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The American Journal of Managed Care January 2011
Hypertension Treatment and Control Within an Independent Nurse Practitioner Setting
Wendy L. Wright, MS; Joan E. Romboli, MSN; Margaret A. DiTulio, MS, MBA; Jenifer Wogen, MS; and Daniel A. Belletti, MA
Relationship Between Short-Acting β-Adrenergic Agonist Use and Healthcare Costs
Harris S. Silver, MD; Christopher M. Blanchette, PhD; Shital Kamble, PhD; Hans Petersen, MS; Matthew A. Letter, BS; David Meddis, PhD; and Benjamin Gutierrez, PhD
Healthcare Costs and Nonadherence Among Chronic Opioid Users
Harry L. Leider, MD, MBA; Jatinder Dhaliwal, MBA; Elizabeth J. Davis, PhD; Mahesh Kulakodlu, MS; and Ami R. Buikema, MPH
A System-Based Intervention to Improve Colorectal Cancer Screening Uptake
Richard M. Hoffman, MD, MPH; Susan R. Steel, RN, MSN; Ellen F. T. Yee, MD; Larry Massie, MD; Ronald M. Schrader, PhD; Maurice L. Moffett, PhD; and Glen H. Murata, MD
Currently Reading
Relationship Between Patient Satisfaction With Inpatient Care and Hospital Readmission Within 30 Days
William Boulding, PhD; Seth W. Glickman, MD, MBA; Matthew P. Manary, MSE; Kevin A. Schulman, MD; and Richard Staelin, PhD
Health Plan Resource Use Bringing Us Closer to Value-Based Decisions
Sally Elizabeth Turbyville, MA, MS; Meredith B. Rosenthal, PhD; L. Gregory Pawlson, MD; and Sarah Hudson Scholle, DrPH
Telephone-Based Disease Management: Why It Does Not Save Money
Brenda R. Motheral, PhD
Economic Model for Emergency Use Authorization of Intravenous Peramivir
Bruce Y. Lee, MD, MBA; Julie H. Y. Tai, MD; Rachel R. Bailey, MPH; Sarah M. McGlone, MPH; Ann E. Wiringa, MPH; Shanta M. Zimmer, MD; Kenneth J. Smith, MD, MS; and Richard K. Zimmerman, MD, MPH
High-Deductible Health Plans and Costs and Utilization of Maternity Care
Katy Backes Kozhimannil, PhD, MPA; Haiden A. Huskamp, PhD; Amy Johnson Graves, MPH; Stephen B. Soumerai, ScD; Dennis Ross-Degnan, ScD; and J. Frank Wharam, MB, BCh, MPH
High-Deductible Health Plans and Costs and Utilization of Maternity Care
Katy Backes Kozhimannil, PhD, MPA; Haiden A. Huskamp, PhD; Amy Johnson Graves, MPH; Stephen B. Soumerai, ScD; Dennis Ross-Degnan, ScD; and J. Frank Wharam, MB, BCh, MPH
Telephone-Based Disease Management: Why It Does Not Save Money
Brenda R. Motheral, PhD
Economic Model for Emergency Use Authorization of Intravenous Peramivir
Bruce Y. Lee, MD, MBA; Julie H. Y. Tai, MD; Rachel R. Bailey, MPH; Sarah M. McGlone, MPH; Ann E. Wiringa, MPH; Shanta M. Zimmer, MD; Kenneth J. Smith, MD, MS; and Richard K. Zimmerman, MD, MPH

Relationship Between Patient Satisfaction With Inpatient Care and Hospital Readmission Within 30 Days

William Boulding, PhD; Seth W. Glickman, MD, MBA; Matthew P. Manary, MSE; Kevin A. Schulman, MD; and Richard Staelin, PhD

Higher overall patient satisfaction with inpatient care and discharge planning is associated with lower 30-day readmission rates after adjusting for clinical quality.

