Potentially More Out of Reach: Public Reporting Exacerbates Inequities in Home Health Access

Policy Points Public reporting is associated with both mitigating and exacerbating inequities in high-quality home health agency use for marginalized groups. Ensuring equitable access to home health requires taking a closer look at potentially inequitable policies to ensure that these policies are not inadvertently exacerbating disparities as home health public reporting potentially does. Targeted federal, state, and local interventions should focus on raising awareness about the five-star quality ratings among marginalized populations for whom inequities have been exacerbated.

CONTEXT

Literature suggests that public reporting of quality may have the unintended consequence of exacerbating disparities in access to high-quality, long-term care for older adults. The objective of this study is to evaluate the impact of the home health five-star ratings on changes in high-quality home health agency use by race, ethnicity, income status, and place-based factors.

METHODS

We use data from the Outcome and Assessment Information Set, Medicare Enrollment Files, Care Compare, and American Community Survey to estimate differential access to high-quality home health agencies between July 2014 and June 2017. To estimate the impact of the home health five-star rating introduction on the use of high-quality home health agencies, we use a longitudinal observational pretest-posttest design.

FINDINGS

After the introduction of the home health five-star ratings in 2016, we found that adjusted rates of high-quality home health agency use increased for all home health patients, except for Hispanic/Latine and Asian American/Pacific Islander patients. Additionally, we found that the disparity in high-quality home health agency use between low-income and higher-income home health patients was exacerbated after the introduction of the five-star quality ratings. We also observed that patients within predominantly Hispanic/Latine neighborhoods had a significant decrease in their use of high-quality home health agencies, whereas patients in predominantly White and integrated neighborhoods had a significant increase in high-quality home health agency use. Other neighborhoods experience a nonsignificant change in high-quality home health agency use.

CONCLUSIONS

Policymakers should be aware of the potential unintended consequences for implementing home health public reporting, specifically for Hispanic/Latine, Asian American/Pacific Islander, and low-income home health patients, as well as patients residing in predominantly Hispanic/Latine neighborhoods. Targeted interventions should focus on raising awareness around the five-star ratings.

Impact of Public Reporting of Center-Specific Survival Analysis Scores on Patient Volumes at Hematopoietic Cell Transplant Centers

BACKGROUND

The Center for International Blood and Marrow Transplant Research (CIBMTR) reports the outcomes of allogeneic hematopoietic cell transplantation (alloHCT) at United States transplant centers (TC) annually through its Center-Specific Survival Analysis (CSA). The CSA compares the actual 1-year overall survival (OS) and predicted 1-year OS rate after alloHCT at each TC, which is then reported as 0 (OS as expected), -1 (OS worse than expected), or +1 (OS better than expected).

OBJECTIVE

We evaluated the impact of public reporting of TC performance on their alloHCT patient volumes.

STUDY DESIGN

Ninety-one TCs that serve adult or combined adult and pediatric populations and had CSA scores reported for 2012-2018 were included. We analyzed prior-calendar year TC volume, prior-calendar year CSA score, whether the CSA score had changed in the prior year from two years earlier, calendar year, TC type (adult only vs. combined adult and pediatric), and years of alloHCT experience for their impact on patient volumes.

RESULTS

A CSA score of -1, as compared with 0 or +1, was associated with an 8%-9% reduction in the mean TC volume (P < 0.001) in the subsequent year, adjusting for the prior year center volume. Additionally, being a TC neighboring an index TC with a -1 CSA score, was associated with a 3.5% increase in mean TC volume (P = 0.04).

CONCLUSION

Our data show that public reporting of CSA scores is associated with changes in alloHCT volumes at TCs. Additional investigation into the causes of this shift in patient volume and the impact on outcomes is ongoing.

Hospital rating websites play a minor role for uro-oncologic patients when choosing a hospital for major surgery: results of the German multicenter NAVIGATOR-study

PURPOSE

Hospital rating websites (HRW) offer decision support in hospital choice for patients. To investigate the impact of HRWs of uro-oncological patients undergoing elective surgery in Germany.

METHODS

From 01/2020 to 04/2021, patients admitted for radical prostatectomy, radical cystectomy, or renal tumor surgery received a questionnaire on decision-making in hospital choice and the use of HRWs at 10 German urologic clinics.

