The Michigan Value Collaborative

Helping Michigan hospitals achieve their best possible patient outcomes at the lowest reasonable cost

Month: December 2017 (page 1 of 2)

How patients make choices about post-acute care

Scott Regenbogen

Scott Regenbogen, M.D. is a colorectal surgeon and Co-Director of MVC

In last week’s blog, Edward Norton discussed the relationship between the Centers for Medicare and Medicaid Services’ (CMS) Hospital Compare “star ratings” and other measures of short-term outcome after major cancer surgery. He suggested that “the star rating may be useful to patients when they are selecting a hospital for major cancer surgery”. To date, however, there is little evidence that patients really take these ratings into account when choosing a hospital.

What about post-acute care choices, though? We’ve talked before in the Michigan Value Collaborative (and in the MVC blog) about the critical role of post-acute care choices in episode spending, especially for surgical conditions. To date, we’ve looked at it primarily from the hospitals’ and payers’ perspectives, but it is actually the patient and family who ultimately choose their site of care after hospitalization.

To help with these decisions, there are a variety of information sources that patients and families—the consumer of post-acute care—could use. For example, CMS Nursing Home Compare provides information on numerous measures of nursing home quality, and has a “star rating” system, much like the Hospital Compare website. Unfortunately, consumers rarely make use of these resources in their decision-making about care after hospitalization.

A recent paper in the Journal of the American Geriatrics Society  interviewed nearly 100 community-dwelling patients newly admitted to skilled nursing facilities (SNF) in eight US cities after acute hospitalization, and inquired about their roles in, and the process of, SNF choice. In general, the patients reported negative experiences with the decision-making process—they felt they were rushed, provided with inadequate information about quality and capabilities of the facilities, and that their physicians were not involved in the decision. They generally stated that their decisions were based on previous experiences with facilities, location, or amenities, but that they would have availed themselves of information about care quality if it had been readily available. Further, most would have been willing to travel further in order to be admitted to a higher-rated facility.

We need better sources of information to aid patients in choosing post-acute care providers. At the moment, some are using Facebook or other online networks to receive information about facilities, but the ratings seen in these sites often disagree with more scientifically validated quality metrics. Tailored information sources that provide information more suited to individuals’ particular preferences and needs could substantially improve the usefulness of recommendations.

For MVC, we need to consider this information gap as we work to optimize the use of post-acute care. Many of our members are focused on appropriate, and better informed, choice of SNF for their patients as a strategy to control episode spending. And as a Coordinating Center, we are increasingly focused on efforts to reduce the potentially unnecessary use of inpatient post-acute care after major joint replacement and other procedures. To achieve these goals, however, we will need to attend to the decision-making needs of the patients and families, in addition to our hospital leaders and policy-makers.

CMS Hospital Compare Star Ratings: Relationships and Quality of Care

Edward Norton

Edward Norton, Ph.D., is a health economist working with MVC

Have you ever wondered whether the Hospital Compare star ratings really mean anything? In particular, do more stars indicate higher quality of care?  One study finds that star ratings can be important for cancer patients.

Both the Centers for Medicare and Medicaid Services’ (CMS) Hospital Compare star rating and surgical case volume have been publicized as metrics that can help patients identify high-quality hospitals for complex care such as cancer surgery. A recent study by Deborah Kaye and colleagues (2017 Cancer) evaluates the relationship between the CMS’ star rating, surgical volume, and short-term outcomes after major cancer surgery.

Their study identified 365,752 patients who underwent major cancer surgery for 1 of 9 cancer types at 2,550 hospitals. Although we generally think that higher volume hospitals have higher quality, the authors found that star rating was not associated with surgical volume (P<.001).

However, both the star rating and surgical volume were correlated with 4 short-term cancer surgery outcomes (mortality, complication rate, readmissions, and prolonged length of stay). The adjusted predicted probabilities for 5- and 1-star hospitals were 2.3% and 4.5% for mortality, 39% and 48% for complications, 10% and 15% for readmissions, and 8% and 16% for a prolonged length of stay, respectively. The adjusted predicted probabilities for hospitals with the highest and lowest quintile cancer surgery volumes were 2.7% and 5.8% for mortality, 41% and 55% for complications, 12.2% and 11.6% for readmissions, and 9.4% and 13% for a prolonged length of stay, respectively.

Furthermore, surgical volume and the star rating were similarly associated with mortality and complications, whereas the star rating was more highly associated with readmissions and prolonged length of stay.

In the absence of other information, these findings suggest that the star rating may be useful to patients when they are selecting a hospital for major cancer surgery. However, more research is needed before these ratings can supplant surgical volume as a measure of surgical quality.


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