate their experience extremely high, skewing the experience rating. Furthermore, HACs data capture only Medicare beneficiaries, while HCAHPS surveys include Medicare and non-Medicare beneficiaries. Additionally, confounders may be present because rates of HACs, unlike HCAHPS scores and PSIs, are not corrected for patient differences and hospital demographics. Last, because this is a retrospective review, the study authors are not able to establish causation between technical quality of care indicators and how patients perceive their hospital care. Future studies could build on the Calikoglu et al24 method of comparing HACs before and after implementation of nonpayment policy. Such an investigation could compare HACs before and after the inclusion of HCAHPS scores into the pay-for-performance programs. This could further support the use of patient experience metrics to improve health care value. Optimizing quality of care while measuring patients’ experience is an essential component of increasing health care value. Health care policy changes have already initiated programs that incentivize better quality of care and improved patient experiences, and there is little doubt that future health care policy will include these metrics in payment calculating schematics. This report of 4605 hospitals demonstrated that at least some quality of care indicators, many of which are applicable to the field of orthopedic surgery, are associated with how patients rate their hospital care. The associations reported herein represent advances in our understanding of how patients perceive the care they receive and will aid in the quest to provide patients with the highest level of care. Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
References 1. Scott A, Sivey P, Ait Ouakrim D, et al. The effect of financial incentives on the quality of health care provided by primary care physicians. Cochrane Database Syst Rev. 2011(9):CD008451. 2. Lee GM, Kleinman K, Soumerai SB, et al. Effect of nonpayment for preventable infections in U.S. hospitals. N Engl J Med. 2012;367:1428-1437.
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3. Fung CH, Lim YW, Mattke S, Damberg C, Shekelle PG. Systematic review: the evidence that publishing patient care performance data improves quality of care. Ann Intern Med. 2008;148:111-123. 4. Centers for Medicare & Medicaid Services. Fact sheets: CMS issues final rule for first year of hospital value-based purchasing program. http://www.cms.gov/apps/media/ press/factsheet.asp?Counter=3947. Published April 29, 2011. Accessed May 2, 2013. 5. Darby C, Hays RD, Kletke P. Development and evaluation of the CAHPS hospital survey. Health Serv Res. 2005;40(6 pt 2):1973-1976. 6. Goldstein E, Farquhar M, Crofton C, Darby C, Garfinkel S. Measuring hospital care from the patients’ perspective: an overview of the CAHPS Hospital Survey development process. Health Serv Res. 2005;40(6 pt 2):1977-1995. 7. Centers for Medicare & Medicaid Services. Hospital Compare. http://www.hospitalcompare.hhs.gov. Accessed May 2, 2013. 8. Jha AK, Orav EJ, Zheng J, Epstein AM. Patients’ perception of hospital care in the United States. N Engl J Med. 2008;359:1921-1931. 9. Isaac T, Zaslavsky AM, Cleary PD, Landon BE. The relationship between patients’ perception of care and measures of hospital quality and safety. Health Serv Res. 2010;45:1024-1040. 10. Saman DM, Kavanagh KT, Johnson B, Lutfiyya MN. Can inpatient hospital experiences predict central line-associated bloodstream infections? PLoS One. 2013;8(4):e61097. 11. Deficit Reduction Act of 2005, 1396a(a)(68) USC, §5001 (2006). 12. Centers for Medicare & Medicaid Services. Fact sheet: CMS proposal to improve quality of care during hospital inpatient stays. http://www.cms.gov/apps/media/press/ factsheet.asp?Counter=4586&intNumPerPage=10&check Date=&checkKey=&srchType=1&numDays=3500&srch Opt=0&srchData=&keywordType=All&chkNewsType=6 &intPage=&showAll=&pYear=&year=&desc=&cboOrde r=date. Published April 26, 2013. Accessed May 2, 2013. 13. Day MS, Hutzler LH, Karia R, Vangsness K, Setia N, Bosco JA. Hospital-acquired conditions after orthopedic surgery do not affect patient satisfaction scores [published online August 23, 2013]. J Healthc Qual. doi:10.1111/ jhq.12031.
