Trends in HCAHPS Survey Scores, 2008-2019: A Quality Improvement Perspective.

BACKGROUND: HCAHPS' 2008 initial public reporting, 2012 inclusion in the Hospital Value-Based Purchasing Program (HVBP), and 2015 inclusion in Hospital Star Ratings were intended to improve patient experiences. OBJECTIVES: Characterize pre-COVID-19 (2008-2019) trends in hospital consumer assessment of healthcare providers and systems (HCAHPS) scores. RESEARCH DESIGN: Describe HCAHPS score trends overall, by phase: (1) initial public reporting period (2008-2013), (2) first 2 years of HVBP (2013-2015), and (3) initial HCAHPS Star Ratings reporting (2015-2019); and by hospital characteristics (HCAHPS decile, ownership, size, teaching affiliation, and urban/rural). SUBJECTS: A total of 3909 HCAHPS-participating US hospitals. MEASURES: HCAHPS summary score (HCAHPS-SS) and 9 measures. RESULTS: The mean 2007-2019 HCAHPS-SS improvement in most-positive-category ("top-box") responses was +5.2 percentage points/pp across all hospitals (where differences of 5pp, 3pp, and 1pp are "large," "medium," and "small"). Improvement rate was largest in phase 1 (+0.8/pp/year vs. +0.2pp/year and +0.1pp/year for phases 2 and 3, respectively). Improvement was largest for Overall Rating of Hospital (+8.5pp), Discharge Information (+7.3pp), and Nurse Communication (+6.5pp), smallest for Doctor Communication (+0.8pp). Some measures improved notably through phases 2 and 3 (Nurse Communication, Staff Responsiveness, Overall Rating of Hospital), but others slowed or reversed in Phase 3 (Communication about Medicines, Quietness). Bottom-decile hospitals improved more than other hospitals for all measures. CONCLUSIONS: All HCAHPS measures improved rapidly 2008-2013, especially among low-performing (bottom-decile) hospitals, narrowing the range of performance and improving scores overall. This initial improvement may reflect widespread, general quality improvement (QI) efforts in lower-performing hospitals. Subsequent slower improvement following the introduction of HVBP and Star Ratings may have reflected targeted, resource-intensive QI in higher-performing hospitals.

Interventions and Hospital Characteristics Associated With Patient Experience: An Update of the Evidence.

Patient experience is a key hospital quality measure. We review and characterize the literature on interventions, care and management processes, and structural characteristics associated with better inpatient experiences as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. Prior reviews identified several promising interventions. We update these previous efforts by including more recent peer-reviewed literature and expanding the review's scope to include observational studies of HCAHPS measures with process measures and structural characteristics. We used PubMed to identify U.S. English-language peer-reviewed articles published in 2017 to 2020 and focused on hospital patient experience. The two HCAHPS domains for which we found the fewest potential quality improvement interventions were Communication with Doctors and Quietness. We identified several modifiable processes that could be rigorously evaluated in the future, including electronic health record patient engagement functionality, care management processes, and nurse-to-patient ratios. We describe implications for future policy, practice, and research.

Survey Protocols, Response Rates, and Representation of Underserved Patients: A Randomized Clinical Trial.

