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Differences in Patient Experience Between Hispanic and Non-Hispanic White Patients Across U.S. Hospitals

Jose F. Figueroa · Kimberly E. Reimold · Jie Zheng · Endel John Orav

ABSTRACT Introduction: Despite the increased emphasis on patient experience, little is known about whether there are meaningful

differences in hospital satisfaction between Hispanic and non-Hispanic whites.

Methods: To determine if satisfaction differs, we used Hospital Consumer Assessment of Healthcare Providers and Systems

(HCAHPS) survey data (2009–2010) reported by hospitals to compare responses between Hispanic and non-Hispanic white patients.

Clustered logistic regression models identified within-hospital and between-hospital differences in satisfaction.

Results: Of the 3,864,938 respondents, 6.2% were Hispanics, who were more often younger and females and less likely to have

graduated from high school. Hispanics were overall more likely to recommend their hospital (74.1% vs. 70.9%, p, .001) and to rate

it 9 or 10 (72.5% vs. 65.9%, p, .001) than whites. Increased satisfaction among Hispanics was more pronounced when compared

with whites within the same hospitals, with significantly higher ratings on all HCAHPS measures. However, hospitals serving a higher

percentage of Hispanics had lower satisfaction scores for both Hispanic and white patients than other hospitals.

Conclusion: There were significant but only modest-sized differences in patient experience between Hispanic and white patients across U.S. hospitals. Hispanics tended to be more satisfied with their care but received care at lower-performing hospitals.

Keywords: disparities/equity of care, patient satisfaction, health policy

Introduction Patient experience is an essential component of measuring health system performance.1 Previous work has shown that high performance on measures of patient experience is associated with high perfor- mance with other measures of quality of care, including clinical processes and health outcomes.2-5

When patients report poor experiences, evidence shows that they are more likely to delay seeking necessary medical care and are also at higher risk of not adhering to treatment recommendations.6-9

Therefore, in recent years, the federal government

has significantly increased emphasis on patient experience by tying Medicare payments directly to measures of patient satisfaction through pay-for- performance efforts, such as the Hospital Value- Based Purchasing (VBP) Program.10

One area of particular concern is disparities in patient experience amongHispanic patients. Among minority populations, Hispanics are the least likely group to seek medical care when it is necessary,11

more likely to lack health insurance coverage12 and a usual source of care,13 and often have limited English proficiency.14 In addition, Hispanics are less likely to receive important treatments for common medical conditions compared with non-Hispanic whites.15-17 As such, barriers in receiving care may influence how Hispanics perceive the delivery of care. Therefore, it is critical to understand the extent to which Hispanic patients may have differences in experience with hospital care as compared to non- Hispanics.

Site of care may play an important role in health care disparities. Previous work found that care for Hispanic patients is highly concentrated, with more than half of the Hispanic patients in a small pro- portion of U.S. hospitals.17 These “Hispanic-serving” hospitals provided worse quality of care than other hospitals.17 However, we know little about the extent

Journal for Healthcare Quality, Vol. 40, No. 5, pp. 292–300

The authors declare no conflicts of interest.

For more information on this article, contact Jose F. Figueroa at jfigueroa@

hsph.harvard.edu

This work was supported by the National Institute on Minority Health and

Disparities (Grant No. 1R01MD006230-01A1) at the National Institutes of

Health (NIH). The NIH had no role in the design and conduct of the study;

collection, management, analysis, and interpretation of the data; or

preparation, review, and approval of the article.

The study was approved by the Harvard T.H. Chan School of Public Health

Institutional Review Board’s Committee on the Use of Human Subjects.

Supplemental digital content is available for this article. Direct URL citations

appear in the printed text and in the HTML and PDF versions of the article at

www.jhqonline.com.

DOI: 10.1097/JHQ.0000000000000113

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of the influence that these hospitals have on overall patient experience for Hispanic patients.

