Overemphasis on Patient Satisfaction May Cause Problems

Kate Johnson

February 13, 2012

February 13, 2012 — Patients who report the highest satisfaction with their physicians and other healthcare providers have fewer emergency department (ED) visits compared with those who are less satisfied, but they also have the highest mortality rate and the highest hospital admission and healthcare expenditure rates, according to a study published online February 13 in the Archives of Internal Medicine.

"[A]n overemphasis on patient satisfaction could have unintended adverse effects on health care utilization, expenditures, and outcomes," write Joshua J. Fenton, MD, MPH, from the Department of Family and Community Medicine and Center for Healthcare Policy and Research, University of California, Davis, in Sacramento, and colleagues.

The prospective cohort study followed-up 51,946 respondents to the 2000 through 2007 Medical Expenditure Panel Survey (MEPS) and included 2 consecutive annual surveys for each patient. Patient satisfaction was assessed in the first year and compared with healthcare use and expenditures in the second year. Mortality outcomes during a mean follow-up of 3.9 years were available for a subset of 36,428 respondents.

Patient satisfaction was assessed with the Consumer Assessment of Health Plans Survey; specifically, with 4 items pertaining to physician communication (which is strongly correlated with global satisfaction) and a fifth item that allowed patients to rate their care from all physicians and healthcare providers.

Healthcare use and expenditure information was collected as part of the MEPS, and mortality was assessed by National Health Interview Survey linkage with the National Death Index.

After adjusting for sociodemographics, health behaviors, healthcare access, propensity to use healthcare, and health status, the authors determined that the odds of any ED visit were lower among patients in the more satisfied quartiles (adjusted odds ratio [aOR], 0.92; 95% confidence interval [CI], 0.84 - 1.00; P = .06), whereas the odds of inpatient admission were higher among the most satisfied patients (aOR, 1.12; 95% CI, 1.02 - 1.23; P = .02).

Similarly, patients who were the most satisfied had 8.8% more health expenditures (95% CI, 1.6% - 16.6%; P = .02) in the second year, as well as 9.1% more drug expenditures (95% CI, 2.3% - 16.4%; P = .01) and a 26% greater mortality risk (adjusted hazard ratio, 1.26; 95% CI, 1.05 - 1.53; P = .02), compared with patients who were least satisfied.

The results were unchanged when each analysis was repeated with the exclusion of patients who had poor self-rated health and 3 or more chronic diseases to control for "the possibility that these patients may be more dependent on (and satisfied with) their physicians but more likely to use hospital care and to die."

Although acknowledging that the data suggest "we do not fully understand what drives patient satisfaction as now measured or how these factors affect health care use and outcomes," the authors simultaneously suggest a possible explanation for the findings.

"Physicians whose compensation is more strongly linked with patient satisfaction are more likely to deliver discretionary services," they write, adding that "discretionary services may lead to iatrogenic harm via overtreatment, labeling, or other causal pathways."

"The authors infer that efforts to cater to patient satisfaction may be ill guided," writes Brenda Sirovich, MD, from the Department of Veterans Affairs Medical Center in White River Junction, Vermont, in an accompanying invited commentary. "There is, however, reason to question the validity of the inference," she continued. "[T]he likelihood of an unmeasured confounder remains high. One nomination is that a patient's strong sense of connection to the health care system, related perhaps to (unmeasured) vulnerability or frailty, might predict more satisfaction, hospitalization, and death.

"And yet, the inference is entirely believable — and cause for concern," she adds.

"Practicing physicians have learned — from reimbursement systems, the medical liability environment, and clinical performance scorekeepers — that they will be rewarded for excess and penalized if they risk not doing enough.... It is time that we, as a profession and as a society, take responsibility for controlling this unrestrained system, by working to overcome the widespread misconception that more care is necessarily better care and to realign the incentives that help nurture this belief."

The authors and commentator have disclosed no relevant financial relationships.

Arch Intern Med. Published online February 13, 2012.

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