Can inpatient hospital experiences predict central line-associated bloodstream infections?

Exploring patient perspectives: A qualitative inquiry into healthcare perceptions, experiences and satisfaction in Lebanon

BACKGROUND

Patient perspectives have received increasing importance within health systems over the past four decades. Measures of patient experience and satisfaction are commonly used. However, these measures do not capture all the information that is available through engaging with patients. An improved understanding of the various types of patient perspectives and the distinctions between them is needed. The lack of such knowledge limits the usefulness of including patient perspectives as components within pay-for-performance initiatives. This study aimed to explore patient perspectives on hospital care in Lebanon. It also aimed to contribute insights that may improve the national pay-for-performance initiative and to the knowledge on engaging patients towards person-centered health systems.

METHODS

We conducted a qualitative study using focus group discussions with persons recently discharged after hospitalization under the coverage of the Lebanese Ministry of Public Health. This study was implemented in 2017 and involved 42 participants across eight focus groups. Qualitative content analysis was used to analyze the information provided by participants.

RESULTS

Five overall themes supported by 17 categories were identified, capturing the meaning of the participants' perspectives: health is everything; being turned into second class citizens; money and personal connections make all the difference; wanting to be treated with dignity and respect; and tolerating letdown, for the sake of right treatment. The most frequently prioritized statement in a ranking exercise regarding patient satisfaction was regular contact with the patient's doctor.

CONCLUSIONS

Patient perspectives include more than what is traditionally incorporated in measures of patient satisfaction and experience. Patient valuing of health and their perceptions on each of the health system, and access and quality of care should also be taken into account. Hospital pay-for-performance initiatives can be made more responsive through a broader consideration of these perspectives. More broadly, health systems would benefit from wider engagement of patients. We propose a framework relating patient perspectives to value-based healthcare and health system performance.

Association of patient experience and the quality of hospital care

The association between patient experience and the quality of hospital care is controversial. We assess the association between clinical outcomes and patient-reported experience measures (PREMs) in hospitals in Saudi Arabia. Knowledge on this issue informs value-based health-care reforms. A retrospective observational study was conducted in 17 hospitals in Saudi Arabia during the period of 2019-22. Hospital data were collected on PREMs, mortality, readmission, length of stay (LOS), central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), and surgical site infection. Descriptive analysis was used to describe hospital characteristics. Spearman's rho correlation tests were used to assess the correlation between these measures, and multivariate generalized linear mixed model regression analysis was used to study associations while controlling for hospital characteristics and year. Our analysis showed that PREMs were negatively correlated with hospital readmission rate (r = -0.332, P ≤ .01), LOS (r = -0.299, P ≤ .01), CLABSI (r = -0.297, P ≤ .01), CAUTI (r = -0.393, P ≤ .01), and surgical site infection (r = -0.298, P ≤ .01). The results indicated that CAUTI and LOS converged negatively with PREMs (β = -0.548, P = .005; β = -0.873, P = .008, respectively) and that larger hospitals tended to have better patient experience scores (β =0.009, P = .003). Our findings suggest that better performance in clinical outcomes is associated with higher PREM scores. PREMs are not a substitute or surrogate for clinical quality. Yet, PREMs are complementary to other objective measures of patient-reported outcomes, the process of care, and clinical outcomes.

Patient Satisfaction Scores Impact Pediatrician Practice Patterns, Job Satisfaction, and Burnout

Patient satisfaction (PS) surveying has become a commonly used measure of physician performance, but little is known about the impact on pediatricians. To investigate our hypothesis that PS surveys negatively impact pediatricians, we conducted a survey at an academic children's medical center. Of 155 eligible physicians, 115 responded (response rate 74%). Two-thirds (68%) did not find the PS score report useful and 88% did not feel that PS scores accurately reflect the physician's clinical ability. A third reported ordering tests, medications, or consultations due to pressure for higher PS scores. In addition, one-third agreed that PS surveys contribute to burnout and make it difficult to practice meaningful medicine. Overall, PS score reporting has a negative impact on pediatricians, especially those who are female, BIPOC (Black, Indigenous, and People of color), subspecialists, younger, and attended non-US medical schools. Further investigation into improved methods for providing feedback to pediatric physicians is warranted.

