Demographic factors and hospital size predict patient satisfaction variance--implications for hospital value-based purchasing.

BACKGROUND: Hospital Value-Based Purchasing (HVBP) incentivizes quality performance-based healthcare by linking payments directly to patient satisfaction scores obtained from Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys. Lower HCAHPS scores appear to cluster in heterogeneous population-dense areas and could bias Centers for Medicare & Medicaid Services (CMS) reimbursement. OBJECTIVE: Assess nonrandom variation in patient satisfaction as determined by HCAHPS. DESIGN: Multivariate regression modeling was performed for individual dimensions of HCAHPS and aggregate scores. Standardized partial regression coefficients assessed strengths of predictors. Weighted Individual (hospital) Patient Satisfaction Adjusted Score (WIPSAS) utilized 4 highly predictive variables, and hospitals were reranked accordingly. SETTING: A total of 3907 HVBP-participating hospitals. PATIENTS: There were 934,800 patient surveys by the most conservative estimate. MEASUREMENTS: A total of 3144 county demographics (US Census) and HCAHPS surveys. RESULTS: Hospital size and primary language (non-English speaking) most strongly predicted unfavorable HCAHPS scores, whereas education and white ethnicity most strongly predicted favorable HCAHPS scores. The average adjusted patient satisfaction scores calculated by WIPSAS approximated the national average of HCAHPS scores. However, WIPSAS changed hospital rankings by variable amounts depending on the strength of the predictive variables in the hospitals' locations. Structural and demographic characteristics that predict lower scores were accounted for by WIPSAS that also improved rankings of many safety-net hospitals and academic medical centers in diverse areas. CONCLUSIONS: Demographic and structural factors (eg, hospital beds) predict patient satisfaction scores even after CMS adjustments. CMS should consider WIPSAS or a similar adjustment to account for the severity of patient satisfaction inequities that hospitals could strive to correct.

The National Practice Benchmark for oncology, 2014 report on 2013 data.

The National Practice Benchmark (NPB) is a unique tool to measure oncology practices against others across the country in a way that allows meaningful comparisons despite differences in practice size or setting. In today's economic environment every oncology practice, regardless of business structure or affiliation, should be able to produce, monitor, and benchmark basic metrics to meet current business pressures for increased efficiency and efficacy of care. Although we recognize that the NPB survey results do not capture the experience of all oncology practices, practices that can and do participate demonstrate exceptional managerial capability, and this year those practices are recognized for their participation. In this report, we continue to emphasize the methodology introduced last year in which we reported medical revenue net of the cost of the drugs as net medical revenue for the hematology/oncology product line. The effect of this is to capture only the gross margin attributable to drugs as revenue. New this year, we introduce six measures of clinical data density and expand the radiation oncology benchmarks.

Evaluation of the work of hospital districts' research ethics committees in Finland.

The main task of research ethics committees (RECs) is to assess research studies before their start. In this study, 24 RECs that evaluate medical research were sent questionnaires about their structure and functions. The RECs were divided into two separate groups: those working in university hospital districts (uRECs) and those in central hospital districts (non-uRECs). The two groups were different in many respects: the uRECs were bigger in size, covered a wider range of disciplines (both medical and non-medical), had better resources and more frequent and regular meetings. After the survey was performed and analysed, the Medical Research Act was amended so that only hospital districts with a medical faculty in their region had a duty to establish ethics committees. After the amendment, the number of RECs evaluating medical research in Finland decreased from 25 to 9. The ethics committees that remained had wider expertise and were better equipped already by the time of this survey. Only one non-uREC was continuing its work, and this was being done under the governance of a university hospital district. Simple measures were used for qualitative analysis of the work of RECs that evaluate medical research. These showed differences between RECs. This may be helpful in establishing an ethics committee network in a research field or administrational area.

The association of intensivists with failure-to-rescue rates in outlier hospitals: results of a national survey of intensive care unit organizational characteristics.