Therefore, in this study, we sought to answer three questions. First, do Hispanics have worse patient experience in U.S. hospitals compared with non- Hispanic whites? Second, given that previous evi- dence has shown that education may affect patient outcomes and experience, if gaps in patient experi- ence do exist, to what extent do they vary according to patients’ level of education?18,19 Finally, are observed differences in experience between His- panic and non-Hispanic whites predominantly seen within the same hospitals, or are they driven primarily by site of care?

Methods

Data Hospitals are required to report data onmeasures of inpatient experience through the Healthcare Pro- viders and Systems (HCAHPS) survey to the Centers for Medicare and Medicaid Services (CMS). This survey was developed by the Agency for Healthcare Research and Quality. It is administered by hospitals to a random sample of adult patients up to 6 weeks after a hospital discharge. We obtained patient-level data from the 2009 and 2010 HCAHPS surveys from the Iowa Quality Improvement Organization (QIO), an affiliate of the Centers for Medicare and Medicaid Services (CMS). These patient-level data are different from data available through Hospital Compare, which contains hospital aggre- gate data only and, therefore, does not allow for comparison of Hispanic vs. non-Hispanic responses within a given hospital.

The HCAHPS survey consists of 27 questions related to patient experience on the following 10 measures: 2 global measures of patient experience, 6 composite measures of clinical domains, and 2 individual items about the hospital environment. The 2 global measures are: overall rating of the hospital on a scale of 0 to 10 and whether or not the patient would recommend the hospital to family members or friends. The six composite measures are related to communication with physicians, commu- nication with nurses, communication about medica- tions, pain control, discharge process, and staff responsiveness. The methodology used by CMS to calculate composite scores has been described pre- viously.20 The remaining two items are individual questions about cleanliness and quietness of the hospital environment.

The survey also contains self-reported patient characteristics on the patient’s age, sex, race, health status, primary language spoken at home, reason for admission, and level of education. In this study, we included only patients who identified themselves as Hispanic white or non-Hispanic white. We excluded black patients because they have been previously studied.21

Because of CMS regulations, we were only able to obtain data on three hospital characteristics: pro- portion of inpatient admissions who were Hispanics versus white Medicare patients, hospital size (small [fewer than 100 beds]; medium [100–399 beds]; or large [400 or more beds]—the size ranges used by the American Hospital Association), and major teaching hospital status (defined as being a member of the Council of Teaching Hospitals of the Association of American Medical Colleges). Mas- sPRO conducted linkage of the AHA survey data to HCAHPS data.

To define “Hispanic-serving” hospitals, we first ranked all hospitals by the proportion of their admitted patients who are of Hispanic ethnicity. We then defined the top 10% of hospitals with the highest proportion of Hispanic patients admitted as the “Hispanic-serving hospitals.” The remaining 90% of hospitals were defined as non-Hispanic–serving hospitals.

Outcomes Our primary outcomes of interest were the two global measures of patient experience: overall hospital rating and willingness to recommend the hospital. Secondary outcomemeasures included the six composites and two hospital environment measures. Our outcome varia- bles were constructed using the CMS method, which represents the percentage of patients who reported the most positive, or “top box,” response.20 The primary outcomes were dichotomized as follows: a rating of 9 or 10 versus a rating of 8 or below for hospital rating; and a rating of “definitely yes” versus “definitely no,” “probably no,” and “probably yes” for willingness to recommend. The secondary domains were dichoto- mized as follows: “yes” versus “no” for dischargeprocess; “always” versus “never,” “sometimes,” and “usually” for the remaining measures.

Analysis Using chi-square tests, we compared the character- istics of Hispanic and non-Hispanic white patients and Hispanic-serving hospitals versus non-Hispanic– serving hospitals. We also used chi-square tests to

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compare unadjusted differences in patient experi- ence for the primary and secondary outcomes across the two groups.