Importance: Surveys often underrepresent certain patients, such as underserved patients. Methods that improve their response rates (RRs) would help patient surveys better represent their experiences and assess equity and equity-targeted quality improvement efforts. Objective: To estimate the effect of adding an initial web mode to existing Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey protocols and extending the fielding period on RR and representativeness of underserved patient groups. Design, Setting, and Participants: This randomized clinical trial included 36 001 patients discharged from 46 US hospitals from May through December 2021. Data analysis was performed from May 2022 to September 2023. Exposures: Patients were randomized to 1 of 6 survey protocols: 3 standard HCAHPS protocols (mail only, phone only, mail-phone) plus 3 web-enhanced protocols (web-mail, web-phone, web-mail-phone). Main Outcomes and Measures: RR and number of respondents per 100 survey attempts (yield) were calculated and compared for each of the 6 survey protocols, overall, and by patient age, service line, sex, and race and ethnicity. Results: A total of 34 335 patients (median age range, 55-59 years; 59.3% female individuals and 40.7% male individuals) were eligible and included in the study. Of the respondents, 6.9% were Asian American or Native Hawaiian or Other Pacific Islander, 0.7% were American Indian or Alaska Native, 11.5% were Black, 17.4% were Hispanic, 61.0% were White, and 2.6% were multiracial. Of the 6 protocols, RRs were highest in web-mail-phone (36.5%), intermediate for the 3 two-mode survey protocols (mail-phone, web-mail, web-phone, 30.3%-31.1%), and lowest for the 2 single-mode protocols (mail only, phone only, 22.1%-24.3%). Web-mail-phone resulted in the highest yield for 3 racial and ethnic groups (Black, Hispanic, and White patients) and second highest for another (multiracial patients). Otherwise, the highest or second highest yield was almost always a 2-mode protocol. Mail only was the lowest-yield protocol for Black, Hispanic, and multiracial patients and phone-only was the lowest-yield protocol for White patients; these 2 protocols tied for lowest-yield for Asian American or Native Hawaiian or Other Pacific Islander patients. Gains from multimode approaches were often 2 to 3 times as large for Asian American or Native Hawaiian or Other Pacific Islander, Black, Hispanic, and multiracial patients as for White patients. Web-mail-phone had the highest RR for 6 of 8 age groups and 4 of 5 combinations of service line and sex. Conclusions and Relevance: In this randomized clinical trial, web-first multimode survey protocols significantly improved the RR and representativeness of patient surveys. The best-performing protocol based on RR and representativeness was web-mail-phone. Web-phone performed well for young and diverse patient populations, and web-mail for older and less diverse patient populations. The US Centers for Medicare & Medicaid Services will allow hospitals to use the web-mail, web-phone, and web-mail-phone protocols for HCAHPS administration beginning in 2025.

Do Hospital Characteristics Predict Racial-and-Ethnic Disparities in Patient Experience? National Results From the HCAHPS Survey.

OBJECTIVE: Assess whether hospital characteristics associated with better patient experiences overall are also associated with smaller racial-and-ethnic disparities in inpatient experience. BACKGROUND: Hospitals that are smaller, non-profit, and serve high proportions of White patients tend to be high-performing overall, but it is not known whether these hospitals also have smaller racial-and-ethnic disparities in care. RESEARCH DESIGN: We used linear mixed-effect regression models to predict a summary measure that averaged eight Hospital CAHPS (HCAHPS) measures (Nurse Communication, Doctor Communication, Staff Responsiveness, Communication about Medicines, Discharge Information, Care Coordination, Hospital Cleanliness, and Quietness) from patient race-and-ethnicity, hospital characteristics (size, ownership, racial-and-ethnic patient-mix), and interactions of race-and-ethnicity with hospital characteristics. SUBJECTS: Inpatients discharged from 4,365 hospitals in 2021 who completed an HCAHPS survey ( N =2,288,862). RESULTS: While hospitals serving larger proportions of Black and Hispanic patients scored lower on all measures, racial-and-ethnic disparities were generally smaller for Black and Hispanic patients who received care from hospitals serving higher proportions of patients in their racial-and-ethnic group. Experiences overall were better in smaller and non-profit hospitals, but racial-and-ethnic differences were slightly larger. CONCLUSIONS: Large, for-profit hospitals and hospitals serving higher proportions of Black and Hispanic patients tend to be lower performing overall but have smaller disparities in patient experience. High-performing hospitals might look at low-performing hospitals for how to provide less disparate care whereas low-performing hospitals may look to high-performing hospitals for how to improve patient experience overall.

Changes in Patient Experiences of Hospital Care During the COVID-19 Pandemic.

