title: Impact of case-mix on comparisons of patient-reported experience in NHS acute hospital trusts in England.
abstract: OBJECTIVE
  To examine the impact of patient-mix on National Health Service (NHS) acute hospital trust scores in two national NHS patient surveys.
  
  
  METHODS
  Secondary analysis of 2012 patient survey data for 57,915 adult inpatients at 142 NHS acute hospital trusts and 45,263 adult emergency department attendees at 146 NHS acute hospital trusts in England. Changes in trust scores for selected questions, ranks, inter-trust variance and score-based performance bands were examined using three methods: no adjustment for case-mix; the current standardization method with weighting for age, sex and, for inpatients only, admission method; and a regression model adjusting in addition for ethnicity, presence of a long-term condition, proxy response (inpatients only) and previous emergency attendances (emergency department survey only).
  
  
  RESULTS
  For both surveys, all the variables examined were associated with patients' responses and affected inter-trust variance in scores, although the direction and strength of impact differed between variables. Inter-trust variance was generally greatest for the unadjusted scores and lowest for scores derived from the full regression model. Although trust scores derived from the three methods were highly correlated (Kendall's tau coefficients 0.70-0.94), up to 14% of trusts had discordant ranks of when the standardization and regression methods were compared. Depending on the survey and question, up to 14 trusts changed performance bands when the regression model with its fuller case-mix adjustment was used rather than the current standardization method.
  
  
  CONCLUSIONS
  More comprehensive case-mix adjustment of patient survey data than the current limited adjustment reduces performance variation between NHS acute hospital trusts and alters the comparative performance bands of some trusts. Given the use of these data for high-impact purposes such as performance assessment, regulation, commissioning, quality improvement and patient choice, a review of the long-standing method for analysing patient survey data would be timely, and could improve rigour and comparability across the NHS. Performance comparisons need to be perceived as fair and scientifically robust to maintain confidence in publicly reported data, and to support their use by both the public and the NHS.
authors.affiliation: Senior Fellow, The King's Fund, UK v.raleigh@kingsfund.org.uk.
authors.forename: Veena
authors.initials: V
authors.lastname: Raleigh
authors.affiliation: Survey Statistician, Picker Institute Europe, UK.
authors.forename: Steve
authors.initials: S
authors.lastname: Sizmur
authors.affiliation: Senior Research Analyst, The King's Fund, UK.
authors.forename: Yang
authors.initials: Y
authors.lastname: Tian
authors.affiliation: Senior Research Analyst, The King's Fund, UK.
authors.forename: James
authors.initials: J
authors.lastname: Thompson
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003627:Data Interpretation, Statistical; D003953:Diagnosis-Related Groups; D004636:Emergency Service, Hospital; D004739:England; D005260:Female; D019538:Health Care Surveys / Q000379:methods* / Q000592:standards*; D006761:Hospitals / Q000592:standards*; D006801:Humans; D007297:Inpatients; D008297:Male; D008875:Middle Aged; D017060:Patient Satisfaction / Q000706:statistics & numerical data*; D012044:Regression Analysis; D013222:State Medicine; D055815:Young Adult
keywords: case mix adjustment; patient experience; patient satisfaction; patient surveys