We then constructed multivariable logistic regres- sion models where we used generalized estimating equations (GEEs) to account for the clustering of patients within hospitals. To capture overall differences between Hispanic and non-Hispanic white patients, we used an initial independent correlation structure, although the final model standard errors were adjusted for the empirically measured correlation from the within-hospital residuals. These models were adjusted for baseline differences in self-reported patient char- acteristics. To examine whether the differences be- tweenHispanic and non-Hispanic white patients varied by their level of education, we dichotomized the education variable at high school or less and added the interaction term between dichotomized education and race, along with all the other covariates above. For satisfaction measures where the interaction terms were significant, we stratified our analyses by education level and compared satisfaction between Hispanic and non- Hispanic white patients within each level of education.

To identify how much of the overall ethnic differences were due to differences in satisfaction within hospitals, we constructed a multilevel logistic regression model using hospital random effects and all of the covariates above. The difference between the overall ethnic gap and the within-hospital gap was calculated and used to represent the effect of differences due to the quality of hospitals at which Hispanics and non-Hispanics were most likely to get their care. To address the quality gap between Hispanic-serving hospitals and non-Hispanic-serving hospitals more directly, we also expanded the GEE model to include an indicator variable for Hispanic- serving hospitals and the interaction between Hispanic-serving hospitals and Hispanic patients. From these models, we were able to estimate for each race the difference in satisfaction if they were seen at a Hispanic-serving hospital versus if they were seen at a non-Hispanic-serving hospital.

The study was approved by Harvard University’s Institutional Review Board Committee on the Use of Human Subjects. Analyses were performed using SAS, version 9.4.

Results

Patient and Hospital Characteristics We had data on 3,864,938 respondents who com- pleted the HCAHPS survey in 2009 and 2010, of

which 238,310 were Hispanic respondents (6.2%) and 3,626,628 were non-Hispanic white respondents (93.8%). Compared with non-Hispanic white patients, Hispanics were more likely to be younger than 65 years (49.2% for whites vs. 66.5% for Hispanics, p , .001) and women (60.7% vs. 67.6%, p, .001) and less likely to have graduated from high school (12.2% vs. 32.3%, p , .001), report excellent health (12.9% vs. 21.0%, p , .001), and be admitted for maternity care (10.7% vs. 24.2%) (Table 1).

We designated 379 hospitals of the 3,796 hospitals that reported HCAHPSmeasures as Hispanic-serving hospitals. These hospitals were more likely than non- Hispanic-serving hospitals to be large (27.9% vs. 23.4%; p , .001) and to be non-teaching hospitals (87.7% vs. 85.3%; p, .01) (see Table 1, Supplemen- tal Digital Content 1, http://links.lww.com/JHQ/ A52). Among Hispanic-serving hospitals, the pro- portion of Hispanic patients admitted was 35.9% compared with 3.6% in the remaining hospitals.

Patient Satisfaction by Race We examined the unadjusted relationship between patient experience and ethnicity. In unadjusted models, we found that Hispanic patients were more likely to rate hospitals a 9 or 10 (72.9% vs. 65.9%, p , .001) and to recommend hospitals (74.2% vs. 70.9%, p, .001) compared with non-Hispanic whites (Table 2). Hispanics were also more likely to report more positive experiences on seven of the eight secondary measures than non-Hispanic whites.

When we adjusted for patient characteristics, Hispanics were stillmore likely to recommendhospitals (74.1%) and rate hospitals a 9 or 10 (72.5%) compared with non-Hispanic whites (70.9% and 65.9%, respec- tively; both p , .001); they were also still significantly more likely to report higher scores on communication with physicians (79.9% vs. 78.3%; p, .001) and about medications (60.1% vs. 57.7%; p , .001) and also report more satisfaction related to staff responsiveness (61.0% vs. 60.4%; p 5 .03) and pain management (54.1% vs. 50.6%; p , .001) (Table 2). However, Hispanics showed a slightly lower level of satisfaction with discharge information (78.5% vs. 79.1%; p5 .003) and hospital cleanliness (68.6% vs. 69.5%; p5 .004).

Effect of Education For all of our outcome measures, we found signifi- cant interactions between the racial differences in satisfaction and level of education. In adjusted models stratified by the level of education, both Hispanic and non-Hispanic patients with at least

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some college education were less likely to recom- mend hospitals or give them a rating of 9 or 10 (see Table 2, Supplemental Digital Content 2, http:// links.lww.com/JHQ/A53). Among patients with a high school education or less, Hispanics gave significantly more positive evaluations on

all 10 HCAHPS measures than non-Hispanic whites.

