Effects of Caregiver and Decedent Characteristics on CAHPS Hospice Survey Scores

Context: The Consumer Assessment of Healthcare Providers and Systems (CAHPS^®) Hospice Survey assesses the care experiences of hospice patients and their families. Public reporting of hospice performance on these survey measures began in February 2018. Objectives: Develop an appropriate case-mix adjustment (CMA) model to allow for fair comparisons between hospices. Methods: We analyzed CAHPS Hospice Survey data reflecting experiences of 915,442 patients who received care from 2513 hospice programs between April 2015 and March 2016. Decedent and caregiver characteristics were identified for inclusion in CMA based on their variation across hospices (as measured by intraclass correlation coefficients [ICCs]) and how predictive they were of responses to survey questions (as assessed by linear regression). Results: The final CMA model included decedent age, payer for hospice care, primary diagnosis, length of final episode of hospice care, caregiver age, caregiver education, relationship to decedent, survey language/language spoken at home, and response percentile. The characteristics that varied most across hospices were language (ICC = 0.48 for Spanish survey or home language) and payer for hospice care (ICC = 0.42 for Medicare only; ICC = 0.35 for Medicare and private insurance). The characteristics that were most predictive of caregivers' survey responses were payer for hospice care, caregiver education, and survey language/language spoken at home. Lack of appropriate adjustment would incorrectly rank hospices by 1.2–5.4 percentile points. Conclusion: To ensure fair comparisons across hospices, CAHPS Hospice Survey measure scores should be adjusted for several caregiver and decedent characteristics.