Patient satisfaction versus quality of care

If there’s one thing that purveyors of “complementary and alternative medicine” (CAM)–or, the preferred term these days, “integrative medicine” (IM)–and hospital administrators seem to agree on, it’s that “patient satisfaction” (whatever that means) is very, very important. Hospital administrators live and die by patient satisfaction surveys, in particular a common measurement derived from Press-Ganey surveys. In fact, Press-Ganey itself sells its services as “driving performance excellence” in health care. The inherent assumption is that if patients are satisfied then they are doing a good job. But it’s subtler than that. The underlying assumption is actually that patient satisfaction equals quality, and the further assumption is that Press-Ganey scores reflect patient satisfaction. Never mind that Press-Ganey scores include questions about a whole host of things that have nothing to do with the quality of care. For example, parking has been a problem at both cancer centers I’ve worked at, and Press-Ganey scores have always taken a hit because parking is a big issue in the surveys.

Similarly, promoters of CAM/IM seem to believe in patient satisfaction über alles. In fact, two large surveys of the state of “integrative medicine” in the U.S. have been published in the last six months or so, one by the Samueli Institute and one by the sugar daddy of quackademic medicine, the Bravewell Collaborative. Did either of them look at outcomes? Well, yes and no. If you’re talking about actual medical outcomes, as in outcomes research, the answer is a resounding no. If you’re talking about “outcomes” as in patient satisfaction outcomes, then the answer is yes. Both surveys focused like a laser beam on patient satisfaction. Lacking any concrete measures for the quality of care they provide, apparently CAM/IM promoters bragged about how happy their patients are with their services. Of course, this makes perfect sense, given that both surveys were nothing more than one huge exercise in argumentum ad populum. Trying to argue that people are very happy with your service is part and parcel of that. Certainly the CAMsters aren’t trying ot argue for the superiority of their woo based on science.

So, both promoters of “integrative” medicine and a large segment of conventional medicine view patient satisfaction as being a major indicator (but, in all fairness, not the only indicator) of quality care. But is this assumption valid? Does patient satisfaction correlate with high quality care? You might be surprised at the answer suggested by a recent study published a week ago in the Archives of Internal Medicine from a group out of UC-Davis entitled The Cost of Satisfaction: A National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality.

This study was designed to look for correlations between patient satisfaction and outcomes, asking the question: Is there a correlation between health care outcomes and patient satisfaction. The answer is yes, but, if this study is to be believed, it’s a negative correlation, in which patient satisfaction is correlated with worse outcomes in some measures. Let’s take a look.

The authors frame the question thusly:

Satisfied patients are more adherent to physician recommendations and more loyal to physicians, but research suggests a tenuous link between patient satisfaction and health care quality and outcomes. Among a vulnerable older population, patient satisfaction had no association with the technical quality of geriatric care,8 and evidence suggests that satisfaction has little or no correlation with Health Plan Employer Data and Information Set quality metrics.

In addition, patients often request discretionary services that are of little or no medical benefit, and physicians frequently accede to these requests, which is associated with higher patient satisfaction. Physicians whose compensation is more strongly linked with patient satisfaction are more likely to deliver discretionary services, such as advanced imaging for acute low back pain.

In order to investigate the relationship between patient satisfaction and outcomes, the investigators undertook a prospective cohort study. Basically, they looked at respondents to the MEPS from 2000 to 2007. The MEPS is described thusly:

The MEPS is an annual nationally representative survey of the US civilian noninstitutionalized population assessing access to, use of, and costs associated with medical services. The MEPS household component uses an overlapping panel design in which individuals are interviewed successively during 2 years. During each year, respondents complete self-administered questionnaires about health status and their experiences with health care. The MEPS sampling frame is drawn from respondents to the National Health Interview Survey, an annual in-person household survey conducted by the National Center for Health Statistics. The National Health Interview Survey data are linked with death certificate data from the National Death Index, enabling mortality ascertainment among MEPS participants.

Basically, tbe investigators followed over 50,000 adults and linked them to mortality outcomes. Let’s start with the good. One correlation that was noted was that patients with higher levels of satisfaction with their care used the emergency room less. It wasn’t a huge amount less. The adjusted odds ratio was only 0.92, which means that the patients who had the highest level of satisfaction (the highest 25%) were 8% less likely to use the emergency room during the study period than those with the lowest level of satisfaction (the lowest 25%). All in all, not that impressively different, but it definitely has to be acknowledged as a positive.

Now let’s look at the negatives.

Patients in the study who demonstrated the highest level of satisfaction were more likely to have an inpatient admission (adjusted odds ratio 1.12) than those with the lowest levels of satisfaction. They also accounted for 8.8% more health care expenditures, including greater prescription drug expenditures. Worst of all, they demonstrated a higher mortality, with an odds ratio of 1.26, which means they had a 26% higher chance of dying.

Data like this always have to make you wonder. Is there a confounding variable that accounts for the negative correlation between patient satisfaction and outcomes? And it’s certainly possible that there may be. However, even if there is, at the very least this study is strong evidence that there isn’t much, if any, correlation between patient satisfaction and the actual quality of care as measured by a few key concrete outcomes. Why might this be?

The authors provide some possible explanations in the discussion. One aspect of this relationship is that patient satisfaction does correlate with how much the physician fulfills the patient’s wishes and expectiations:

Patients typically bring expectations to medical encounters, often making specific requests of physicians, and satisfaction correlates with the extent to which physicians fulfill patient expectations. Patient requests have also been shown to have a powerful influence on physician prescribing behavior, and our findings suggest that patient satisfaction may be particularly strongly linked with prescription drug expenditures.

In other words, giving the patient what he or she wants isn’t always what’s best for the patient. As “paternalistic,” as this might sound, this is not a new observation. Physicians have known this for a very long time. Perhaps the most striking example of this phenomenon is antivaccine parents. Such parents don’t want their children to be vaccinated, but not vaccinating is rarely in the best interests of the child. Physicians who just go along with such parents, such as antivaccine apologist Dr. Jay Gordon, are very popular and likely generate high Press-Ganey scores because they basically give the people what they want. In contrast, pediatricians who try to do the right thing and persuade such parents to vaccinate their children (or even fire such patients whose parents won’t vaccinate) don’t and as a result generate a lot less patient satisfaction. This is an intentionally chosen extreme example, but the same sort of dynamic occurs in more subtle ways in every patient encounter. A less extreme example is very common in primary care, specifically the example of the patient who demands antibiotics for a viral infection. The doctor who acquiesces will have the more satisfied patient than the doctor who does not. But who provided the better care? Not the doctor who gave unnecessary antibiotics, which can select for resistant organisms and cause complications for no benefit.

The next time you see a hospital brag about its Press-Ganey scores, remember that at the very minimum it’s meaningless in terms of whether that hospital actually delivers quality care and at the worst Press-Ganey scores correlate negatively with some outcomes. Although we don’t know for sure yet whether patient satisfaction correlates with outcomes in CAM/IM, the medical literature suggests that it very likely will not.CAM/IM, of course, is nothing if not the philosophy of “keeping the customer satisfied” to a whole new level in medicine. Indeed, that is its only purpose. CAM proponents think this is a good thing. However, evidence from conventional, science-based medicine suggests that it very well isn’t. None of this is to say that we should revert back to a paternalistic, doctor knows best” approach. It is, however, an indication that it is not the job of doctors to “keep the customer satisfied.” Ideally, we should do that in partnership with patients, not dictating to them what they need the way we did in the old days. However, there are dangers in going too far in the other direction. Patients need a doctor, not someone whose primary consideration is to satisfy them.