Patient Satisfaction by Site of Care In our within-hospital analyses, which controlled for the influence of individual hospitals on the patient experience measures, Hispanics reported more positive experiences for all 10 HCAHPS measures (Figure 1). In addition, the gap between Hispanics’ and whites’ experiences was wider in our within- hospital analyses than in the unadjusted models except for cleanliness of the hospital environment, which now showed Hispanics giving a slightly more positive evaluation (Table 3).

We subtracted the within-hospital differences from the overall differences to obtain the between- hospital components of difference. These estimated components reflect the differences in hospital scores attributable to the influence of hospitals on patient experience—which, in turn, reflects the differences in the average patient experience between Hispanic- serving hospitals and non-Hispanic–serving hospi- tals. The between-hospital components of difference between Hispanics and whites were22.3% points for recommendation of hospitals and 22.6% points for ratings of hospitals (Table 3). For all eight secondary domains, the components were also negative (rang- ing from 21.4% to 23.3% points). The negative signs suggest that Hispanic patients get care at hospitals where, on average, the experience of care is worse for all patients.

We then compared patient experience of His- panic and non-Hispanic whites stratified by Hispanic- serving and non-Hispanic-serving hospitals. Both whites andHispanics ratedHispanic-serving hospitals lower than non-Hispanic-serving hospitals on all 10 HCAHPS measures. Hispanic patients in Hispanic- serving hospitals rated their satisfaction 2.5%–5.8% lower (depending on the satisfaction measure) than Hispanic patients in non-Hispanic-serving hospitals. Likewise, white patients in Hispanic-serving hospitals rated their satisfaction 4.5%–9.2% lower than white patients in non-Hispanic-serving hospitals (see Table 3, Supplemental Digital Content 3, http:// links.lww.com/JHQ/A54). In addition, Hispanics were still much more likely to rate each hospital more positively than whites.

Limitations Our study had several limitations. First, HCAHPS measures are subjective, so it is difficult to determine the differences between patients’ expectations and

Table 1. Characteristics of Hispanic and Non- Hispanic White Patients Admitted to U.S. Hospitals

Characteristic

Ethnicity

Hispanic White

No. of patients 238,310 3,626,628

Age, years

Less than 65 66.5 49.2

65–69 8.2 11.2

70–79 15.2 21.6

80 or more 10.1 18.0

Sex, %

Male 30.6 38.7

Female 67.6 60.7

Education, %

Less than high school 32.3 12.2

High school graduate or GED 27.1 32.4

Some college or beyond 40.5 55.4

Overall health, %

Excellent 21.0 12.9

Very good or good 54.5 58.8

Fair or poor 24.5 28.3

Reason for admission, %

Maternity care 24.2 10.7

Medical 41.7 48.0

Surgical 28.8 34.9

Missing 5.4 6.3

Note: GED 5 General Education Diploma. These are respondents of the HCAHPS survey in 2009 and 2010. Some percentages do not sum to 100 because of rounding. All differences between Hispanics and whites were significant (p , .001).

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differences in hospital quality using these measures;22

however, it is still critically important to examine patient experience because the underlying expect- ations are a part of how a patient experiences care. Second, the HCAHPS survey only has a 30% response rate. Although it is possible that the views of the respondents do not necessarily reflect those who did not respond to the survey, the HCAHPS survey has undergone extensive testing that shows results are not substantially affected by nonresponse bias. Third, we were unable to evaluate Hispanic ethnicity in more detail because Hispanics represent people frommany Latin American countries, with different cultural norms, lifestyles, varying degree of economic circum- stances, and significant differences in overall health depending on the country of origin. Fourth, it is possible that insurance status (or lack of insurance status) may influence how patients experience care. Differences in insurance statusmay thus partly explain some of the differences in patient satisfaction between

whites and Hispanics. Next, we did not have in- formation on exact reasons why patients were admitted beyond the type of ward so we were unable to adjust for severity and type of admission. Finally, our data were collected before the start of the Hospital VBP program. However, we have no reason to believe that our results would changebecause recent evidence showed that HCAHPS scores have only risen slightly over the last several years, and the introduction of the VBP program had no effect on improving patient experience.10,23

