Nursing Home Satisfaction Surveys: Differences by Race, Age, and Gender

Nursing home satisfaction information has gained substantial traction as a quality indicator representing the consumers perspective. However, very little research has examined differences in satisfaction related to race, age and gender. As a quality metric, satisfaction measures are variously used for quality improvement, benchmarking, public reporting, and for adjustment to payments. As such, valid comparisons among facilities are important. To our knowledge, no adjustment to satisfaction scores are currently used for nursing homes. However, in many other settings this is a common practice. In this research, nursing home resident, family, and discharge satisfaction scores were examined from >4,000 participants. The data were collected in 2020 and come from 420 facilities. Satisfaction information came from the CoreQ surveys, which include 23 individual questions four of which can be combined to produce an overall satisfaction score. These CoreQ nursing home surveys are endorsed by NQF. Generally lower overall satisfaction scores were found for family members compared to current residents or discharged residents. Minorities (Black, Asian, Hispanic) had lower overall satisfaction scores compared to whites; however, the differences were not significant at conventional levels. Participants of the lowest age (<65 years) were significantly (p=<.05) less satisfied than older participants (>75 years) and males were significantly (p=<.05) less satisfied than females. The findings indicate that some case-mix adjustment may be applicable for nursing home satisfaction scores.

Case-mix adjustment to compare colonoscopy performance between endoscopy centres: a nationwide registry study

Background: Non-modifiable patient and endoscopy characteristics might influence colonoscopy performance. Differences in these so-called case-mix factors are likely to exist between endoscopy centres. This study aims to examine the importance of case-mix adjustment when comparing performance between endoscopy centres. Methods: Prospectively collected data recorded in the Dutch national colonoscopy registry between 2016-2019 were retrospectively analyzed. Performance on cecal intubation rate (CIR) and adequate bowel preparation rate (ABPR) were studied. Additionally, polyp detection rate (PDR) was studied in fecal immunochemical test (FIT)-positive screening colonoscopies. Variation in case-mix factors between endoscopy centres and expected outcomes for each performance measure were calculated per endoscopy centre, based on their case-mix factors (sex, age, ASA score, indication), using multivariable logistic regression. Results: In total, 363,840 colonoscopies were included from 51 endoscopy centres. The mean percentages per endoscopy centre were significantly different for age > 65 years, male patients, ASA > III and diagnostic colonoscopies (all p < 0.001). In the FIT-positive screening population, significant differences were observed per endoscopy centre for age > 65 years, male patients and ASA > III (all p value < 0.001). The expected CIR, ABPR and PDR ranged from 95.0% to 96.9%, from 93.6% to 96.4% and from 76.2% to 79.1%, respectively. Age, sex, ASA classification and indication were significant case-mix factors for CIR and ABPR. In the FIT-positive screening population, age, sex and ASA classification were significant case-mix factors for PDR. Conclusion: Our findings emphasize that when comparing colonoscopy performance measures between endoscopy centres, case-mix adjustment should be considered.

Different Approaches for Case-Mix Adjustment of Patient-Reported Outcomes to Compare Healthcare Providers—Methodological Results of a Systematic Review

Patient-reported outcomes (PROs) are increasingly being used to compare the quality of outcomes between different healthcare providers (medical practices, hospitals, rehabilitation facilities). However, such comparisons can only be fair if differences in the case-mix between different types of provider are taken into account. This can be achieved with adequate statistical case-mix adjustment (CMA). To date, there is a lack of overview studies on current CMA methods for PROs. The aim of this study was to investigate which approaches are currently used to report and examine PROs for case-mix-adjusted comparison between providers. A systematic MEDLINE literature search was conducted (February 2021). The results were examined by two reviewers. Articles were included if they compared (a) different healthcare providers using (b) case-mix-adjusted (c) patient-reported outcomes (all AND conditions). From 640 hits obtained, 11 articles were included in the analysis. A wide variety of patient characteristics were used as adjustors, and baseline PRO scores and basic sociodemographic and clinical information were included in all models. Overall, the adjustment models used vary considerably. This evaluation is an initial attempt to systematically investigate different CMA approaches for PROs. As a standardized approach has not yet been established, we suggest creating a consensus-based methodological guideline for case-mix adjustment of PROs.

