By Carol A. Kemper, MD, FACP

Clinical Associate Professor of Medicine, Stanford University, Division of Infectious Diseases, Santa Clara Valley Medical Center

Dr. Kemper reports no financial relationships relevant to this field of study.

SOURCE: Fenton JJ, Jerant AF, Bertakis KD, Franks P. The cost of satisfaction: A national study of patient satisfaction, health care utilization, expenditures, and mortality. Arch Intern Med 2012;172:405-411.

Increasingly, patient satisfaction is an important and commonly used surrogate marker for healthcare quality. Further, reimbursement to physicians may be based on patient satisfaction as a “quality” metric. But the evidence linking a patient’s subjective sense of satisfaction and the actual delivery of quality care remains tenuous, at best.

Fenton et al conducted a prospective cohort study of 51,946 adults participating in the national Medical Expenditure Panel Survey from 2000-2007. The researchers compared patient satisfaction (based on five items from the Consumer Assessment of Health Plans Survey) at one year with healthcare expenditures (total cost, prescription drug cost) and healthcare use (ED visits, hospitalization) at two years, and mortality. Mortality figures were assessed at an average of 3.9 years of follow-up. The data were adjusted for demographics, health status, chronic illness, insurance status, and socioeconomic status. The authors found that those with the highest level of satisfaction paid the highest healthcare costs and demonstrated the highest rates of mortality. Patients in the highest quartile for year 1 patient satisfaction paid an adjusted 8.8% greater healthcare expenditure at year 2, and 9.1% higher prescription drug costs at year 2. They also exhibited a 12% greater risk of hospitalization (adjusted odds ratio, 1.12; P = 0.02) and a 26% greater risk of mortality (adjusted hazard ratio, 1.267; P = 0.02). The risk of mortality remained significantly higher even when researchers eliminated patients with three or more diseases or the worst self-rated health scores from the analysis. Only the risk of going to the ED appeared lower in those more satisfied.

How does one make sense of this? I suggest that the wrong questions are asked. Perhaps we have trained patients to think about their healthcare in the wrong way. How many times have I heard patients complain that their surgeon was not warm? I have had to explain to patients that they do not want a warm and fuzzy surgeon; you want him or her to excel at surgery.

Our large, multispecialty clinic randomly contacts 10 of patients per month with a lengthy questionnaire, detailing their satisfaction with their visit. This includes a few questions about their actual visit with the doctor (e.g., Did the doctor listen to your concerns?), but also questions such as “Were the chairs in the waiting room comfortable?” and “Was the parking adequate?” As best I can tell, all it takes is one in 10 patients who hated their experience, for whatever reason, to skew the results. Aside from the cost of generating all these data, how relevant is it? I do not know, but when I go to a movie and reflect on the experience, I do not think about the parking lot or fault the acting because the popcorn did not contain enough butter. The most demanding patients may not be the most satisfied, unless they get everything they want, which simply cannot translate into the best healthcare. I see a patient who loves her plastic surgeon. He is attractive and friendly, gave the patient a discount for her last surgery, and she raves that the facility is so gorgeous — there are wait staff who take her drink orders; it is like going to the spa. Never mind the nasty infection she contracted for a routine tummy tuck. She still loves the surgeon.

My male partner has read that patients trust their male doctors more when their shoes are polished, they wear a nice watch, and their shirt is ironed, so he makes sure to polish his shoes every day he is on call, wears a conspicuous gold watch, and presses his shirts. Patients believe male doctors should look like successful salesmen because they do not know what else to think.

Although access to parking is important, I am concerned we are training patients to rate their subjective “experience” as a measure of healthcare quality, rather than educating them on how to assess the actual appropriateness and quality of their care. We need to train patients to understand what is important for their healthcare. If one wants quality, look at physicians’ evaluations of each other, their referral base, and other hard indicators, like surgical outcomes and infection rates, not the color of the chairs in the waiting room.