14. Lyu H, Wick E, Housman M, Freischlag J, Makary M. Patient satisfaction as a possible indicator of quality surgical care. JAMA Surg. 2013;148:362-367. 15. Chang JT, Hays RD, Shekelle PG, et al. Patients’ global ratings of their health care are not associated with the technical quality of their care. Ann Intern Med. 2006;144: 665-672. 16. Gandhi TK, Cook FE, Puopolo AL, Burstin HR, Haas JS, Brennan TA. Inconsistent report cards: assessing the comparability of various measures of the quality of ambulatory care. Med Care. 2002;40:155-165. 17. Hargraves J, Hays RD, Cleary PD. Psychometric properties of the consumer assessment of health plans study (CAHPS) 2.0 adult core survey. Health Serv Res. 2003;38(6 pt 1):1509-1528. 18. Rao M, Clarke A, Sanderson C, Hammersley R. Patients’ own assessments of quality of primary care compared with objective records based measures of technical quality of care: cross sectional study. BMJ. 2006;333(7557):19. 19. QualityNet. Overview: Agency for Healthcare Research and Quality (AHRQ) Indicators. http://www.qualitynet. org/dcs/ContentServer?cid=1228695321101&pagena me=QnetPublic%2FPage%2FQnetTier3&%20c=Page. Accessed May 6, 2013. 20. Falck-Ytter Y, Francis CW, Johanson NA, et al. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 suppl):e278Se325S. 21. Fenton JJ, Jerant AF, Bertakis KD, Franks P. The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality. Arch Intern Med. 2012;172:405-411. 22. Deyo RA. Imaging idolatry: the uneasy intersection of patient satisfaction, quality of care, and overuse. Arch Intern Med. 2009;169:921-923. 23. Shahian DM, Nordberg P, Meyer GS, et al. Contemporary performance of U.S. teaching and nonteaching hospitals. Acad Med. 2012;87:701-708. 24. Calikoglu S, Murray R, Feeney D. Hospital pay-for-performance programs in Maryland produced strong results, including reduced hospital-acquired conditions. Health Aff (Millwood). 2012;31:2649-2658.
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research-article2014
AJMXXX10.1177/1062860614530773American Journal of Medical QualityStein et al
Article
Patients’ Perceptions of Care Are Associated With Quality of Hospital Care: A Survey of 4605 Hospitals
American Journal of Medical Quality 2015, Vol. 30(4) 382–388 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1062860614530773 ajmq.sagepub.com
Spencer M. Stein, BA1, Michael Day, MD, MPhil1, Raj Karia, MPH1, Lorraine Hutzler, BA1, and Joseph A. Bosco III, MD1
Abstract Favorable patient experience and low complication rates have been proposed as essential components of patientcentered medical care. Patients’ perception of care is a key performance metric and is used to determine payments to hospitals. It is unclear if there is a correlation between technical quality of care and patient satisfaction. The study authors correlated patient perceptions of care measured by the Hospital Consumer Assessment of Healthcare Providers and Systems scores with accepted quality of care indicators. The Hospital Compare database (4605 hospitals) was used to examine complication rates and patient-reported experience for hospitals across the nation in 2011. The majority of the correlations demonstrated an inverse relationship between patient experience and complication rates. This negative correlation suggests that reducing these complications can lead to a better hospital experience. Overall, these results suggest that patient experience is generally correlated with the quality of care provided. Keywords patient satisfaction, quality, HCAHPS, value-based purchasing All stakeholders of medical care including physicians, patients, policy makers, and payors understand the increasing importance of measuring quality of care and patient experience. Despite minimal high-quality evidence that financial incentives improve quality of care,1-3 the Deficit Reduction Act of 2005 and the Patient Protection and Affordable Care Act have mandated that the Centers for Medicare & Medicaid Services (CMS) implement payment for performance initiatives. These initiatives include a hospital-acquired condition (HAC) reduction program and a value-based purchasing (VBP) program. VBP provides financial incentives for hospitals based on the patient experience,4 the premise being that patient experience is a key component of quality of care. Prior studies have investigated the correlation between quality of care and patient experience with varied results. However, none has specifically studied HACs and patient satisfaction on a national level. Since its implementation in 2012, CMS has included self-reported patient experience in the VBP model. CMS employs the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey to measure patient experience. HCAHPS is the first national, standardized, publically reported information on patient satisfaction.5,6 It includes questions on 10 areas of health care interaction such as communication,