PURPOSE: Critical care is often an integral part of rescue for patients with surgical complications. We sought to understand critical care characteristics predictive of failure-to-rescue (FTR) performance at the hospital level. METHODS: Using 2009 to 2011 FTR data from Hospital Compare, we identified 144 outlier hospitals with significantly better/worse performance than the national average. We surveyed intensive care unit (ICU) directors and nurse managers regarding physical structures, patient composition, staffing, care protocols, and rapid response teams (RRTs). Hospitals were compared using descriptive statistics and logistic regression. RESULTS: Of 67 hospitals completing the survey, 56.1% were low performing, and 43.9% were high performing. Responders were more likely to be teaching hospitals (40.9% vs 25.0%; P=.05) but were similar to nonresponders in terms of size, region, ownership, and FTR performance. Poor performers were more likely to serve higher proportions of Medicaid patients (68.4% vs 20.7%; P<.0001) and be level 1 trauma centers (55.9% vs 25.9%; P=.02). After controlling for these 2 characteristics, an intensivist on the RRT (adjusted odds ratio, 4.27; confidence interval, 1.45-23.02; P=.005) and an internist on staff in the ICU (adjusted odds ratio, 2.13; P=.04) were predictors of high performance. CONCLUSIONS: Intensivists on the RRT and internists in the ICU may represent discrete organizational strategies for improving patient rescue. Hospitals with high Medicaid burden fare poorly on the FTR metric.

Does practice size matter? Review of effects on quality of care in primary care.

BACKGROUND: There is a trend towards consolidating smaller primary care practices into larger practices worldwide. However, the effects of practice size on quality of care remain unclear. AIM: This review aims to systematically appraise the effects of practice size on the quality of care in primary care. DESIGN AND SETTING: A systematic review and narrative synthesis of studies examining the relationship between practice size and quality of care in primary care. METHOD: Quantitative studies that focused on primary care practices or practitioners were identified through PubMed, CINAHL, Embase, Cochrane Library, CRD databases, ProQuest dissertations and theses, conference proceedings, and MedNar databases, as well as the reference lists of included studies. Independent variables were team or list size; outcome variables were measures of clinical processes, clinical outcomes, or patient-reported outcomes. A narrative synthesis of the results was conducted. RESULTS: The database search yielded 371 articles, of which 34 underwent quality assessment, and 17 articles (13 cross-sectional studies) were included. Ten studies examined the association of practice size and clinical processes, but only five found associations of larger practices with selected process measures such as higher specialist referral rates, better adherence to guidelines, higher mammography rates, and better monitoring of haemoglobin A1c. There were mixed results for cytology and pneumococcal coverage. Only one of two studies on clinical outcomes found an effect of larger practices on lower random haemoglobin A1 value. Of the three studies on patient-reported outcomes, smaller practices were consistently found to be associated with satisfaction with access, but evidence was inconsistent for other patient-reported outcomes evaluated. CONCLUSION: There is limited evidence to support an association between practice size and quality of care in primary care.

The impact of provider surgical volumes on survival in children with primary tumors of the central nervous system--a population-based study.

BACKGROUND: Provider volume is often a central topic in debates about centralization of procedures. In Norway, there is considerable variation in provider volumes of the neurosurgical centers treating children. We sought to explore long-term survival after surgery for central nervous system tumors in children in relation to regional provider volumes. METHOD: Based on data from the Norwegian Cancer Registry we analyzed survival in all reported central nervous system tumors in children under the age of 16 treated over two decades, between March 1988 and April 2008; a total of 816 patients with histologically confirmed disease. RESULTS: There was no overall difference in survival between regions. In the subgroup of PNET/medulloblastomas, both living in the high-provider volume health region and receiving treatment in the high-volume region was significantly associated with inferior survival. CONCLUSIONS: In this population-based study of children operated over a period of two decades, we found no evidence of improved long-term survival in the high-provider volume region. Surprisingly, a subgroup analysis indicated that survival in PNET/medulloblastomas was significantly better if living outside the most populated health region with the highest provider volumes. One should, however, be careful of interpreting this directly as a symptom of quality of care, as there may be unseen confounders. Our study demonstrates that provider case volume may serve as an axiom in debates about centralization of cancer surgery while perhaps much more reliable and valid but less quantifiable factors are important for the final results.

¿Es más eficiente el implante de marcapasos permanentes en hospitales de nivel I? / Is the permanent pacemaker implant more efficient in level 1 hospital?

