This study establishes the convergent validity of the new P-TEM with existing, validated hospital-to-home process and outcome measures for hospitalized children.
Abstract
OBJECTIVES:
The Pediatric Transition Experience Measure (P-TEM) is an 8-item, parent-reported measure that globally assesses hospital-to-home transition quality from discharge through follow-up. Our goal was to examine the convergent validity of the P-TEM with existing, validated process and outcome measures of pediatric hospital-to-home transitions.
METHODS:
This was a prospective, cohort study of English-speaking parents and legal guardians who completed the P-TEM after their children’s discharge from a tertiary children’s hospital between January 2016 and October 2016. By using data from 3 surveys, we assessed convergent validity by examining associations between total and domain-specific P-TEM scores (0–100 scale) and 4 pediatric hospital-to-home transition validation measures: (1) Child Hospital Consumer Assessment of Healthcare Providers and Systems Discharge Composite, (2) Center of Excellence on Quality of Care Measures for Children With Complex Needs parent-reported transition measures, (3) change in health-related quality of life from admission to postdischarge, and (4) 30-day emergency department revisits or readmissions.
RESULTS:
P-TEM total scores were 7.5 points (95% confidence interval: 4.6 to 10.4) higher for participants with top-box responses on the Child Hospital Consumer Assessment of Healthcare Providers and Systems Discharge Composite compared with those of participants with lower Discharge Composite scores. Participants with highet P-TEM scores (ie, top-box responses) had 6.3-points–greater improvement (95% confidence interval: 2.8 to 9.8) in health-related quality of life compared with participants who reported lower P-TEM scores. P-TEM scores were not significantly associated with 7- or 30-day reuse.
CONCLUSIONS:
The P-TEM demonstrated convergent validity with existing hospital-to-home process and outcome validation measures in a population of hospitalized children.
What’s Known on This Subject:
Improving pediatric hospital-to-home transition quality has become a national priority. Obtaining a global assessment of the hospital-to-home transition experience from discharge through follow-up requires the administration of multiple measures or instruments, which can pose administrative challenges and considerable response burden.
What This Study Adds:
We established the validity of the Pediatric Transition Experience Measure: an 8-item, parent-reported measure that provides a global assessment of hospital-to-home transition quality. Pediatric Transition Experience Measure scores were associated with validated process measures and health-related quality-of-life outcomes.
Improving the quality of transitions from inpatient to outpatient settings is a national priority.1,2 Growing evidence demonstrates that adverse events, inefficient communication, and inadequate support for families are commonplace during transitions of care after hospitalization.3–6 In response, several quality-improvement efforts are underway to address these issues.7–12 These efforts assess improvement with measures such as documentation of processes of care (eg, using teach-back techniques), adherence to recommended care after discharge, and reduction in 30-day readmission rates.
Patient-centered care transition quality measures help ensure that health services are responsive to the needs of patients and families. Fortunately, several patient- and family-centered measures for pediatric hospital-to-home transitions have been recently developed and/or validated. These measures assess specific aspects of the hospital-to-home transition process, such as discharge teaching quality, family discharge preparation, family discharge readiness, postdischarge instruction comprehensiveness and completeness, and family perceptions of postdischarge support and difficulty coping.13–17 However, obtaining a global assessment of the full transition experience from discharge through follow-up requires the administration of multiple measures or instruments, posing logistic challenges to widespread implementation and considerable response burden on families.18 Identifying a short, validated, patient-centered outcome measure to assess transition quality may lead to wider inclusion of these measures in quality-improvement evaluation and use by health care organizations and payers to measure system-level performance.
For this reason, we developed the Pediatric Transition Experience Measure (P-TEM): a brief, 8-item, parent-reported outcome measure to assess hospital-to-home transition quality.19 Our 2018 study described the development of this measure, including examinations of its face validity and psychometric properties.19 The P-TEM provides a global assessment of the full transition experience and is applicable to pediatric patients with a wide variety of diagnoses and medical complexity. Our objective in this study was to examine the convergent validity of the P-TEM with existing process and outcome measures of pediatric hospital-to-home transition quality.
