Survey Protocols, Response Rates, and Representation of Underserved Patients: A Randomized Clinical Trial

Importance

Surveys often underrepresent certain patients, such as underserved patients. Methods that improve their response rates (RRs) would help patient surveys better represent their experiences and assess equity and equity-targeted quality improvement efforts.

Objective

To estimate the effect of adding an initial web mode to existing Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey protocols and extending the fielding period on RR and representativeness of underserved patient groups.

Design, Setting, and Participants

This randomized clinical trial included 36 001 patients discharged from 46 US hospitals from May through December 2021. Data analysis was performed from May 2022 to September 2023.

Exposures

Patients were randomized to 1 of 6 survey protocols: 3 standard HCAHPS protocols (mail only, phone only, mail-phone) plus 3 web-enhanced protocols (web-mail, web-phone, web-mail-phone).

Main Outcomes and Measures

RR and number of respondents per 100 survey attempts (yield) were calculated and compared for each of the 6 survey protocols, overall, and by patient age, service line, sex, and race and ethnicity.

Results

A total of 34 335 patients (median age range, 55-59 years; 59.3% female individuals and 40.7% male individuals) were eligible and included in the study. Of the respondents, 6.9% were Asian American or Native Hawaiian or Other Pacific Islander, 0.7% were American Indian or Alaska Native, 11.5% were Black, 17.4% were Hispanic, 61.0% were White, and 2.6% were multiracial. Of the 6 protocols, RRs were highest in web-mail-phone (36.5%), intermediate for the 3 two-mode survey protocols (mail-phone, web-mail, web-phone, 30.3%-31.1%), and lowest for the 2 single-mode protocols (mail only, phone only, 22.1%-24.3%). Web-mail-phone resulted in the highest yield for 3 racial and ethnic groups (Black, Hispanic, and White patients) and second highest for another (multiracial patients). Otherwise, the highest or second highest yield was almost always a 2-mode protocol. Mail only was the lowest-yield protocol for Black, Hispanic, and multiracial patients and phone-only was the lowest-yield protocol for White patients; these 2 protocols tied for lowest-yield for Asian American or Native Hawaiian or Other Pacific Islander patients. Gains from multimode approaches were often 2 to 3 times as large for Asian American or Native Hawaiian or Other Pacific Islander, Black, Hispanic, and multiracial patients as for White patients. Web-mail-phone had the highest RR for 6 of 8 age groups and 4 of 5 combinations of service line and sex.

Conclusions and Relevance

In this randomized clinical trial, web-first multimode survey protocols significantly improved the RR and representativeness of patient surveys. The best-performing protocol based on RR and representativeness was web-mail-phone. Web-phone performed well for young and diverse patient populations, and web-mail for older and less diverse patient populations. The US Centers for Medicare & Medicaid Services will allow hospitals to use the web-mail, web-phone, and web-mail-phone protocols for HCAHPS administration beginning in 2025.

Do Hospital Characteristics Predict Racial-and-Ethnic Disparities in Patient Experience? National Results From the HCAHPS Survey

OBJECTIVE

Assess whether hospital characteristics associated with better patient experiences overall are also associated with smaller racial-and-ethnic disparities in inpatient experience.

BACKGROUND

Hospitals that are smaller, non-profit, and serve high proportions of White patients tend to be high-performing overall, but it is not known whether these hospitals also have smaller racial-and-ethnic disparities in care.

RESEARCH DESIGN

We used linear mixed-effect regression models to predict a summary measure that averaged eight Hospital CAHPS (HCAHPS) measures (Nurse Communication, Doctor Communication, Staff Responsiveness, Communication about Medicines, Discharge Information, Care Coordination, Hospital Cleanliness, and Quietness) from patient race-and-ethnicity, hospital characteristics (size, ownership, racial-and-ethnic patient-mix), and interactions of race-and-ethnicity with hospital characteristics.

SUBJECTS

Inpatients discharged from 4,365 hospitals in 2021 who completed an HCAHPS survey ( N =2,288,862).

RESULTS

While hospitals serving larger proportions of Black and Hispanic patients scored lower on all measures, racial-and-ethnic disparities were generally smaller for Black and Hispanic patients who received care from hospitals serving higher proportions of patients in their racial-and-ethnic group. Experiences overall were better in smaller and non-profit hospitals, but racial-and-ethnic differences were slightly larger.

