Published Online: January 25, 2011
William Boulding, PhD; Seth W. Glickman, MD, MBA; Matthew P. Manary, MSE; Kevin A. Schulman, MD; and Richard Staelin, PhD
Objectives: To determine whether hospitals where patients report higher overall satisfaction with their interactions among the hospital and staff and specifically their experience with the discharge process are more likely to have lower 30-day readmission rates after adjustment for hospital clinical performance.
Study Design: Among patients 18 years or older, an observational analysis was conducted using Hospital Compare data on clinical performance, patient satisfaction, and 30-day risk-standardized readmission rates for acute myocardial infarction, heart failure, and pneumonia for the period July 2005 through June 2008.
Methods: A hospital-level multivariable logistic regression analysis was performed for each of 3 clinical conditions to determine the relationship between patient-reported measures of their satisfaction with the hospital stay and staff and the discharge process and 30-day readmission rates, while controlling for clinical performance.
Results: In samples ranging from 1798 hospitals for acute myocardial infarction to 2562 hospitals for pneumonia, higher hospital-level patient satisfaction scores (overall and for discharge planning) were independently associated with lower 30-day readmission rates for acute myocardial infarction (odds ratio [OR] for readmission per interquartile improvement in hospital score, 0.97; 95% confidence interval [CI], 0.94-0.99), heart failure (OR, 0.96; 95% CI, 0.95-0.97), and pneumonia (OR, 0.97; 95% CI, 0.96-0.99). These improvements were between 1.6 and 4.9 times higher than those for the 3 clinical performance measures.
Conclusions: Higher overall patient satisfaction and satisfaction with discharge planning are associated with lower 30-day risk-standardized hospital readmission rates after adjusting for clinical quality. This finding suggests that patient-centered information can have an important role in the evaluation and management of hospital performance.
(Am J Manag Care. 2011;17(1):41-48)
Hospitals routinely use patient satisfaction surveys to assess the quality of care, although it remains unclear whether patient satisfaction data provide valid information about the medically related quality of hospital care.
Higher patient satisfaction with inpatient care and discharge planning is associated with lower 30-day readmission rates even after controlling for hospital adherence to evidence-based practice guidelines.
Patient-centered information can have an important role in the evaluation and management of hospital performance.
Hospital readmission rates are an important measure of the quality and costs of healthcare. Recent estimates suggest that almost one-fifth of Medicare beneficiaries discharged from a hospital are readmitted within 30 days, resulting in an estimated annual cost of unplanned readmissions of $17.4 billion.1,2 Although factors outside of the hospital contribute to unplanned readmissions,3,4 the fact that one-quarter of readmissions occur within 30 days of discharge suggests that there is room for improvement in the quality of inpatient care and discharge planning. Therefore, understanding the factors associated with hospital readmission has important implications for managing the provision of healthcare.
Until recently, the measurement of hospital quality has focused on how often the hospital delivers evidence-based clinical care. In June 2009, Medicare released the Hospital Care Quality Information from the Consumer Perspective (HCAHPS), a large database of information on patients’ perceptions of their hospital experiences and, in particular, their interactions with the hospital’s staff.5,6 It is unknown whether patients can “sense” from these interactions and experiences if they are getting highquality care even if they do not have deep medical knowledge about the proper courses of treatment. Even if they can form beliefs about the appropriateness of the treatments, it is unclear whether their responses to the HCAHPS capture these beliefs. It is also unclear whether these patient satisfaction data provide information about the overall quality of inpatient care beyond that obtained from commonly accepted clinical performance measures that also are used to assess the quality of a hospital’s care.
We sought to address these questions by studying hospital-level patient perceptions of their inpatient care and discharge planning at approximately 2500 hospitals in the United States for which we also have clinical performance measures and 30-day readmission rates for the following 3 clinical areas within the hospital: acute myocardial infarction, heart failure, and pneumonia. Specifically, we sought to determine whether hospitals where patients reported higher satisfaction with inpatient care and discharge planning were more likely to have lower 30-day readmission rates for these 3 clinical areas after adjustment for hospital clinical performance.
Our goal was to obtain measures of each hospital’s quality of care, as well as good indicators of the hospital’s objective clinical performance and patients’ perceptions of this performance. To do this, we used 2 major data sources.
The first major data source was the June 2009 release of the Hospital Compare database by the US Department of Health and Human Services.7 It contained a 3-year aggregated mean of a hospital’s 30-day risk-standardized readmission rates for 3 clinical areas (acute myocardial infarction, heart failure, and pneumonia) for the period July 2005 through June 2008. We also used this data source to obtain the annualclinical process-of-care performance for the same 3 clinical areas for the same 3 years. We then combined these 3 years of data to form a 3-year mean for the same period for each hospital for each of the 3 clinical areas. We used the readmission rates to measure the hospital’s quality of care and the clinical process-of-care data to measure the hospital’s objective clinical performance.
