The number of inpatient consultations is negatively correlated with patient satisfaction in patients with prolonged hospital stays

Drivers of Inpatient Subspecialty Consultation Among Pediatric Hospitalists: A Qualitative Study

BACKGROUND AND OBJECTIVE

Inpatient subspecialty consultation is often medically necessary but in some cases may represent overuse. While pediatric consultation patterns have been described using observational data, qualitative methods may generate knowledge about contextual determinants of consultation behavior. Our objective was to understand how pediatric hospitalists make decisions about subspecialty consultation.

METHODS

This qualitative study took place at a large academic children's hospital as part of an explanatory sequential mixed-methods design (QUAN → qual). We conducted semistructured interviews with a purposive sample of previously identified high-consulting (top quartile) and low-consulting (bottom quartile) pediatric hospitalists. Interviews were conducted virtually, and audio recordings were transcribed. Two analysts coded transcripts using an integrated approach and established high interrater reliability (κ > 0.75). We organized findings using the Social Ecological Model.

RESULTS

Participants (n = 12) included high-(n = 6) and low-(n = 6) consulting hospitalists. Our respondents identified considerations including patient characteristics, confidence in their own competence and that of their team, and perceived helpfulness of consultants. Participants viewed consultation requests as being strongly influenced by a desire to maintain relationships with families. Specific to this context, the hospital's elite reputation was believed to influence families to expect consultations. Other considerations included medicolegal risk, clinical pathways, and availability of secure text messaging to facilitate informal "curbside" conversations with subspecialists.

CONCLUSIONS

Decision-making around pediatric subspecialty consultation is complex and influenced by factors unrelated to a patient's clinical need. Efforts to reduce low-value consultation must account for the social and organizational dynamics that promote consultation.

Factors influencing patient experience in hospital wards: a systematic review

BACKGROUND

Patient experience plays an essential role in improving clinical effectiveness and patient safety. It's important to identify factors influencing patient experience and to improve quality of healthcare.

OBJECTIVE

To identify factors that influence patient experience in hospital wards.

METHODS

We conducted a systematic review including six databases; they were PubMed, CINAHL, Embase, PsycInfo, ProQuest, and Cochrane. Studies were included if they met the inclusion criteria. The JBI checklist was used to perform quality appraisal. We used 5 domains of the ecological model to organize and synthesize our findings to comprehensively understand the multi-level factors influencing the issue.

RESULT

A total of 138 studies were included, and 164 factors were identified. These factors were integrated into 6 domains. All domains but one (survey-related factors) could be mapped onto the attributes of the ecological framework: intrapersonal, interpersonal, institutional, community, and public policy level factors. All factors had mixed effect on patient experience. The intrapersonal level refers to individual characteristics of patients. The interpersonal level refers to interactions between patients and healthcare providers, such as the caring time spent by a nurse. The institutional level refers to organizational characteristics, rules and regulations for operations, such as hospital size and accreditation. The community level refers to relationships among organizations, institutions, and informational networks within defined boundaries, such as a hospital located in a larger population area. Public policy level refers to local, state, national, and global laws and policies, including health insurance policies. The sixth domain, survey-related factors, was added to the framework and included factors such as survey response rate and survey response time.

CONCLUSION

The factors influencing patient experience are comprehensive, ranging from intrapersonal to public policy. Providers should adopt a holistic and integrated perspective to assess patient experience and develop context-specific interventions to improve the quality of care. PROSPERO REGISTRATION NUMBER CRD42023401066.

Does Practice Match Training? Consultation Practices in Surgical Critical Care

INTRODUCTION

Intensive care unit (ICU) patient and provider attributes may prompt specialty consultation. We sought to determine practice patterns of surgical critical care (SCC) physicians for ICU consultation.

METHODS

We surveyed American Association for the Surgery of Trauma members. Various diagnoses were listed under each of nine related specialties. Respondents were asked for which conditions they would consult a specialist. Conditions were cross-referenced with the SCC fellowship curriculum. Other perspectives on practice and consultation were queried.