CONCLUSIONS

Large, for-profit hospitals and hospitals serving higher proportions of Black and Hispanic patients tend to be lower performing overall but have smaller disparities in patient experience. High-performing hospitals might look at low-performing hospitals for how to provide less disparate care whereas low-performing hospitals may look to high-performing hospitals for how to improve patient experience overall.

Exploring Which Patients Use Their Closest Emergency Departments Using Geocoded Data

BACKGROUND

Each year, roughly 20% of U.S. adults visit an emergency department (ED), but little is known about patients' choice of ED.

OBJECTIVES

Examine the discretion patients have to choose among EDs, characteristics associated with ED choice, and relationship between ED choice and self-reported care experiences of ED patients.

METHODS

We surveyed adult patients discharged to the community (DTC) in January-March 2018 from 16 geographically dispersed hospital-based EDs, geocoded patient and hospital-based ED addresses within 100 miles of patient addresses, and calculated travel distances. We examined the likelihood of visiting the closest ED based on patient and ED characteristics. Linear regression models examined the association of choosing the closest ED with seven measures of patient experience of care (scaled 0-100), adjusting for patient characteristics.

RESULTS

43.6% of 4647 responding patients visited the ED nearest their home (on average, 5.7 miles away). Patients who chose a farther ED had more urgent conditions, were more educated, and were less likely to be non-Hispanic White. They were significantly more likely to have visited an ED in a higher-rated, metropolitan, network hospital with major teaching status, a cardiac intensive care unit, and a certified trauma center. Patients who chose a farther ED were more likely to recommend that ED, with "medium-to-large" differences in scores (+4.3% more selected "definitely yes", p < 0.05).

CONCLUSIONS

Fewer than half of patients visited the closest ED. Patients who chose a farther ED tended to seek higher-rated hospitals and report more favorable experiences.

Changes in Patient Experiences of Hospital Care During the COVID-19 Pandemic

Importance

It is important to assess how the COVID-19 pandemic was adversely associated with patients' care experiences.

Objective

To describe differences in 2020 to 2021 patient experiences from what would have been expected from prepandemic (2018-2019) trends and assess correlates of changes across hospitals.

Design, Setting, and Participants

This cohort study compared 2020 to 2021 data with 2018 to 2019 data from 3 900 887 HCAHPS respondents discharged from 3381 HCAHPS-participating US hospitals. The data were analyzed from 2022 to 2023.

Main Outcomes and Measures

The primary outcome was an HCAHPS summary score (HCAHPS-SS), which averaged 10 HCAHPS measures. The primary analysis estimated whether HCAHPS scores from patients discharged from 2020 to 2021 differed from scores that would be expected based on quarterly and linear trends from 2018 to 2019 discharges. Secondary analyses stratified hospitals by prepandemic overall star ratings and staffing levels.

Results

Of the 3 900 887 HCAHPS 2020 to 2021 respondents, 59% were age 65 years or older, and 35% (11%) were in the surgical (maternity) service lines. Compared with trends expected based on prepandemic (2018-2019) data, HCAHPS-SS was 1.2 percentage points (pp) lower for quarter (Q) 2/2020 discharges and -1.9 to -2.0 pp for Q3/2020 to Q1/2021, which then declined to -3.6 pp by Q4/2021. The most affected measures (Q4/2021) were staff responsiveness (-5.6 pp) and cleanliness (-4.9 pp); the least affected were discharge information (-1.6 pp) and quietness (-1.8 pp). Overall rating and hospital recommendation measures initially exhibited smaller-than-average decreases, but then fell as much as the more specific experience measures by Q2/2021. Quietness did not decline until Q2/2021. The HCAHPS-SS fell most for hospitals with the lowest prepandemic staffing levels; hospitals with bottom-quartile staffing showed the largest decrements, whereas top-quartile hospitals showed smaller decrements in most quarters. Hospitals with better overall prepandemic quality showed consistently smaller HCAHPS-SS drops, with effects for 5-star hospitals about 25% smaller than for 1-star and 2-star hospitals.

Conclusions and Relevance

The results of this cohort study of HCAHPS-participating hospitals found that patient experience scores declined during 2020 to 2021. By Q4/2021, the HCAHPS-SS was 3.6 pp lower than would have been expected, a medium effect size. The most affected measures (staff responsiveness and cleanliness) showed large effect sizes, possibly reflecting high illness-associated hospital workforce absenteeism. Hospitals that were lower performing and less staffed prepandemic may have been less resilient to reduced staff availability and other pandemic-associated challenges. However, by Q4/2021, even prepandemic high-performing hospitals had similar declines.