Importance: It is important to assess how the COVID-19 pandemic was adversely associated with patients' care experiences. Objective: To describe differences in 2020 to 2021 patient experiences from what would have been expected from prepandemic (2018-2019) trends and assess correlates of changes across hospitals. Design, Setting, and Participants: This cohort study compared 2020 to 2021 data with 2018 to 2019 data from 3 900 887 HCAHPS respondents discharged from 3381 HCAHPS-participating US hospitals. The data were analyzed from 2022 to 2023. Main Outcomes and Measures: The primary outcome was an HCAHPS summary score (HCAHPS-SS), which averaged 10 HCAHPS measures. The primary analysis estimated whether HCAHPS scores from patients discharged from 2020 to 2021 differed from scores that would be expected based on quarterly and linear trends from 2018 to 2019 discharges. Secondary analyses stratified hospitals by prepandemic overall star ratings and staffing levels. Results: Of the 3 900 887 HCAHPS 2020 to 2021 respondents, 59% were age 65 years or older, and 35% (11%) were in the surgical (maternity) service lines. Compared with trends expected based on prepandemic (2018-2019) data, HCAHPS-SS was 1.2 percentage points (pp) lower for quarter (Q) 2/2020 discharges and -1.9 to -2.0 pp for Q3/2020 to Q1/2021, which then declined to -3.6 pp by Q4/2021. The most affected measures (Q4/2021) were staff responsiveness (-5.6 pp) and cleanliness (-4.9 pp); the least affected were discharge information (-1.6 pp) and quietness (-1.8 pp). Overall rating and hospital recommendation measures initially exhibited smaller-than-average decreases, but then fell as much as the more specific experience measures by Q2/2021. Quietness did not decline until Q2/2021. The HCAHPS-SS fell most for hospitals with the lowest prepandemic staffing levels; hospitals with bottom-quartile staffing showed the largest decrements, whereas top-quartile hospitals showed smaller decrements in most quarters. Hospitals with better overall prepandemic quality showed consistently smaller HCAHPS-SS drops, with effects for 5-star hospitals about 25% smaller than for 1-star and 2-star hospitals. Conclusions and Relevance: The results of this cohort study of HCAHPS-participating hospitals found that patient experience scores declined during 2020 to 2021. By Q4/2021, the HCAHPS-SS was 3.6 pp lower than would have been expected, a medium effect size. The most affected measures (staff responsiveness and cleanliness) showed large effect sizes, possibly reflecting high illness-associated hospital workforce absenteeism. Hospitals that were lower performing and less staffed prepandemic may have been less resilient to reduced staff availability and other pandemic-associated challenges. However, by Q4/2021, even prepandemic high-performing hospitals had similar declines.

The hospital care experiences of older patients compared to younger patients.

BACKGROUND: Hospitals may provide less positive patient experiences for older than younger patients. METHODS: We used 2019 HCAHPS data from 4358 hospitals to compare patient-mix adjusted HCAHPS Survey scores for 19 experience of care items for patients ages 75+ versus 55-74 years and tested for interactions of age group with patient and hospital characteristics. We contrasted the age patterns observed for inpatient experiences with those among respondents to the 2019 Medicare CAHPS (MCAHPS) Survey of overall experience. RESULTS: Patients 75+ years (31% of all HCAHPS respondents) reported less-positive experiences than those 55-74 (46% of respondents) for 18 of 19 substantive HCAHPS items (mean difference -3.3% points). Age differences in HCAHPS top-box scores were large (>5 points) for 1 of 3 Nurse Communication items, 1 of 3 Doctor Communication, 2 of 2 Communication about Medication items, 1 of 2 Discharge Information items, and 2 of 3 Care Transition items. In contrast, for MCAHPS, those 75+ reported similar experiences to younger adults. The magnitude of age differences varied considerably across hospitals; some hospitals had very large age disparities for older patients (age 75+ vs. ages 55-74), while others had none. These age differences were generally smaller for patients in government and non-profit than in for-profit hospitals, and in the Pacific region than in other parts of the United States. This variation in age disparities across hospitals may help to identify best practices. CONCLUSIONS: Patients ages 75+ reported less-positive experiences than patients ages 55-74, especially for measures of communication. These differences may be specific to inpatient care. Further study should investigate the effectiveness of hospital staffs' communication with older patients. Hospital protocols designed for younger patients may need to be adjusted to meet the needs of older patients. There may also be opportunities to learn from outpatient interactions with older patients.

