Pandemic ushered 'unprecedented' declines in hospital patient experience scores, study finds

Though hospitals’ patient experience scores broadly suffered during the COVID-19 pandemic, the “unprecedented” declines were greatest among facilities that were already facing staffing issues prior to 2020, according to a new analysis published in JAMA Health Forum.

The analysis of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) responses found a steady decrease in summary HCAHPS scores across nearly 3,400 participating hospitals.

Compared to expected trends based on survey data from 2018 and 2019, U.S. hospitals logged a 1.2 percentage point decline in the second quarter of 2020, the start of the pandemic, that deteriorated to a 3.6 percentage point reduction by the end of 2021, per the study.

“This unprecedented decline in patient experience was seen in every region of the U.S., with relatively little regional variation,” Marc Elliott, the study’s lead author and a senior principal researcher at RAND Corporation, said in a release. “Hospitals with higher staffing levels and better overall pre-pandemic quality were more resilient and slower to see their decline. But eventually even their patients also reported worse experiences.”

RAND conducted the study alongside collaborators from the Health Services Advisory Group, the Centers for Medicare & Medicaid Services (CMS)—which runs the HCAHPS surveys and funded the new research under contract—and Yale School of Public Health. The analysis included about 5.3 million completed HCAHPS surveys from 2018 and 2019 as well as 3.9 million from 2020 and 2021.

Across individual HCAHPS measures, patients reported the largest hits to hospital staff responsiveness (a 5.6 percentage point decline in scores as of the fourth quarter of 2021) and hospitals’ cleanliness (a 4.9 percentage point decline), “possibly reflecting high absenteeism in the hospital workforce and delays in care associated with staff having to wear [personal protective equipment],” the researchers wrote.

Less impacted were HCAHPS metrics addressing discharge information and hospital quietness, though those ultimately logged respective 1.6 and 1.8 percentage point declines. Measures of overall hospital ratings as to whether patients would recommend a hospital were initially slow to drop but caught up to the other more specific HCAHPS metrics by the second quarter of 2021, researchers wrote.

“This pattern suggests that global ratings alone do not fully capture changes in specific patient experiences, nor do they identify the areas in need of improvement, especially in the face of unusual events such as a pandemic,” Elliott said.

Hospitals with the lowest prepandemic staffing levels saw the greatest initial hit to their summary HCAHPS score, researchers found, though those with greater staffing had reached similar decrements by the study period’s final quarter.

Similarly, facilities with five-star hospital ratings “showed consistently smaller declines” in summary scores across the period than one-star and two-star hospitals. That gap narrowed by the fourth quarter of 2021 with just a 13% difference in impact between the groups, or a 3.2% percentage point decline for high-quality hospitals and a 3.7% percentage point drop for the low-quality hospitals.

Based on these findings, researchers speculated that the high-quality hospitals were more resistant to staff reductions, allowing them to better adapt to pandemic challenges until the cumulative effects of staff burnout and the emergence of the omicron variant.

Though the researchers’ findings paint a clearer picture of patient experience during the pandemic, the team’s conclusions shouldn’t come as a surprise to patients or providers alike.

Prior reports from the Leapfrog Group, Press Ganey and the Centers for Disease Control and Prevention have outlined hospitals and other provider settings’ sliding patient experience, safety and quality measures. At one point, CMS even considered temporarily pausing its public reporting on certain hospital safety metrics over concerns that the sliding scores could unfairly harm facilities’ reputations.