Higher patient satisfaction scores are linked to increased health care costs, and higher mortality1.
Pause. Take a second, and re-read that last sentence.
The follow up question is obvious – why would administrators push patient satisfaction if it results in worse outcomes? This post seeks to delve into the harms of targeting patient satisfaction, why it appears to be done, and the importance of speaking to our administrators in order to advocate on behalf of patients and the healthcare system.
What is patient satisfaction?
There is no clear consensus as to the definition of patient satisfaction, but most literature suggests that it is the degree of congruency between the patient’s perceived care and their expectations2. As we continue to advance the field of quality improvement, patient satisfaction is becoming a proxy for the quality of care provided to individuals. There is no general consensus as to how to collect this information, but the vast majority of administrations doing this provide questionnaires to their patients, to assess how satisfied they were with their healthcare visit3.
Show me the evidence!
I can’t. At least, none that exists. Alarmingly, despite it’s inclusion as a growing measure of quality of care, there is no evidence to suggest that patient satisfaction is an effective or useful measurement. A systematic review in the BMJ4 correlated patient experience with clinical safety and effectiveness, and found that the patient experience is positively associated with clinical effectiveness and safety. I would suggest it is fair to assume that the vast majority of us would know/agree this to be true. However, I would argue that patient experience is by no means a correlate to patient satisfaction. Patient experience tracks an individual’s journey through the healthcare system – it focuses on the primary interactions that the patient has during their hospital or clinic visit. Satisfaction, however, relies on the patient’s expectations and perception of appropriate care – something that they may have little to no insight about.
What could go wrong?
To highlight this point, I think it is important to utilize a case example. Imagine that you have a patient who presents with “bronchitis, and requires antibiotics”. First off, there is no convincing evidence that bronchitis is even a real disease (seriously, smokers with tight lungs do certainly get viral URTI’s, this does not equate to a novel disease entity). Secondly, there is excellent evidence that these patient’s do not require antibiotics. However, the patient expectation is that they should receive antibiotics (because their previous GP or walk-in clinic physician did this), despite expertise demonstrating why antibiotics are inappropriate, the patient will be unsatisfied with anything except a prescription. Thereby, the physician has lower patient satisfaction scores, and perceived lower quality of care. In this scenario, the physician is punished by doing the right thing and practicing appropriate/high quality medicine.
To provide some evidence to help further conceptualize this, if we go back to the initial statement in this post, an prospective study found that a focus on patient satisfaction resulted in increased hospital admissions, increased drug and total healthcare expenditures and increased mortality1. In essence, focusing on patient satisfaction encourages physicians to provide the perception of better care, while potentially harming the patient and delivering worse overall care. Patients may often think that “more is better“, and that they would benefit from more investigations or therapies, without appreciating the potential iatrogenic or negative effects from this. By doing more, physicians can provide the illusion of better care, even though a plethora of evidence exists showing that the patient will most likely have worse outcomes.
Part of what makes patient satisfaction so difficult, is that it is based upon patient expectations of the type of care they should receive. Patient’s nowadays have so much information within reach (we google everything; from what taco’s to eat to how to remove a splinter), and so patient’s are certainly googling their symptoms and presentations. The problem, however, is the amount of misinformation on the internet5. Resources are consistently inaccurate, peddle to fear mongering or dabble in anecdotal evidence, which provides an unfortunate bias from the patient perspective.
We’ve all seen an example of this – a patient with back pain or a headache requesting an MRI. Physicians scoff at this comment, but if an MRI was an easily obtainable investigation (i.e.: we didn’t need to sell our soul to radiology), lots of patient’s would get their wish. How often do we undertake imaging, or bloodwork simply because a patient has requested it, even when we know the studies will be negative?
When entering the realm of patient satisfaction, hospitals adopt a “customer is always right mentality”, which can be quite a dangerous precedent to be setting in a healthcare environment. Unfortunately, patient’s are not always right, and yet hospitals are being forced to devote entire “complaint departments” to when patient expectations are not met. This places healthcare providers in a difficult situation – attempting to navigate between the most medically appropriate course of action versus the patient’s expectations or satisfaction.
If it’s no good, why is it being done?
There is certainly no evidence to help guide us here, but personally I think it is fairly obvious why patient satisfaction is being used as a proxy for healthcare outcomes, because it’s easy. As previously discussed, the limited literature in this area seems to focus more on patient experience. Patient satisfaction, however, only requires a follow up patient survey with relatively vague questions that can be answered on a 0-5 scale (i.e.: how satisfied were you with your physicians diagnosis, etc). For hospital administrators, it is fairly simple to collect and collate this data. I suspect it is for this reason that patient satisfaction is becoming an proxy for quality of care, because the vast majority of other ways to assess care would be more difficult, time consuming and arduous. For example, an excellent measure would be tracking individual patient outcomes for physicians after their healthcare visit, however, this would be quite difficult and costly. I don’t think it is clearly evident what would make a good quality measure, both from an effectiveness and cost efficiency standpoint, however, the potential harms that may be incurred from utilizing patient satisfaction should make it a rather unappealing option.
The evidence for utilizing patient satisfaction as a proxy for quality of healthcare is sparse, with most literature looking at the patient experience, rather than satisfaction. When patient satisfaction is employed as a quality measure – it results in increased spending, resource utilization and increased mortality. If hospitals continue to push patient satisfaction as a measure of care, the onus is on us to report back to administrators to ensure they’re aware of our concerns and outcomes. Furthermore, we have a responsibility to ensure our patient’s are well educated and informed around their own healthcare, so that we can make appropriate decisions together.