title: Inpatients' willingness to recommend: a multilevel analysis.
abstract: BACKGROUND
  Satisfaction with health care is one of the most widely assessed measures of hospital care quality, yet studies that account for clustering effects are uncommon. We constructed a multilevel model to identify predictors of willingness to recommend while controlling for clustering effects due to hospital and care unit. We also examined differences in predictors by care unit.
  
  
  OBJECTIVE
  The aim of this study was to identify factors that both influence patient perceptions of care and are potentially modifiable by the hospital delivering care.
  
  
  METHODS
  Our sample includes Hospital Consumer Assessment of Healthcare Providers and Systems survey data collected between July 1, 2007, and June 30, 2008, for 131 hospitals and 33,445 patients. The primary outcome was willingness to recommend the hospital to family and friends. Variables were collected at three levels: patient (Hospital Consumer Assessment of Healthcare Providers and Systems survey item responses and demographics), care unit, and hospital. Data were analyzed using multilevel modeling. We also ran a series of two-level models to explore differences in predictors by care type.
  
  
  RESULTS
  The strongest predictors of willingness to recommend, controlling for clustering effects, were items that generally reflected interpersonal aspects of care such as nursing and physician behaviors. In the two-level models, predictors of willingness to recommend overlapped across care units, but important differences were noted.
  
  
  CONCLUSIONS
  Our results suggest that hospitals that wish to improve their performance would benefit most from focusing on interpersonal aspects of care. Hospitals that focus resources on improving in these areas, that assess care units separately, and that investigate the meaning and context of survey responses will be most likely to see improvements in satisfaction scores.
authors.affiliation: Klinkenberg Evaluation Services, St. Louis, Missouri, USA. freudianslip52@hotmail.com
authors.forename: W Dean
authors.initials: WD
authors.lastname: Klinkenberg
authors.forename: Sarah
authors.initials: S
authors.lastname: Boslaugh
authors.forename: Brian M
authors.initials: BM
authors.lastname: Waterman
authors.forename: Koichiro
authors.initials: K
authors.lastname: Otani
authors.forename: Joe M
authors.initials: JM
authors.lastname: Inguanzo
authors.forename: Jan Carolus
authors.initials: JC
authors.lastname: Gnida
authors.forename: Wm Claiborne
authors.initials: WC
authors.lastname: Dunagan
mesh_terms: D016208:Databases, Factual; D019538:Health Care Surveys / Q000379:methods; D006761:Hospitals; D006801:Humans; D007297:Inpatients; D017060:Patient Satisfaction; D011787:Quality of Health Care; D014481:United States