Objetivo Determinar si el implante de marcapasos permanentes (MPP) y cambio de generador resultan más eficientes en hospitales pequeños.DiseñoAnálisis de costeefectividad. Estudio retrospectivo, transversal y observacional de cinco GDR.AmbitoLos datos son procedentes del conjunto mínimo básico de datos (CMBD) nacional del año 2007, facilitado por el Ministerio de Sanidad.PacientesSon el total de los pacientes que requirieron asistencia en algún hospital nacional por 5 GRD: 115, complicación bradiarrítmica durante la fase aguda de un síndrome coronario, insuficiencia cardíaca o shock; 116, trastorno de conducción sintomático aislado; 117, revisión pero sin cambio de batería; 118, aplicación de una nueva, y 549, implantación o revisión pero con complicaciones graves.Variables de interés principalesSe analizaron variables demográficas, clínicas (número de diagnósticos secundarios (NDS), de procedimientos (NP), mortalidad) y de gestión (estancia total y preoperatoria (Epo), forma de acceso y alta, tamaño de hospital), definiendo ineficiente una estancia superior 2 días a la media.Resultados23.154 episodios (5,3% en hospitales<200 camas). El estudio bivariado comparativo entre hospitales pequeños y el resto, no discriminado por GDR, mostró estancia media 7,87±11,01 días vs 8,78±12,95 (p=0,005, IC 95% [0,17; 1,65]) y Epo 3,62±6,14 vs 4,22±6,68 días [p=0,015]), sin mayor comorbilidad, medida como proxy por NDS (5,23±2,88 vs 5,42±3,28 [p=0,055]); y NP como proxy de esfuerzo diagnóstico-terapéutico (3,79±2,50 vs 3,55±2,69 [p=0,002]). 24,1% fueron ineficientes, encontrándose asociación con Epo, NDS, NP y acceso urgente.ConclusionesLa implantación de marcapasos y cambio de generador en hospitales pequeños es más eficiente, con consistencia interna por subgrupos (AU)

Abstract Objective: To determine if permanent pacemaker implants (PPM) interventions and change ofgenerator are more efficient in small hospitals.Design: A cost-effective analysis and retrospective, cross-sectional and observational study ofdiagnostic related groups (DRG).Setting: The data was obtained from the national Minimum Basic Data Set (MBDS) for the year2007 provided by the Health Ministry.Patients: This includes the total number of patients who required treatment in all nationalhospitals for 5 DRG: 115 - bradyarrhythmic complication during the acute coronary syndrome,heart failure or shock; 116 -symptomatic isolated conduction defects; 117 -revisions, but withoutchanging the battery, 118- application of a new one, 549 - implementation or revision butwith serious complications.Principal variables of interest: demographic, clinical (number of secondary diagnoses (NSD)and procedures (NP), mortality) and management (total and preoperative length of stay (LOS),access, discharge, hospital size), defining inefficient stays as those exceeding 2 days on theaverage.Results: 23,154 episodes, 5.3% small hospitals. The comparative bivariate study between smallhospitals and the rest, not discriminated by DRG, showed a mean LOS of 7.87±8.78 days vs11.01±12.95 (p=0.005, 95% CI for mean difference [0.17, 1.65]) and also lower than preoperatively(3.62±6.14 vs. 4.22±6.68 days (p=0.015)) without greater comorbidity, as measured byproxy through the NSD (5.23±2.88 vs 5.42±3.28 (p=0.055)) and NP as proxy of diagnostic andtherapeutic effort (3.79±2.50 vs 3.55±2.69 (p=0.002)). A total of 24.1% were inefficient, therebeing an association with preoperative stay, NDS, NP and emergency access.Conclusion: Pacemaker implantation and generator change in small hospitals is more efficient,with internal consistency by subgroups (AU)

Monitoring quality of care in residential care for the elderly: the information challenge.

This study assesses the administrative data compiled on residential care facilities for the elderly (RCFEs) by the state of California and considers the feasibility of their adaptation into a comprehensive information system. Required state RCFE reporting forms were reviewed for potential data elements. Recording and reporting variation was evaluated using a stratified probability sample of 340 facilities licensed in Northern and Central California. Stratification was by facility size and state district office. Data collection included a 5-year retrospective review of forms and documents in each facility's public file. Little of the information required from RCFEs is computerized. Most of it is maintained at the individual facility and not included in public files. Basic information, while included in the public file, is commonly either not available or not current. Resident characteristics and outcomes are not compiled, except indirectly in citations. The information required from RCFEs, if appropriately compiled and maintained, would produce a comprehensive quality assurance system and more effectively support consumer information and policy needs.

Long-term care: changing demographics, changing residents.

Long-term care facilities have tracked resident data for decades. Using those data, researchers have been able to identify and track trends. Resident demographics, facility information, and types of deficiencies uncovered by state surveys are three types of data of interest to consultant pharmacists. Examining trends can provide clues about areas where improved training, greater scrutiny, or targeted interventions may next be needed.