responsiveness of staff, and overall hospital rating.7 Prior studies have noted an association between technical quality of care measures and global score, communication with doctors, and responsiveness of staff.8-10 One way to measure technical quality of care is by complication rate. The Deficit Reduction Act of 2005 required CMS to establish a list of HACs, or conditions that are (a) high cost and/or high volume, (b) result in assignment of a case to a diagnosis-related group that has a higher payment when listed as a secondary diagnosis, and (c) “could reasonably have been prevented through the application of evidence-based guidelines.”11 Since 2008, hospitals have not received additional compensation from CMS for treating these conditions. In April 2013, CMS laid out its new Hospital-Acquired Condition Reduction Program for fiscal year 2015 implementation. Under this proposed rule, hospitals in the highest quartile of reported HACs or Patient Safety Indicators (PSIs) will receive a 1% penalty in payment (Table 1).12 PSIs were developed by the Agency for Healthcare Research and 1
NYU Hospital for Joint Diseases, New York, NY
Corresponding Author: Lorraine Hutzler, BA, NYU Hospital for Joint Diseases, 301 East 17th Street, Suite 1402, New York, NY 10003. Email: [email protected]
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Stein et al Table 1. Proposed Hospital-Acquired Condition Reduction Program Measures.a Domain 1
1 2 3 4
Domain 2
5 6 1
2
Pressure ulcer rate Volume of foreign object left in body Iatrogenic pneumothorax rate Postoperative physiological and metabolic derangement rate Postoperative PE or DVT rate Accidental puncture or laceration rate Central line–associated bloodstream infection Catheter-associated urinary tract infection
Abbreviations: PE, pulmonary embolism; DVT, deep vein thrombosis; CMS, Centers for Medicare & Medicaid Services; HAC, hospitalacquired condition. a CMS will calculate a composite score from the averages of Domain 1 and Domain 2 to rank hospitals into quartiles. Hospitals in the highest quartiles of HACs will receive a 1% reduction in pay.
Quality (AHRQ) and represent “serious” but potentially preventable complications. Both HCAHPS scores and HACs/PSIs are publically reported on the Hospital Compare Web site (Hospitalcompare.hhs.gov).7 It remains unclear whether there is an association between developing a HAC and patients’ ratings of their hospital experience. Establishing a correlation between a lower rate of HACs and higher HCAHPS scores would validate CMS’s strategy and help guide efforts to optimize both quality of care and patient experience. To the authors’ knowledge, 2 studies have found associations suggesting HACs may correlate with HCAHPS scores. Isaac et al9 found varying degrees of correlation between PSIs, or “serious but preventable conditions,” and HCAHPS questions using 2005-2006 data. More recently, Saman et al10 reported a significant correlation between slower responsiveness of staff and higher rates of central line–associated bloodstream infections, a hospitalacquired infection. However, Day et al13 reported no significant difference in HCAHPS scores among a cohort of patients with and without HACs. Others have failed to find a correlation between patient satisfaction and technical quality of care measures.14-16 These mixed results raise questions about the validity of using patient satisfaction as a proxy for quality of care. The goal of this study is to determine if a correlation exists between 4 HCAHPS measures and 13 publically reported HACs using a large national database of 4500 hospitals. Based on a literature review, the study authors chose to focus the investigation on the following survey responses: (a) hospital overall rating 9 or 10, (b) definitely would recommend the hospital, (c) doctors always communicated well, and (d) patients always received help as soon as they wanted. The hypothesis was that there will be an inverse relationship between quality of
care as measured by complication rate and patient experience as measured by HCAHPS scores. This investigation aimed to establish a correlation between the quality of care received and how patients perceive that care using the updated Hospital Compare database of over 4500 hospitals.
