William G. Lehrman

Development, Implementation, and Public Reporting of the HCAHPS Survey

The authors describe the history and development of the CAHPS Hospital Survey (also known as HCAHPS) and its associated protocols. The randomized mode experiment, vendor training, and “dry runs” that set the stage for initial public reporting are described. The rapid linkage of HCAHPS data to annual payment updates (“pay for reporting”) is noted, which in turn led to the participation of approximately 3,900 general acute care hospitals (about 90% of all such United States hospitals). The authors highlight the opportunities afforded by this publicly reported data on hospital inpatients’ experiences and perceptions of care. These data, reported on www.hospitalcompare.hhs. gov, facilitate the national comparison of patients’ perspectives of hospital care and can be used alone or in conjunction with other clinical and outcome measures. Potential benefits include increased transparency, improved consumer decision making, and increased incentives for the delivery of high-quality health care.

Effects of Survey Mode, Patient Mix, and Nonresponse on CAHPS® Hospital Survey Scores

OBJECTIVE To evaluate the need for survey mode adjustments to hospital care evaluations by discharged inpatients and develop the appropriate adjustments. DATA SOURCE A total of 7,555 respondents from a 2006 national random sample of 45 hospitals who completed the CAHPS Hospital (HCAHPS [Hospital Consumer Assessments of Healthcare Providers and Systems]) Survey. STUDY DESIGN/DATA COLLECTION/EXTRACTION METHODS We estimated mode effects in linear models that predicted each HCAHPS outcome from hospital-fixed effects and patient-mix adjustors. PRINCIPAL FINDINGS Patients randomized to the telephone and active interactive voice response (IVR) modes provided more positive evaluations than patients randomized to mail and mixed (mail with telephone follow-up) modes, with some effects equivalent to more than 30 percentile points in hospital rankings. Mode effects are consistent across hospitals and are generally larger than total patient-mix effects. Patient-mix adjustment accounts for any nonresponse bias that could have been addressed through weighting. CONCLUSIONS Valid comparisons of hospital performance require that reported hospital scores be adjusted for survey mode and patient mix.

Examining the Role of Patient Experience Surveys in Measuring Health Care Quality

Patient care experience surveys evaluate the degree to which care is patient-centered. This article reviews the literature on the association between patient experiences and other measures of health care quality. Research indicates that better patient care experiences are associated with higher levels of adherence to recommended prevention and treatment processes, better clinical outcomes, better patient safety within hospitals, and less health care utilization. Patient experience measures that are collected using psychometrically sound instruments, employing recommended sample sizes and adjustment procedures, and implemented according to standard protocols are intrinsically meaningful and are appropriate complements for clinical process and outcome measures in public reporting and pay-for-performance programs.

Characteristics of Hospitals Demonstrating Superior Performance in Patient Experience and Clinical Process Measures of Care

Prior research suggests hospital quality of care is multidimensional. In this study, the authors jointly examine patient experience of care and clinical care measures from 2,583 hospitals based on inpatients discharged in 2006 and 2007. The authors use multinomial logistic regression to identify key characteristics of hospitals that perform in the top quartile on both, either, and neither dimension of quality. Top performers on both quality measures tend to be small (<100 beds), large (>200 beds) and rural, located in the New England or West North Central Census divisions, and nonprofit. Top performers in patient experience only are most often small and rural, located in the East South Central division, and government owned. Top performers in clinical care only are most often medium to large and urban, located in the West North Central division, and non—government owned. These findings provide an overview of how these dimensions of quality vary across hospitals.

Racial/Ethnic Differences in Patients’ Perceptions of Inpatient Care Using the HCAHPS Survey:

Using HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems, also known as the CAHPS Hospital Survey) data from 2,684 hospitals, the authors compare the experiences of Hispanic, African American, Asian/Pacific Islander, American Indian/Alaska Native, and multiracial inpatients with those of non-Hispanic White inpatients to understand the roles of between- and within-hospital differences in patients’ perspectives of hospital care. The study finds that, on average, non-Hispanic White inpatients receive care at hospitals that provide better experiences for all patients than the hospitals more often used by minority patients. Within hospitals, patient experiences are more similar by race/ethnicity, though some disparities do exist, especially for Asians. This research suggests that targeting hospitals that serve predominantly minority patients, improving the access of minority patients to better hospitals, and targeting the experiences of Asians within hospitals may be promising means of reducing disparities in patient experience.