Synthesis of enantioenriched 2,2-disubstituted pyrrolidines via sequential asymmetric allylic alkylation and ring contraction.

The synthesis of a variety of enantioenriched 2,2-disubstituted pyrrolidines is described. A stereogenic quaternary center is first formed utilizing an asymmetric allylic alkylation reaction of a benzyloxy imide, which can then be reduced to a chiral hydroxamic acid. This compound can then undergo a thermal "Spino" ring contraction to afford a carbamate protected 2,2-disubstituted pyrrolidine stereospecifically. These pyrrolidines can be further advanced to enantioenriched indolizidine compounds. This reaction sequence allows access to new molecules that could be useful in the development of pharmaceutical agents.

Inpatient care experiences differ by preferred language within racial/ethnic groups.

OBJECTIVE: To describe differences in patient experiences of hospital care by preferred language within racial/ethnic groups. DATA SOURCE: 2014-2015 HCAHPS survey data. STUDY DESIGN: We compared six composite measures for seven languages (English, Spanish, Russian, Portuguese, Chinese, Vietnamese, and Other) within applicable subsets of five racial/ethnic groups (Hispanics, Asian/Pacific Islanders, American Indian/Alaska Natives, Blacks, and Whites). We measured patient-mix adjusted overall, between- and within-hospital differences in patient experience by language, using linear regression. DATA COLLECTION METHODS: Surveys from 5 480 308 patients discharged from 4517 hospitals 2014-2015. PRINCIPAL FINDINGS: Within each racial/ethnic group, mean reported experiences for non-English-preferring patients were almost always worse than their English-preferring counterparts. Language differences were largest and most consistent for Care Coordination. Within-hospital differences by language were often larger than between-hospital differences and were largest for Care Coordination. Where between-hospital differences existed, non-English-preferring patients usually attended hospitals whose average patient experience scores for all patients were lower than the average scores for the hospitals of their English-preferring counterparts. CONCLUSIONS: Efforts should be made to increase access to better hospitals for language minorities and improve care coordination and other facets of patient experience in hospitals with high proportions of non-English-preferring patients, focusing on cultural competence and language-appropriate services.

Characteristics of Hospice Referrals From an Inpatient Geriatric Psychiatry Unit.

OBJECTIVE: Geriatric psychiatrists who treat neuropsychiatric symptoms of dementia are in the unique position of offering palliation to people with terminal illness in whom neuropsychiatric symptoms may be indicators of the illness's end stage (e.g., feeding problems). Little is known, however, about the characteristics of hospice referrals from inpatient geriatric psychiatry units. METHODS: This was a retrospective chart review of patients with dementia admitted to an inpatient geriatric psychiatry unit and referred to hospice on discharge. RESULTS: Patients were referred to hospice because of feeding problems, with oral intake insufficient to sustain life. Most patients (78%) died within 31 days of discharge, and all patients (100%) died within 6 months of discharge. CONCLUSION: The results from this study support a symptom-based approach to hospice referral for people with dementia, as opposed to prognostic estimation, where certain symptom clusters may indicate a more rapidly progressing course.

Catalyst-Controlled Selective Functionalization of Unactivated C-H Bonds in the Presence of Electronically Activated C-H Bonds.

A new chiral dirhodium tetracarboxylate catalyst, Rh2( S-2-Cl-5-BrTPCP)4, has been developed for C-H functionalization reactions by means of donor/acceptor carbene intermediates. The dirhodium catalyst contains four ( S)-1-(2-chloro-5-bromophenyl)-2,2-diphenylcyclopropane-1-carboxylate ligands, in which all four 2-chloro-5-bromophenyl groups are on the same face of the catalyst, leading to a structure, which is close to C4 symmetric. The catalyst induces highly site selective functionalization of remote, unactivated methylene C-H bonds even in the presence of electronically activated benzylic C-H bonds, which are typically favored using earlier established dirhodium catalysts, and the reactions proceed with high levels of diastereo- and enantioselectivity. This C-H functionalization method is applicable to a variety of aryl and heteroaryl derivatives. Furthermore, the potential of this methodology was illustrated by sequential C-H functionalization reactions to access the macrocyclic core of the cylindrocyclophane class of natural products.