Patient-Reported Care Coordination is Associated with Better Performance on Clinical Care Measures

BACKGROUND

Prior studies using aggregated data suggest that better care coordination is associated with higher performance on measures of clinical care process; it is unclear whether this relationship reflects care coordination activities of health plans or physician practices.

OBJECTIVE

Estimate within-plan relationships between beneficiary-reported care coordination measures and HEDIS measures of clinical process for the same individuals.

DESIGN

Mixed-effect regression models in cross-sectional data.

PARTICIPANTS

2013 Medicare Advantage CAHPS respondents (n=152,069) with care coordination items linked to independently collected HEDIS data on clinical processes.

MAIN MEASURES

Care coordination measures assessed follow-up, whether doctors had medical records during visits, whether doctors discussed medicines being taken, how informed doctors seemed about specialist care, and help received with managing care among different providers. HEDIS measures included mammography, colorectal cancer screening, cardiovascular LDL-C screening, controlling blood pressure, 5 diabetes care measures (LDL-C screening, retinal eye exam, nephropathy, blood sugar/HbA1c <9%, LCL-C<100 mg/dL), glaucoma screening in older adults, BMI assessment, osteoporosis management for women with a fracture, and rheumatoid arthritis therapy.

KEY RESULTS

For 9 of the 13 HEDIS measures, within health plans, beneficiaries who reported better care coordination also received better clinical care (p<0.05) and none of the associations went in the opposite direction; HEDIS differences between those with excellent and poor coordination exceeded 5 percentage points for 7 measures. Nine measures had positive associations (breast cancer screening, colorectal cancer screening, cardiovascular care LDL-C screening, 4 of 5 diabetes care measures, osteoporosis management, and rheumatoid arthritis therapy).

CONCLUSIONS

Within health plans, beneficiaries who report better care coordination also received higher-quality clinical care, particularly for care processes that entail organizing patient care activities and sharing information among different healthcare providers. These results extend prior research showing that health plans with better beneficiary-reported care coordination achieved higher HEDIS performance scores.

Can patient-reported room cleanliness measures predict hospital-acquired C. difficile infection? A study of acute care facilities in New York state

BACKGROUND

Patient experience measures, like those form the Hospital Consumer Assessment of Healthcare providers and Systems survey, are increasingly used in healthcare policy decisions. However, it remains unclear if these reflect quality of care, like rates of hospital-acquired infections (HAIs). This study examined the relationship between patient-reported room cleanliness, from the Hospital Consumer Assessment of Healthcare providers and Systems survey, and hospital-acquired C. difficile infection (HA-CDI) rates in NYS acute care hospitals.

METHODS

A random-effects regression analysis compared the percentage of patients indicating their room was "always" and "sometimes/never" kept clean to that facility's average HA-CDI rates, controlling for known predictors.

RESULTS

A higher percentage of patients reporting their room was "always" kept clean was associated with significantly lower rates of HA-CDI. Facilities experience 0.031 fewer cases of HA-CDI/1,000 discharges for every percentage point increase in the number of patients rating their room as "always" clean (P = .006). A higher percentage of patients reporting their room was "sometimes/never" kept clean was associated with higher rates of HA-CDI (β = 0.033), but this was not significant (P = .096).

CONCLUSIONS

These findings suggest patient perceptions of cleanliness may reflect microbial cleanliness and these measures could assist in the prevention of HAIs. However, further research is needed.

An approach to exploring associations between hospital structural measures and patient satisfaction by distance-based analysis

BACKGROUND

Patient satisfaction studies have explored domains of patient satisfaction, the determinants of domains, and score differences of domains by patient/hospital structural measures but reports on the structure of patient satisfaction with respect to similarities among domains are scarce. This study is to explore by distance-based analysis whether similarities among patient-satisfaction domains are influenced by hospital structural measures, and to design a model evaluating relationships between the structure of patient satisfaction and hospital structural measures.

