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Effect of Hospital Case Mix on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Star Scores: Are all Stars the same?
Cornelius A Thiels*, Kristine T Hanson*, Kathleen J. Yost*, Martin D Zielinski*, Elizabeth B Habermann*, Robert R Cima
Mayo Clinic, Rochester, MN

OBJECTIVE(S): HCAHPS is a publicly reported survey of patients’ hospital experiences that directly influences Medicare reimbursement.
METHODS: All adult surgical inpatients meeting criteria for HCAHPS sampling from 2013 to 2014 at a single academic center were identified. HCAHPS measures were analyzed according to published HCAHPS top-box and Star rating methodologies and dichotomized (“high” vs “low”). Multivariable logistic regression was used to identify independent associations of high patient scores on various HCAHPS measures with specialty, DRG complexity, cancer diagnosis, sex, and emergency visit after adjusting for standard HCAHPS case-mix adjusters (education, overall health status, language, and age).
RESULTS: We identified 36,551 eligible patients, of which 29.6% (n=10,822) completed HCAHPS. Women (OR 0.79, 95% CI 0.72-0.86, p<0.001), complex cases (0.89, 0.81-0.98, p=0.016), emergency visits (0.68, 0.56-0.84, p<0.001), and non-cancer diagnosis (OR 0.87, 0.77-0.97, p=0.013) had lesser Star scores on adjusted analysis. Using general surgery as the reference, the Star scores varied significantly across 12 specialties (range OR 0.59 for plastics to 1.35 for transplant surgery). Patient responses to individual HCAHPS composite scores (pain, discharge, physician, and nurse scores) also varied by specialty (Figure).
CONCLUSIONS: HCAHPS case-mix adjustment does not include adjustment for complexity, specialty, or diagnosis, which may result in artificially lower scores for centers that provide a high level of complex care. Further research is needed to ensure that the HCAHPS is an unbiased comparison tool.


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