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

Patient experience and 30-day readmission are important measures of quality of care for hospitalized patients. Performance on both of these measures impact hospitals financially. Performance on the Hospital Consumer Assessment of Healthcare Systems and Providers (HCAHPS) survey is linked to 25% of the incentive payment under Value Based Purchasing (VBP) Program.¹ Starting in 2012, the Centers for Medicare and Medicaid Services (CMS) introduced the Readmission Reduction Program, penalizing hospitals financially for excessive readmissions.²

A relationship between patient experience and readmissions has been explored at the hospital level. Studies have mostly found that higher patient experience scores are associated with lower 30-day readmission rates. In a study of the relationship between 30-day risk-standardized readmission rates for three medical conditions (acute myocardial infarction, heart failure, and pneumonia) and patient experience, the authors noted that higher experience scores for overall care and discharge planning were associated with lower readmission rates for these conditions. They also concluded that patient experience scores were more predictive of 30-day readmission than clinical performance measures. Additionally, the authors predicted that if a hospital increased its total experience scores from the 25th percentile to the 75th percentile, there would be an associated decrease in readmissions by at least 2.3% for each of these conditions.³ Practice management companies and the media have cited this finding to conclude that higher patient experience drives clinical outcomes such as 30-day readmission and that patients are often the best judges of the quality of care delivered.^4,5

Other hospital-level studies have found that high 30-day readmission rates are associated with lower overall experience scores in a mixed surgical patient population; worse reports of pain control and overall care in the colorectal surgery population; lower experience scores with discharge preparedness in vascular surgery patients; and lower experience scores with physician communication, nurse communication, and discharge preparedness.^6-9 A patient-level study noted higher readmissions are associated with worse experience with physician and nursing communication along with a paradoxically better experience with discharge information.¹⁰

Because these studies used an observational design, they demonstrated associations rather than causality. An alternative hypothesis is that readmitted patients complete their patient experience survey after readmission and the low experience is the result, rather than the cause, of their readmission. For patients who are readmitted, it is unclear whether there is an opportunity to complete the survey prior to readmission and whether being readmitted may impact patient perception of quality of care. Using patient-level data, we sought to assess HCAHPS patient-experience responses linked to the index admission of the patients who were readmitted in 30 days and compare it with those patients who were not readmitted during this time period. We paid particular attention to when the surveys were returned.