The second major data source was the HCAHPS patient satisfaction survey for the period July 2007 through June 2008. We used this data source to measure patients’ perceptions of a hospital’s clinical performance. Patients included in the satisfaction survey were 18 years or older, stayed at least 1 night in the hospital, and had a nonpsychiatric diagnosis at discharge. The surveys covered admissions for medical and surgical care and were initiated between 48 hours and 42 days after discharge. Hospital-level means were adjusted by the Centers for Medicare & Medicaid Services to account for factors known to affect patient responses. These factors include the mode of survey delivery (eg, mail vs phone), patient mix (eg, self-reported health and time between discharge and survey completion), and nonresponse percentages.
These data were supplemented by data on hospital structural characteristics. These were obtained from the database of the American Hospital Association.
It should be noted that these data sources do not allow us to link individual patients to the objective clinical performance or their readmission. Instead, these should be viewed as fallible measures of a hospital’s objective quality of care (ie, readmission rates) and the performance of in-hospital care provided to the hospital’s patients in general (ie, process-of-care and patient satisfaction scores).
We identified 4469 hospitals that reported 30-day risk-standardized readmission rates, 4488 hospitals that collected clinical performance measures, 3746 hospitals that collected HCAHPS surveys, and 6338 hospitals in the American Hospital Association database. Using the hospital as the unit of analysis for a given clinical area (eg, acute myocardial infarction, heart failure, pneumonia), we included all hospitals that had complete information for readmission rates, clinical performance measures, patient satisfaction scores, and American Hospital Association hospital structural characteristics. This process resulted in a sample of 1798 hospitals for acute myocardial infarction, 2561 hospitals for heart failure, and 2562 hospitals for pneumonia. The clinical performance data were based on 430,982 patients with acute myocardial infarction (mean, 240 per hospital); 1,029,578 patients with heart failure (mean, 402 per hospital); and 912,522 patients with pneumonia (mean, 356 per hospital).
There were 18 clinical performance measures in the 3 clinical categories (7 for acute myocardial infarction, 4 for heart failure, and 7 for pneumonia). Using the composite scoring method by the Centers for Medicare & Medicaid Services, we calculated hospital-level scores for each clinical category by dividing the number of times the procedures in a category were followed by the total number of eligible times associated with those measures.8,9
The HCAHPS database contains patient assessments of 10 dimensions of patient care derived from 18 of 22 individual survey questions. Most of the 10 dimensions of patient care were highly correlated. Based on prior work on customer satisfaction, we used 2 hospital-specific questions (“How do you rate the hospital overall?” and “Would you recommend the hospital to friends and family?”) to assess patients’ overall satisfaction with their hospital experience.10-12 We postulated that this overall patient satisfaction measure would be an excellent (albeit fallible) measure of patients’ observations of the performance of the hospital’s staff and would be an important predictor of readmission rates. Note that such patient observations do not require literacy in medicine but only an ability to know if the service provider “cares” and shows some concern. We also postulated that patient satisfaction with a hospital’s discharge process would be a good indicator of the hospital’s adherence to good discharge policies and predict readmission rates for each of the clinical areas. We captured these perceptions using the following 2 questions from the HCAHPS: “During this hospital stay, did doctors, nurses or other hospital staff talk with you about whether you would have the help you needed when you left the hospital?” and “During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?”
We transformed the HCAHPS information on each hospital into overall satisfaction and discharge satisfaction scores as follows. The HCAHPS database reported the total number of patients surveyed and the percentage of patients who responded to the different levels of the particular question. For the 2 overall satisfaction questions, the database provided 3 levels (ie, a satisfaction rating of 1-6 [low], 7-8 [medium], or 9-10 [high]). We multiplied the percentage of patients who responded to a given level by the numerical values of 0, 0.5, and 1 for low, medium, and high, respectively, to obtain scores between 0 and 1, where 1 indicates that all patients gave a high response and 0 indicates that all patients gave a low response to the particular question. The hospital-level overall patient satisfaction score is the mean of these 2 numerical values. For the 2 discharge questions, we converted the reported percentages into numerical values by assigning the percentage of “no” responses the value of 0 and the percentage of “yes” responses the value of 1 and averaging the 2 questions across respondents. Note that the Hospital Compare documentation does not provide patient satisfaction information for specific diagnosis related groups but instead reflects patient responses for several other units, as well as the 3 units we analyze. Therefore, the patient satisfaction scores used for analyzing readmission rates for acute myocardial infarction, heart failure, and pneumonia are the same for a given hospital.
PDF is available on the last page.