The hospital care experiences of older patients compared to younger patients

BACKGROUND

Hospitals may provide less positive patient experiences for older than younger patients.

METHODS

We used 2019 HCAHPS data from 4358 hospitals to compare patient-mix adjusted HCAHPS Survey scores for 19 experience of care items for patients ages 75+ versus 55-74 years and tested for interactions of age group with patient and hospital characteristics. We contrasted the age patterns observed for inpatient experiences with those among respondents to the 2019 Medicare CAHPS (MCAHPS) Survey of overall experience.

RESULTS

Patients 75+ years (31% of all HCAHPS respondents) reported less-positive experiences than those 55-74 (46% of respondents) for 18 of 19 substantive HCAHPS items (mean difference -3.3% points). Age differences in HCAHPS top-box scores were large (>5 points) for 1 of 3 Nurse Communication items, 1 of 3 Doctor Communication, 2 of 2 Communication about Medication items, 1 of 2 Discharge Information items, and 2 of 3 Care Transition items. In contrast, for MCAHPS, those 75+ reported similar experiences to younger adults. The magnitude of age differences varied considerably across hospitals; some hospitals had very large age disparities for older patients (age 75+ vs. ages 55-74), while others had none. These age differences were generally smaller for patients in government and non-profit than in for-profit hospitals, and in the Pacific region than in other parts of the United States. This variation in age disparities across hospitals may help to identify best practices.

CONCLUSIONS

Patients ages 75+ reported less-positive experiences than patients ages 55-74, especially for measures of communication. These differences may be specific to inpatient care. Further study should investigate the effectiveness of hospital staffs' communication with older patients. Hospital protocols designed for younger patients may need to be adjusted to meet the needs of older patients. There may also be opportunities to learn from outpatient interactions with older patients.

National travel distances for emergency care

Background

Most emergency department (ED) patients arrive by their own transport and, for various reasons, may not choose the nearest ED. How far patients travel for ED treatment may reflect both patients’ access to care and severity of illness. In this study, we aimed to examine the travel distance and travel time between a patient’s home and ED they visited and investigate how these distances/times vary by patient and hospital characteristics.

Methods

We randomly sampled and collected data from 14,812 patients discharged to the community (DTC) between January and March 2016 from 50 hospital-based EDs nationwide. We geocoded and calculated the distance and travel time between patient and hospital-based ED addresses, examined the travel distances/ times between patients’ home and the ED they visited, and used mixed-effects regression models to investigate how these distances/times vary by patient and hospital characteristics.

Results

Patients travelled an average of 8.0 (SD = 10.9) miles and 17.3 (SD = 18.0) driving minutes to the ED. Patients travelled significantly farther to avoid EDs in lower performing hospitals (p < 0.01) and in the West (p < 0.05) and Midwest (p < 0.05). Patients travelled farther when visiting EDs in rural areas. Younger patients travelled farther than older patients.

Conclusions

Understanding how far patients are willing to travel is indicative of whether patient populations have adequate access to ED services. By showing that patients travel farther to avoid a low-performing hospital, we provide evidence that DTC patients likely do exercise some choice among EDs, indicating some market incentives for higher-quality care, even for some ED admissions. Understanding these issues will help policymakers better define access to ED care and assist in directing quality improvement efforts. To our knowledge, our study is the most comprehensive nationwide characterization of patient travel for ED treatment to date.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07743-7.

Development and validation of a patient experience of care survey for emergency departments

OBJECTIVES

To (1) develop a survey to assess the patient experience of care in hospital-based emergency departments (ED) and (2) evaluate the reliability and validity of composite measures of patient experience using data collected through the experimental implementation of the newly developed Emergency Department Patient Experience of Care (EDPEC) Discharged to Community (DTC) Survey.

DATA SOURCE

4893 adult patients were treated in the ED of 16 hospitals across the United States in 2018.

STUDY DESIGN

The study utilized a cross-sectional survey.