RESULTS

Our study includes n = 812 completed questionnaires (response rate 81.2%). The mean age was 65.2 ± 10.2 years; 16.5% were women. Patients were scheduled for prostatectomy in 49.1%, renal tumor surgery in 20.3%, and cystectomy in 13.5% (other 17.1%). Following sources of information influenced the decision process of hospital choice: urologists' recommendation (52.6%), previous experience in the hospital (20.3%), recommendations from social environment (17.6%), the hospital's website (10.8%) and 8.2% used other sources. Only 4.3% (n = 35) used a HRW for decision making. However, 29% changed their hospital choice due to the information provided HRW. The most frequently used platforms were Weisse-Liste.de (32%), the AOK-Krankenhausnavigator (13%) and Qualitaetskliniken.de (8%). On average, patients rated positively concerning satisfaction with the respective HRW on the Acceptability E-Scale (mean values of the individual items: 1.8-2.1).

CONCLUSION

In Germany, HRWs play a minor role for uro-oncologic patients undergoing elective surgery. Instead, personal consultation of the treating urologist seems to be far more important. Although patients predominantly rated the provided information of the HRW as positive, only a quarter of users changed the initial choice of hospital.

The impact of transparency constraints on the efficiency of the Russian healthcare system: systematic literature review

There is an ongoing debate among researchers and policy-makers on how to make transparency a powerful tool of healthcare systems. This study addresses how the availability and accessibility of information about medical services to the general population affects healthcare outcomes in Russia. A systematic review was conducted and reported according to the Preferred Reporting Items for Systematic Reviewing and Meta-Analysis (PRISMA) guidelines. Transparency indicators of health facilities used in the world's most efficient healthcare systems are also reviewed. Although the increase of transparency in the Russian healthcare system is considered as a tool for improving its efficiency, very little has been done to improve the actual level of transparency. The existing institutional specifics of the Russian healthcare system impose serious restrictions on acceptable levels of transparency. In the reviewed empirical Russian studies, transparency is often viewed simplistically as either information available on the websites of medical organizations or issues related to the amount of accessible indicators of compulsory medical statistical reporting. The novelty of this study consists in (a) reviewing the most recent studies on the topic and (b) including studies in Russian in the analysis. We elaborate on general and specific policy implications for improving transparency-driven outcomes in the Russian healthcare system.

The impact of hospital price and quality transparency tools on healthcare spending: a systematic review

BACKGROUND

Global spending on health was continuing to rise over the past 20 years. To reduce the growth rates, alleviate information asymmetry, and improve the efficiency of healthcare markets, global health systems have initiated price and quality transparency tools in the hospital industry in the last two decades. OBJECTIVE : The objective of this review is to synthesize whether, to what extent, and how hospital price and quality transparency tools affected 1) the price of healthcare procedures and services, 2) the payments of consumers, and 3) the premium of health insurance plans bonding with hospital networks.

METHODS

A literature search of EMBASE, Web of Science, Econlit, Scopus, Pubmed, CINAHL, and PsychINFO was conducted, from inception to Oct 31, 2021. Reference lists and tracked citations of retrieved articles were hand-searched. Study characteristics were extracted, and included studies were scored through a risk of bias assessment framework. This systematic review was reported according to the PRISMA guidelines and registered in PROSPERO with registration No. CRD42022319070.

RESULTS

Of 2157 records identified, 18 studies met the inclusion criteria. Near 40 percent of studies focused on hospital quality transparency tools, and more than 90 percent of studies were from the US. Hospital price transparency reduced the price of laboratory and imaging tests except for office-visit services. Hospital quality transparency declined the level or growth rates of healthcare spending, while it adversely and significantly raised the price of healthcare services and consumers' payment in higher-ranked or rated facilities, which was referred to as the reputation premium in the healthcare industry. Hospital quality transparency not only leveraged private insurers bonding with a higher-rated hospital network to increase premiums, but also induced their anticipated pricing behaviors.

CONCLUSION

Hospital price and quality transparency was not effective as expected. Future research should explore the understudied consequences of hospital quality transparency programs, such as the reputation/rating premium and its policy intervention.

Accuracy and Completeness of Intermediate-Level Nursery Descriptions on Hospital Websites

IMPORTANCE

Birth at hospitals with an appropriate level of neonatal intensive care units is associated with better neonatal outcomes. The primary sources for information about hospital neonatal unit levels for prospective parents, referring physicians, and the public are hospital websites, but the accuracy of neonatal unit capacity is unclear.

OBJECTIVE

To determine if hospital websites accurately report the capabilities of intermediate (ie, level II) units, which are intended for care of newborns with low to moderate illness levels or the stabilization of newborns prior to transfer.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study compared descriptions of level II unit capabilities on hospital web pages in 10 large states with their respective state-level designation. Analyzed units were located in the 10 states with the highest number of live births in 2019 (excluding states with no level II regulations) and had active websites as of May 2021.

