Does Patient Experience Predict 30-Day Readmission? A Patient-Level Analysis of HCAHPS Data

In this retrospective analysis of prospectively collected Press Ganey and HCAHPS patient-experience survey data, we found that the overwhelming majority of patients readmitted within 30 days of discharge respond to HCAHPS surveys after readmission even though the survey is sent linked to the first admission. This is not unexpected since the median time to survey response is 33 days for this group, while median time to readmission is 10 days. The dissatisfaction pattern of Postreadmission responders was similar to those who responded to the survey linked to the readmission. When a patient is readmitted prior to completing the survey, their responses appear to reflect the cumulative experience of the index admission and the readmission. The lower scores of those who respond to the survey after their readmission appear to be a driver for lower patient-experience scores related to readmissions. Overall, readmission was associated with lower scores on items in five of the nine domains used to calculate patient experience related payments under VBP.¹⁶

These findings have important implications in inferring the direction of potential causal relationship between readmissions and patient experience at the hospital level. Additionally, these patients show broad dissatisfaction with areas beyond physician communication and discharge planning. These include staff responsiveness, phlebotomy, meals, hospital cleanliness, and noise level. This pattern of dissatisfaction may represent impatience and frustration with spending additional time in the hospital environment.

Our results are consistent with findings of many of the earlier studies, but our study goes a step further by using patient-level data and incorporating survey response time in our analysis.^3,7,9,10 By separating out the readmitted patients who responded to the survey prior to admission, we attempted to address the ability of patients’ perception of care to predict future readmissions. Our results do not support this idea, since pre-readmission responders had similar experience scores to non-readmitted patients. However, because of the low numbers of pre-readmission responders, the comparison lacks precision. Current HCAHPS and Press Ganey questions may lack the ability to predict future readmissions because of the timing of the survey (postdischarge) or the questions themselves.

Overall, postreadmission responders are dissatisfied with multiple domains of hospital care. Many of these survey responses may simply be related to general frustration. Alternatively, they may represent a patient population with a high degree of needs that are not as easily met by a hospital’s routine processes of care. Even though the readmission rates were 10.6% among survey responders, 14.6% of the survey responses were associated with readmissions after accounting for those who respond to surveys linked to readmission. These patients could have significant impact on cumulative experience scores.

Our study has a few limitations. First, it involves a single tertiary care academic center study, and our results may not be generalizable. Second, we did not adjust for some of the patient characteristics associated with readmissions. Patients who were admitted within 30 days are different than those not readmitted based on payor, race, length of stay, and severity of illness, and we did not adjust for these factors in our analysis. This was intentional, however. Our goal was to better understand the relationship between 30-day readmission and patient experience scores as they are used for hospital-level studies, VBP, and public reporting. For these purposes, the scores are not adjusted for factors, such as payor and length of stay. We did adjust for patient-mix adjustment factors used by CMS. Third, the response rates to the HCAHPS were low and may have biased the scores. However, HCAHPS is widely used for comparisons between hospitals has been validated, and our study results have implications with regard to comparing hospital-level performance. HCAHPS results are relevant to policy and have financial consequences.¹⁷ Fourth, our study did not directly compare whether the relationship between patient experience for the postreadmission group and nonreadmitted group was different from the relationship between the pre-readmission group and postreadmission group. It is possible that there is no difference in relationship between the groups. However, despite the small number of pre-readmission responders, these patients tended to have more favorable experience responses than those who responded after being readmitted, even after adjusting for response time. Although the P values are nonsignificant for many comparisons, the directionality of the effect is relatively consistent. Also, the vast majority of the patients fall in the postreadmission group, and these patients appear to drive the overall experience related to readmissions. Finally, since relatively few patients turned in surveys prior to readmission, we had limited power to detect a significant difference between these pre-readmission responders and nonreadmitted patients.

Our study has implications for policy makers, researchers, and providers. The HCAHPS scores of patients who are readmitted and completed the survey after being readmitted reflects their experience of both the index admission and the readmission. We did not find evidence to support that HCAHPS survey responses predict future readmissions at the patient level. Our findings do support the concept that lower readmissions rates (whether due to the patient population or processes of care that decrease readmission rates) may improve HCAHPS scores. We suggest caution in assuming that improving patient experience is likely to reduce readmission rates.