To help inform the policy implications of the results, we performed sensitivity analyses to determine the change in predicted risk-standardized 30-day readmission rates associated with a change in hospital score from the 25th percentile to the 75th percentile for the overall patient satisfaction score and for the patient satisfaction with discharge planning score, while keeping the hospital-level clinical composite score fixed. Conversely, we also examined the effect of the same interquartile change in hospital-level clinical composite score, while keeping the patient satisfaction measures fixed.

Finally, we calculated pairwise Pearson product moment correlation coefficients between the overall patient satisfaction score and the 8 other HCAHPS-reported dimensions of quality. This was to assess which dimensions were most associated with the patients’ overall satisfaction with the hospital’s quality of care.

We used JMP version 7.0.2 (SAS Institute Inc, Cary, North Carolina) for all statistical analyses. P <.05 was considered statistically significant.

RESULTS

Table 1 gives the characteristics of the study hospitals. Although hospitals in the sample tended to be larger and better resourced than hospitals in the total sample of American   Hospital Association acute care hospitals, the 3 samples represent a broad cross-section of US hospitals. Table 2 gives the distributions of the variables of interest, including the scores for overall patient satisfaction and patient satisfaction with discharge planning, the clinical composite score, and 30-day risk-standardized readmission rates. There was considerable variability in patient-reported measures and clinical measures across hospitals. Note that the mean 30-day risk-standardized readmission rates are approximately 20% for all 3 clinical areas.

Table 3 gives the correlations among the variables. The 2 hospital-level patient-reported measures were not highly correlated with the hospitals’ clinical performance measures.  Overall patient satisfaction and patient satisfaction with discharge planning were negatively and significantly correlated with higher 30-day risk-standardized readmission rates for all 3 clinical conditions. In addition, all 3 clinical composite scores were negatively and significantly correlated with higher 30-day risk-standardized readmission rates, although these correlations are smaller than those associated with the patient satisfaction scores.

Table 4 gives the results of the multivariable logistic regression analyses for the variables of interest. All 3 clinical performance measures were negatively associated with higher 30-day risk-standardized readmission rates, although the acute myocardial infarction and heart failure measures were not statistically significant (P = .16 and P = .06, respectively).  Higher overall patient satisfaction scores also were associated with lower 30-day risk-standardized readmission rates for all 3 clinical conditions. In this case, all 3 measures were highly statistically significant (P <.001). Finally, scores for patient satisfaction with discharge planning were associated with lower 30-day risk-standardized readmission rates for all 3 clinical areas and were statistically significant for heart failure and for pneumonia (P <.001 and P = .02, respectively).

The Figure shows that the odds of 30-day risk-standardized readmission were associated with interquartile improvements in hospitals’ patient total satisfaction scores (ie, overall patient satisfaction and patient satisfaction with discharge planning), while holding the clinical composite scores fixed, and vice versa. Interquartile improvements in patient total satisfaction scores were associated with significantly lower predicted 30-day risk-standardized readmission rates for acute myocardial infarction (odds ratio [OR] = 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). Also shown are the interquartile improvements in the 3 clinical performance measures. The improvements in 30-day risk-standardized readmission rates associated with interquartile improvements in the patient total satisfaction scores for heart failure, acute myocardial infarction, and pneumonia were 4.9, 2.2, and 1.6 times higher, respectively, than those associated with interquartile improvements in the same 3 clinical composite scores.

Table 5 gives the correlations of the overall patient satisfaction measure with each HCAHPS question category. Quality of communication by nurses had the strongest correlation with overall patient satisfaction, followed by several other measures that capture the patient’s interaction with the hospital staff. Patient satisfaction with discharge planning was seventh of the 8 questions in terms of correlation, indicating that it captured a different dimension from that captured by overall patient satisfaction. Also low in terms of correlation with overall patient satisfaction were the 2 questions concerning the hospital facilities (ie, cleanliness and noise level), again highlighting that overall patient satisfaction seems to be capturing the patients’ interactions with the hospital staff.

