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Despite benefits, can patient satisfaction scores lead us astray?

Despite benefits, can patient satisfaction scores lead us astray?

Many have argued that a focus on pleasing patients may ultimately compromise the quality of health care. Perhaps doctors who are eager to achieve the highest possible patient satisfaction scores will be too liberal when prescribing narcotics or antibiotics? Or when ordering MRI scans? Maybe some will even begin serving chocolate chip cookies in the waiting room!

One of the key tenants of Slow Medicine involves focusing care delivery on the goals, needs, and expectations of our patients. Thus, we believe patient experience and satisfaction are valuable measures of the care we deliver. On the other hand, we recognize that overemphasizing patient satisfaction scores may have unintended consequences.

That is why we were somewhat reassured by this recent report in JAMA Internal Medicine, which found that hospitals with higher patient experience and satisfaction scores also had better outcomes — specifically, lower mortality and readmission rates. In the study, Harvard researchers linked data on patient experience and satisfaction from Medicare’s Hospital Compare database — which ranks hospitals based on their scores on the widely used Hospital Consumer Assessment of Health Providers and Systems survey (H-CAHPS) — with data on mortality and readmission rates. The researchers took pains to control for differences between hospitals that might confound their analyses. Specifically, they controlled for factors including the hospital’s size, its ownership, the presence of an intensive care unit, and teaching status.

In this analysis, they found that hospitals with higher patient rankings on the H-CAHPS survey tended to have lower mortality and readmission rates. While there are some important methodological concerns with this study — most notably it was not a randomized trial and thus unmeasured factors may have influenced the results — we believe these findings demonstrate it is possible to simultaneously deliver both high quality care and patient-centered care.

Importantly, the CAHPS patient survey used in this study — the most widely used patient survey instrument —is aimed at capturing patient experience, not simply patient satisfaction. What does this mean? By carefully selecting their wording, the survey developers aimed to ask questions objectively in order to measure the experience of care, not just the patient’s overall satisfaction.  For example, rather than asking questions such as: “Do you like your doctor?” the survey asks questions such as, “Does your doctor know important information about you?”  The thoughtful way in which the CAHPS survey was developed, we believe, makes it a more valuable measure than many other patient surveys, as well as the informal feedback from websites like Yelp.  Nonetheless, subjective factors undoubtedly influence CAHPS results, and thus we must recognize that even CAHPS survey responses represent just one of many factors to consider when judging the quality of care.

Despite the importance of high quality patient surveys like CAHPS, we believe it’s important for physicians and health care administrators to avoid becoming obsessed with patient satisfaction scores. Such overemphasis could lead health systems to focus their efforts on marketing and other activities aimed at improving scores but not necessarily impacting the experience of care for patients. It could also potentially lead to care that is not in the best interest of patients, such as inappropriate opioid or antibiotic prescriptions. Indeed, prior studies have suggested that this may occur in some instances.

Still, of all of the quality indicators currently being promoted within health care systems — technical measures of care quality, measures of cost, emergency room and hospital utilization metrics, among others — we believe those that assess patient perspectives are among the most important.

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[Photo by Pedagog Skåne Nordväst via Flickr.]

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