Safety-Net Hospitals Perform More Poorly According to Patient-Reported Experiences

Safety-net hospitals, those that care for vulnerable and poor populations, performed more poorly in patient-reported experiences compared with nonsafety-net hospitals, according to results of a recent study [Arch Intern Med. doi:10.1001/archinternmed.2012.3158]. The gaps in measures used to score performance were large and increased over time.

Hospital reimbursements are increasingly based on their performance on value-based purchasing (VBP) metrics, a program run by the Centers for the Medicare & Medicaid Services. Improving patient experience is becoming a larger priority for all hospitals, but may be especially important for safety-net hospitals as high performance under VBP will be crucial to their economic viability.

Researchers conducted a study using data from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, which VBP metrics are based on, and Disproportionate Share Hospital (DSH) index data to better understand to what degree being a safety-net hospital was associated with worse performance, apart from hospital characteristics out of the hospital’s control. The data were from 3096 hospitals.

HCAHPS survey data consisted of information related to patient experiences during hospitalization for a medical or surgical condition and were grouped by composite quality measures: communication with physicians and nurses, communication regarding medications, quality of nursing services, presence of discharge planning, pain management, cleanliness, and quietness of the hospital.

Additionally, patients were asked to provide an overall rating of the hospital on a scale from 0 to 10 and if they would recommend the hospital to family and friends. American Hospital Association survey data were used to obtain hospital characteristics such as size and location. The primary outcome measure of the study was patient-reported overall hospital rating; secondary outcome measures were each of the individual composite measures. Generalized linear regression models were among those used in the researchers’ analysis.

The researchers found safety-net hospitals were more likely to be located in the South and West (P<.001 for both) and have fewer Medicare patients and more Medicaid and black patients than other hospitals. Hospitals with higher DSH index scores were associated with worse performance on overall hospital rating. Results also showed that safety-net hospitals had the lowest HCAHPS scores on all measures of patient-reported experience with the exception of quietness of hospital environment.

In 2007, the beginning of the public reporting period, safety-net hospitals showed worse performance on overall hospital rating compared with nonsafety-net hospitals. All groups of hospitals improved over the next 3 years, however, the improvement was smaller among safety-net hospitals compared with nonsafety-net hospitals, resulting in a performance gap of 5.6% in 2010 versus 3.8% in 2007. The safety-net hospitals that improved more than the median tended to be larger facilities, for-profit institutions, and teaching hospitals, and served a smaller proportion of black patients.

The researchers also found 11% of safety-net hospitals achieved the median or above on all 8 HCAHPS measures of patient experience in 2010, and safety-net hospitals had a 60% lower chance of reaching the benchmark (odds ratio, 0.4; 95% confidence interval, 0.3-0.5; P<.001) compared with hospitals in the lowest DSH index quartile. Safety-net hospitals were also more likely not to score at or above the median on any of the 8 HCAHPS measures.

Study limitations included the inherently subjective nature of HCAHPS measures and the examination of data over a 4-year period, as it is possible efforts to improve hospital performance may take longer.