Impact of surgical approach and patient factors on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey scoring in gynecologic surgery

Identifying service quality gaps between patients and providers in a Native American outpatient clinic

Background

Native American communities in Montana reservations have reported low-level satisfaction in health services. This research explored if the services provided at a Blackfeet Indian Reservation outpatient clinic were designed to meet patient expectations.

Methods

Staff and patient interviews and surveys allowed service expectations to be assessed according to the clinic’s ability to meet those expectations. A total of 48 patients and ten staff members (83% of the staff at this clinic) participated in the study voluntarily.

Results

We found a disconnect between what patients anticipate for care and what staff think they are anticipating. We also found a discontent between what staff believes patients need versus what the patients feel is needed.

Conclusions

These gaps combine to increase the breach between patient expectations and perceptions of their healthcare services. With better insight that captures what patients are looking for from a service, the potential to meet those needs increases, and patients feel that their voice is respected and valued.

Hidden consequences of patient satisfaction: A survey of pediatric surgeons

BACKGROUND

Patient satisfaction surveys are increasingly utilized to assess patients' perceptions of their health care. Recently, these scores have been linked to payment, potentially incentivizing practices to meet certain metrics. We hypothesize that increasing pressures to receive positive reviews have led physicians to alter the delivery of their care to accommodate patient expectations over standards of care.

METHODS

An 11-question REDCap™ survey was developed and emailed anonymously to all sixty-two surgeons across all surgical subspecialties at our children's hospital. Multiple-choice and open-ended questions were included. A modified Delphi method was used to acquire general consensus.

RESULTS

Survey response rate for analysis was 41/62 (66%). 23 (56%) stated that they have changed their clinical practice patterns due to concerns regarding patient dissatisfaction. Examples of such changes included: requesting imaging tests or laboratory studies, performing invasive procedures, referring for second opinions, and prescribing medications. Only 2% felt that these interventions led to any significant change in outcome of a patient's condition. Several respondents expressed concerns that factors outside their control (scheduling, parking, wait times) contributed to patient dissatisfaction and affected providers' ratings, while others expressed concerns about inherent biases driving survey participants.

CONCLUSIONS

As a result of patient satisfaction surveys, a significant number of surgeons reported altering their clinical practice beyond standard care to meet patient expectations. Some of these modifications included performing unnecessary interventions. Reliance on these surveys may be at odds with reducing health care costs and avoiding physician burnout. These and other unintended consequences of patient satisfaction surveys warrant further study before they are widely accepted as appropriate quality metrics.

LEVEL OF EVIDENCE

Level IV, questionnaire.

CMS Hospital Compare System of Star Ratings and Surgical Outcomes Among Patients Undergoing Surgery for Cancer: Do the Ratings Matter?

BACKGROUND

The Centers for Medicare and Medicaid Services (CMS) Hospital Compare star rating system has been proposed as a means to assess hospital quality performance. The current study aimed to investigate outcomes and payments among patients undergoing surgery for colorectal, lung, esophageal, pancreatic, and liver cancer across hospital star rating groups.

METHODS

The Medicare Standard Analytic Files (SAF) from 2013 to 2015 were used to derive the analytic cohort. The association of star ratings to perioperative outcomes and expenditures was examined.

RESULTS

Among 119,854 patients, the majority underwent surgery at a 3-star (n = 34,901, 29.1%) or 4-star (n = 30,492, 25.4%) hospital. Only 12.2% (n = 14,732) were treated at a 5-star hospital. Across all procedures examined, patients who underwent surgery at a 1-star hospital had greater odds of death within 90 days than patients who had surgery at a 5-star hospital (colorectal, 1.41 [95% confidence interval {CI}, 1.25-1.60]; lung, 1.97 [95% CI 1.56-2.48]; esophagectomy, 1.83 [95% CI 0.81-4.16]; pancreatectomy, 1.70 [95% CI 1.20-2.41]; hepatectomy, 1.63 [95% CI 0.96-2.77]). A similar trend was noted for failure to rescue (FTR), with the greatest odds of FTR associated with 1-star hospitals. The median expenditure associated with an abdominal operation was $1661 more at a 1-star hospital than at a 5-star hospital (1-star: $17,399 vs 5-star: $15,738). A similar trend was noted for thoracic operations.

CONCLUSION

The risk of FTR, 90-day mortality, and increased hospital expenditure were all higher at a 1-star hospital. Further research is needed to investigate barriers to care at 5-star-rated hospitals and to target specific interventions to improve outcomes at 1-star hospitals.

Impact of length of stay on HCAHPS scores following lumbar spine surgery

OBJECTIVE

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys, completed by patients following an inpatient stay, are utilized to assess patient satisfaction and quality of the patient experience. HCAHPS results directly impact hospital and provider reimbursements. While recent work has demonstrated that pre- and postoperative factors can affect HCAHPS results following lumbar spine surgery, little is known about how these results are influenced by hospital length of stay (LOS). Here, the authors examined HCAHPS results in patients with LOSs greater or less than expected following lumbar spine surgery to determine whether LOS influences survey scores after these procedures.

