INTRODUCTION
US hospitals seek to improve quality and safety by engaging patients and their families in care delivery and organization.1 Patient and family advisory councils (PFACs) constitute one form of engagement in which patients and families advise hospitals on issues that impact care quality and provide perspectives to ensure patient-centered care.2,3 Our study purpose was to analyze US hospitals’ characteristics associated with the presence of PFACs.
METHODS
In this retrospective cross-sectional analysis of the 2020 American Hospital Association (AHA) annual survey, our outcome was a binary variable indicating a “yes/no” response to the question: “Does your hospital have an established patient and family advisory council that meets regularly to actively engage the perspectives of patients and families?” Our sample excluded all non-respondents to this question. We calculated the percentage of hospitals with PFAC presence by state. We investigated hospital characteristics associated with PFAC presence using a multivariable logistic regression (RStudio v.2022.02.3) with robust standard errors and two-tailed α = 0.05. Independent variables included those presented in Table 1 as well as indicator variables denoting hospital presence in US states. We examined multicollinearity using the variance inflation factor.
Table 1.
Sample Characteristics and Multivariable Logistic Regression Model Associating Hospital Characteristics with PFAC presence
| Organizational characteristics | All hospitals | Hospitals without PFACs | Hospitals with PFACs | Adjusted odds ratio of PFAC presence (95% confidence interval) |
p-value |
|---|---|---|---|---|---|
| % |
N (%) |
N (%) |
|||
| Total | 100% |
1734 (48%) |
1882 (52%) |
- | - |
| Hospital size | |||||
| < 100 beds | 51.9% |
1152 (66.4%) |
724 (38.5%) |
Reference | - |
| 100–300 beds | 29.5% |
412 (23.8%) |
655 (34.8%) |
1.9 (1.5–2.3) |
< 0.001 |
| 300–500 beds | 10.8% |
118 (6.8%) |
272 (14.5%) |
2.3 (1.7–3.1) |
< 0.001 |
| > 500 beds | 7.8% |
52 (3%) |
231 (12.2%) |
4.4 (2.9–6.8) |
< 0.001 |
| Ownership structure | |||||
| Private, non-profit | 62.3% |
891 (51.4%) |
1364 (72.5%) |
Reference | - |
| Private, for-profit | 18% |
453 (26.1%) |
198 (10.5%) |
0.7 (0.6–0.93) |
0.01 |
| Government, non-federal | 18.9% |
384 (22.1%) |
298 (15.8%) |
0.9 (0.7–1.1) |
0.4 |
| Government, federal | 0.8% |
6 (0.3%) |
22 (1.2%) |
2.5 (0.9–6.4) |
0.07 |
| General vs. specialty hospitala | |||||
| Specialty hospital | 17.5% |
433 (25%) |
199 (10.6%) |
Reference | - |
| General medical and surgical hospital | 82.5% |
1301 (75%) |
1683 (89.4%) |
1.8 (1.4–2.3) |
< 0.001 |
| Pediatric specific hospital | |||||
| Non-pediatric only hospital | 97.7% |
1703 (98.2%) |
1830 (97.2%) |
Reference | |
| Pediatric hospital | 2.3% |
31 (1.8%) |
52 (2.8%) |
2.2 (1.4–3.5) |
< 0.001 |
| Core-based statistical area | |||||
| Metropolitan | 67.6% |
1081 (62.3%) |
1365 (72.5%) |
Reference | - |
| Micropolitan | 14.9% |
283 (16.3%) |
257 (13.7%) |
0.99 (0.8–1.3) |
0.94 |
| Rural | 17.4% |
370 (21.4%) |
260 (13.8%) |
0.95 (0.7–1.2) |
0.70 |
| System membership | |||||
| Non-member | 29.8% |
610 (35.2%) |
468 (24.9%) |
Reference | - |
| Health system member | 70.2% |
1124 (64.8%) |
1414 (75.1%) |
1.4 (1.2–1.7) |
< 0.001 |
| Critical access designation | |||||
| Non-designee | 77.2% |
1261 (72.7%) |
1531 (81.3%) |
Reference | - |
| Critical access hospital | 22.8 |
473 (27.3%) |
351 (18.7%) |
0.9 (0.7–1.1) |
0.3 |
| Member of the Council of Teaching Hospitals (COTH) | |||||
| Non-member | 93.5% |
1696 (97.8%) |
1684 (89.5%) |
Reference | - |
| Member of the COTH | 6.5% |
38 (2.2%) |
198 (10.5%) |
1.6 (1.01–2.5) |
0.04 |
Abbreviation: PFAC, patient and family advisory council
Multivariable regression model includes all independent variables provided in the table as well as indicator variables for all US states. Results for each state are not reported in the table for clarity of presentation
aHospitals were provided a choice to indicate the type of service offered to a majority of the patients they served. These choices included general medical and surgical, as well as psychiatric, heart, orthopedic, and cancer among other non-general types
RESULTS
Of the 6165 hospitals asked to participate, 4077 hospitals responded to the survey (survey response rate = 66%). In total, 3616 hospitals responded to the question indicating PFAC presence (question response rate = 89%). A total of 1879 hospitals (52%) indicated having an established PFAC. We provide descriptive statistics in Table 1 and demonstrate substantial variation of PFAC presence by state in Fig. 1.