DATA COLLECTION

Survey development activities included a literature review, focus groups, and cognitive interviews with recently discharged ED patients, technical expert panels, and multiple field experiments. Survey development resulted in a 34-item instrument; the analysis reported here focuses on 18 items on patient experience of care. Using data from the EDPEC DTC Survey in the 2018 Feasibility Test, we performed confirmatory factor analysis to group 15 evaluative survey items into composite measures. We examined internal consistency reliability, interunit reliability, and associations between each composite measure and patients' overall rating and willingness to recommend the ED.

PRINCIPAL FINDINGS

Analyses of 15 evaluative items identified four composite measures: Getting Timely Care, How Well Doctors and Nurses Communicate, Communication about Medications, and Communication about Follow-up. Patient-level internal consistency reliability exceeded 0.75 for two of four composites; ED-level internal consistency reliability exceeded 0.83 for all four composites. Interunit reliability estimates indicated that 450 survey completes per ED results in at least 0.70 reliability for all composites. Higher scores on each composite were associated with higher overall ratings and willingness to recommend the ED.

CONCLUSIONS

The composite measures derived from the EDPEC DTC Survey are statistically reliable and valid. These results provide guidance for EDPEC DTC Survey adopters on how to construct meaningful and psychometrically-sound composite measures for monitoring the quality of care they provide.

Racial/Ethnic Differences in Emergency Department Utilization and Experience

BACKGROUND

Previous work has demonstrated racial/ethnic differences in emergency department (ED) utilization, but less is known about racial/ethnic differences in the experience of care received during an ED visit.

OBJECTIVE

To examine differences in self-reported healthcare utilization and experiences with ED care by patients' race/ethnicity.

DESIGN

Adult ED patients discharged to community (DTC) were surveyed (response rate: 20.25%) using the Emergency Department Patient Experience of Care (EDPEC) DTC Survey. Linear regression was used to estimate case-mix-adjusted differences in patient experience between racial/ethnic groups.

PARTICIPANTS

3122 survey respondents who were discharged from the EDs of 50 hospitals nationwide January-March 2016.

MAIN MEASURES

Six measures: getting timely care, doctor and nurse communication, communication about medications, receipt of sufficient information about test results, whether hospital staff discussed the patient's ability to receive follow-up care, and willingness to recommend the ED.

KEY RESULTS

Black and Hispanic patients were significantly more likely than White patients to report visiting the ED for an ongoing health condition (40% Black, 30% Hispanic, 28% White, p<0.001), report having visited an ED 3+ times in the last 6 months (26% Black, 25% Hispanic, 19% White, p<0.001), and report not having a usual source of care (19% Black, 19% Hispanic, 8% White, p<0.001). Compared with White patients, Hispanic patients more often reported that hospital staff talked with them about their ability to receive needed follow-up care (+7.2 percentile points, p=0.038) and recommended the ED (+7.2 points, p=0.037); Hispanic and Black patients reported better doctor and nurse communication (+6.4 points, p=0.008; +4 points, p=0.036, respectively).

CONCLUSIONS

Hispanic and Black ED patients reported higher ED utilization, lacked a usual source of care, and reported better experience with ED care than White patients. Results may reflect differences in care delivery by staff and/or different expectations of ED care among Hispanic and Black patients.

Inpatient care experiences differ by preferred language within racial/ethnic groups

Objective

To describe differences in patient experiences of hospital care by preferred language within racial/ethnic groups.

Data Source

2014‐2015 HCAHPS survey data.

Study Design

We compared six composite measures for seven languages (English, Spanish, Russian, Portuguese, Chinese, Vietnamese, and Other) within applicable subsets of five racial/ethnic groups (Hispanics, Asian/Pacific Islanders, American Indian/Alaska Natives, Blacks, and Whites). We measured patient‐mix adjusted overall, between‐ and within‐hospital differences in patient experience by language, using linear regression.

Data Collection Methods

Surveys from 5 480 308 patients discharged from 4517 hospitals 2014‐2015.

Principal Findings

Within each racial/ethnic group, mean reported experiences for non‐English‐preferring patients were almost always worse than their English‐preferring counterparts. Language differences were largest and most consistent for Care Coordination. Within‐hospital differences by language were often larger than between‐hospital differences and were largest for Care Coordination. Where between‐hospital differences existed, non‐English‐preferring patients usually attended hospitals whose average patient experience scores for all patients were lower than the average scores for the hospitals of their English‐preferring counterparts.

Conclusions

Efforts should be made to increase access to better hospitals for language minorities and improve care coordination and other facets of patient experience in hospitals with high proportions of non‐English‐preferring patients, focusing on cultural competence and language‐appropriate services.