Does size matter? A population-based study of birth in lower volume maternity hospitals for low risk women.

OBJECTIVE: To study the association between volume of hospital births per annum and birth outcome for low risk women. DESIGN: Population-based study using the National Perinatal Data Collection (NPDC). SETTING: Australia. PARTICIPANTS: Of 750,491 women who gave birth during 1999-2001, there were 331,147 (47.14%) medically 'low risk' including 132,696 (40.07%) primiparae and 198,451 (59.93%) multiparae. METHODS: The frequency of each birth and infant outcome was described according to the size of the hospital where birth took place. We investigated whether unit size (defined by volume) was an independent risk factor for each outcome factor using public hospitals with greater than 2000 births per annum as a reference point. MAIN OUTCOME MEASURES: Rates of intervention at birth and neonatal mortality for low risk women in relation to hospitals with <100, 100-500, 501-1000, 1001-2000 and >2001 births per annum. RESULTS: Neonatal death was less likely in hospitals with less than 2000 births per annum regardless of parity. For multiparous low risk women in hospitals of 100 and 500 births per annum compared with hospitals of >2000 births per annum the adjusted odds of neonatal mortality [adjusted odds ratio (AOR) 0.36; 99% confidence interval (CI) 0.14-0.93]. For low risk primiparous women in hospitals with less than 100 births per annum, there were lower rates of induction of labour (AOR 0.62; 99% CI 0.54-0.73); intrathecal analgesia/anaesthesia (AOR 0.34; 99% CI 0.28-0.42); instrumental birth (AOR 0.80; 99% CI 0.69-0.93); caesarean section after labour (AOR 0.59; 99% CI 0.49-0.72) and admission to a neonatal unit (AOR 0.15; 99% CI 0.10-0.22) and for low risk multiparous women in hospitals with less than 100 births per annum: induction (AOR 0.69; 99% CI 0.62-0.76); intrathecal analgesia/anaesthesia (AOR 0.32; 99% CI 0.29-0.36); instrumental birth (AOR 0.52; 99% CI 0.41-0.67); caesarean section after labour (AOR 0.41; 99% CI 0.33-0.52); and admission to a neonatal unit (AOR 0.09; 99% CI 0.07-0.12). CONCLUSIONS: In Australia, lower hospital volume is not associated with adverse outcomes for low risk women.

[Is there a relationship between hospital size and patient experience?]. / Er det sammenheng mellom sykehusstørrelse og pasienterfaringer?

BACKGROUND: Hospitals in Norway are undergoing changes in structure and organisation. Patient experience has been selected as a national indicator of hospital quality. The objective of this study was to investigate the relationship between hospital size and patient experience. MATERIAL AND METHODS: A patient experience questionnaire was sent to a representative sample of patients after discharge from 46 somatic hospitals, which were classified by function and by annual number of patients admitted. RESULTS: 10,975 patients (50%) responded. Generally, the patients expressed a positive attitude towards their hospitals. The patient experience was significantly more positive among those discharged from small hospitals than among those discharged from medium-sized or large hospitals, especially with regard to organisation. INTERPRETATION: Our study shows that patient experience was significantly more positive among those discharged from small hospitals than from medium-sized or large hospitals, especially with regard to organisation. However, the score differences between hospitals are small and should be interpreted with caution.

Inpatient care of mentally ill people in prison: results of a year's programme of semistructured inspections.

OBJECTIVE: To investigate the facilities for inpatient care of mentally disordered people in prison. DESIGN: Semistructured inspections conducted by doctor and nurse. Expected standards were based on healthcare quality standards published by the Prison Service or the NHS. SETTING: 13 prisons with inpatient beds in England and Wales subject to the prison inspectorate's routine inspection programme during 1997-8. MAIN OUTCOMES MEASURES: Appraisals of quality of care against published standards. RESULTS: The 13 prisons had 348 beds, 20% of all beds in prisons. Inpatient units had between 3 and 75 beds. No doctor in charge of inpatients had completed specialist psychiatric training. 24% of nursing staff had mental health training; 32% were non-nursing trained healthcare officers. Only one prison had occupational therapy input; two had input from a clinical psychologist. Most patients were unlocked for about 3.5 hours a day and none for more than nine hours a day. Four prisons provided statistics on the use of seclusion. The average length of an episode of seclusion was 50 hours. CONCLUSION: The quality of services for mentally ill prisoners fell far below the standards in the NHS. Patients' lives were unacceptably restricted and therapy limited. The present policy dividing inpatient care of mentally disordered prisoners between the prison service and the NHS needs reconsideration.