Methods
Study Design and Population
We conducted a prospective cohort study of English-speaking patients 1 month to 17 years old who were hospitalized on medical or surgical units at a single, tertiary, academic children’s hospital between January 2016 and October 2016. The study also included English-speaking parents and legal guardians (18 years of age or older) of these same patients (henceforth referred to as parents). Patients and parents were only included in this study if the parent completed the P-TEM postdischarge through participation in the Seattle Children’s Hospital Outcomes Assessment Program (OAP).20 Per OAP protocol, patients were excluded if they were hospitalized and discharged from a hematology-oncology or intensive care (neonatal and pediatric) unit. All study procedures were approved by the Seattle Children’s Hospital Institutional Review Board with implementation of the appropriate informed consent for parents and assent procedures for minors.
Data Collection
We used data from 3 OAP surveys to collect 3 groups of validation measures. The first survey included an initial assessment of the child’s health-related quality of life (HRQoL); it was administered within 72 hours of admission. The second survey included survey items from the Child Hospital Consumer Assessment of Healthcare Providers and Systems (Child HCAHPS)17; it was administered within 10 days of the patient’s hospital discharge. The third survey included the P-TEM survey items, a second assessment of HRQoL, and transition-related process measures developed by the Center of Excellence on Quality of Care Measures for Children With Complex Needs (COE4CCN)21; it was administered 2 to 8 weeks after hospital discharge. Because of a programming error, only a subset of those who were eligible to receive the third survey received the P-TEM items. Additionally, some respondents who completed the P-TEM completed a different HRQoL measure that was not analyzed in this study (N = 101). The timing of each survey was consistent with validation studies of these measures.17,19–21
Hospital administrative data were used to ascertain reuse data, the fourth group of validation measures. We also used administrative and survey data to collect patient and respondent demographic characteristics, encounter information, and survey mode to identify potential case-mix adjusters that should be considered when using the P-TEM. Patient age, sex, medical complexity categorization, hospital unit, and length of stay were obtained from hospital administrative data. Medical complexity was determined by using the Pediatric Medical Complexity Algorithm.22 Patient race and/or ethnicity, parent age, sex, race and/or ethnicity, education, number of times the patient was hospitalized, survey mode, and time to follow-up survey were obtained from survey data.
Primary Measure: P-TEM
The P-TEM is an 8-item, parent-reported measure consisting of 2 domains: transition preparation and transition support (4 items each; Table 1).19 The measure also includes 3 screener items to determine eligibility for 4 of the items. Participants were provided with the following introduction before the administration of P-TEM items: “Please think about your experience leaving the hospital and caring for your child at home after your child’s most recent hospital stay when answering the following set of questions. How much do you agree with the following statements…” Response options included a 0-to-10 Likert scale with the following anchors: 0 = strongly disagree, 5 = neutral, and 10 = strongly agree. Domain and total measure scores were computed if a parent answered ≥50% of items for which they were eligible. Scores were calculated as the mean of nonmissing responses and were linearly transformed on a 0-to-100 scale, in which higher scores reflected better quality.
TABLE 1.
P-TEM Survey Items and Scores
| No. Respondents | Mean Score (SD) | Minimum Score | Median Score | Maximum Score | Responses in Top Box,a % | |
|---|---|---|---|---|---|---|
| P-TEM total score | 459 | 90.2 (14.0) | 20 | 96.3 | 100 | 40.1 |
| Transition preparation domain | 459 | 91.4 (14.9) | 0 | 100 | 100 | 52.3 |
| 1. “I had a clear understanding of all the discharge instructions I received before we left the hospital.” | 459 | 92.1 (16.0) | 0 | 100 | 100 | 69.4 |
| 2. “I felt confident about how to care for my child at home.” | 457 | 91.5 (15.6) | 0 | 100 | 100 | 63.7 |
| 3. “The written discharge instructions I was given were helpful for taking care of my child at home.” | 456 | 89.8 (18.6) | 0 | 100 | 100 | 64.9 |
| 4. “I felt I had everything I needed to take care of my child at home after we left the hospital.” | 457 | 92.1 (17.0) | 0 | 100 | 100 | 72.4 |
| Transition support domain | 386 | 86.2 (20.1) | 0 | 96.7 | 100 | 47.7 |
| Screener 1. Did you need to contact your child’s hospital doctors (eg, specialists) with any questions after you left the hospital? (if no, skip to Screener 2) | ||||||
| 5. “I was able to easily contact my child’s hospital doctors (eg, specialists) with questions after we left the hospital.” | 133b | 85.1 (24.1) | 0 | 100 | 100 | 60.2 |
| Screener 2. Did your child have any follow-up appointments that needed to be scheduled after your child's hospitalization? (if no, end survey) | ||||||
| 6. “My preferences (dates and times, location, doctors) were considered when scheduling follow-up appointments for my child.” | 372b | 80.8 (28.4) | 0 | 100 | 100 | 55.9 |
| Screener 3. Have you already seen any of your child’s follow-up doctors? (if no, end survey) | ||||||
| 7. “The follow-up doctor(s) knew what happened to my child in the hospital.” | 283b | 92.9 (15.5) | 0 | 100 | 100 | 73.9 |
| 8. “The follow-up doctor(s) knew how to manage my child's medical care after we left the hospital.” | 283b | 93.2 (14.8) | 0 | 100 | 100 | 75.3 |
For the P-TEM total score, transition preparation domain score, and transition support domain score, top-box responses referred to the proportion of respondents with a score of 100. For the individual measure items, top-box responses referred to the proportion of respondents who selected 10 on the Likert scale (which corresponded to “strongly agree”).