Understanding The Role Played By Medicare's Patient Experience Points System In Hospital Reimbursement

In 2015 the Medicare Hospital Value-Based Purchasing (VBP) program paid hospitals $1.4 billion in performance-based incentives; 30 percent of a hospital's VBP Total Performance Score was based on performance on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) measures of the patient experience of care. Hospitals receive patient experience points based on three components: achievement, improvement, and consistency. For 2015 we examined how the three components affected reimbursement for 3,152 hospitals, including their impact on low-performing and high-minority hospitals. Achievement accounted for 96 percent of the differences among hospitals in total HCAHPS points. Although achievement had the biggest influence on payments, payments related to improvement and consistency were more beneficial for low-performing hospitals that disproportionately served minority patients. The findings highlight the important inducement that paying for improvement provides to initially low-performing hospitals to improve care and the role this incentive structure plays in minimizing resource redistributions away from hospitals serving minority populations. Additional emphasis on improvement points could benefit hospitals serving disadvantaged patients.

Accelerating Improvement and Narrowing Gaps: Trends in Patients' Experiences with Hospital Care Reflected in HCAHPS Public Reporting

OBJECTIVE

Measure HCAHPS improvement in hospitals participating in the second and fifth years of HCAHPS public reporting; determine whether change is greater for some hospital types.

DATA

Surveys from 4,822,960 adult inpatients discharged July 2007-June 2008 or July 2010-June 2011 from 3,541 U.S. hospitals.

STUDY DESIGN

Linear mixed-effect regression models with fixed effects for time, patient mix, and hospital characteristics (bedsize, ownership, Census division, teaching status, Critical Access status); random effects for hospitals and hospital-time interactions; fixed-effect interactions of hospital characteristics and patient characteristics (gender, health, education) with time predicted HCAHPS measures correcting for regression-to-the-mean biases.

DATA COLLECTION METHODS

National probability sample of adult inpatients in any of four approved survey modes.

PRINCIPAL FINDINGS

HCAHPS scores increased by 2.8 percentage points from 2008 to 2011 in the most positive response category. Among the middle 95 percent of hospitals, changes ranged from a 5.1 percent decrease to a 10.2 percent gain overall. The greatest improvement was in for-profit and larger (200 or more beds) hospitals.

CONCLUSIONS

Five years after HCAHPS public reporting began, meaningful improvement of patients' hospital care experiences continues, especially among initially low-scoring hospitals, reducing some gaps among hospitals.

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.

A Randomized Experiment Investigating the Suitability of Speech-Enabled IVR and Web Modes for Publicly Reported Surveys of Patients’ Experience of Hospital Care

The HCAHPS Survey obtains hospital patients’ experiences using four modes: Mail Only, Phone Only, Mixed (mail/phone follow-up), and Touch-Tone (push-button) Interactive Voice Response with option to transfer to live interviewer (TT-IVR/Phone). A new randomized experiment examines two less expensive modes: Web/Mail (mail invitation to participate by Web or request a mail survey) and Speech-Enabled IVR (SE-IVR/Phone; speaking to a voice recognition system; optional transfer to an interviewer). Web/Mail had a 12% response rate (vs. 32% for Mail Only and 33% for SE-IVR/Phone); Web/Mail respondents were more educated and less often Black than Mail Only respondents. SE-IVR/Phone respondents (who usually switched to an interviewer) were less often older than 75 years, more often English-preferring, and reported better care than Mail Only respondents. Concerns regarding inconsistencies across implementations, low adherence to primary modes, or low response rate may limit the applicability of the SE-IVR/Phone and Web/Mail modes in HCAHPS and similar standardized environments.

Gender differences in patients' perceptions of inpatient care

OBJECTIVE

To examine gender differences in inpatient experiences and how they vary by dimensions of care and other patient characteristics.

DATA SOURCE

A total of 1,971,632 patients (medical and surgical service lines) discharged from 3,830 hospitals, July 2007-June 2008, and completing the HCAHPS survey.

STUDY DESIGN

We compare the experiences of male and female inpatients on 10 HCAHPS dimensions using multiple linear regression, adjusting for survey mode and patient mix. Additional models add additional patient characteristics and their interactions with patient gender.

