The built environment as a component of quality care: understanding and including the patient's perspective

Risk-Standardized Home Time as a Novel Hospital Performance Metric for Pneumonia Hospitalization Among Medicare Beneficiaries: a Retrospective Cohort Study

BACKGROUND

The Centers for Medicare & Medicaid Services (CMS) use hospital readmissions as a performance metric to incentivize hospital care for acute conditions including pneumonia. However, there are limitations to using readmission alone as a hospital performance metric.

OBJECTIVE

To characterize 30-day risk-standardized home time (RSHT), a novel patient-centered post-discharge performance metric for acute pneumonia hospitalizations in Medicare patients, and compare hospital rankings based on this metric with mortality and readmissions.

STUDY DESIGN

Retrospective, cohort study.

PARTICIPANTS

A cohort of Medicare fee-for-service beneficiaries admitted between January 01, 2015 and November 30, 2017.

INTERVENTIONS

None.

MAIN MEASURES

Risk-standardized hospital-level home time within 30 days of discharge was evaluated as a novel performance metric. Multilevel regression models were used to calculate hospital-level estimates and rank hospitals based on RSHT, readmission rate (RSRR), and mortality rate (RSMR).

KEY RESULTS

A total of 1.7 million pneumonia admissions admitted to one of the 3116 hospitals were eligible for inclusion. The median 30-day RSHT was 20.5 days (interquartile range: 18.9-21.9 days; range: 5-29 days). Hospital-level characteristics such as case volume, bed size, for-profit ownership, rural location of the hospital, teaching status, and participation in the bundled payment program were significantly associated with home time. We found a modest, inverse correlation of RSHT with RSRR (rho: -0.233, p< 0.0001) and RSMR (rho: -0.223, p< 0.0001) for pneumonia. About 1/3rd of hospitals were reclassified as high performers based on their RSHT metric compared with the rank on their RSRR and RSMR metrics.

CONCLUSION

Home time is a novel, patient-centered, hospital-level metric that can be easily calculated using claims data and accounts for mortality, readmission to an acute care facility, and admission to a skilled nursing facility or long-term care facility after discharge. Utilization of this patient-centered metric could have policy implications in assessing hospital performance on delivery of healthcare to pneumonia patients.

Home Time as a Patient-Centered Outcome in Administrative Claims Data

BACKGROUND

Home time, the number of days alive and spent out of hospital and skilled nursing facility, has been proposed as a patient-centered outcome that can be readily calculated in administrative claims data.

OBJECTIVES

To compare home time against existing patient-centered outcome measures.

DESIGN

Retrospective cohort study.

SETTING

Community.

PARTICIPANTS

A total of 4594 Medicare beneficiaries 65 years or older with complete survey and claims data in the Medicare Current Beneficiary Survey 2010 to 2011.

MEASUREMENTS

Home time was calculated from the 2011 claims data (range, 0-365 days). The 1-year incidence of patient-centered outcomes (poor self-rated health, mobility impairment, depression, limited social activity, and difficulty in self-care) was measured. The minimum clinically important difference (MCID) was derived by contrasting the mean home time between those who experienced functional decline or death and those who did not.

RESULTS

The mean home time was 355.8 days (SD, 42.1 days); 84.1% had a home time of 365 days, and 5.7% had a home time of 336 days or fewer. The incidence of poor self-rated health ranged from 2% (home time, 365 days) to 21% (home time, less than 337 days). Similarly, the corresponding incidence risks were 11% to 59% for mobility impairment, 5% to 19% for depression, 17% to 67% for limited social activity, and 13% to 68% for difficulty in self-care. The risk of mobility impairment, depression, and difficulty in self-care increased steeply after home time loss of 15 days or greater. The MCID of home time was 18.6 days.

CONCLUSION

A loss in home time is associated with decline in several patient-centered outcome measures in community-dwelling Medicare beneficiaries. These results provide empirical evidence to promote adoption of home time and its clinical interpretation for database studies of medical interventions. J Am Geriatr Soc 67:347-351, 2019.

Optimizing the patient-centered environment: results of guided tours with health care providers and employees

OBJECTIVE

To examine providers' perspectives on the care environment and patient-centered care (PCC) through the eyes of the veteran patient, using guided tours qualitative methodology.