Methods Data Sources The study authors used publically available and downloadable HCAHPS, HACs, and PSI data available from CMS on its Hospital Compare Web site from 2011.7
Patient Experience HCAHPS is the first national, standardized, publically reported information on patient satisfaction.5,6 It was developed by CMS and AHRQ and is administered to a random sample of patients, not limited to Medicare beneficiaries. Patients receive the survey throughout the year, via mail, phone, mail with phone follow-up, or interactive voice recognition, between 48 hours and 6 weeks after discharge. It includes 32 questions in total: 21 on patient experience, 4 screening questions, and 7 demographic items. The patient experience questions fall into 10 domains (Table 2): 6 composite topics (nurse communication, doctor communication, responsiveness of hospital staff, pain management, communication about medicines, discharge information), 2 individual topics (cleanliness and quietness of hospital environment), and 2 global questions (overall rating of hospital and willingness to recommend hospital). HCAHPS scores are adjusted for demographic data and are reported quarterly on a hospital level. Responses are presented as percent of patients and are grouped into thirds; for example, doctors always, sometimes, or never communicated well. The highest possible response in each category is known as the “top box” response. “Top box” responses for the 10 domains are reported online at hospitalcompare.hhs.gov. The study authors used Hospital Compare databases for 2011, which includes HCAHPS results for discharges from January 2011 to December 2011. Four “top box” HCAHPS responses were examined: (a) hospital overall rating of 9 or 10, (b) patients would definitely recommend the hospital, (c) doctors always communicated well, and (d) patients always received help as soon as they wanted. The study authors chose to look at physician communication in additional to global rating because prior reports have noted patients value communication.17,18 The authors also chose to study the responsiveness of hospital staff because a prior study linked this to central line infections.10
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Table 2. The 10 Domains of HCAHPS Questions.a Composite topics How often did doctors communicate well with patients? How often did nurses communicate well with patients? How often did patients receive help quickly from hospital staff? How often did staff explain about medicines before giving them to patients How often was patients’ pain well controlled? Were patients given information about what to do during their recovery at home? Individual topics How often was the area around the patients’ rooms kept quiet at night? How often were the patients’ room and bathrooms kept clean? Global topics How do patients rate the hospital overall? Would patients recommend the hospital to family and friends? Abbreviation: HCAHPS, Hospital Consumer Assessment of Healthcare Providers and Services. a Percentage of patients reporting “top box,” or highest possible response for each category, is publically available from the Hospital Compare Web site. The download includes percentage of patients for “top box,” as well as lower answer responses. Adapted from: Centers for Medicare and Medicaid Services: Hospital Compare: Downloads. http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/HospitalQualityInits/HospitalCompare.html. Accessed May 7, 2013.
The 5 following PSIs were excluded because CMS did not report data for these in 2011: postoperative respiratory failure, serious complications, death after abdominal aortic aneurysm repair, postoperative hip fracture rate, and death after certain conditions.19
Statistical Analysis To compare patient experience with quality of care, hospitals were divided into quartiles based on their performance on each of the 4 HCHAPS responses. Then, averages for each of the 13 quality of care indicators were averaged across those quartiles. Finally, a Cochran– Armitage test for trend was applied to evaluate the association between the presence of HACs and the patient experience as reported by HCAHPS scores.
Results Of the 4605 hospitals reporting HCAHPS data in 2011, a total 3275 (71.1%) reported rates of HACs and 2871 (62%) reported rates of PSI (Table 3). Overall, there were 31 trends out of a total of 52 relationships examined (60%). Of 31 trends, 23 (74%) demonstrated an inverse relationship (ie, higher complication rate was associated with lower patient experience). These relationships are detailed in the following sections by HCAHPS question.