Number of respondents does not equal the total number who completed the P-TEM (N = 459) because parents did not respond affirmatively to the preceding screener question.
Validation Measures
We examined the convergent validity of the P-TEM with 4 groups of pediatric hospital-to-home transition process and outcome validation measures.
Child HCAHPS Discharge Composite
The first validation measure was the parent-reported Child HCAHPS “Preparing You and Your Child To Leave the Hospital” composite (henceforth referred to as the Child HCAHPS Discharge Composite).17 This 5-item composite includes process measures such as assessing readiness for discharge, providing sufficient time at discharge to discuss follow-up care, providing information about when the child could return to their regular activities, providing information about what concerning symptoms and signs the parent should look for after hospitalization, and providing families with written information about these concerning signs and symptoms. Consistent with the Child HCAHPS top-box scoring method,17 a Discharge Composite score was computed if a parent answered ≥1 item (97.5% of parents), and scores were calculated as the mean of nonmissing items by using the following algorithm: responses were scored as 0 if the parent selected “never, sometimes, or usually” and as 100 if the parent selected “always.” Higher scores reflected better discharge preparation.
COE4CCN Measures
The second group of validation measures was the parent-reported, pediatric quality measures for transitions between sites of care developed and tested by the COE4CCN.14,21 We included 4 individual COE4CCN measures that assess processes of care related to (1) providing families with the opportunity to ask questions before discharge; (2) providing education regarding the use of new medical equipment; (3) providing assistance with scheduling follow-up appointments; and (4) providing comprehensive, understandable, and useful written discharge instructions. Consistent with the COE4CCN measures scoring algorithm, each measure was scored either on a 0-to-100 scale, in which higher scores reflected better quality, or as a dichotomous yes-no variable, in which “yes” indicated they received the recommended care.21 We separately measured convergent validity between each of the 4 measures and the P-TEM.
Change in HRQoL
The third validation measure was an assessment of change in HRQoL from admission to postdischarge follow-up, with the hypothesis being that higher-quality transitions would be associated with greater improvements in HRQoL. We examined change in HRQoL using the Pediatric Quality of Life Inventory (PedsQL) 4.0 Generic Core Scales and Infant Scales, which provide a multidimensional assessment of a child’s physical, mental, emotional, and social functioning.20 Parents of patients 2 to 16 years old completed the PedsQL 4.0 Generic Core Scales instrument, whereas parents of patients 2 weeks to 23 months old completed the PedsQL Infant Scales instrument. Patients 8 to 16 years old completed the self-reported PedsQL 4.0 Generic Core Scales instrument if they assented and were cognitively able to do so. Parents and patients were asked to reflect on their children’s (or their own health) at that moment when completing the admission assessment, whereas they were asked to reflect on the past 7 days when completing the postdischarge follow-up assessment. We used a single set of the PedsQL total scale scores for each patient-parent dyad in our analyses. We used self-reported patient scores if the patient completed the PedsQL instrument; otherwise, we used proxy-reported scores from the parent. Items were scored by using a standard method on a 0-to-100 scale, in which higher scores reflected better HRQoL.20 Change scores were computed by using the follow-up PedsQL score as the dependent variable and adjusting for the admission score as a covariate in the validation models. This approach was used to control for correlations between PedsQL admission and follow-up scores as well as ceiling effects of the PedsQL instrument.23
Health Care Reuse
The fourth group of validation measures included health care reuse outcomes, which we defined as any unplanned 7- or 30-day emergency department (ED) revisit or hospital readmission. These data were collected from the hospital administrative database.
