Hospitals with consistently low cardiac performance measure rankings also received a thumbs down in patient satisfaction, according to a study published online April 10 in Circulation: Cardiovascular Quality and Outcomes. But the authors warn that without understanding factors that contribute to poor performance, pay-for-performance and value-based initiatives may exacerbate problems at these hospitals and adversely impact care.

Saket Girotra, MD, of the cardiovascular diseases division at the University of Iowa Hospitals and Clinics in Iowa City, and colleagues wrote that previous research has identified groups of hospitals that perform poorly in cardiac care, based on hospital-level analyses using Centers for Medicare & Medicaid Services (CMS) data in Hospital Compare. They wrote that critics of process measures such as heart failure (HF) and acute MI (AMI) metrics argue that they are imprecise and subject to gaming by hospitals that self-report the data.

The addition of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey may provide another vehicle for gauging hospital quality. Whether poor performing hospitals also are deemed unsatisfactory by patients remains unknown, Girotra and colleagues said. If they align, the authors argued, then the relationship may add further evidence that these hospitals are in need of attention.

To find out, they used three databases: 2006-2008 CMS Hospital Compare, which includes HCAHPS; the 2006 American Hospital Association annual survey; and the 2000 U.S. Census. They focused on seven measures for reporting AMI and four measures for HF.

The AMI measures were aspirin on arrival; aspirin at discharge; beta blockers at discharge; ACE inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) for left ventricular systolic dysfunction; advice on smoking cessation; fibrinolytic medication within 30 minutes of arrival; and primary PCI within 90 minutes of arrival during each year. HF performance measures included receiving discharge instructions; evaluation of left ventricular systolic function; ACEIs or ARBs for systolic dysfunction; and advice on smoking cessation.    

With HCAHPS, they selected two measures of overall satisfaction: willingness to recommend the hospital to family and friends (yes, probably or definitely no) and a global rating of the hospital on a scale of 0 to 10.  

They identified 2,467 hospitals for the AMI analysis and 3,115 for HF analysis. Based on a composite score and stratification, 88 hospitals in the AMI group and 147 hospitals in the HF group were consistently low-performers. Some 49 AMI hospitals and 105 HF ranked as consistent top performers. Only 19 hospitals ranked in the low-performing category for both cardiac measures and only 18 hospitals garnered top performing ranking for both measures.

Correlating performance ranking with patient satisfaction analyses, they found that 64 percent of respondents at AMI hospitals would recommend the hospital to others and 62.2 percent ranked their care as high quality. Approximately half (51.4 percent) of the low-performing AMI hospitals fell in the bottom quartile for patient satisfaction and 79.5 percent were in the bottom half while among top-performers, 51 percent ranked in the top quartile for patient satisfaction and 69.4 percent ranked in the top half.

In the HF hospitals, though, the two measures did not always align. They found that that 39.6 percent of the low-performing HF hospitals made it in the top half of patient satisfaction ratings and 40 percent of the top-performing HF hospitals were in the bottom half. On recommendations, an analysis adjusted for hospital characteristics showed 61.3 percent said they would recommend a low-performing hospital.

The authors wrote that their findings show that poor adherence to process measures is associated with lower patient satisfaction, adding that such findings support the concept that a discrete group of hospitals consistently performs poorly. While quality improvement initiatives might theoretically positively impact patient care, pay-for-performance programs may actually backfire, they wrote.

“Low-performing hospitals may be disadvantaged if they lack the resources necessary to engage in quality improvement efforts,” they wrote. “By rewarding top performance or net improvement and penalizing low-performing hospitals, pay for performance could worsen disparities and adversely impact care of the poor, underserved, minority patients that seek care at these hospitals.”

They urged policymakers to better understand the factors associated with poor performance such as organizational values and communication as well as their community benefit and patient options. Value-based purchasing plans, which may include a patent satisfaction component, also may pose problems.    

“[H]ospital characteristics that are associated with patient satisfaction are not easily modifiable (urban location, nonprofit status, number of beds), and scant data exist to show whether hospital investment in the modifiable factors (greater number of nurses) will result in improved quality of care,” they wrote.

They cautioned against hospitals investing in programs until they understand the determinants of patient satisfaction to ensure any changes are effective. They also pointed out that in HF hospitals, nearly 40 percent had a better than average patient satisfaction rating while 40 percent of the top performers had below average rankings.

They also noted that their study had limitations, including the use of self-reported data and the fact that with HCAHPS they had access to aggregate responses and not patient-level data from those solely treated for cardiovascular disease.

“[T]hese findings illustrate that process measures and satisfaction ratings measure relatively distinct facets of hospital quality and support the notion that evaluation of hospital quality should be based on multiple measures,” they concluded, calling for further studies to better understand the factors for this variability.