There currently is interest in evaluating medical outcomes based on patient perceptions. However, in the US there may be biases associated with these perceptions because of past marketing activities and other factors, such as facility location. The research question examined is whether perceived overall quality could predict hospital occupancy. To assess this, the quality ratings of 155 local hospitals by over 20000 household beads surveyed in 20 US states were analyzed using an ecological research design. Facility image and hospital occupancy were assessed after controlling for community, facility and quality care differences between facilities. Results indicated that hospitals in more urbanized areas (p = 0.003), with lower costs (p = 0.0001), that were non-teaching (p = 0.033) and those with more employees per bed (p<0.0001) had higher occupancies, but that perceived quality did not predict admissions after facility differences were controlled (p = 0.302). However, further analysis suggested both positive and negative biases may exist: controlling for community, facility, and quality care differences, facilities with ''high'' ratings appeared to have consistently higher occupancies, those with ''low'' ratings consistently lower occupancies, and facilities with ''average'' ratings appeared to be unaffected. Based on this finding, an interaction effect was tested and confirmed for community rating x facility size (p = 0.015), suggesting that smaller hospitals with low ratings had lower than expected occupancies. Although this study has limitations, it was suggested that researchers should use quality indicators based on patients' perceptions with caution and be open to additional scientific research, until these measures are better understood. Copyright (C) 1996 Elsevier Science Ltd.