RESULTS

314 physicians (18.6%) responded (68% male; 79% White; 96.2% surgical intensivist); 284 (16.8%) completed all questions. Percentage of clinical time practicing SCC was 26-50% in 57% and >50% in 14.5%. ICUs were closed (39%), open (25%), or hybrid (36%). Highest average confidence ratings (1 = least, 5 = most) for managing select conditions were ventilator, 4.64; palliative care, 4.51; infections, 4.44; organ donation, hemodynamics (tie), 4.31; lowest rating was myocardial ischemia, 3.85. Consults were more frequent for Cardiology, Hematology, and Neurology; less frequent for nephrology, palliative care, gastroenterology, infectious disease, and pulmonary; and low for curriculum topics (<25%) except for infectious diseases and palliative care. Attending staffing 24 h/day was associated with a lower mean number of topics for consultation (mean 24.03 versus 26.31, P = 0.015).

CONCLUSIONS

ICU consultation practices vary based on consultant specialty and patient diagnosis. Consultation is most common for specialty-specific diseases and specialist interventions, but uncommon for topics found in the SCC curriculum, suggesting that respondents' scope of practice closely matched their training.

Association of Models of Care for Kawasaki Disease With Utilization and Cardiac Outcomes

OBJECTIVES

Describe the prevalence of different care models for children with Kawasaki disease (KD) and evaluate utilization and cardiac outcomes by care model.

METHODS

Multicenter, retrospective cohort study of children aged 0 to 18 hospitalized with KD in US children's hospitals from 2017 to 2018. We classified hospital model of care via survey: hospitalist primary service with as-needed consultation (Model 1), hospitalist primary service with automatic consultation (Model 2), or subspecialist primary service (Model 3). Additional data sources included administrative data from the Pediatric Health Information System database supplemented by a 6-site chart review. Utilization outcomes included laboratory, medication and imaging usage, length of stay, and readmission rates. We measured the frequency of coronary artery aneurysms (CAAs) in the full cohort and new CAAs within 12 weeks in the 6-site chart review subset.

RESULTS

We included 2080 children from 44 children's hospitals; 21 hospitals (48%) identified as Model 1, 19 (43%) as Model 2, and 4 (9%) as Model 3. Model 1 institutions obtained more laboratory tests and had lower overall costs (P < .001), whereas echocardiogram (P < .001) and immune modulator use (P < .001) were more frequent in Model 3. Secondary outcomes, including length of stay, readmission rates, emergency department revisits, CAA frequency, receipt of anticoagulation, and postdischarge CAA development, did not differ among models.

CONCLUSIONS

Modest cost and utilization differences exist among different models of care for KD without significant differences in outcomes. Further research is needed to investigate primary service and consultation practices for KD to optimize health care value and outcomes.

Analysis of Patient Handoff Between Providers at a Tertiary Urban Medical Center

Introduction

Few studies have quantified the total number of attending and consulting physicians involved in inpatients’ care, and no other research quantifies the total number of all providers participating in inpatients’ care. The purpose of this study was to calculate the number of attending hand-offs, the attending encounter time, and the total number of providers participating in inpatients’ care for all admitted patients at a tertiary urban medical center.

Methods

The study design was an observational retrospective cohort. Subjects included pediatric and adult patients who were admitted to and discharged from Ascension Via Christi St. Francis (AVCSF) in Wichita, Kansas between November 1, 2019 and January 31, 2020. Data were abstracted from the Cerner Electronic Medical Record. Variables included: patient demographics, admitting diagnosis, diagnosis related group (DRG), admission service, and duration of inpatient stay. Provider variables abstracted included provider type and provider specialty. Categorical variables were presented as frequencies and percentages, while continuous variables were presented as means ± standard deviation.

Results

The sample included information from 200 patient charts. Patients’ ages ranged from 5 to 94 years, with a mean of 61 years. Approximately 52% were female and 74.9% were admitted to a surgical service. The length of all inpatients’ stays ranged from less than 1 day to 31 days, with a mean of 4 days. Seventy-six different DRGs were recorded. The most frequent attending specialties were hospital medicine, internal medicine, general surgery, and interventional cardiology. Consulting physicians had more patient encounters than any other healthcare provider. For all inpatients, an average of two attending physicians participated in care over the duration of their stay with a range of one to six attending physicians. There was an average of one hand-off between attending physicians. Patients had an average of five consulting physicians, two resident physicians, two physician assistants, and two nurse practitioners during a stay. There was an average of 10 total providers, with a range of one to 46 total providers participating in care.

Conclusions

Understanding the provider data surrounding an inpatient stay is a foundational step in assessing the quality of the provider-inpatient encounter and potential areas for improvement. In this study, the average number of attending physicians and handoffs was reasonable; however, the total number of providers involved in care was relatively high. Assessment of staffing and scheduling requirements by hospital administration could identify areas of improvement to reduce the potential for medical error caused by multiple providers being involved in patient care.