MAIN OUTCOMES AND MEASURES

Hospital websites were assessed for whether there was any mention of the unit, the description of the unit was provided, the unit was identified as a level III or both levels II and III, the terms "neonatal intensive care unit" or "NICU" were used without indicating limits in care available or newborn acuity, or the unit was claimed to provide the most advanced level of care.

RESULTS

A total 28 states had no regulation of nursery unit levels; in the 10 large, regulated states, web descriptions of level II units were incomplete for 39.2% of hospitals (95% CI, 33.3%-45.3%) and inaccurate for 24.6% (95% CI, 19.6%-30.2%). Within incomplete descriptions, 2.6% (95% CI, 1.1%-5.3%) of hospitals did not mention an advanced care unit and 22.0% (95% CI, 17.2%-27.5%) identified a level II unit without providing further description. Within inaccurate descriptions, 25.4% (95% CI, 20.3%-31.0%) of hospitals described the unit as a "neonatal intensive care unit" or "NICU" without any qualification and 9.3% (95% CI, 6.3%-13.5%) claimed that the unit provided the most advanced neonatal care or care to the sickest newborns; 3.0% of hospitals (95% CI, 1.3%-6.0%) stated that their unit was level III and 1.5% (95% CI, 0.4%-3.8%) as level II and III. Across states there was substantial variation in rates of incompleteness and inaccuracy.

CONCLUSIONS AND RELEVANCE

Incomplete and inaccurate hospital web descriptions of intermediate newborn care units are common. These deficits can mislead parents, clinicians, and the public about the appropriateness of a hospital for sick newborns, which raises important ethical questions.

Drivers of paediatric inpatient experience: retrospective analysis of casemix factors for the Alberta Paediatric Inpatient Experience Survey in Alberta, Canada

OBJECTIVE

In Alberta, the Alberta Paediatric Inpatient Experience Survey (APIES) is used as a proxy-reported measure of paediatric experience. To our knowledge, the influence of casemix factors on patient experience as measured by paediatric patient experience surveys have not been reported within Canadian paediatric samples. In this paper, we sought to determine the patient and respondent factors associated with paediatric inpatient experiences in Alberta, Canada.

DESIGN

Retrospective analysis of patient experience survey data.

SETTING

Inpatiet acute care hospitals in Alberta, Canada.

INTERVENTION AND MAIN OUTCOME MEASURES

Retrospective analyses were conducted using APIES surveys linked with eligible inpatient records (n=6262). Descriptive statistics were reported. χ² tests were performed to assess distribution of casemix between general and paediatric hospitals. Logistic regression was performed with overall hospital experience as the dependent variable with casemix and hospital variables as independent variables.

RESULTS

Casemix characteristics were unevenly distributed between general and paediatric hospitals. Compared with reference categories, older respondents, healthier patients and treatment at paediatric facilities had increased odds of providing most-positive ratings. Increased respondent education was associated with decreased odds of providing most-positive ratings. Likelihood-ratio tests showed that most casemix variables improved model fit, except for respondent relationship to the patient.

CONCLUSIONS

To improve reports of paediatric inpatient experience, administrators and providers require reliable and comparable measurement. Both the Child Hospital Consumer Assessment of Healthcare Providers and Systems and other measures of patient and family experience need to consider patient and respondent characteristics when interpreting results. Considered with other research from patient experience in Alberta, we discuss future directions and quality improvement implications.

Qualitätstransparenz in der stationären Krankenhausversorgung der Schweiz

Qualitätstransparenz ist eine entscheidende Grundlage für den Abbau von Informationsasymmetrien im Gesundheitswesen. Doch welche Informationen zur stationären, akutsomatischen Versorgung sind in der Schweiz vorhanden, wie können diese genutzt werden und welche Folgen ergeben sich daraus? Für diese Fragestellungen wird ein Review des Datenangebots vorgenommen, systematisch aufbereitet sowie Stärken und Schwächen aufgezeigt. Auf dieser Grundlage sowie internationalen Vergleichen folgen gesundheitspolitische Empfehlungen für eine Verbesserung der aktuellen Bedingungen. Die Studie zeigt auf, dass Qualitätstransparenz in der Schweiz trotz des bereits im Jahr 2011 vereinbarten nationalen Qualitätsvertrags nur begrenzt gegeben ist. Dies erschwert die Stärkung eines Qualitätswettbewerbs, die informierte Entscheidung über die Krankenhauswahl von Patienten sowie das selektive Kontrahieren. Eine Weiterentwicklung der in der Schweiz verfügbaren Daten und Messinstrumente in Krankenhäusern ist daher angezeigt und bedarf einer priorisierten Umsetzung.