Palladium-Catalyzed Enantioselective Csp3-Csp3 Cross-Coupling for the Synthesis of (Poly)fluorinated Chiral Building Blocks.

A general method for the enantioselective synthesis of carbo- and heterocyclic carbonyl compounds bearing fluorinated α-tetrasubstituted stereocenters using palladium-catalyzed decarboxylative allylic alkylation is described. The stereoselective Csp3-Csp3 cross-coupling reaction delivers five- and six-membered ketone and lactam products bearing (poly)fluorinated tetrasubstituted chiral centers in high yields and enantioselectivities. These fluorinated, stereochemically rich building blocks hold potential value in medicinal chemistry and are prepared using an orthogonal and enantioselective approach into such chiral moieties compared to traditional approaches, often without the use of electrophilic fluorinating reagents.

Medicare Advantage and Fee-for-Service Performance on Clinical Quality and Patient Experience Measures: Comparisons from Three Large States.

OBJECTIVE: To compare performance between Medicare Advantage (MA) and Fee-for-Service (FFS) Medicare during a time of policy changes affecting both programs. DATA SOURCES/STUDY SETTING: Performance data for 16 clinical quality measures and 6 patient experience measures for 9.9 million beneficiaries living in California, New York, and Florida. STUDY DESIGN: We compared MA and FFS performance overall, by plan type, and within service areas associated with contracts between CMS and MA organizations. Case mix-adjusted analyses (for measures not typically adjusted) were used to explore the effect of case mix on MA/FFS differences. DATA COLLECTION/EXTRACTION METHODS: Performance measures were submitted by MA organizations, obtained from the nationwide fielding of the Medicare Consumer Assessment of Healthcare Providers and Systems (MCAHPS) Survey, or derived from claims. PRINCIPAL FINDINGS: Overall, MA outperformed FFS on all 16 clinical quality measures. Differences were large for HEDIS measures and small for Part D measures and remained after case mix adjustment. MA enrollees reported better experiences overall, but FFS beneficiaries reported better access to care. Relative to FFS, performance gaps were much wider for HMOs than PPOs. Excluding HEDIS measures, MA/FFS differences were much smaller in contract-level comparisons. CONCLUSIONS: Medicare Advantage/Fee-for-Service differences are often large but vary in important ways across types of measures and contracts.

Poliovirus intrahost evolution is required to overcome tissue-specific innate immune responses.

RNA viruses, such as poliovirus, have a great evolutionary capacity, allowing them to quickly adapt and overcome challenges encountered during infection. Here we show that poliovirus infection in immune-competent mice requires adaptation to tissue-specific innate immune microenvironments. The ability of the virus to establish robust infection and virulence correlates with its evolutionary capacity. We further identify a region in the multi-functional poliovirus protein 2B as a hotspot for the accumulation of minor alleles that facilitate a more effective suppression of the interferon response. We propose that population genetic dynamics enables poliovirus spread between tissues through optimization of the genetic composition of low frequency variants, which together cooperate to circumvent tissue-specific challenges. Thus, intrahost virus evolution determines pathogenesis, allowing a dynamic regulation of viral functions required to overcome barriers to infection.RNA viruses, such as polioviruses, have a great evolutionary capacity and can adapt quickly during infection. Here, the authors show that poliovirus infection in mice requires adaptation to innate immune microenvironments encountered in different tissues.

Patient experience and process measures of quality of care at home health agencies: Factors associated with high performance.

We examined the effects of provider characteristics on home health agency performance on patient experience of care (Home Health CAHPS) and process (OASIS) measures. Descriptive, multivariate, and factor analyses were used. While agencies score high on both domains, factor analyses showed that the underlying items represent separate constructs. Freestanding and Visiting Nurse Association agencies, higher number of home health aides per 100 episodes, and urban location were statistically significant predictors of lower performance. Lack of variation in composite measures potentially led to counterintuitive results for effects of organizational characteristics. This exploratory study showed the value of having separate quality domains.

Understanding The Role Played By Medicare's Patient Experience Points System In Hospital Reimbursement.