PRINCIPAL FINDINGS

We find generally less positive experiences for women than men, especially for Communication about Medicines, Discharge Information, and Cleanliness. Gender differences are similar in magnitude to previously reported HCAHPS differences by race/ethnicity. The gender gap is generally larger for older patients and for patients with worse self-reported health status. Gender disparities are largest in for-profit hospitals.

CONCLUSIONS

Targeting the experiences of women may be a promising means of improving overall patient experience scores (because women comprise a majority of all inpatients); the experiences of older and sicker women, and those in for-profit hospitals, may merit additional examination.

Hospital survey shows improvements in patient experience

Hospitals are improving the inpatient care experience. A government survey that measures patients' experiences with a range of issues from staff responsiveness to hospital cleanliness-the Hospital Consumer Assessment of Healthcare Providers and Systems survey-is showing modest but meaningful gains. Using data from the surveys reported in March 2008 and March 2009, we present the first comprehensive national assessment of changes in patients' experiences with inpatient care since public reporting of the results began. We found improvements in all measures of patient experience, except doctors' communication. These improvements were fairly uniform across hospitals. The largest increases were in measures related to staff responsiveness and the discharge information that patients received.

Racial/ethnic differences in patients' perceptions of inpatient care using the HCAHPS survey

Using HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems, also known as the CAHPS Hospital Survey) data from 2,684 hospitals, the authors compare the experiences of Hispanic, African American, Asian/Pacific Islander, American Indian/Alaska Native, and multiracial inpatients with those of non-Hispanic White inpatients to understand the roles of between- and within-hospital differences in patients' perspectives of hospital care. The study finds that, on average, non-Hispanic White inpatients receive care at hospitals that provide better experiences for all patients than the hospitals more often used by minority patients. Within hospitals, patient experiences are more similar by race/ethnicity, though some disparities do exist, especially for Asians. This research suggests that targeting hospitals that serve predominantly minority patients, improving the access of minority patients to better hospitals, and targeting the experiences of Asians within hospitals may be promising means of reducing disparities in patient experience.

Development, implementation, and public reporting of the HCAHPS survey

The authors describe the history and development of the CAHPS Hospital Survey (also known as HCAHPS) and its associated protocols. The randomized mode experiment, vendor training, and "dry runs" that set the stage for initial public reporting are described. The rapid linkage of HCAHPS data to annual payment updates ("pay for reporting") is noted, which in turn led to the participation of approximately 3,900 general acute care hospitals (about 90% of all such United States hospitals). The authors highlight the opportunities afforded by this publicly reported data on hospital inpatients' experiences and perceptions of care. These data, reported on www.hospitalcompare.hhs. gov, facilitate the national comparison of patients' perspectives of hospital care and can be used alone or in conjunction with other clinical and outcome measures. Potential benefits include increased transparency, improved consumer decision making, and increased incentives for the delivery of high-quality health care.

Characteristics of hospitals demonstrating superior performance in patient experience and clinical process measures of care

Prior research suggests hospital quality of care is multidimensional. In this study, the authors jointly examine patient experience of care and clinical care measures from 2,583 hospitals based on inpatients discharged in 2006 and 2007. The authors use multinomial logistic regression to identify key characteristics of hospitals that perform in the top quartile on both, either, and neither dimension of quality. Top performers on both quality measures tend to be small (<100 beds), large (>200 beds) and rural, located in the New England or West North Central Census divisions, and nonprofit. Top performers in patient experience only are most often small and rural, located in the East South Central division, and government owned. Top performers in clinical care only are most often medium to large and urban, located in the West North Central division, and non-government owned. These findings provide an overview of how these dimensions of quality vary across hospitals.

Do hospitals rank differently on HCAHPS for different patient subgroups?

Prior research documents differences in patient-reported experiences by patient characteristics. Using nine measures of patient experience from 1,203,229 patients discharged in 2006-2007 from 2,684 acute and critical access hospitals, the authors find that adjusted hospital scores measure distinctions in quality for the average patient with high reliability. The authors also find that hospital "ranks" (the relative scores of hospitals for patients of a given type) vary substantially by patient health status and race/ ethnicity/language, and moderately by patient education and age (p < .05 for almost all measures). Quality improvement efforts should examine hospital performance with both sicker and healthier patients, because many hospitals that do well with one group (relative to other hospitals) may not do well with another. The experiences of American Indians/Alaska Natives should also receive particular attention. As HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) data accumulate, reports that drill down to hospital performance for patient subtypes (especially by health status) may be valuable.