Determinants of inpatient satisfaction: evidence from Switzerland

PURPOSE

A common way to handle quality problems and increasing costs of modern health care systems is more transparency through public reporting. Thereby, patient satisfaction is seen as one main reported outcome. Previous studies proposed several associated factors. Only a few of them included organizational determinants with potential to inform the health care provider's management. Therefore, the aim of this study was to investigate the influence of organizational contingency factors on patient satisfaction.

DESIGN/METHODOLOGY/APPROACH

As a case, Switzerland's inpatient rehabilitation sector was used. Therein, a cross-sectional study of public released secondary data with an exploratory multiple linear regression (MLR) modeling approach was conducted.

FINDINGS

Five significant influencing factors on patient satisfaction were found. They declared 42.2% of the variance in satisfaction on provider level. The organizations' supplementary insured patients, staff payment, outpatients, extracantonal patients and permanent resident population revealed significant correlations with patient satisfaction.

RESEARCH LIMITATIONS/IMPLICATIONS

Drawing on publicly available cross-sectional data, statistically no causality can be proved. However, integration of routine data and organization theory can be useful for further studies.

PRACTICAL IMPLICATIONS

Regarding inpatient satisfaction, improvement levers for providers' managers are as follow: first, service provision should be customized to patients' needs, expectations and context; second, employees' salary should be adequate to prevent dissatisfaction; third, the main business should be prioritized to avoid frittering.

ORIGINALITY/VALUE

Former studies regarding public reporting are often atheoretical and rarely used organizational variables as determinants for relevant outcomes. Therefore, uniformed data are useful.

Rethinking health services operations to embrace patient experience of healthcare journey

Patient experience is assumed pivotal for improving health services operations. The patient experience of healthcare services in Iran has been mostly assessed through the satisfaction and quality of single services or activities at individual providers, clinical departments, or health facilities. However, given the rise of chronic and multi-morbid conditions, health services for these conditions consist of several activities and interactions through a journey that patients take in the health system. To fill in this gap, we propose focusing on the assessment of patient experience on the patient journey through the health system. We advocate that there is much potential for improving the patient experience by rethinking the operations management of health services to embrace the patient experience of the healthcare journey. Rethinking health operations management may include an exhaustive list of interventions. Concisely, at the strategic level, policy-makers while understanding the need for shifting towards the patient experience, make sure that operational level management is experience oriented. This would be pursued through a strategic approach to patient experience, reconsidering qualifications for operational management, and benchmarking to identify and share best practices. Lessons learnt from previous quality improvement programmes are also considered as a capacity to establish the experience orientation.

Does public report card matter? A 10-year interrupted time series analysis on total knee replacement

BACKGROUND

There is a lack of evidence that shows whether a report card can improve health outcomes in terms of infection rates or unscheduled readmission by using rigorous methods to evaluate its impact.

METHODS

We used the National Health Insurance Administration's claims database from 1 January 2004 to 30 December 2013 and a time series analysis to evaluate the impact of the quality report card initiative on three negative outcomes of total knee replacement for each quarter of the year, including the rates of superficial infection of a knee replacement, deep infection of knee arthroplasty and unplanned readmissions for surgical site infection.

RESULTS

These negative outcomes (original scale) do not show significant decreases in terms of superficial infection (-0.05‰, -0.63 to 0.53‰, P = 0.87), deep infection (-0.003‰, -0.19 to 0.18‰, P = 0.97) and unscheduled readmission (0.02‰, -0.21 to 0.25‰, P = 0.88).

CONCLUSION

The total knee replacement public report card initiative did not improve the rate of infection and unscheduled readmission for surgical site infection. This report card in Taiwan should involve physicians' participation in the design and be tailored to be suitable for reading by patients in order to further enhance the chance of improvement in these negative outcomes.

Mechanisms and impact of public reporting on physicians and hospitals' performance: A systematic review (2000-2020)

BACKGROUND

Public performance reporting (PPR) of physician and hospital data aims to improve health outcomes by promoting quality improvement and informing consumer choice. However, previous studies have demonstrated inconsistent effects of PPR, potentially due to the various PPR characteristics examined. The aim of this study was to undertake a systematic review of the impact and mechanisms (selection and change), by which PPR exerts its influence.

METHODS

Studies published between 2000 and 2020 were retrieved from five databases and eight reviews. Data extraction, quality assessment and synthesis were conducted. Studies were categorised into: user and provider responses to PPR and impact of PPR on quality of care.

RESULTS

Forty-five studies were identified: 24 on user and provider responses to PPR, 14 on impact of PPR on quality of care, and seven on both. Most of the studies reported positive effects of PPR on the selection of providers by patients, purchasers and providers, quality improvement activities in primary care clinics and hospitals, clinical outcomes and patient experiences.