BACKGROUND

Environmental factors, such as attractiveness and function, have the potential to improve patients' experiences. Participatory qualitative methods allow researchers to explore the environment and facilitate discussion.

METHODS

Guided tours were conducted with 25 health care providers/employees at two Veterans Affairs (VA) health care facilities. In guided tours, participants lead the researcher through an environment, commenting on their surroundings, thoughts, and feelings. The researcher walks along with the participant, asking open-ended questions as needed to foster discussion and gain an understanding of the participant's view. Participants were asked to walk through the facility as though they were a veteran. Tours were audio recorded, with participant permission, and transcribed verbatim by research assistants. Three qualitative researchers were responsible for codebook development and coding transcripts and used data-driven coding approaches.

RESULTS

Participants discussed physical appearance of the environment and how that influences perceptions about care. Overall, participants highlighted the need to shed the "institutional" appearance. Differences between VA and non-VA health care facilities were discussed, including availability of private rooms and staff to assist with navigating the facility. They reviewed resources in the facility, such as the information desk to assist patients and families. Finally, they offered suggestions for future improvements, including improvements to waiting areas and quiet areas for patients to relax and "get away" from their rooms.

CONCLUSIONS

Participants highlighted many small changes to the care environment that could enhance the patient experience. Additionally, they examined the environment from the patient's perspective, to identify elements that enhance, or detract from, the patient's care experience.

Consumer Satisfaction in Nursing Homes

Surveys of resident satisfaction are commonplace in most nursing homes, although surveys used in many facilities may be biased toward concerns of providers and regulators instead of residents. In this study, content for a nursing home satisfaction survey was synthesized from analysis of 11 published and 5 commercially available instruments, as well as qualitative data from interviews with a diverse group of 15 residents in three New Jersey nursing homes. Content analysis of the 16 instruments yielded six broad domains of resident satisfaction: activities, care and services, caregivers, environment, meals, and well-being. Data from residents yielded 87 discrete areas of content across the six domains. In all domains except meals, existing instruments failed to address at least one area of content considered important by residents. Findings from this study provided a framework to generate items for a standardized resident satisfaction survey to be used in New Jersey nursing homes.

Exploring the impact of the physical environment on patient outcomes in ambulatory care settings

OBJECTIVE

This report of empirical literature on ambulatory care centers (ACCs) addresses a gap in the healthcare field by exploring physical features of ACC settings that have been associated with favorable patient outcomes.

BACKGROUND

Growing numbers of ACCs correspond with an increasing shift from inpatient to outpatient services. As the focus of ACCs shifts from treating episodes of illnesses to comprehensive, longitudinal, patient-centered care, different types of ACC settings seek to accommodate a variety of patient groups from different demographics.

METHODS

Given the range of ACC settings and population types and the paucity of literature focused on any one of these settings, the literature search process was broad based to include not only peer-reviewed literature, but also "gray literature" on ACC design. The primary focus was on research studies and reports that centered on some aspect of the physical environment in ACCs and their relationship to outcomes in these settings.

RESULTS

The following patient outcomes were identified in different phases of ACC patient experience: improved access and wayfinding, enhanced waiting experience, enhanced privacy, enhanced physician/staff-patient communication, reduced patient anxiety, and reduced risk of infection.

CONCLUSIONS

This article identifies physical design features of ACCs that can promote favorable patient outcomes. However, most literature reviewed adheres to a physician-centered model of episodic illness in which care ends with the experience in the exam room of the ACC. A more patient-centered approach has not been explored fully in the literature. The results indicate that there are many opportunities for future inquiry.

Patients’ Satisfaction with Quality Attributes of Primary Health Care Services in Nigeria

Patients’ satisfaction with health care is an important health outcome which has implications for capacity utilisation. And, in health systems that emphasise the cooperation and involvement of the community, both in terms of resources contribution and management, satisfaction with health care assumes an important dimension in terms of its implication for success of public health programmes. This study, based on administered questionnaires, examines patients/users’ satisfaction with quality attributes of health care services at the primary level facilities in order to provide feedback to health personnel and management for change and learning. The study employs correlation and multivariate regression analysis to determine the quality attributes that determine overall satisfaction with care. Our findings suggest the need to emphasis ‘empathy’ for care providers; and while a reasonable level of physical facilities should be provided, care providers have the task to communicate their technical competence to care seekers to ensure capacity utilisation at the primary level.