METHODS

The Hospital Consumer Assessment of Healthcare Providers and Systems 2012 survey scores and their structural measures from the Hospital Compare website reported adjusted percentages of scale for each hospital. Contingency tables of nine measures and their ratings were designed based on hospital structural measures, followed by three different distance-based analyses - clustering, correspondence analysis, and ordinal multidimensional scaling - for robustness to identify homogenous groups with respect to similarities.

RESULTS

Of 4,677 hospitals, 3,711 (79.3%) met the inclusion criteria and were analyzed. The measures were divided into three groups plus cleanliness. Certain combinations of these groups were shown to be dependent on hospital structural measures. High value ratings for communication and low value ratings for medication explanation, quietness and staff responsiveness were not influenced by hospital structural measures, but the varied-ratings domain group similarities, including items such as global evaluation and pain management, were affected by hospital structural measures.

CONCLUSIONS

Distance-based analysis can reveal the hidden structure of patient satisfaction. This study suggests that hospital structural measures including hospital size, the ability to provide acute surgical treatment, and hospital interest in improving medical care quality are factors which may influence the structure of patient satisfaction.

What do patients really want? An in-depth examination of patient experience in four Australian hospitals

BACKGROUND

Patient satisfaction is an important outcome measure guiding quality improvement in the healthcare setting while the patient-centred care movement places increasing importance on patient engagement in clinical decision-making. However, the concept of patient satisfaction is not clearly defined, and beliefs of patients are not always evident in health surveys. Researchers rarely follow up on surveys to explore patient views and what they mean in greater depth. This study set out to examine perceptions of hospital care, through in-depth, qualitative data capture and as a result, to gather rich, patient-driven information on user experience and satisfaction in the Australian healthcare setting; and identify influencing factors.

METHODS

Focus groups were undertaken in four St Vincent's Health Australia (SVHA) hospitals in 2017 where participants discussed responses to eight questions from the Press Ganey Patient Experience Survey. Thirty people who were inpatients at SVHA.

RESULTS

Good communication and high-quality information at arrival and discharge were found to be important to patients. Communication breakdown was also evident, further exacerbated by a range of environmental factors such as sharing a room with others. Overall, patients' felt that while their spiritual needs were well-supported by the hospital staff at all SVHA hospitals, it was the clinical teams prioritised their emotional needs. Good communication and environments can improve patient experience and follow-up at home is vital.

CONCLUSIONS

Patient-centred care needs careful planning with patients involved at entry and exit from hospital. Focused communication, environmental changes, attending to complaints, and clearer discharge strategies are recommended.

Predicting central line-associated bloodstream infections and mortality using supervised machine learning

PURPOSE

The purpose of this study was to compare machine learning techniques for predicting central line-associated bloodstream infection (CLABSI).

MATERIALS AND METHODS

The Multiparameter Intelligent Monitoring in Intensive Care III database was queried for all ICU admissions. The variables included six different severities of illness scores calculated on the first day of ICU admission with their components and comorbidities. The outcomes of interest were in-hospital mortality, central line placement, and CLABSI. Predictive models were created for these outcomes using classifiers with different algorithms: logistic regression, gradient boosted trees, and deep learning.

RESULTS

There were 57,786 total hospital admissions and the mortality rate was 10.1%. There were 38.4% patients with a central line and the rate of CLABSI was 1.5%. The classifiers using deep learning performed with the highest AUC for mortality, 0.885±0.010 (p<0.01) and central line placement, 0.816±0.006 (p<0.01). The classifier using logistic regression for predicting CLABSI performed with an AUC of 0.722±0.048 (p<0.01).

CONCLUSIONS

This study demonstrates models for identifying patients who will develop CLABSI. Early identification of these patients has implications for quality, cost, and outcome improvements.

Patients' perceptions of interactions with hospital staff are associated with hospital readmissions: a national survey of 4535 hospitals

BACKGROUND

Reducing 30-day hospital readmissions has become a focus of the current national payment policies. Medicare requires that hospitals collect and report patients' experience with their care as a condition of payment. However, the extent to which patients' experience with hospital care is related to hospital readmission is unknown.

