The Effects of Hospital Safety Scores, Total Price, Out-of-Pocket Cost, and Household Income on Consumers' Self-reported Choice of Hospitals Christopher C. Duke, PhD,* Brad Smith, PhD,† Wendy Lynch, PhD,* and Michael Slover, MS* Objectives: The study measured the relative influence of the following 3 factors in consumers' choice of hospitals: (1) cost, (2) out-of-pocket cost, and (3) safety as measured by Leapfrog Hospital Safety Score letter grade. Methods: Two hospital-choice questions regarding a hypothetical medical procedure were administered to 2357 online respondents. In question 1, respondents were assigned a scenario in which hospital 1 grade (A through D), hospital 2 grade (B through F), and hospital 2 total cost (3 levels) were randomly varied across respondents. In all cases, hospital 2 had a lower safety grade than hospital 1, and hospital 1 cost was held constant. In question 2, scenarios varied out-of-pocket cost rather than total cost. Demographic characteristics, income level, health status, health literacy, and opinions about value were also measured. Results: On average, 94% and 88% of the respondents chose the safer hospital in questions 1 and 2, respectively. In all but 1 of 30 possible scenarios, where hospital 2 cost the individual $1000 less and was rated a B whereas hospital 1 was rated an A, respondents chose the safer hospital. Higher incomes, higher health literacy, and being female were associated with a stronger preference for hospital 1 (safer). There was a small effect suggesting that approximately 4% of the respondents selected a higher- cost hospital despite lower safety, but it was outweighed by predominant selections of the safer hospital. Conclusions: When shown Hospital Safety Score and cost information, consumers chose safer hospitals in 97% of cost and safety scenarios. Key Words: patient safety, consumer health information, hospital costs (J Patient Saf 2014;00: 00–00) I ncreasing levels of transparency in health care costs, safety, and quality are becoming part of public reporting in the U.S. health care system. Significant developments in transparency have occurred in 2013. The Department of Health and Human Services released price information comparing 100 different procedures across 3000 hospitals. 1 In addition, the status of state laws rein- forcing transparency received attention through the release of a public report card. 2 As consumers face increasing levels of cost responsibility in the form of high-deductible plans and health spending accounts, the availability of price information becomes more essential. 3 Price transparency is presumed to introduce more competition and to increase consumers' ability to assess the value of their health care choices. 4 However, studies indicate that price infor- mation alone can lead to misinterpretation by consumers who may equate higher cost with higher quality. 5–7 Thus, researchers suggest balancing price information with indicators of health care quality or safety. 6 Similarly, there is concern that many consumers do not trust public reporting of health care quality 8 and that quality data can be complex and confusing. 9 Ideally, consumers could access simple, straightforward indicators that support meaningful choices about both cost and quality. 10 To better explain hospital safety to consumers, a variety of patient safety measures have been developed, such as those from Consumer Reports, Health Grades, and the Leapfrog Group. The Leapfrog Hospital Safety Score was calculated under the guidance of a blue ribbon panel of patient safety experts, and its methodology and data were publicly disclosed and reviewed in the literature. This score combines numerous metrics regarding error rates, accidents, and infections into a single, simple letter grade from A to F. 11 Its developers sought to simplify consumer choice into one easy-to-understand yet scientifically valid metric. As such, it could serve the purpose of informing consumers without adding complexity. 12 Given the increasing availability of hospital pricing, such as those available through the Department of Health and Human Services 1,2 and safety scores, 11 we sought to investigate how both pricing and safety information influenced patient choice in hospitals. This study conducted a survey that combined Hospital Safety Scores and price information to test the degree to which a safety letter grade and cost of surgery influenced consumer choice of hospital. Both total cost (to payer and consumer) and individual cost were studied in combination with safety score. In addition, the survey included measures of household income, health literacy, and opinions about health care value to assess whether these attributes influence choices about safety and cost. METHODS Survey questions were administered via a Web portal to a panel of respondents managed by Survey Sampling International. Eligible respondents had to have traditional indemnity or preferred pro- vider organization health insurance, not Medicare or Medicaid. A total of 2592 respondents completed the survey. Of those, 235 surveys were removed because of incomplete or questionable responses, for example, completing the survey 70% faster than the median duration, choosing nonsensical or repeat pattern responses. Panel participants provided self-reported information about age, sex, and household income. The typical completion time for the survey was approximately 15 minutes. Survey questions collected information about health status and recent hospital care, opinions about health care value, health literacy, and 2 questions posing hypothetical choices between 2 hospitals. For health status, respondents rated their current health on a scale of poor, fair, good, very good, or excellent. They were also asked if they had 1 or more hospital stays in the past 12 months. Regarding health care value, respondents were asked their level of agreement (5-point Likert scale from strongly disagree to strongly agree) with the following statements: “Cost is an important part of my health care choices”; “I look for the best health care, regardless of cost”; and “Sometimes, I shop to find the best value in health care. ” Moreover, respondents were asked to From the *Center for Consumer Choice in Health Care, Altarum Institute, Ann Arbor, Michigan; and †Health Systems and Services Research, Drexel University, Philadelphia, Pennsylvania. Correspondence: Christopher C. Duke, PhD, Center for Consumer Choice in Health Care, Altarum Institute, 3520 Green Court, Suite 300, Ann Arbor, MI 48105 (e‐mail: chris.duke@altarum.org). The authors disclose no conflict of interest. Copyright © 2014 by Lippincott Williams & Wilkins ORIGINAL ARTICLE J Patient Saf • Volume 00, Number 00, Month 2014 www.journalpatientsafety.com 1 Copyright © 2014 Lippincott Williams & Wilkins. 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