Enhancing the therapeutic potential of hospital environments by increasing the personal control and emotional comfort of hospitalized patients

Previous literature has revealed that patients in various health-care facilities worldwide have experienced dissatisfaction with aspects of the hospital environment. This article focuses on the impact of the hospital environment on patients' perceptions of personal control. The grounded theory method was used, and interviews with 40 patient participants and 75 hours of field observations provided data for this study. Personal control was found to be a central feature of emotional comfort, a therapeutic state that was considered to be an integral part of recovery. This study outlines some new directions for enhancing the therapeutic potential of hospital environments.

Response formats and satisfaction surveys for elders

PURPOSE

A factor common to the results of many satisfaction surveys of elders is a lack of response variability. Increasing response variability may be useful if satisfaction surveys of elders are to be productively used in the future. In this paper, we first examine elders' preferences between five response formats and then examine the response variability of these five commonly used formats.

DESIGN AND METHODS

Satisfaction, demographic, and Short-Form 36 Health Survey data were self-reported by patients in four outpatient surgery centers during 1998 and 1999. We used six different survey instruments randomly given to 3,122 elders. Five instruments varied in response format (5-item Likert format, 5-item satisfaction format, 5-item valuation format, 4-item Chernoff faces, and 10-item visual analogue format). The sixth survey used all five different response sets, and then it asked for the respondents' preferences among the different response sets.

RESULTS

A total of 2,450 questionnaires were examined (response rate of 78.5%). The response format using four Chernoff faces was liked the least, with only 5% of the respondents preferring this format. The 10-item visual analogue format (10VAF) was liked the most, with 39% of the respondents preferring this format. In addition, 10% more elders thought this format was easier to use than the second-place choice (i.e., 32% vs. 22%). The coefficient of variation for the 10VAF was also higher than those in identical domains using the other response formats. This would seem to indicate that the 10VAF is less prone to a ceiling effect than the other response formats.

IMPLICATIONS

Our results show that elders have a preference for some response formats, and from the choices we gave them a 10VAF was preferred. The 10VAF also had more response variability then the other formats we tested.

Patient-friendly hospital environments: exploring the patients' perspective

OBJECTIVE

To investigate the perceptions and attitudes of patients to the built environments of NHS Trust hospitals, in order to inform design excellence so as to make future hospitals places and spaces responsive to patient needs.

DESIGN

An exploratory study of patients perceptions based on qualitative semi-structured personal interviews.

SETTING AND PARTICIPANTS

Fifty one-to-one interviews held with hospital in-patients across the four directorates of surgery, medicine, care of the elderly and maternity at Salford Royal Hospitals NHS Trust, Salford, UK.

RESULTS

The research found that there was much similarity in the priorities, issues and concerns raised by patients in each of the four directorates. Patients perceived the built environment of the hospital as a supportive environment. Their accounts in each area pointed to the significance of the factors that immediately impacted on them and their families. Patients identified having a need for personal space, a homely welcoming atmosphere, a supportive environment, good physical design, access to external areas and provision of facilities for recreation and leisure. Responses suggest that patient attitudes and perceptions to the built environment of hospital facilities relates to whether the hospital provides a welcoming homely space for themselves and their visitors that promotes health and wellbeing.

CONCLUSIONS

The findings have important implications for capital development teams, clinical staff, managers and NHS Estates personnel. Although the study has immediate relevance for Salford Royal Hospitals Trust, findings and recommendations reported provide NHS Estates and other relevant stakeholders with evidence-based knowledge and understanding of patients' perceptions and expectations of and preferences for particular facilities and estates provision in NHS hospitals.

Meeting the health care needs of persons with disabilities

The Agency for Healthcare Research and Quality (AHRQ) has established the Office of Priority Populations Research and is currently developing a research agenda to improve health care for persons with disability (PWDs). This article describes the background of and potential for the AHRQ disability agenda and some of the challenges ahead and considers future directions for disability-related health services research. Strategies for this agenda might include ensuring the inclusion of PWDs in current and future health care research studies and database development; support for studies and data focusing exclusively on PWDs; and support for studies of the challenges common to all or most of the priority populations.