Predictors of a Top-Box Patient Experience: A Retrospective Observational Study of HCAHPS Data at a Safety Net Institution

Hospitals commonly seek to improve patient experience as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, yet there are limited data to guide improvement efforts. The HCAHPS survey was developed for interhospital comparisons, whereas its use in intrahospital comparisons has not been validated. We sought to better understand the validity of utilizing intrahospital score comparisons and to identify the factors that may predict top-box HCAHPS scores. We performed a retrospective observational cohort study at an academic urban safety-net hospital examining 4898 HCAHPS surveys completed by hospitalized patients. We found that while most Patient-Mix Adjustment factors for which HCAHPS scores are adjusted were associated with top-box scores on intrahospital comparisons, few additional variables were associated with top-box scores. Further, HCAHPS questions pertaining to nurse and doctor communication were highly correlated with overall hospital rating, suggesting that communication-related factors may influence a patient’s hospital experience more strongly than do administrative factors.

A multifaceted study of hospital variables and interventions to improve inpatient satisfaction in a multi-hospital system

Knowing the areas of service, actions, and parameters that can influence patient perception about a service provided can help hospital executives and healthcare workers to devise improvement plans, leading to higher patient satisfaction. To identify inpatient satisfaction determinants, assess their relationships with hospital variables, and improve patient satisfaction through interventions. We studied the inpatient population of an eight-hospital tertiary medical center in 2015. The satisfaction determinants were based on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey answers and included clinical and organizational variables. Interventions began at the end of 2016 included bedside care coordination rounds (BCCR), medications best practices alert (BPA), connect transitions post-discharge calls (CONNECT Transitions) and a framework for provider-patient interactions called AIDET (Acknowledge, Introduce, Duration, Explain, and Thank). Substantial impact upon patient satisfaction was observed after the introduction of these interventions. Three groups were identified: 1. high satisfaction, which correlated with race, surgery, and cancer care; 2. low satisfaction, correlated with elderly, emergency room, intensive care unit, chronic obstructive pulmonary disease, and vascular diseases; and 3. neutral, correlated with hospital-acquired complications, several diagnostic procedures, and medical care delay. Significant improvements in the 3 groups were achieved with interventions that optimize care provider interactions with patients and their families. Based on the HCAHPS-based analysis, we implemented new measures and programs for addressing coordination of care, improving patient safety, reducing the length of stay, and ultimately improving patient satisfaction.

The use of hospital consumer assessment of healthcare services and the Press Ganey medical practice surveys in guiding surgical patient care practices

Background

Patient satisfaction questionaries have become popular in the past decade after the institution of the Patient Care and Affordable Care Act of 2010. This study evaluated whether the Hospital Consumer Assessment of Healthcare Services (H-CAHPS) and Press Ganey scores improved after institutional changes to the rounding system.

Methods

In the summer of 2017, utilizing H-CAHPS and Press Ganey scores, we asked whether switching from mid-level rounding providers to resident physicians improved patient care. Pre- and post-intervention groups, each lasting four quarters, were divided into care provided by mid-level personnel versus residents. For these periods, H-CAHPS respondent data were compared by a Chi-squared test (P < 0.05), while Press Ganey responses were analyzed with an independent samples t-test (P < 0.05).

Results

Significant improvement was noted in patients answering "Definitely yes" in recommending our institution in both H-CAHPS and Press Ganey satisfaction surveys. Significant improvement regarding the speed of discharge, instructions for post-hospital care, and the overall rating of care given was observed in the Press Ganey responses alone.

Conclusion

Significant improvement in satisfaction was noted in the Press Ganey responses regarding the discharge process and speed of discharge. The quality of this last encounter likely contributed to+ the significant improvement observed in both the H-CAPHS and Press Ganey Scores for an overall hospital stay and the percentage of those definitely recommending our institution.