METHODS

We established multivariate regression models in which 30-day risk-adjusted readmission rates were the dependent variables and patients' perceptions of the responsiveness of the hospital staff and communication (as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores) were the independent variables of interest. We selected six different clinical conditions for analyses, including acute myocardial infarction (AMI), chronic obstructive pulmonary disease (COPD), heart failure, hip/knee surgery, pneumonia, and stroke. Data included all acute care hospitals reporting in Hospital Compare in 2014.

RESULTS

The number of hospitals with reported readmissions ranged from 2234 hospitals for AMI to 3758 hospitals for pneumonia. The average 30-day readmission rates ranged from 5.19% for knee/hip surgery to 22.7% for COPD. Patient experience of hospital-staff responsiveness as "top-box" ranged from 64% to 67% across the six clinical conditions, communication with nurses ranged from 77% to 79% and communication with doctors ranged from 80% to 81% (higher numbers are better). Our finding suggests that hospitals with better staff responsiveness were significantly more likely to have lower 30-day readmissions for all conditions. The effect size depended on the baseline readmission rates, with the largest effect on hospitals in the upper 75th quartile. A ten-percentage-point increase in staff responsiveness led to a 0.03-0.18 percentage point decrease in readmission rates. We found that neither communication with physicians nor communication with nurses was significantly associated with hospital readmissions.

CONCLUSIONS

Our findings suggest that elements of care related to staff responsiveness during patients' stay may influence rehospitalization rates. Changes in staff responsiveness may offer an additional tool for hospitals to employ ongoing efforts to achieve reductions in readmissions, an important objective both financially and for patient health outcomes.

Improving Prediction Accuracy of "Central Line-Associated Blood Stream Infections" Using Data Mining Models

Prediction of nosocomial infections among patients is an important part of clinical surveillance programs to enable the related personnel to take preventive actions in advance. Designing a clinical surveillance program with capability of predicting nosocomial infections is a challenging task due to several reasons, including high dimensionality of medical data, heterogenous data representation, and special knowledge required to extract patterns for prediction. In this paper, we present details of six data mining methods implemented using cross industry standard process for data mining to predict central line-associated blood stream infections. For our study, we selected datasets of healthcare-associated infections from US National Healthcare Safety Network and consumer survey data from Hospital Consumer Assessment of Healthcare Providers and Systems. Our experiments show that central line-associated blood stream infections (CLABSIs) can be successfully predicted using AdaBoost method with an accuracy up to 89.7%. This will help in implementing effective clinical surveillance programs for infection control, as well as improving the accuracy detection of CLABSIs. Also, this reduces patients' hospital stay cost and maintains patients' safety.

Patient experience with outpatient encounters at public hospitals in Shanghai: Examining different aspects of physician services and implications of overcrowding

BACKGROUND

Over 90% of outpatient care in China was delivered at public hospitals, making outpatient experience in this setting an important aspect of quality of care.

OBJECTIVE

To assess outpatient experience with different aspects of physician services at China's public hospitals and its association with overcrowding of the hospital outpatient departments.

RESEARCH DESIGN

Retrospective analysis of a large survey of outpatient experience in Shanghai, China. We tested the hypotheses that patient experience was poorer with physician-patient communication, education, and shared decision-making and where and when there was greater overcrowding of the hospital outpatient departments. Ordered logistic models were estimated separately for general and specialty hospitals.

SUBJECTS

7,147 outpatients at 40 public hospitals in Shanghai, China, in 2014.

MEASURES

Patient experience with physician services were self-reported based on 12 questions as part of a validated instrument. Indicators of overcrowding included time of visit (morning vs. afternoon, Monday vs. rest of the week) and hospital outpatient volume in the first half of 2014.

RESULTS

Overall, patients reported very favorable experience with physician services. Two out of the 12 questions pertaining to both communication and shared decision-making consistently received lower ratings. Hospitals whose outpatient volumes were in the top two quartiles received lower patient ratings, but the relationship achieved statistical significance among specialty hospitals only.

