Patient Satisfaction and Quality of Care: Are They Linked?

An Expert Interview With Joshua J. Fenton, MD, MPH

Linda Brookes, MSc; Joshua J. Fenton, MD, MPH


June 11, 2014

In This Article

The Interview

Medscape: Have articles citing your study as evidence that patient satisfaction scores are not directly associated with quality of care provided an accurate interpretation of your results?

Dr. Fenton: First of all, our study actually was not a study of quality of care. We were studying the relationship between patient satisfaction and healthcare utilization and mortality, so it was more of a study of healthcare intensity; there were no technical quality measurements, such as Healthcare Effectiveness Data and Information Set (HEDIS) measures, in the study. However, in our article, we cited several other studies suggesting that the relationship between patient satisfaction and technical healthcare quality is unclear.[16,17,18]

We recently published another study that looked at the relationship between satisfaction and several preventive healthcare outcomes that are similar to HEDIS measures. That was more of a study of satisfaction and its relation to clinical healthcare quality in the setting of preventive care, and after accounting for confounding patient factors, we generally found that satisfaction was unrelated to receipt of preventive care.[19]

Medscape: So how do you see the relationship, if there is one, between patient satisfaction and health outcomes?

Dr. Fenton: I question the premise that patient satisfaction is associated with improved health outcomes. By "health outcomes," I mean hard outcomes, such as health status and mortality, or perhaps disease-specific outcomes, such as well-controlled blood pressure.

In my view, the evidence of a causal relationship between patient satisfaction and any of these hard health outcomes is weak. For most outcomes, measures of the patient experience are probably orthogonal, or unrelated to technical measures of the quality of care. In most settings, technical healthcare quality is simply invisible to patients -- they can't see it, so it doesn't affect their satisfaction. That has been shown in several settings.

Like all complex phenomena, it isn't a totally black-and-white issue. In some settings, patients might be able to appreciate a certain feature of technically high-quality healthcare. For example, in the hospital setting, nursing staff levels affect the patient's experience; if the nursing staff-to-patient ratio is high, the patient's experience measure in that situation might very well correlate with a technical quality measure that really does drive important outcomes. That is an example of a relationship that is positive and probably meaningful.

But in other settings, such as primary care, a lot of technically high-quality care flies beneath the patient's radar, and satisfaction is driven more by whether physicians fulfill patients' expectations for care. There is probably a null relationship. For example, in preventive healthcare, there might be an unadjusted relationship between patient satisfaction and receiving an appropriate cancer screening test, but when you adjust for patient characteristics and other confounding factors, that relationship is no longer present. Therefore, I don't believe that patient satisfaction has a strong relationship with technical quality, which would allow us to infer that because patients are satisfied in the outpatient setting, they are probably getting technically high-quality care.


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