Does High Patient Satisfaction Mean High Quality of Care ?

In “Seven Principles for Improving Service and Patient Satisfaction,” Jon T. Nordrum, DPT, and Denise M. Kennedy, MBA, present a useful model and practical tips for offering the kind of service quality that will increase your patients’ satisfaction (page 15). It’s well worth the read. Patient satisfaction surveys are here to stay, and various versions of the CAHPS (Consumer Assessment of Healthcare Providers and Systems) survey from the Agency for Healthcare Research and Quality have made their way into various Medicare quality initiatives. These surveys measure patients’ perceptions of things like provider communication skills, access to care, customer service, and coordination of care. If your practice hasn’t been surveyed yet, it almost certainly will by 2019 when MACRA (Medicare Access and CHIP Reauthorization Act of 2015) goes into effect. Not only will the results of these surveys be made public, but the results will likely (if they don’t already) influence your income. But I keep wondering if high patient satisfaction scores equate to high quality in the sense that I as a clinician care about most. Yes, patient satisfaction matters. It has intrinsic value. But is high patient satisfaction a proxy for highquality clinical care? The research on this is quite mixed. Consider this scenario. A patient presents to Dr. A with a painful abdominal rash of two days’ duration. Dr. A’s office is welcoming, and Dr. A and the patient spend several minutes talking about their kids and catching up. Dr. A seems interested in the patient’s condition and spends a lot of time asking questions and examining her but isn’t certain as to the diagnosis. He refers her to a dermatologist. His office staff calls her the next day to see if she got an appointment, and when they learn the appointment is in two weeks, they call the dermatologist’s office and get an appointment in three days. The dermatologist diagnoses herpes zoster and gives the patient an antiviral medication even though it is past the 72-hour window when it is likely to be effective. The patient is pleased. The same patient goes to Dr. B. Although Dr. B’s staff gets the patient in immediately, the staff don’t smile and Dr. B doesn’t chit-chat. He quickly diagnoses herpes zoster, prescribes an antiviral (within the 72-hour window), and advises the patient what to expect and to call if she is still having pain in a month. The visit lasts five minutes. The patient isn’t too impressed with Dr. B. Who got better care? Which doctor would you prefer? Consider another scenario. A perfectly healthy 70-yearold patient goes to his family doctor requesting a screening carotid Doppler ultrasound because a friend of his recently had a stroke. Dr. A spends a great deal of time explaining why this isn’t a good screening test for the patient. The patient isn’t convinced. He goes to Dr. B who immediately orders the test, much to the patient’s delight. Research shows that high patient satisfaction can be a proxy for better clinical outcomes. It also shows the opposite. A hospital-based study involving 6,467 patients correlated increased patient satisfaction with improved guideline adherence and lower inpatient mortality in acute myocardial infarction. Another study, using a nationally representative sample of 36,428 patients and controlled for severity of illness, found higher patient satisfaction associated with lower emergency department use, yet higher inpatient use, higher overall health care and prescription drug expenditures, and increased mortality. Yikes! Would you rather be a highly satisfied but dead patient or a ticked-off but alive one? Clearly more research is needed before we place equal or even disproportionate emphasis on patient satisfaction compared with clinical outcomes. And we certainly don’t want physicians ordering unnecessary tests or doing inappropriate procedures “just to make patients happy.”