Statistical Analysis
We used multivariable regression models to assess convergent validity of the P-TEM with the Child HCAHPS Discharge Composite and COE4CCN measures. We hypothesized that consistent delivery of these processes of care (independent variables) would be associated with higher-quality transition experiences as measured by the P-TEM total and domain-specific scores (dependent variables). For the independent variable, we dichotomized each validation measure score using the top-box scoring method on the premise that in a system of high-quality of care, parents should always report receiving these processes of care as opposed to usually or sometimes.21,24 This approach was also used to ease the interpretation of the results. For each process measure, we grouped respondents with scores of 100 (top box) versus those with scores <100. The P-TEM was analyzed as a continuous dependent variable on a 0-to-100 scale. Regression coefficients (β) in the models represent the difference in P-TEM scores between respondents with scores of 100 on these process measures (ie, top-box score indicating highest possible endorsement) compared with those with lower scores. Separate regression models were used for each process-of-care validation measure.
To examine convergent validity with change in HRQoL, we used multivariable regression models with P-TEM scores as the predictor (independent) variable and change in HRQoL as the outcome (dependent) variable. We hypothesized that higher P-TEM scores would be associated with greater improvement in HRQoL from admission to follow-up. We used a similar top-box scoring approach, as noted above, given the ceiling effects observed for the P-TEM survey items and to ease interpretation of the results; we divided respondents into 2 groups: those with P-TEM scores of 100 and those with scores <100. Regression coefficients (β) represent the change in HRQoL (on a 0–100 scale) for patients with P-TEM scores of 100 (ie, top-box score indicating highest possible transition experience) compared with those with lower P-TEM scores.
We used a similar predictor (independent) variable to examine convergent validity between P-TEM scores and health care reuse outcomes (dependent variable). Therefore, for these models, the adjusted odds ratio represents the odds of any 7- or 30-day ED revisit or readmission for patients with P-TEM scores of 100 (top-box score) versus those with lower P-TEM scores.
We adjusted for the following variables in the models as case-mix adjusters because they were significantly associated with P-TEM scores and at least 1 of the validation measures (P < .05): parent age, race and/or ethnicity, and education; patient length of stay; survey mode (telephone versus online); and time to follow-up survey. Patient demographics (including medical complexity), parent sex, and hospital unit did not meet these criteria.
Results
Of the 2049 parents and/or patients who were approached to participate in the OAP, a total of 479 parents (23%) completed the P-TEM during the study period (Fig 1). Thirty-eight percent completed the survey by telephone, and 62% completed the survey online (data not shown). Patient, respondent, and hospital encounter characteristics of our final sample were similar to those of the sampling frame, with some notable exceptions: the final sample had a higher proportion of non-Hispanic white patients and parents, a lower proportion of children with medical complexity, and a higher proportion of patients with a length of stay ≥3 days (Table 2). The programming error did not result in differential characteristics of those who did and did not receive the P-TEM.
FIGURE 1.
Study sample size algorithm.
TABLE 2.
Patient, Respondent, and Hospital Encounter Characteristics of Those Who Completed the Third OAP Survey Compared With Medical and Surgical Patients at Seattle Children’s Hospital
| Final Sample | Sampling Frame | ||
|---|---|---|---|
| Received P-TEM Items (N = 459), %a | Did Not Receive P-TEM Items (N = 335), %a | Medical and Surgical Patientsb (N = 7620), %a | |
| Patient age, y | |||
| 0–<2 | 26 | 26 | 27 |
| 2–4 | 15 | 18 | 18 |
| 5–12 | 38 | 36 | 33 |
| 13–18 | 22 | 21 | 22 |
| Patient female sex | 44 | 45 | 46 |
| Patient race and/or ethnicity | |||
| White | 61 | 58 | 49 |
| African American | 2 | 2 | 6 |
| Hispanic | 11 | 14 | 20 |
| Asian American | 7 | 10 | 8 |
| Other or multiracial | 19 | 15 | 17 |
| Patient PMCA category | |||
| No chronic conditions | 30 | 31 | 24 |
| Noncomplex chronic conditions | 30 | 34 | 26 |
| Medical complexity | 40 | 35 | 50 |
| No. times patient has been hospitalized | |||
| Once | 46 | — | — |
| More than once | 54 | — | — |
| Parent age, y | |||
| 18–34 | 35 | 37 | — |
| 35–44 | 42 | 42 | — |
| ≥45 | 23 | 21 | — |
| Parent female sex | 81 | 80 | — |
| Parent race and/or ethnicity | |||
| White | 74 | 70 | — |
| African American | 3 | 3 | — |
| Hispanic | 9 | 9 | — |
| Asian American | 6 | 11 | — |
| Other or multiracial | 7 | 6 | — |
| Parent education | |||
| High school graduate or less | 16 | 14 | — |
| Some college | 36 | 35 | — |
| College graduate | 48 | 50 | — |
| Hospital unit | |||
| Medical | 54 | 56 | 57 |
| Surgical | 46 | 44 | 43 |
| Length of stay, d | |||
| <3 | 58 | 61 | 70 |
| ≥3 | 42 | 39 | 30 |
PMCA, Pediatric Medical Complexity Algorithm; —, not available.