In 2015 the Medicare Hospital Value-Based Purchasing (VBP) program paid hospitals $1.4 billion in performance-based incentives; 30 percent of a hospital's VBP Total Performance Score was based on performance on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) measures of the patient experience of care. Hospitals receive patient experience points based on three components: achievement, improvement, and consistency. For 2015 we examined how the three components affected reimbursement for 3,152 hospitals, including their impact on low-performing and high-minority hospitals. Achievement accounted for 96 percent of the differences among hospitals in total HCAHPS points. Although achievement had the biggest influence on payments, payments related to improvement and consistency were more beneficial for low-performing hospitals that disproportionately served minority patients. The findings highlight the important inducement that paying for improvement provides to initially low-performing hospitals to improve care and the role this incentive structure plays in minimizing resource redistributions away from hospitals serving minority populations. Additional emphasis on improvement points could benefit hospitals serving disadvantaged patients.

RNA Recombination Enhances Adaptability and Is Required for Virus Spread and Virulence.

Mutation and recombination are central processes driving microbial evolution. A high mutation rate fuels adaptation but also generates deleterious mutations. Recombination between two different genomes may resolve this paradox, alleviating effects of clonal interference and purging deleterious mutations. Here we demonstrate that recombination significantly accelerates adaptation and evolution during acute virus infection. We identified a poliovirus recombination determinant within the virus polymerase, mutation of which reduces recombination rates without altering replication fidelity. By generating a panel of variants with distinct mutation rates and recombination ability, we demonstrate that recombination is essential to enrich the population in beneficial mutations and purge it from deleterious mutations. The concerted activities of mutation and recombination are key to virus spread and virulence in infected animals. These findings inform a mathematical model to demonstrate that poliovirus adapts most rapidly at an optimal mutation rate determined by the trade-off between selection and accumulation of detrimental mutations.

Racial and Ethnic Disparities in Patients' Experience With Skilled Home Health Care Services.

Racial and ethnic disparities are found in many health care settings; however, there is little prior research on such disparities among patients receiving home health care services. This study used 2012 Home Health Care CAHPS(®) data to identify any overall patient-level disparities in self-reported experience of care and to decompose these disparities according to whether they result from within-agency versus between-agency differences. Although patient experience of care ratings were high across all groups, the study identified consistently lower ratings for all minority groups on two of three Home Health Care CAHPS measures, with Asians reporting the greatest disparities. Three quarters of disparities were found to be within-agency disparities, which were primarily related to care processes and provider/patient communications rather than to specific health care services received. Despite high ratings in general, home health agencies may need to focus on cultural competency initiatives to address racial and ethnic disparities within their agencies.

Accelerating Improvement and Narrowing Gaps: Trends in Patients' Experiences with Hospital Care Reflected in HCAHPS Public Reporting.

OBJECTIVE: Measure HCAHPS improvement in hospitals participating in the second and fifth years of HCAHPS public reporting; determine whether change is greater for some hospital types. DATA: Surveys from 4,822,960 adult inpatients discharged July 2007-June 2008 or July 2010-June 2011 from 3,541 U.S. hospitals. STUDY DESIGN: Linear mixed-effect regression models with fixed effects for time, patient mix, and hospital characteristics (bedsize, ownership, Census division, teaching status, Critical Access status); random effects for hospitals and hospital-time interactions; fixed-effect interactions of hospital characteristics and patient characteristics (gender, health, education) with time predicted HCAHPS measures correcting for regression-to-the-mean biases. DATA COLLECTION METHODS: National probability sample of adult inpatients in any of four approved survey modes. PRINCIPAL FINDINGS: HCAHPS scores increased by 2.8 percentage points from 2008 to 2011 in the most positive response category. Among the middle 95 percent of hospitals, changes ranged from a 5.1 percent decrease to a 10.2 percent gain overall. The greatest improvement was in for-profit and larger (200 or more beds) hospitals. CONCLUSIONS: Five years after HCAHPS public reporting began, meaningful improvement of patients' hospital care experiences continues, especially among initially low-scoring hospitals, reducing some gaps among hospitals.