Patient Satisfaction and Quality of Care: Are They Linked?

What Drives Satisfaction?

Medscape: In 2012, you and your coauthors concluded that there might be insufficient understanding of the factors associated with patient satisfaction. Do you think that our understanding has improved since?

Dr. Fenton: Two years is not a lot of time for data to accrue that would substantially change my conclusions about the state of the field, so I don't think our understanding has really shifted that much since then. In 2012, we were talking about the fact that our study pointed to the potential contribution of utilization and expenditures in driving satisfaction among an ambulatory population.

For example, we found a strong association between total medical expenditures and satisfaction, and between prescription drug expenditures and satisfaction. Those findings pointed to the possibility that utilization in and of itself is a driver of ambulatory satisfaction. We still don't understand what types of utilization and expenditures are driving satisfaction.

Our study was in the ambulatory setting, but satisfaction metrics (eg, the CAHPS survey) are being rolled out in all healthcare settings. We can expect that drivers of satisfaction will be different in the dialysis setting, the emergency department, and the outpatient surgery department. We also have an insufficient understanding of how patient factors -- mental health, patient personality, and cultural factors -- drive satisfaction.

A related question, also not yet understood, is how these patient differences, such as mental health, personality, or other sociocultural factors, at the patient level contribute to how patients express themselves on satisfaction surveys. Those factors are not measured in CAHPS surveys, so it is conceivable that they could have an impact when you survey patients of different physicians who might serve different populations with different balances of mental health disorders or different sociocultural mixes. We don't understand that very well yet, either.

Medscape: It sounds as though there is still a lot of work to be done on the makeup of health satisfaction surveys.

Dr. Fenton: It is tough. On the one hand, I admire CAHPS, because without them we wouldn't have any standardized measures of patient experience. Having a standardized method, with everybody using the same instrument, is a major contribution, without which there would be no way to compare performance across different settings. A standardized metric is critical. The HEDIS measures, for example, are very useful because they are collected in a standardized fashion across different organizations.

On the other hand, it is a challenge to adapt CAHPS to different settings. The factors that influence the patient experience metrics in these different settings haven't been elucidated. There are probably going to be unmeasured confounding factors that CAHPS does not capture and might be very difficult to incorporate, because CAHPS is a self-administered mailed survey and has to be judicious in length. It is already a fairly long survey for patients to complete.

But there isn't a good measure of mental health on the CAHPS survey, although I am sure that such a measure was considered, and probably eliminated at some point during the testing period. You can't measure everything in a mailed survey, and decisions need to be made about what is going to be in and what is going to be out.

Nevertheless, it is something that needs further evaluation. We don't currently know whether serving a larger population of patients with mental disorders could penalize a practice in terms of patient satisfaction scores.

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