Association of Demographics and Hospital Stay Characteristics With Patient Experience in Hospitalized Pediatric Patients

There is limited research on patient experience in hospitalized pediatric patients. Our aim was to investigate the association of patient demographics and hospital stay characteristics with experience in a tertiary-care, freestanding children's hospital. We conducted a retrospective cross-sectional study of patient experience surveys. We designated the highest rating as "top-box" and examined data across 8 domains, including overall assessment (OA). A total of 4602 surveys were analyzed. Top-box percentages were lower for younger patients in 6 domains, including OA (0-<1 year old: 57.6%; 1-<4 years old: 61.3%; 4-<12 years old: 68.4%; ≥12 years old: 70.2%; P < .001), and were lower for patients with private insurance in 5 domains, including OA (private 63.2%, public 68.9%; P < .001). There was no association between other demographics (gender, race/ethnicity, primary language) and OA. Overall assessment was also not associated with length of stay (P = .071) and number of consulting services (P = .703). The most important domain predictor of OA was personal issues (odds ratio = 4.79), which assessed concern, sensitivity, and communication from staff. In conclusion, patient experience was associated with age and insurance status but not hospital stay characteristics.

Modeling the communication-satisfaction relationship in hospital patients

Objectives:

Although it has long been known that communication with medical professionals presents a strong relationship with patient satisfaction, research on this topic has been hindered by conceptual and methodological issues (e.g. single-item measures, inclusion of idiosyncratic patient characteristics, etc.). Using a more comprehensive and integrated approach, this study had two objectives: to document the multidimensional structure of the Picker Patient Experience–15, and to test a patient communication/satisfaction model that organizes its dimensions in a conceptually logical array of relationships. First, the factorial structure of the Picker Patient Experience–15 was hypothesized to comprise five dimensions: communication with patient, with family, addressing fears/concerns, preparation for discharge, and patient satisfaction. Second, the hypothesized model included positive relationships between all four communications dimensions, on the one hand, and patient satisfaction, on the other. Within communication dimensions, communication with patient was hypothesized to be the incipient factor for other dimensions, and thus to be positively associated with the other three forms of communication.

Methods:

This research is based on a single time point design, which relied on administrative and questionnaire data. The study was conducted at a large University Hospital in Switzerland. The sample included 54,686 patients who received inpatient treatment, excluding those who were cared for in the intensive and intermediate care units. Patients filled out, over a 5-year period, the Picker Patient Experience questionnaire (PPE-15) after discharge (overall response rate of 41%).

Results:

The proposed five-factor structure of the Picker Patient Experience–15 was successfully supported by the results of a confirmatory factor analysis. Moreover, the hypothesized network of associations between communication and satisfaction latent constructs was substantiated using structural equation modeling. With the exception of the association between preparation for discharge and patient satisfaction, the hypothesized model was fully corroborated.

Conclusion:

A more in-depth understanding of patient satisfaction can be achieved when it is studied as a multifaceted phenomenon.

Impact of Inpatient Consults by a Family Medicine Teaching Service

OBJECTIVES

Inpatient consult rates by family physicians significantly affect many aspects of medical care. Limited research has investigated the consultant rate by family medicine residents and their impact on length of stay (LOS) and direct cost. This study examines the inpatient consultant rate of family medicine residents.

METHODS

We conducted a retrospective electronic chart review of consults associated with hospitalizations on a family medicine teaching service at a large academic medical center during a 12-month period. The primary outcome was the consultant rate. Multivariate regressions were used to predict outcomes of LOS and direct costs while controlling for patient severity with the Charlson Comorbidity Index.

RESULTS

For hospitalized adults on a family medicine teaching service, almost 1 in 2 receives some type of consult (47%), with more than half of those (52%) to physician specialists as opposed to ancillary services. The top physician consults were to cardiology, infectious disease, and gastroenterology. LOS as well as cost significantly increased with any type of consult. After controlling for severity, consults to physician specialists (as opposed to ancillary services) had the greatest impact on LOS and cost.

CONCLUSIONS

Each consult placed for hospitalized adults on a family medicine teaching service resulted in an increase in LOS and direct cost, even after controlling for patient severity. Further analysis to ensure that appropriate referrals are being placed and that residents are receiving full-scope training is needed to ensure primary care graduates are prepared to care for a diverse and complex patient population.

Satisfaction with surgeon care as measured by the Surgery-CAHPS survey is not related to NSQIP outcomes

BACKGROUND

Patient satisfaction is a patient-centered outcome of particular interest. Previous work has suggested that global measures of satisfaction may not adequately evaluate surgical care, therefore the surgery-specific Consumer Assessment of Healthcare Providers and Systems survey was developed. It remains unclear how traditional outcome measures, such as morbidity, impact patient satisfaction. Our aim was to determine whether National Surgical Quality Improvement Program-defined complications impacted satisfaction with the surgeon as measured by a surgery-specific survey, the surgery-specific Consumer Assessment of Healthcare Providers and Systems survey.