Discussion Across U.S. hospitals, we found surprisingly few meaningful differences in patient experience be- tween Hispanic and non-Hispanic white patients. In fact, Hispanics generally reported more positive experiences than non-Hispanic white patients across most measures of patient experience as reported

Table 2. Differences in Patient Experience Between Hispanic and Non-Hispanic White Patients, Overall and Adjusted by Patient Characteristics

HCAHPS measure

Unadjusted Adjusted for patient characteristics

Hispanic White Difference p-value Hispanic White Difference p-value

Overall satisfaction

Recommend hospital 74.2% 70.9% 3.4% ,.0001 74.1% 70.9% 3.3% ,.0001

Best rated hospital 72.9% 65.9% 7.1% ,.0001 72.5% 65.9% 6.6% ,.0001

Communication

Communication with doctors 81.8% 78.2% 3.7% ,.0001 79.9% 78.3% 1.6% ,.0001

Communication with nurses 76.4% 75.0% 1.4% ,.0001 75.0% 75.1% 0.0% .94

Communication about medications 63.4% 57.5% 5.9% ,.0001 60.1% 57.7% 2.4% ,.0001

Clinical management

Adequate staff services 64.9% 60.2% 4.8% ,.0001 61.0% 60.4% 0.6% .03

Pain management 59.0% 50.3% 8.6% ,.0001 54.1% 50.6% 3.5% ,.0001

Discharge information 80.0% 79.0% 1.0% ,.0001 78.5% 79.1% 20.6% .003

Hospital environment

Quietness of hospital environment 63.4% 53.0% 10.4% ,.0001 58.0% 53.3% 4.7% ,.0001

Cleanliness of hospital environment 69.8% 69.4% 0.5% .1304 68.6% 69.5% 20.9% .004

Note: Multivariable regression models were used to adjust differences between Hispanic and white satisfaction scores for correlation within hospitals, as well as for age, sex, health status, education, primary language spoken at home, and source of admission. Differences may not match values precisely because of rounding.

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through the HCAHPS survey. However, the gap between Hispanic and white patient experience was substantially smaller among patients with at least some college education than among those with less education.

It is reassuring that there are no meaningful differences in the report of patient experience within the given U.S. hospitals. Even in the area of communication, where concerns about language proficiency or cultural competency may be more of an issue, we found that Hispanic patients generally reported more positive experiences than non- Hispanic patients.

These results are consistent with a well-known observation called the “Hispanic paradox.” Despite having, on average, lower socioeconomic status and less access to education and health services than non- Hispanic whites, Hispanic health status is closer or even better than non-Hispanic whites.24 Previous work has shown that Hispanics have longer life expectancy than non-Hispanic whites25 and also lower mortality rates in seven of the 10 leading causes of death in the United States.26

There are some plausible explanations for why Hispanics report better satisfaction than whites. First, there is a strong relationship between an individual’s

overall health status and health experience: individ- uals with better health status are more likely to be satisfied with the health system.21,27 Part of what may explain the Hispanic paradox is that Latinos that migrate into the United States tend to be younger and healthier than the average population.28 In addition, when they become severely ill, a large number of Hispanics return to their home countries to get treatment and often stay there until the end of their lives, which do not get recorded officially byU.S. figures.29 Second, it is possible that differences in patient experience reflect the underlying expect- ations of care. It may be that Hispanics on average have different expectations for the care they receive in hospitals. Differing expectations of care is sup- ported by the fact that patients with higher educa- tional attainment report more negative evaluations of care across both races. This may be due to educated patients having higher expectations for how they should be treated, which translates to lower evaluations of hospital experience.30-32

However, although it is reassuring that Hispanic and non-Hispanic whites report comparable experi- ences, it is concerning that Hispanic patients are, on average, receiving care at hospitals that perform worse on measures of patient experience for all

Figure 1. Within-hospital differences in patient experience between Hispanic and non-Hispanic white patients, adjusted for patient characteristics. Note: The difference in performance score between Hispanics and whites was statistically significant for all measures (p , .001).