Sum may not equal 100% because of rounding.
Patients 1 mo to 17 y old who were discharged from the medical or surgical units at Seattle Children’s Hospital during the study period.
P-TEM and Validation Scores
Mean scores on the P-TEM were 90.2 (total), 91.4 (transition preparation domain), and 86.2 (transition support domain; Table 1). The percentages of respondents with top-box responses on the P-TEM were 40.1% (total score), 52.3% (preparation domain), and 47.7% (support domain). Validation measure scores (Table 3) are consistent with previously published studies.20,21,24,25
TABLE 3.
Validation Measure Scores
| Validation Measure | No. Respondentsa | Mean Score (SD) | Median Score | Responses in Top Box,b % |
|---|---|---|---|---|
| Child HCAHPS Discharge Composite | 447 | 78.8 (20.2) | 80 | 29.8 |
| COE4CCN measures | ||||
| Had the opportunity to ask questions before discharge | 455 | 96.2 (14.5) | 100 | 93.0 |
| Understood how to use medical equipment at home and who to call with questions | 79 | 84.8 (36.1) | 100 | 84.8 |
| Received assistance with scheduling follow-up appointments | 449 | 84.4 (36.3) | 100 | 84.4 |
| Written discharge instructions were easy to understand and useful and contained necessary follow-up and contingency plan information | 449 | 87.1 (24.6) | 100 | 71.3 |
| HRQoL | ||||
| PedsQL admission assessment | 359 | 60.4 (23.8) | 60.3 | — |
| PedsQL follow-up assessment | 358 | 82.0 (17.0) | 87.8 | — |
| Health care reuse | ||||
| Any 7-d return ED visit or readmission | 459 | 2.6% | — | — |
| Any 30-d return ED visit or readmission | 459 | 6.3% | — | — |
—, not applicable.
Number of respondents does not equal the total number who completed the P-TEM (N = 459) because of missing data for some of the validation measures or some patients not being eligible for the measure (eg, the COE4CCN medical equipment measure was only applicable to those discharged with new medical equipment). Missing PedsQL HRQoL data are due to parents completing a different HRQoL measure (not the PedsQL) as part of the OAP.
Top-box responses referred to the proportion of respondents with a score of 100 on each validation measure, which corresponded to the highest level of affirmation on measure items.
Convergent Validity of the P-TEM
We found significant associations between the P-TEM and all of the validation process measures, with the exception of the COE4CCN measure related to providing assistance with scheduling follow-up appointments (Table 4). For example, respondents with top-box responses on the Child HCAHPS Discharge Composite reported significantly higher P-TEM scores compared with respondents with lower HCAHPS Discharge Composite scores (7.5-point–higher total score, 8.0-point–higher transition preparation domain score, and 9.1-point–higher transition support domain score).
TABLE 4.