Small business size standards; health care. Small Business Administration. Final rule.

The Small Business Administration is adopting new size standards for 19 Health Care industries and retaining the existing $5 million size standard for the remaining 11 Health Care industries. The North American Industry Classification System classifies Health Care industries under Subsector 621, Ambulatory Health Care Services; Subsector 622, Hospitals; and Subsector 623, Nursing and Residential Care Facilities. These revisions are made to more appropriately define the size of businesses in these industries that SBA believes should be eligible for Federal small business assistance programs.

Variations in the treatment of early-stage breast cancer in Quebec between 1988 and 1994.

BACKGROUND: The influence of organizational factors on the process and outcomes of the treatment of breast cancer has been extensively investigated. Although the quality of care is presumed to be better in larger centres, evidence is inconsistent. This study was conducted to determine whether therapies for patients with breast cancer varied according to hospital caseload. METHODS: Women newly diagnosed between 1988 and 1994 with early-stage node-negative primary breast cancer were randomly selected from the Quebec tumour registry and the Quebec hospital discharge database. Data were collected from medical charts, and only women having undergone dissection of the axilla were included in the analyses. Logistic regression analysis was used to adjust for case mix and organizational variables. RESULTS: The final sample included 1259 patients with node-negative stage I or II primary breast cancer. The proportion of women who underwent breast-conserving surgery increased significantly with hospital caseload (from 78.0% in hospitals admitting fewer than 25 new cases each year to 88.0% in those admitting 100 patients or more; p for trend < 0.001). This trend remained significant even after statistical adjustment for case mix and organizational factors (p for trend = 0.001). Of the 1039 women who underwent breast-conserving surgery 965 (92.9%) received radiotherapy. Use of systemic adjuvant therapy (tamoxifen or chemotherapy, or both) increased with the number of patients treated in a given centre (from 60.1% to 68.5%), but this trend disappeared after adjustment for case mix and other factors. The proportion of patients receiving systemic adjuvant therapy consistent with published consensus guidelines tended to increase with caseload for those treated in hospitals participating in multicentre clinical trials but decrease with caseload for patients in hospitals not involved in clinical research. INTERPRETATION: The care of patients in Quebec with early-stage breast cancer is characterized by a high prevalence of both breast-conserving surgery and systemic adjuvant therapy. Large centres, especially those actively involved in clinical research, rapidly adopt innovative therapeutic modalities.

Technical, scale, and size efficiency in nursing home care: a nonparametric analysis of Connecticut homes.

Maindiratta (1990) questioned the usefulness of the concept of scale efficiency in production as the most productive scale size (MPSS) usually requires altering the scale of output produced. If the decision making unit (DMU) is required to deliver a specific output bundle, then altering output along with the input scale to reach the MPSS is not a valid recommendation. He proposed a measure of the size efficiency of a DMU. In this paper, we apply Data Envelopment Analysis (DEA) to examine the levels of technical, scale, and size efficiency of individual nursing homes providing health care to the elderly. The data used relate to the operations of 140 nursing homes from Connecticut, USA during the year 1982-83. Maindiratta's model is input-oriented. By contrast, our study is output-oriented and we appropriately reformulate Maindiratta's model. The findings show that in several cases size efficiency is less than unity. This suggests that the most efficient production of output would require restructuring of the nursing home under investigation as more than one small unit. We also compare the efficiency levels of 'for-profit' homes with those of 'not-for-profit' homes.

Incorporating patient travel times in decisions about size and location of dialysis facilities.

This report demonstrates the power and usefulness of mathematical optimization as a decision support tool in the medical services industry by presenting an application to dialysis service planning. Models to predict the number of dialysis beds in a given region are usually population-based. Dialysis planners and providers have found a need to accommodate sparsely populated regions by making some allowance for patient travel times. A formal approach to incorporating travel times into dialysis planning, based on the formulation and solution of a mixed-integer programming model, is presented. The development of a method for dialysis planning serves as a platform to demonstrate the use of integer programming to support decision making. Major modeling principles are presented; output interpretation and sensitivity analysis are illustrated by examples; and computational requirements are discussed.