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patients. Previous work has shown that hospitals with high patient experience also have better outcomes, including lower 30-day mortality and readmission rates after admission for acute myocardial infarction, heart failure, and pneumonia.2 Thus, the fact that Hispanics are generally receiving care at lower performing hospitals raises concern, especially con- sidering that they are already less likely to receive timely care compared with non-Hispanic patients.15-17

Our study adds to a growing body of literature examining patient experience by race and ethnic- ity. To our knowledge, this is the first national study examining patient experience of Hispanic patients across all U.S. hospitals that reported HCAHPS. Previous work by Goldstein and colleagues evalu- ated a sample of U.S. hospitals that chose to voluntarily report patient experience scores and

found similar results.33 These results are also consistent with a recently published study that showed black patients reported comparable pa- tient experience to white patients in U.S. hospitals, and black patients were also more likely to receive care at hospitals with lower patient experience scores for all patients.21 Therefore, our findings are consistent with a broader set of studies suggesting that minority populations are more likely to receive care at hospitals with poor quality than white patients rather than differential treatment within the same hospital.34,35

Conclusions Hispanic patients on average reported comparable or even better patient experience than non-Hispanic white patients within a given U.S. hospital. However,

Table 3. Adjusted Differences in Patient Experience Between Hispanic and Non-Hispanic White Patients

HCAHPS measure Overall difference Within-hospital component

of difference Between-hospital component

of differencea

Overall satisfaction

Recommend hospital 3.3%** 5.5%** 22.3%

Best rated hospital 6.6%** 9.2%** 22.6%

Communication

With doctors 1.6%** 3.4%** 21.8%

With nurses 0.0% 3.3%** 23.3%

About medications 2.4%** 4.1%** 21.7%

Clinical management

Staff services 0.6% 3.9%** 23.3%

Pain management 3.5%** 5.5%** 22.0%

Discharge information 20.6% 1.0%** 21.6%

Hospital environment

Quietness 4.7%** 7.3%** 22.6%

Cleanliness 20.9%* 0.6%** 21.4%

Note:Multivariable regression models were used to adjust differences between Hispanic and white satisfaction scores for correlation within-hospital, as well as age, sex, health status, education, primary language spoken at home, and source of admission.

a The between-hospital component of difference was determined by subtracting the within-hospital component of difference from the adjusted overall difference. The percentages in this column indicate the average difference in the performance scores on satisfaction between hospitals where Hispanics on average receive care and hospitals where whites on average receive care. Significance of this component cannot be assessed.

*p , .01, **p , .001.

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it is still concerning that Hispanics are, on average, receiving care at lower-performing hospitals.

Implications Our work suggests that efforts targeting minority populations may be more effective if they focus on the hospitals that predominantly care for minority patients.

Authors’ Biographies

Jose F. Figueroa, MD, MPH is a research specialist at the Harvard T.H. Chan School of Public Health in Cambridge, MA. J. F. Figueroa also practices medicine at the Brigham and Women’s Hospital and Harvard Medical School.

Kimberly E. Reimold, BA is a research assistant at the Harvard T.H. Chan School of Public Health in Cambridge, MA. She works with Dr. Ashish Jha’s research team.

Jie Zheng, PhD is a statistician at the Harvard T.H. Chan School of Public Health in Cambridge, MA. She works with Dr. Jha’s research team as well.

Endel John Orav, PhD is a statistician at the Harvard T.H Chan School of Public Health and Brigham and Women’s Hospital. He frequently works with members of Dr. Jha’s research team to determine the best methods and refine analytical plans.

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300 September/October 2018·Volume 40·Number 5 www.jhqonline.com

Original Article