Figure 1.
Percentage of hospitals reporting PFACs as present by state. The intensity map presents the percent of hospitals which reported presence of PFACs by state. Increasing opacity denotes higher percentage of hospitals reporting presence of PFACs.
After multivariable adjustment, larger, general medical and surgical, children’s, health system member, and teaching hospitals were more likely to report PFAC presence (Table 1). For-profit hospitals (as opposed to private, non-profit hospitals) were less likely to report PFAC presence. Variance inflation factors ranged between 1.1 and 2.5, revealing no evidence of multicollinearity.
DISCUSSION
Our results demonstrate that organizational characteristics such as size and ownership are associated with PFAC presence in hospitals. The strong positive relationship of increasing bed size and health system membership with PFAC presence may be evidence that larger hospitals have more resources to overcome competing organizational priorities, which is a significant barrier to patient and family engagement.3 However, the negative association between for-profit status and PFAC presence suggests an area of improvement for for-profit hospitals to engage patients, families, and local communities. Recent research on ownership type as a predictor of hospital behavior demonstrates profitability as a consequential factor in services provided4 and yet, for-profit hospitals are likely to serve vulnerable populations in counties with demonstrated social, economic, and health needs.5 For-profit hospitals may be foregoing opportunities to incorporate patient and family voices in organizational decision-making by not implementing PFACs, thereby missing feedback that can improve patient-centered care.2
Further, our results suggest the importance of exploring hospital variation by geography as a driver to PFAC presence, and that regulatory pressures may bear strongly on PFAC adoption. Massachusetts is currently the only state wherein all hospitals are mandated by state law to have a PFAC and annually report on PFAC activities and engagement.6 Developing a stronger evidence base linking PFAC adoption to care quality could incentivize other states and regulators to consider implementing similar systemic structural requirements.
Our exploratory study has certain limitations. We leveraged the only available national survey regarding PFAC presence in US hospitals, which included a single, binary, self-reported question. Hospitals reporting lack of PFACs may have adopted different forms of patient and family engagement. Not all US hospitals responded to the survey and question of interest. Moreover, these data neither contain details regarding the structural properties of PFACs such as size, membership criteria, and role division, nor visibility into their engagement and management processes. Because our dataset does not describe the form of PFAC implementation, our results cannot discriminate between hospitals meeting some minimum internal reporting threshold from those participating in more intensive forms, such as shared governance models.
Future research could leverage the variation we observed to examine differences in hospital PFAC structures and processes, especially by ownership and profit status, and explore these properties in relation to PFAC effectiveness and outcomes that matter most to patients and their loved ones.
Funding
Tuna C. Hayirli is supported by award number T32GM144273 from the National Institute of General Medical Sciences. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of General Medical Sciences or the National Institutes of Health.
Data Availability:
Data are either publicly available or available for purchase.
Declarations:
Conflict of Interest:
The authors declare that they do not have a conflict of interest.
Footnotes
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References
- 1.Carman KL, Dardess P, Maurer M, et al. Patient and family engagement: a framework for understanding the elements and developing interventions and policies. Health Aff. 2013;32(2):223–231. doi: 10.1377/hlthaff.2012.1133. [DOI] [PubMed] [Google Scholar]
- 2.Oldfield BJ, Harrison MA, Genao I, et al. Patient, family, and community advisory councils in health care and research: a systematic review. J Gen Intern Med. 2019;34(7):1292–1303. doi: 10.1007/s11606-018-4565-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Herrin J, Harris KG, Kenward K, Hines S, Joshi MS, Frosch DL. Patient and family engagement: a survey of US hospital practices. BMJ Qual Saf. 2016;25(3):182–189. doi: 10.1136/bmjqs-2015-004006. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Horwitz JR, Nichols A. Hospital service offerings still differ substantially by ownership type: study examines service offerings by hospital ownership type. HealthAff. 2022;41(3):331–340. doi: 10.1377/hlthaff.2021.01115. [DOI] [PubMed] [Google Scholar]
- 5.Cronin CE, Franz B, Choyke K, Rodriguez V, Gran BK. For-profit hospitals have a unique opportunity to serve as anchor institutions in the U.S. Prev Med Rep. 2021 Apr 3;22:101372. [DOI] [PMC free article] [PubMed]
- 6.Commonwealth of Massachusetts Circular Letter: DHCQ 09–07–514. Patient and Family Advisory Councils. Available at: https://www.mass.gov/doc/09-07-514-patient-and-family-advisory-councils-782009/download
Associated Data
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Data Availability Statement
Data are either publicly available or available for purchase.