Overall Rating of 9 or 10 Out of 10
Quality of Care HACs are a measure of how often certain potentially preventable events occur among Medicare beneficiaries. CMS includes only Medicare beneficiaries enrolled in a traditional fee-for-service plan who were discharged from a hospital paid through the Inpatient Prospective Payment System. Rates are given per 1000 patients and are not adjusted for demographic data. The Hospital Compare database for 2011 includes HACS for 20 months from July 2009 to April 2011. The reported HACs are (a) foreign object retained after surgery, (b) air embolism, (c) blood incompatibility, (d) pressure ulcers stage III and IV, (e) falls and trauma, (f) vascular catheter-associated infection (VCAI), (g) catheter-associated urinary tract infections (CAUTI), and (h) manifestations of poor glycemic control. In 2011, the number of hospitals that reported PSIs ranged from 2005 to 3261. These are calculated among Medicare beneficiaries per 1000 patients in a similar fashion to HACs. The PSIs considered in this study were (a) postoperative mortality from serious treatable complications, (b) iatrogenic pneumothorax, (c) postoperative pulmonary embolism or deep venous thrombosis rate (VTE), (d) postoperative wound dehiscence, and (e) accidental puncture or laceration.
Of the 8 HACs investigated for the top box response to the overall rating of the hospital question, 5 were statistically significantly associated (P < .05). Hospitals with high rates of serious pressure ulcers, VCAI, and manifestations of poor glycemic control demonstrated lower overall ratings of 9 or 10. However, hospitals with higher rates of air embolism and CAUTI demonstrated higher overall ratings of 9 or 10. Four of the 5 PSIs investigated were associated with overall hospital rating. Hospitals with higher postoperative deaths from serious treatable complications after surgery, VTE, and postoperative wound dehiscence had lower overall ratings of 9 or 10, while hospitals with higher rates of accidental puncture or laceration had higher percentages of overall hospital ratings. Rates of iatrogenic pneumothorax were not significantly associated with overall hospital rating. (See online Appendix A at http://ajm.sagepub.com/content/by/supplemental-data.)
Would Definitely Recommend the Hospital Two of the 8 HACs were significantly associated with likeliness to recommend the hospital, one positively and one negatively. Hospitals with higher rates of serious pressure ulcers were less likely to have patients report
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Table 3. Summary of the Significant Associations Between Hospital-Acquired Conditions/Patient Safety Indicators and Hospital Consumer Assessment of Healthcare Providers and Systems Responses.
HCAHPS Response HAC
Pressure ulcers stage III and IV
Falls and trauma Vascular catheterassociated infection
Catheter-associated urinary tract infection
Manifestation of poor glycemic control
PSI
Postoperative death due to treatable complications
Overall rating of 9 or 10 Definitely recommend the hospital Doctors always communicated well Always received timely help No significant associations Overall rating of 9 or 10 Doctors always communicated well Always received timely help Overall rating of 9 or 10 Definitely recommend the hospital Doctors always communicated well Always received timely help Overall rating of 9 or 10 Doctors always communicated well Always received timely help Overall rating of 9 or 10
Definitely recommend the hospital Always received timely help Iatrogenic pneumothorax Definitely recommend the hospital Doctors always communicated well Always received timely help Venous thromboembolism Overall rating of 9 or 10 Definitely recommend the hospital Doctors always communicated well Always received timely help Postoperative wound Overall rating of 9 or 10 dehiscence Definitely recommend the hospital Accidental puncture or Overall rating of 9 or 10 laceration Definitely recommend the hospital
Number of Responding Hospitals 3273
3273 3273
3273
3273
2005
3261
3104
2728
3255
Respondent Percentage 71.1
71.1 71.1
71.1
71.1
43.5
70.8
67.4
59.2
70.7
Direction of Trend
P Value for Trend
Negative
0
Negative
0
Negative
0
Negative Negative
0 0
Negative
0
Negative Positive
0 .005
Positive
0
Negative
.021
Negative Negative
.001 .024
Negative
0
Negative Negative
0 0
Negative
0
Negative Positive
.004 .008
Negative
.009
Negative Negative Negative
.01 0 .001
Negative
0
Negative Negative
0 0
Negative
0
Positive
0
Positive
0
Abbreviations: HCAHPS, Hospital Consumer Assessment of Healthcare Providers and Systems; HAC, hospital-acquired condition; PSI, Patient Safety Indicator.