METHODS

All patients undergoing a general surgical operation from June 2013-November 2013 were sent the surgery-specific Consumer Assessment of Healthcare Providers and Systems survey after discharge. Retrospective chart review was conducted using the National Surgical Quality Improvement Program variable definitions, and major complications were defined. Data were analyzed as a function of response to the overall surgeon-rating item, and those surgeons rated as the "best possible" or "topbox" were compared with those rated lower. Univariate and logistic regression were used to determine variable importance.

RESULTS

A total of 529 patients responded, and 71.5% (378/529) rated the surgeon as topbox. The overall National Surgical Quality Improvement Program complication rate was 14.2% (75/529), with 26.7% of those (20/75) being major complications. On univariate analysis, patients who rated their surgeon more highly were somewhat older (59 vs 54 years: P < .001), more often underwent elective surgery (81% vs 57%: P < .001), and had an increased rate of operation for malignancy (31% vs 17%). Neither the complication rate (total or major) nor the number of complications were associated with satisfaction scores.

CONCLUSIONS

When examined on a patient level with surgery-specific measures and outcomes, the presence of complications after an operation does not appear to be associated with overall patient satisfaction with surgeon care. This finding suggests that satisfaction may be an outcome distinct from traditional measures.

Relationship Between Patient Satisfaction And Physician Characteristics

BACKGROUND

Physician care influences patient satisfaction. Inherent physician attributes may also affect scores.

OBJECTIVE

To determine the relationship between physician characteristics and patient satisfaction regarding physician care and communication.

METHOD

Observational retrospective study. We examined patient satisfaction surveys from inpatient adults across 9 questions (HCAHPS: Courtesy, Listen, and Explain; Press Ganey: Time, Concern, Informed, Friendliness, Skill, Rating) in relation to physician gender, age, ethnicity, race, and specialty.

RESULTS

We analyzed 51 896 surveys on 914 physicians. In univariate analysis, males were rated significantly more often in the highest category (top box) compared to females on Informed and Skill, and whites were rated in the top box more often than nonwhites on all questions. In multivariate analysis, there were no significant associations between ratings and physician gender, ethnicity, and race. On all questions, the odds of being rated in the top box were highest for obstetricians, second highest for surgeons, and lowest for medicine providers. On the question of Skill, the odds of being rated in the top box were higher with increasing age.

CONCLUSION

Patient satisfaction regarding physicians is associated with physician specialty and age.

Parent-Provider Miscommunications in Hospitalized Children

BACKGROUND

Miscommunications lead to medical errors and suboptimal hospital experience. Parent-provider miscommunications are understudied.

OBJECTIVES

(1) Examine characteristics of parent-provider miscommunications about hospitalized children, (2) describe associations among parent-provider miscommunications, parent-reported errors, and hospital experience, and (3) compare parent and attending physician reports of parent-provider miscommunications.

METHODS

Prospective cohort study of 471 parents of 0- to 17-year-old medical inpatients in a pediatric hospital between May 1, 2013 and October 1, 2014. At discharge, parents reported parent-provider miscommunication and type (selecting all applicable responses), overall experience, and errors during hospitalization. During discharge billing, the attending physicians (n = 52) of a subset of patients (n = 217) also reported miscommunications, enabling comparison of parent and attending physician reports. We used logistic regression to examine characteristics of parent-reported miscommunications; McNemar's test to examine associations between miscommunications, errors, and top-box (eg, "excellent") experience; and generalized estimating equations to compare parent- and attending physician-reported miscommunication rates.

RESULTS

Parents completed 406 surveys (86.2% response rate). 15.3% of parents (n = 62) reported miscommunications. Parents of patients with nonpublic insurance (odds ratio: 1.99; 95% confidence interval: 1.03-3.85) and longer lengths of stay (odds ratio: 1.12; 95% confidence interval: 1.02-1.23) more commonly reported miscommunications. Parents reporting miscommunications were 5.3 times more likely to report errors and 78.6% less likely to report top-box overall experience (P < .001 for both). Among patients with both parent and attending physician surveys, 16.1% (n = 35) of parents and 3.7% (n = 8) of attending physicians reported miscommunications (P < .001). Both parents and attending physicians attributed miscommunications most often to family receipt of conflicting information.

CONCLUSIONS

Parent-provider miscommunications were associated with parent-reported errors and suboptimal hospital experience. Parents reported parent-provider miscommunications more often than attending physicians did.