Do hospitals rank differently on HCAHPS for different patient subgroups

Prior research documents differences in patient-reported experiences by patient characteristics. Using nine measures of patient experience from 1,203,229 patients discharged in 2006-2007 from 2,684 acute and critical access hospitals, the authors find that adjusted hospital scores measure distinctions in quality for the average patient with high reliability. The authors also find that hospital “ranks” (the relative scores of hospitals for patients of a given type) vary substantially by patient health status and race/ ethnicity/language, and moderately by patient education and age (p < .05 for almost all measures). Quality improvement efforts should examine hospital performance with both sicker and healthier patients, because many hospitals that do well with one group (relative to other hospitals) may not do well with another. The experiences of American Indians/Alaska Natives should also receive particular attention. As HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) data accumulate, reports that drill down to hospital performance for patient subtypes (especially by health status) may be valuable.

Gender differences in patients' perceptions of inpatient care.

OBJECTIVE To examine gender differences in inpatient experiences and how they vary by dimensions of care and other patient characteristics. DATA SOURCE A total of 1,971,632 patients (medical and surgical service lines) discharged from 3,830 hospitals, July 2007-June 2008, and completing the HCAHPS survey. STUDY DESIGN We compare the experiences of male and female inpatients on 10 HCAHPS dimensions using multiple linear regression, adjusting for survey mode and patient mix. Additional models add additional patient characteristics and their interactions with patient gender. PRINCIPAL FINDINGS We find generally less positive experiences for women than men, especially for Communication about Medicines, Discharge Information, and Cleanliness. Gender differences are similar in magnitude to previously reported HCAHPS differences by race/ethnicity. The gender gap is generally larger for older patients and for patients with worse self-reported health status. Gender disparities are largest in for-profit hospitals. CONCLUSIONS Targeting the experiences of women may be a promising means of improving overall patient experience scores (because women comprise a majority of all inpatients); the experiences of older and sicker women, and those in for-profit hospitals, may merit additional examination.

A Randomized Experiment Investigating the Suitability of Speech-Enabled IVR and Web Modes for Publicly Reported Surveys of Patients’ Experience of Hospital Care

The HCAHPS Survey obtains hospital patients’ experiences using four modes: Mail Only, Phone Only, Mixed (mail/phone follow-up), and Touch-Tone (push-button) Interactive Voice Response with option to transfer to live interviewer (TT-IVR/Phone). A new randomized experiment examines two less expensive modes: Web/Mail (mail invitation to participate by Web or request a mail survey) and Speech-Enabled IVR (SE-IVR/Phone; speaking to a voice recognition system; optional transfer to an interviewer). Web/Mail had a 12% response rate (vs. 32% for Mail Only and 33% for SE-IVR/Phone); Web/Mail respondents were more educated and less often Black than Mail Only respondents. SE-IVR/Phone respondents (who usually switched to an interviewer) were less often older than 75 years, more often English-preferring, and reported better care than Mail Only respondents. Concerns regarding inconsistencies across implementations, low adherence to primary modes, or low response rate may limit the applicability of the SE-IVR/Phone and Web/Mail modes in HCAHPS and similar standardized environments.

CAHPS Surveys: Valid and Valuable Measures of Patient Experience

A commentary on “Patient-Satisfaction Surveys on a Scale of 0 to 10: Improving Health Care, or Leading It Astray?,” byAlexandra Junewicz and Stuart J. Youngner in the May-June 2015 issue..

A Special Contribution from the Centers for Medicare and Medicaid Services: Valuing Patient Experience While Addressing the Prescription Opioid Epidemic

Today, our country and health system face an extraordinary challenge regarding to the epidemic abuse of opioids. The system is burdened with persons seeking treatment for one of the largest substance use disorders of our time. We at the Centers for Medicare & Medicaid Services (CMS) are working closely with all our programs, other federal agencies, stakeholders, states, and the private sector to make sure we support efforts to educate physicians on the appropriate management of acute and chronic pain. As we respond to this crisis, we are also evaluating our policies toward pain management to ensure they don’t have the unintended consequence of encouraging the overprescription of opioid pain medications. Since 2008, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) has empowered patients with meaningful information to allow valid comparisons to be made across hospitals locally, regionally, and nationally. The HCAHPS survey is the first national, standardized, publicly reported survey of patients’ experience of hospital care. Data were first collected in 2006, with hospital scores publicly reported in 2008. In 2012, the HCAHPS survey became one component of the newly created Hospital Value-Based Purchasing (HVBP) program, which ties a portion of hospital payment to performance on quality and cost measures. The HCAHPS survey contains 32 questions and is administered to a random sample of adult inpatients between 48 hours and 6 weeks after discharge from short-term, acute care hospitals. Patients admitted in the medical, surgical, and maternity care service lines are eligible for the survey. The HCAHPS survey, its methodology, and the scores it produces are in the public