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they were willing to recommend the hospital. Hospitals with higher rates of CAUTI were more likely to have patients recommend the hospital. No significant trend was established between air embolism, falls and trauma, VCAI, manifestations of poor glycemic control, and willingness to recommend the hospital. All 5 PSIs were significantly associated with likeliness to recommend the hospital, 3 negatively and 2 positively. Hospitals with higher rates of postoperative death related to serious treatable complications, VTE, and postoperative wound dehiscence were less likely to have patients report they were willing to recommend the hospital. Hospitals with higher rates of iatrogenic pneumothorax and accidental punctures or lacerations were more likely to have patients report they were willing to recommend the hospital. (See online Appendix B at http://ajm. sagepub.com/content/by/supplemental-data.)
Doctors Always Communicated Well Four of the 8 HACs demonstrated significant negative trends with physician communication. Hospitals with higher rates of pressure ulcers, VCAI, CAUTI, and manifestations of poor glycemic control were significantly less likely to have patients report that doctors always communicated well. There was no statistical trend between physician communication and rates of postoperative foreign object retention, air embolism, blood incompatibility, or falls and trauma. Two of the 5 PSIs demonstrated significant negative trends with physician communication. Physicians at hospitals with higher rates of iatrogenic pneumothorax and VTE were less likely to be rated as “always communicated well.” There was no significant trend between physician communication and postoperative death from serious treatable complications, postoperative wound dehiscence, or accidental puncture or laceration. (See online Appendix C at http://ajm.sagepub.com/content/by/ supplemental-data.)
Patients Always Received Help as Soon as They Wanted (Timely Responsiveness of Staff) Four of the 8 HACs were statistically negatively associated with the timely responsiveness of staff. Hospitals with higher rates of pressure ulcers, VCAI, CAUTI, and manifestations of poor glycemic control were less likely to obtain a top box rating for the timely responsiveness of their staff. Three of the 5 PSIs were statistically negatively associated with the timely responsiveness of staff. Hospitals with higher rates of postoperative death from serious treatable complications, iatrogenic pneumothorax, and
VTE were less likely to receive a top box rating for timely responsiveness of staff. Postoperative wound dehiscence and accidental puncture or laceration were not significantly associated with responsiveness of staff. (See online Appendix D at http://ajm.sagepub.com/content/by/ supplemental-data.)
Discussion Measuring quality of medical care is an essential aspect of patient-centered care. There is general agreement that objective measures of care, such as HACs and PSIs, should be optimized to improve overall care quality. To accomplish this goal, professional guidelines have been established, such as the American College of Chest Physicians guidelines to prevent VTE.20 However, patient experience is more subjective, less quantifiable, and may be more difficult to improve. Nevertheless, CMS now publically reports patients’ perception of their hospital care and incorporates patient satisfaction scores, along with technical quality of care indicators, in its pay-forperformance initiatives. This present report established a trend between how patients rate their care and the quality of hospital care received utilizing the Hospital Compare Web site of over 4500 hospitals. To date, there have been mixed results of investigations that aim to correlate patients’ experience with objective quality of care metrics. Two reports studied HCAHPS and quality of care as measured by complication rates on a national level and found significant trends.9,10 Additionally, Jha et al8 reported a significant correlation between hospital overall rating and (a) nurse-to-patient ratios and (b) process of care measures for acute myocardial infection, heart failure, pneumonia, and surgical processes. Other studies have noted that patients value communication as reflective of their overall experience and the technical quality of care.15,18,21-23 These results suggest HACs and patient satisfaction are associated and related metrics. There also have been numerous reports with contradictory results.15,16 For example, Day et al13 reported no significant difference in HCAHPS scores among a single, hospital-based cohort of patients with and without HACs. Additionally, Lyu et al14 found no correlation between HCAHPS global score and surgical process of care measures. Fenton et al21 reported that the most satisfied patients had more inpatient hospitalizations, higher total health expenditures, and a 26% greater mortality risk than less satisfied patients. Deyo22 suggested that physicians’ decisions may be influenced by what will satisfy patients and may result in lower quality of care. Taken together, these results suggest measuring patient satisfaction is a poor indicator of quality of care.