CONCLUSIONS

The findings provide moderate level of evidence to support the role of PPR in stimulating quality improvement activities, informing consumer choice and improving clinical outcomes. There was some evidence to demonstrate a relationship between PPR and patient experience. The effects of PPR varied across clinical areas which may be related to the type of indicators, level of data reported and the mode of dissemination. It is important to ensure that the design and implementation of PPR considered the perspectives of different users and the health system in which PPR operates in. There is a need to account for factors such as the structural characteristics and culture of the hospitals that could influence the uptake of PPR.

Two Decades of Nursing Home Compare: What Have We Learned?

Approximately two decades ago, federally mandated public reporting began for U.S. nursing homes through a system now known as Nursing Home Compare. The goals were to provide information to enable consumers to choose higher quality nursing homes and to incent providers to improve the quality of care delivered. We conduct a systematic review of the literature on responses to Nursing Home Compare and its effectiveness in meeting these goals. We find evidence of modest but meaningful response by both consumers and providers. However, we also find evidence that some improvement in scores does not reflect true quality improvement, that disparities by race and income have increased, that risk-adjustment of the measures is likely inadequate, and that several key domains of quality are not represented. Our results support moderate success of Nursing Home Compare in achieving intended goals but also reveal the need for continued refinement.

Promoting access to family medicine in Québec, Canada: Analysis of bill 20, enacted in November 2015

Primary care can potentially make an important contribution to improving health system performance. However, Canada does not fare as well as other developed countries in terms of timely access to primary health care services. In November 2015, Bill 20 was introduced in the province of Québec. The goal of Bill 20 was to optimize the utilisation of medical and financial resources to improve access to primary care. Bill 20 states the obligations of general practitioners to register a minimum number of patients, ensure the continuity of care of that population, and practice a minimum number of hours in hospitals. Many actors agreed that access to primary care had to be improved in Québec, but disagreed with Bill 20. In particular, family physicians strongly opposed the financial penalties that were introduced for physicians failing to meet the specified targets. In January 2018, 3 years after Bill 20, indicators for patient registration and continuity of care have considerably improved. However, the attractiveness of general practice seems to have decreased among medical graduates, which creates uncertainty regarding the sustainability of the achievements brought on by Bill 20.

Interprofessional perceptions and emotional impact of multidrug-resistant organisms: A qualitative study

BACKGROUND

Hospital-acquired infections caused by multidrug-resistant organisms (MDROs) are a threat to patient safety and hospital economy. Training in hygiene precautions is known to limit MDRO spread and patient morbidity. As infection prevention is a collaborative task, we developed an interprofessional educational intervention, including a reflective unit about MDRO. This article reports on the perceptions of professionals for MDRO management.

METHODS

In 2017, we conducted 8 trainings, including facilitated group discussions focusing on the question how participants think others experience MDRO. Results were analyzed using a socio-constructivist qualitative approach.

RESULTS

A total of 51 health care workers from 13 professions and 5 hospitals participated, generating 366 items for coding. Three main themes could be identified: (1) significant barriers in educating clinicians and informing lay persons, (2) emotional reactions-especially anxiety and anger-from the perspective of lay persons and professionals evoked by MDRO, and (3) perceived economic burden.

CONCLUSIONS

MDROs generate psychosocial side effects with an impact on health care management and on professional-patient relationships and interprofessional relationships. Specifically, emotions evoked by insufficient information and transparency play a major role. Therefore, hygiene trainings must not be limited to basic skills. In addition, they should be comprised of communication and educational techniques and evoke attentiveness for emotional stress.

Improving Patient Experience of Care Providers in a Multispecialty Ambulatory Pediatrics Practice

Patient experience is positively associated with superior medical outcomes, clinical quality, patient safety measures, physician job satisfaction, doctor-patient communication, and patient compliance with treatment recommendations. A concrete pediatrics-focused methodology for improving patient experience in a multispecialty ambulatory setting has not been described, nor has the impact on practice outcomes been assessed. The primary aim of this study was to improve patient experience care provider scores at a single multiclinic children's hospital in the Midwest to the 70th percentile in a 5-year period. The secondary aim sought to determine the impact of quality improvement efforts on practice growth, patient complaint rate, and provider/staff engagement. Patient experience was measured by returned Press-Ganey surveys. Interventions involved establishing infrastructure, promoting feedback and transparency, providing education, and transforming culture. Provider scores improved from the 19th to the 70th percentile within 5 years. Practice volume increased by 17.1%; patient complaint/grievance frequency decreased 33-fold; and provider/staff engagement did not appreciably change.