DISCUSSION

A substantial proportion of Medicare beneficiaries experience an unplanned hospital readmission within 30 days of discharge. In this study, we found that patients’ stated overall satisfaction score and their perception of the hospital’s discharge process were significantly and negatively correlated with the hospital’s 30-day readmission rates in the 3 clinical areas studied. Moreover, these 2 patient-related measures were more predictive than the objective clinical performance measures often used to assess the quality of hospital care.  Although the key drivers of hospital readmission are complex, our findings suggest that patients’ perspectives on inpatient care and discharge planning provide important insights  into hospital performance with respect to quality. Moreover, because the overall satisfaction score is most highly correlated with factors associated with the patients’ interaction with  the hospital staff, our findings are consistent with the observation by the Institute of Medicine that high-quality care is “patient centered” and responsive to patients’ preferences,  eeds, and values.14 More generally, given the association between these patient perceptions and better outcomes, our findings suggest that patient-centered information can be  used to assess the degree to which patients will be more likely to experience better health outcomes, at least as measured by hospital readmission rates.

Our findings support the use of patient-reported information to complement the more used and more objective clinical measures when assessing the quality of patient care for a given hospital. These patient-level measures not only are more pren dictive and offer insights into a different dimension of hospital activities than those obtained from clinical  performancemeasures alone, but they also seem to be clinically important in terms of providing a way to increase the quality of care. For example, using our model estimates we would predict that, if a hospital increased its patient total satisfaction score from the 25th percentile to the 75th percentile, this increase would be associated with decreases in 30-day readmission of 2.6% for acute myocardial infarction, 3.1% for heart failure, and 2.3% for pneumonia. If these reductions were obtained for our total sample of patients, this would have been associated with a reduction of more than 14,000 readmissions.

Our finding that good communication is associated with higher patient satisfaction is consistent with previous studies15-17 that found a positive association between effective provider–patient communication and health outcomes. It also is compatible with a recent study18 by our author group that used more fine-grained measures of patient satisfaction. Specifically, the study found that overall satisfaction was best predicted by patients’ perceptions of the skill and responsiveness of nurses and physicians, followed by issues concerning pain and communication with the staff about the patients’ concerns and emotional health. Again, the study found that factors associated with the physical plant had a much smaller influence on overall patient satisfaction. Consequently, patients seem to differentiate between the technical (ie, medical) and nontechnical (ie, aesthetic) aspects of  medical care. This leads us to believe that patient satisfaction is less about trying to make patients “happy” (eg, improving the food or the decor of the room) and is more about  increasing the quality of their interactions with hospital personnel, especially nurses and physicians.

Finally, we note that hospitals have devoted substantial resources to managing the current core set of clinical performance measures.19 Despite dramatic improvements in clinical process performance for heart failure, there has been virtually no reduction in these readmission rates or costs.20 Our findings confirm the lack of association between heart failure clinical measures and readmission rates.21,22 Conversely, we found that patient-reported measures were highly associated with 30-day readmission rates. Therefore, patient perceptions about hospital care in general and discharge planning specifically may provide an important new tool for measuring the quality of transitions of care.

Our study has several limitations. First, because our data are cross-sectional versus longitudinal, we were only able to make associational and not causal inferences about the relationship between patient satisfaction and hospital readmission. Moreover, patient-reported information is likely a surrogate measure for specific hospital characteristics and practices (eg, quality of staff and the use of clinical protocols) that determine quality of care. More research is needed to evaluate these links.

Second, it is also possible that some patients actually were readmitted before they filled out the survey. Such patients may have used their readmission as a signal of the quality of the hospital’s performance. In any case, a key insight of this study is that patients notice and can assess hospital experiences that otherwise go unmeasured.

Third, our analysis is limited in that it does not include factors such as patient compliance and access to primary care, which are known to influence the likelihood of hospital  readmission.23 Moreover, our study only focused on short-term (ie, 30 day) readmission rates and provides little information on long-term care.

Fourth, because our focus was on determining whether the Centers for Medicare & Medicaid Services measures of clinical performance and patient satisfaction are useful  indicators of the overall quality of hospital care, the unit of analysis was the hospital and not the patient. This approach precluded the possibility of patient-level analyses that might provide insight into specific dimensions of the patient experience and related outcomes.

 
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