Patient satisfaction surveys don’t tell the whole story about health care quality

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The following is a guest post by Harold DeMonaco, one of our expert editors for and director of the Innovation Support Center at the Massachusetts General Hospital.


A recent study published in the Archives of Internal Medicine is turning a few heads in the health policy arena.  The cost of satisfaction: A national study of patient satisfaction, health care utilization, expenditures and mortality  study examined the records of more than 34,000 adults for 4 years.  The results are a surprise to say the least.

For years, patients, insurers and government programs have pushed hard for improvement in the level of satisfaction of patients receiving healthcare.  The most recent push involves the development of Accountable Care Organization (ACO)  initiated by the Centers for Medicare  and Medicaid Services(CMS).  ACO’s link the quality and cost of healthcare directly to the reimbursement to providers.  Quality, as defined by CMS, is measured in five domains: patient/caregiver experience, care coordination, patient safety, preventative health, and at-risk population/frail elderly health.

The study in The Archives came to some interesting conclusions:

  1. The most satisfied patients had an 8% lower rate of visits to the emergency room compared to the least satisfied
  2. The most satisfied patients had a 12% higher hospital inpatient admission rate.
  3. The most satisfied patients had a 9% higher prescription and total healthcare costs
  4. AND a 26% higher mortality.

I will apologize up front for providing only relative and not absolute numbers.  Absolute numbers are not provided in the article.  I get the lower ER visits but the rest comes as a surprise especially the higher mortality rate.  The least satisfied patients differed from the most satisfied at baseline in several ways.  The least satisfied tended to have poorer self rated health and there were more smokers.  But even after controlling for confounders, the authors concluded, “The association between higher patient satisfaction and mortality remained significant in an analysis that excluded patients with poor self rated health and three or more chronic diseases.”

A brief report published last September provided the results of a survey of primary care physicians on the topic of appropriate care.  Forty two percent of those responding thought that their patients were receiving too much care.  Only 6% thought that their patients did not receive enough. The reasons for over treatment remain a mystery but likely lie in both the clinicians and patient/family hands.

The Archives paper may suggest how great is the challenge of educating American health care consumers that “More Is Not Always Better.”  And it also suggests – once again – that patient satisfaction surveys don’t tell the whole story of quality health care.

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