Differences in P-TEM Scores Between Respondents With and Without Top-Box Responses on Validation Process Measures
| Validation Measure | P-TEM Total Score | Transition Preparation Domain | Transition Support Domain | |||
|---|---|---|---|---|---|---|
| Na | β (95% CI)b | Na | β (95% CI)b | Na | β (95% CI)b | |
| Child HCAHPS Discharge Composite | 436 | 7.5 (4.6 to 10.4)** | 436 | 8.0 (4.9 to 11.2)** | 366 | 9.1 (4.4 to 13.9)** |
| COE4CCN measures | ||||||
| Had the opportunity to ask questions before discharge | 441 | 14.1 (9.3 to 18.8)** | 441 | 16.2 (11.2 to 21.3)** | 372 | 10.7 (2.8 to 18.6)* |
| Received discharge education on how to use medical equipment at home and who to call with questions | 78 | 19.1 (9.1 to 29.2)** | 78 | 26.3 (15.4 to 37.2)** | 74 | 8.0 (−5.7 to 21.7) |
| Received assistance with scheduling follow-up appointments | 435 | .2 (−3.3 to 3.7) | 435 | −.2 (−3.9 to 3.5) | 372 | 4.6 (−1.6 to 10.7) |
| Received written discharge instructions that were easy to understand and useful and contained necessary follow-up and contingency plan information | 437 | 11.9 (9.3 to 14.4)** | 437 | 11.2 (8.5 to 13.9)** | 369 | 14.8 (10.6 to 19.1)** |
CI, confidence interval.
The denominators for these analyses are dependent on the number eligible for either the independent or dependent variable or are due to missing data for the covariates.
β coefficient represents the difference in P-TEM score (0–100 scale), comparing respondents with top-box to those without top-box responses on the process measure. Models were adjusted for parent age, parent race and/or ethnicity, parent education, length of stay, survey mode, and time to follow-up survey.
*P < .01.
**P < .001.
For some of the validation measures, we found significantly higher P-TEM scores for the total score and only 1 of the domain scores. For example, respondents who reported that they understood how to use medical equipment at home and who to call with questions reported significantly higher P-TEM total scores (19.1 points) and transition preparation domain scores (26.3 points) compared with those who did not endorse this understanding; however, scores were not significantly higher on the transition support domain.
In terms of outcomes, respondents who reported P-TEM total scores of 100 (top-box scores) had significantly greater improvement in HRQoL (6.3 points) from admission to follow-up compared with those with lower P-TEM total scores. Adjusted results were similar for P-TEM domain-specific scores (Table 5). P-TEM scores were not significantly associated with 30-day ED revisits or hospital readmissions (Table 5).
TABLE 5.
Difference in HRQoL and Health Care Use Outcomes for Respondents With and Without Top-Box Responses on the P-TEM
| Predictor Variable | Change in HRQoL | Any 7-d ED Revisit or Readmission | Any 30-d ED Revisit or Readmission | |||
|---|---|---|---|---|---|---|
| Na | β (95% CI)b | Na | aOR (95% CI)c | Na | aOR (95% CI)c | |
| P-TEM total score | 346 | 6.3 (2.8 to 9.8)** | 451 | 1.2 (0.3 to 4.3) | 442 | 0.8 (0.3 to 2.0) |
| Transition preparation domain | 346 | 5.1 (1.7 to 8.4)* | 451 | 0.6 (0.2 to 2.1) | 442 | 0.8 (0.3 to 1.7) |
| Transition support domain | 287 | 5.9 (1.8 to 9.9)* | 379 | 1.7 (0.4 to 6.1) | 363 | 1.0 (0.4 to 2.6) |
aOR, adjusted odds ratio; CI, confidence interval.
The denominators for these analyses are dependent on the number eligible for the P-TEM transition support domain or are due to missing data for the HRQoL measure or covariates.
β coefficient represents the difference in PedsQL score (0–100 scale), comparing respondents with to those without top-box responses on the P-TEM. Models were adjusted for parent age, parent race and/or ethnicity, parent education, length of stay, survey mode, time to follow-up survey, and PedsQL admission score. We removed parent race and/or ethnicity as a covariate from the 7-d reuse models because the initial model excluded patients in 2 of the race and/or ethnicity categories in which patients did not have a 7-d reuse event. Results were unchanged with and without inclusion of this covariate.
Adjusted odds ratio represents the odds of either a 7- or 30-d ED revisit or readmission, comparing respondents with top-box responses on the P-TEM to those without top-box responses on the P-TEM. Models were adjusted for parent age, parent race and/or ethnicity, parent education, length of stay, survey mode, and time to follow-up survey.
*P < .01.
**P < .001.
Discussion
This study established the convergent validity of the P-TEM in a population of hospitalized children because scores were associated with the Child HCAHPS Discharge Composite, evidence-based transition measures developed by the COE4CCN, and change in HRQoL from admission to postdischarge follow-up. Respondents who reported the highest possible transition experience quality (based on the P-TEM scores) were noted to have a 6.3-point–greater improvement in PedsQL scores compared with respondents who reported lower-quality transitions. This difference is above the minimal clinically important difference of 4.5 points on the PedsQL instrument.26 However, we did not find a significant association between P-TEM scores and health care reuse.