Assessing the performance of a method for case-mix adjustment in the Korean Diagnosis-Related Groups (KDRG) system and its policy implications

Background To evaluate the performance of the patient clinical complexity level (PCCL) mechanism, which is the patient-level complexity adjustment factor within the Korean Diagnosis-Related Groups (KDRG) patient classification system, in explaining the variation in resource consumption within age adjacent diagnosis-related groups (AADRGs). Methods We used the inpatient claims data from a public hospital in Korea from 1 January 2017 to 30 June 2019, with 18 846 claims and 138 AADRGs. The differences in the total average payment between the four PCCL levels for each AADRG was tested using ANOVA and Duncan’s post hoc test. The three patterns of differences with R-squared were as follows: the PCCL reflected the complexity well (valid); the average payment for PCCL 2, 3, and 4 was greater than PCCL 0 (partially valid); the PCCL did not reflect the complexity (not valid). Results There were 9 (6.52%), 26 (18.84%), and 103 (74.64%) ADRGs included in the valid, partially valid, and not valid categories, respectively. The average R-squared values were 32.18, 40.81, and 35.41%, respectively, with an average R-squared for all patterns of 36.21%. Conclusions Adjustment using the PCCL in the KDRG classification system exhibited low performance in explaining the variation in resource consumption within AADRGs. As the KDRG classification system is used for reimbursement under the new DRG-based prospective payment system (PPS) pilot project, with plans for expansion, there should be an overall review of the validity of the complexity and rationality of using the KDRG classification system.

Development of an international standard set of clinical and patient-reported outcomes for children and adults with congenital heart disease: A report from the International Consortium for Health Outcomes Measurement Congenital Heart Disease Working Group

Aims Congenital heart disease (CHD) is the most common congenital malformation. Despite the worldwide burden to patient wellbeing and health system resource utilization, tracking of long-term outcomes is lacking, limiting the delivery and measurement of high-value care. To begin transitioning to value-based healthcare in CHD, the International Consortium for Health Outcomes Measurement aligned an international collaborative of CHD experts, patient representatives, and other stakeholders to construct a standard set of outcomes and risk-adjustment variables that are meaningful to patients. Methods and results The primary aim was to identify a minimum standard set of outcomes to be used by health systems worldwide. The methodological process included four key steps: 1) develop a working group representative of all CHD stakeholders; 2) conduct extensive literature reviews to identify scope, outcomes of interest, tools used to measure outcomes, and case-mix adjustment variables; 3) create the outcome set using a series of multi-round Delphi processes; and 4) disseminate set worldwide. The WG established a 15-item outcome set, incorporating physical, mental, social, and overall health outcomes accompanied by tools for measurement and case-mix adjustment variables. Patients with any CHD diagnoses of all ages are included. Following an open review process, over 80% of patients and providers surveyed agreed with the set in its final form. Conclusion This is the first international development of a stakeholder-informed standard set of outcomes for CHD. It can serve as a first step for a lifespan outcomes measurement approach to guide benchmarking and improvement among health systems.

Indirect Standardization as a Case Mix Adjustment Method to Improve Comparison of Children’s Hospitals’ Antimicrobial Use

Antimicrobial use (AU) in days of therapy per 1000 patient-days (DOT/1000pd) varies widely among children’s hospitals. We evaluated indirect standardization to adjust AU for case mix, a source of variation inadequately addressed by current measurements. Hospitalizations from the Pediatric Health Information System were grouped into 85 clinical strata. Observed to expected (O:E) ratios were calculated by indirect standardization and compared to DOT/1000pd. Outliers were defined by O:E z-scores. Antibacterial DOT/1000pd ranged from 345 to 776 (2.2-fold variation; interquartile range [IQR] 552-679), whereas O:E ratios ranged from 0.8 to 1.14 (1.4-fold variation; IQR 0.93-1.05). O:E ratios were moderately correlated with DOT/1000pd (correlation estimate 0.44; 95% CI 0.19-0.64; p=0.0009). Using indirect standardization to adjust for case mix reduces apparent AU variation and may enhance stewardship efforts by providing adjusted comparisons to inform interventions.

The added value of the advanced practice provider in paediatric acute care cardiology

Objectives: Advanced practice providers (APPs) are being employed at increasing rates in order to meet new in-hospital care demands. Utilising the Paediatric Acute Care Cardiology Collaborative (PAC3) hospital survey, we evaluated variations in staffing models regarding first-line providers and assessed associations with programme volume, acuity of care, and post-operative length of stay (LOS). Study design: The PAC3 hospital survey defined staffing models and resource availability across member institutions. A resource acuity score was derived for each participating acute care cardiology unit. Surgical volume was obtained from The Society of Thoracic Surgeons database. Pearson’s correlation coefficients were used to evaluate the relationship between staffing models and centre volume as well as unit acuity. A previously developed case-mix adjustment model for total post-operative LOS was utilised in a multinomial regression model to evaluate the association of APP patient coverage with observed-to-expected post-operative LOS. Results: Surveys were completed by 31 (91%) PAC3 centres in 2017. Nearly all centres (94%) employ APPs, with a mean of 1.7 (range 0–5) APPs present on weekday rounds. The number of APPs present has a positive correlation with surgical volume (r = 0.49, p < 0.01) and increased acuity (r = 0.39, p = 0.03). In the multivariate model, as coverage by APPs increased from low to moderate or high, there was greater likelihood of having a shorter-than-expected post-operative LOS (p < 0.001). Conclusions: The incorporation of paediatric acute care cardiology APPs is associated with reduced post-operative LOS. Future studies are necessary to understand how APPs impact these patient-specific outcomes.