CONCLUSIONS

Inadequate physician-patient communication and shared decision-making and hospital overcrowding compromise outpatient experience with physician services at Chinese public hospitals. Effective diversion of patients with chronic and less complex conditions to community health centers will be critical to alleviate the extreme workloads at hospitals with high patient volumes and, in turn, improve patient experience.

Measuring Quality of Care with Patient Satisfaction Scores

Quality of care is a multidimensional concept encompassing safety, efficiency, outcomes, and the patient experience. Traditional quality metrics, such as mortality rates, complication rates, and patient-reported outcomes, are time-consuming and cost-consuming to obtain and risk-stratify. The implications of reimbursement related to patient satisfaction and the ease of data collection have contributed to the perception that satisfaction is a global indicator of health-care quality; however, high satisfaction scores are not consistently correlated with traditional outcome and safety indicators. Higher patient satisfaction may be associated with increased costs of care. Costs may be further increased by the implementation of the satisfaction surveys themselves, which can increase imaging studies and prescriptions. Therefore, satisfaction surveys are not appropriate measures of overall quality of care. Accurate assessment of quality requires a multidimensional approach that includes specific measures for each domain.

Risk factors for central line-associated bloodstream infections in the era of prevention bundles

Little is known about central line-associated bloodstream infection risk factors in the bundle era. In our case-control investigation, we found that independent risk factors for central line-associated bloodstream infection at our center included the number of recent lab tests, catheter duration, and lack of hemodynamic monitoring as the insertion indication. Infect Control Hosp Epidemiol 2014;00(0): 1-3.

Do clinicians know which of their patients have central venous catheters?: a multicenter observational study

BACKGROUND

Complications associated with central venous catheters (CVCs) increase over time. Although early removal of unnecessary CVCs is important to prevent complications, the extent to which clinicians are aware that their patients have a CVC is unknown.

OBJECTIVE

To assess how often clinicians were unaware of the presence of triple-lumen catheters or peripherally inserted central catheters (PICCs) in hospitalized patients.

DESIGN

Multicenter, cross-sectional study.

SETTING

3 academic medical centers in the United States.

PATIENTS

Hospitalized medical patients in intensive care unit (ICU) and non-ICU settings.

MEASUREMENTS

To ascertain awareness of CVCs, whether a PICC or triple-lumen catheter was present was determined; clinicians were then queried about device presence. Differences in device awareness among clinicians were assessed by chi-square tests.

RESULTS

990 patients were evaluated, and 1881 clinician assessments were done. The overall prevalence of CVCs was 21.1% (n=209), of which 60.3% (126 of 209) were PICCs. A total of 21.2% (90 of 425) of clinicians interviewed were unaware of the presence of a CVC. Unawareness was greatest among patients with PICCs, where 25.1% (60 of 239) of clinicians were unaware of PICC presence. Teaching attendings and hospitalists were more frequently unaware of the presence of CVCs than interns and residents (25.8% and 30.5%, respectively, vs. 16.4%). Critical care physicians were more likely to be aware of CVC presence than general medicine physicians (12.6% vs. 26.2%; P=0.003).

LIMITATIONS

Awareness was determined at 1 point in time and was not linked to outcomes. Patient length of stay and indication for CVC were not recorded.

CONCLUSION

Clinicians are frequently unaware of the presence of PICCs and triple-lumen catheters in hospitalized patients. Further study of mechanisms that ensure that clinicians are aware of these devices so that they may assess their necessity seems warranted.

PRIMARY FUNDING SOURCE

None.

Examining the role of patient experience surveys in measuring health care quality

Patient care experience surveys evaluate the degree to which care is patient-centered. This article reviews the literature on the association between patient experiences and other measures of health care quality. Research indicates that better patient care experiences are associated with higher levels of adherence to recommended prevention and treatment processes, better clinical outcomes, better patient safety within hospitals, and less health care utilization. Patient experience measures that are collected using psychometrically sound instruments, employing recommended sample sizes and adjustment procedures, and implemented according to standard protocols are intrinsically meaningful and are appropriate complements for clinical process and outcome measures in public reporting and pay-for-performance programs.