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Stein et al The present report investigated a trend between patient experience and quality of care using publicly available data from 4605 hospitals in 2011. It focused on 4 HCAHPS questions to gauge patient experience and rates of 8 HACs and 5 PSIs to measure quality of care. Those chosen were overall hospital rating, willingness to recommend the hospital, communication with doctors, and responsiveness of staff, as others have demonstrated that these are representative of the HCAHPS questionnaire and are associated with technical quality of care.8,10,15,17,18,22 Most of the relationships investigated demonstrated an association between higher patient satisfaction scores and better quality of medical care. Of the 52 possible relationships studied, 29 (56%) demonstrated a significant trend (P < .05). Of these, 23 (79%) demonstrated an inverse trend (higher HCAHPS scores and lower HACs or PSIs), as was hypothesized. Hospitals with higher rates of pressure ulcers, VCAIs, manifestation of poor glycemic control, postoperative death related to treatable conditions, VTEs, and wound dehiscence had lower HCAHPS scores for least 2 questions. Two metrics had mixed results: CAUTI and iatrogenic pneumothorax demonstrated an inverse correlation with communication and timely help, but an unexpected positive trend in overall rating metrics. Only the rate of falls and trauma demonstrated no trends with patient satisfaction (Table 3). One goal of this report is to establish methods to improve patients’ experience. The inverse associations between rates of pressure ulcers, VCAI, manifestation of poor glycemic control, treatable postoperative mortality, VTE, wound dehiscence, and HCAHPS responses suggests that minimizing the rates of these indicators could improve the perception of care. The study authors also noted unexpected positive associations between quality of care and patients’ experience. However, the low rates of occurrence are considered to be limitations of those analyses. Still, Shahian et al23 reported similar associations when they noted that academic hospitals have lower HCAHPS scores as well as lower rates of hospital-acquired infections and pressure ulcers when compared with nonacademic hospitals. The relationship between higher rates of HACs and PSIs and higher HCAHPS scores could be attributed to the response to adverse events, termed “service recovery.” This method of interacting with consumers, borrowed from the business world, is rooted in addressing the negative experience, apologizing to the patient, and making extra efforts to ensure the patient is satisfied with the remainder of their care. That all positive associations were between overall perception measures and quality measures supports the notion that service recovery can be an effective model to ensure patients remain satisfied despite the occurrence of complications.
This study has several limitations. Overall hospital data were used to compare HACs and HCAHPs, but this limited the examination of individual patient responses. This may introduce selection bias if those without HACs or PSIs rate their experience extremely high, skewing the experience rating. Furthermore, HACs data capture only Medicare beneficiaries, while HCAHPS surveys include Medicare and non-Medicare beneficiaries. Additionally, confounders may be present because rates of HACs, unlike HCAHPS scores and PSIs, are not corrected for patient differences and hospital demographics. Last, because this is a retrospective review, the study authors are not able to establish causation between technical quality of care indicators and how patients perceive their hospital care. Future studies could build on the Calikoglu et al24 method of comparing HACs before and after implementation of nonpayment policy. Such an investigation could compare HACs before and after the inclusion of HCAHPS scores into the pay-for-performance programs. This could further support the use of patient experience metrics to improve health care value. Optimizing quality of care while measuring patients’ experience is an essential component of increasing health care value. Health care policy changes have already initiated programs that incentivize better quality of care and improved patient experiences, and there is little doubt that future health care policy will include these metrics in payment calculating schematics. This report of 4605 hospitals demonstrated that at least some quality of care indicators, many of which are applicable to the field of orthopedic surgery, are associated with how patients rate their hospital care. The associations reported herein represent advances in our understanding of how patients perceive the care they receive and will aid in the quest to provide patients with the highest level of care. Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
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