METHODS

The authors conducted a retrospective review of HCAHPS surveys, patient demographics, and outcomes following lumbar spine surgery at a single institution. A total of 391 patients who had undergone lumbar spine surgery and had completed an HCAHPS survey in the period between 2013 and 2015 were included in this analysis. Patients were divided into those with a hospital LOS equal to or less than the expected (LTE-LOS) and those with a hospital LOS longer than expected (GTE-LOS). Expected LOS was based on the University HealthSystem Consortium benchmarks. Nineteen questions from the HCAHPS survey were examined in relation to patient LOS. The primary outcome measure was a comparison of "top-box" ("9-10" or "always or usually") versus "low-box" ("1-8" and "somewhat or never") scores on the HCAHPS questions. Secondary outcomes of interest were whether the comorbid conditions of cancer, chronic renal failure, diabetes, coronary artery disease, hypertension, stroke, or depression occurred differently with respect to LOS. Statistical analysis was performed using Fisher's exact test for the 2 × 2 contingency tables and the chi-square test for categorical variables.

RESULTS

Two hundred fifty-seven patients had an LTE-LOS, whereas 134 patients had a GTE-LOS. The only statistically significant difference in preoperative characteristics between the patient groups was hypertension, which correlated to a shorter LOS. A GTE-LOS was associated with a decreased likelihood of a top-box score for the HCAHPS survey items on doctor listening and pain control.

CONCLUSIONS

Here, the authors report a decreased likelihood of top-box responses for some HCAHPS questions following lumbar spine surgery if LOS is prolonged. This study highlights the need to further examine the factors impacting LOS, identify patients at risk for long hospital stays, and improve mechanisms to increase the quality and efficiency of care delivered to this patient population.

Patient Satisfaction After Lung Cancer Surgery: Do Clinical Outcomes Affect Hospital Consumer Assessment of Health Care Providers and Systems Scores?

BACKGROUND

Little is known about patients' hospital experience and satisfaction after lung cancer surgery. We sought to determine how length of hospital stay (LOS) and postoperative complications affect hospital consumer assessment of health care providers and systems (HCAHPS) scores.

METHODS

Patients undergoing lung resection for cancer at a single academic cancer center between years 2014 and 2018 were analyzed. Clinical data were derived from The Society of Thoracic Surgeons institutional database and supplemented with HCAHPS survey data. Endpoints were "top-box" satisfaction scores and domain-specific scores for physicians and nurses communication.

RESULTS

In total, 181 of 478 patients (38%) who underwent pulmonary resection for lung cancer completed HCAHPS surveys. Median age was 65 years, and most patients underwent lobectomy (94%). The top-box rating for the overall hospital experience, physician communication, and nurse communication were 92%, 84%, and 69%, respectively. Overall and major complication rates were 43% and 3%, and were not associated with top-box HCAHPS scores. Increasing length of stay was associated with worse satisfaction with provider communication. Adjusted for patient factors, increasing length of stay was associated with worse patient satisfaction in the domains of communication with physicians and nurses. Patients with length of stay more than 6 days were less likely to endorse that doctors gave understandable explanations (odds ratio 0.15, 95% confidence interval, 0.04 to 0.56) and that nurses listened carefully (odds ratio 0.11, 95% confidence interval, 0.06 to 0.69).

CONCLUSIONS

Overall HCAHPS satisfaction scores after lung resection for cancer were high and were negatively associated with increasing length of stay. Patient satisfaction may be affected more by the perception of effective communication during prolonged hospitalizations than by complications.

Patient-reported experience after outpatient breast surgery

BACKGROUND

Given the growing emphasis on patient-centered care, we determined contributory factors to a positive experience among patients undergoing outpatient breast procedures.

METHODS

We retrospectively identified patients ≥18 years-old who underwent a breast operation 7/2015-12/2016 and completed a survey within two weeks. Univariate analyses evaluated associations of factors with top survey composite measures. Key driver analysis identified top-priority survey factors for improving the overall assessment measure.

RESULTS

Of 270 patients, patients who gave a top surgeon score were older (mean 62.5 vs 58.6 years, p = 0.048), more likely to report a pain score of 0 before discharge (87% vs 68%, p < 0.01), and were 30.8 times more likely to give a top rating overall (p < 0.01) than those who gave a lower surgeon score. Key driver analysis identified personal issues as the main target for improvement.

CONCLUSION

To achieve top outpatient ratings, providers should focus on personal issues, including pain control, especially in younger patients. Surgeons should consider focusing on involving the patient in treatment decisions and emphasizing pain control and overall needs to improve the patient experience.