This study builds on our previous P-TEM development work, which was informed by a qualitative study to ensure that constructs assessed by the P-TEM were consistent with the needs and preferences of families experiencing hospital-to-home transitions.6 We subsequently found that the P-TEM demonstrated strong face validity and acceptable psychometric properties and was broadly applicable across children with varying levels of medical complexity.19 In combination with these validation findings, the P-TEM may serve as a useful measure to examine the effectiveness of hospital-to-home transition interventions, particularly in the case of bundled interventions in which improvement on multiple care processes are targeted concurrently.9,10,12 By capturing multiple constructs of the transition experience, such as discharge preparation, family support, parent confidence, information exchange, and care coordination, in a single measure, the P-TEM may provide a comprehensive assessment of these care bundles. The domain related to transition support has not been well represented in previous measures and provides additional insights regarding the family’s experiences with care in the few weeks after discharge as they are reestablishing connections with outpatient providers. As health care settings increasingly become interconnected and begin to focus on patient experience across the care continuum, parsimonious measures such as the P-TEM that provide this type of comprehensive assessment may be more attractive to health care organizations and payers to measure system-level performance versus those that only measure performance within a specific care setting.
This study did not find significant associations between P-TEM scores and reuse outcomes. We were likely underpowered to detect significant associations given that only 30 patients had a 30-day return ED visit or readmission. Additionally, we may not have identified return ED visits or readmissions that occurred at other institutions. Therefore, the association between P-TEM scores and reuse outcomes should be explored further with a larger sample size and predictive validity models.
Other limitations of this study include that we only included English-speaking respondents; therefore, further testing is required to understand how the P-TEM performs in a more racially and/or ethnically diverse population and among those with limited English proficiency. Additionally, respondents who completed the P-TEM represent a subset of patients who were discharged from the medical or surgical units at a single institution and those who participated in the OAP; thus, further testing is required in oncology patients and those discharged from ICU settings. This was also due to the programming error, which seemed to occur at random because demographic characteristics did not differ between those who did and did not receive the P-TEM items (Table 2). Furthermore, the PedsQL 4.0 Generic Core Scales and Infant Scales were not designed for children with moderate or severe developmental delays; thus, parents of these children completed a different HRQoL measure and were excluded. Although the final sample did include a wide distribution of patients and parents with diverse demographic and hospital encounter characteristics, further testing of the P-TEM in multiple institutions and demographically diverse samples is required to improve the generalizability of these findings.
Conclusions
The P-TEM demonstrated convergent validity in a medically diverse population of hospitalized children and may be useful for assessing the effectiveness of hospital-to-home transition interventions. The P-TEM may be particularly useful in the evaluation of bundled interventions because it provides a global assessment of multiple facets of hospital-to-home transition quality, including discharge preparation, postdischarge support at home, and care coordination between the inpatient and outpatient settings. Further research is needed to establish the measure’s responsiveness to change and potential for use as a performance measure at the population level.
Glossary
- Child HCAHPS
Child Hospital Consumer Assessment of Healthcare Providers and Systems
- COE4CCN
Center of Excellence on Quality of Care Measures for Children With Complex Needs
- ED
emergency department
- HRQoL
health-related quality of life
- OAP
Outcomes Assessment Program
- P-TEM
Pediatric Transition Experience Measure
- PedsQL
Pediatric Quality of Life Inventory
Footnotes
Dr Desai conceptualized and designed the study, conducted the data analysis, and drafted the initial manuscript; Dr Zhou participated in the design of the study and participated in the data analysis; Drs Simon, Mangione-Smith, and Britto participated in the design of the study interpretation of the data; and all authors reviewed and revised the manuscript, approved the final manuscript as submitted, and agree to be accountable for all aspects of the work.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Funded by the Academic Pediatric Association Young Investigator Award and the Seattle Children’s Research Institute Pediatric Early Research Career Award. Dr Desai is supported by the Agency for Healthcare Research and Quality (grant K08HS024299). Funded by the National Institutes of Health (NIH).
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality. The sponsors had no role in the study design; collection, analysis, or interpretation of data; writing of the report; or decision to submit the article for publication.
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