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Volume 10, Number 9

In many communities, including the area in which I live, health care organizations compete for patients to use their facilities and services. Competition for market share in health care is not unlike competition between financial institutions, grocery stores, or car dealers. While competition in the marketplace often serves to drive prices down, this has not been the case in health care.

Intense emphasis on patient satisfaction is one of the by products of health care competition. New facilities and new services are, in part, fueled by the desire to attract patients. Patients are incessantly surveyed regarding their satisfaction with their experience, and health care executives give a great deal of attention to the results of such surveys.

Aside from the costs associated with efforts to attract patients, it may seem that emphasizing patient satisfaction is a good thing. Satisfied patients are less likely to file malpractice suits, and there are some research data suggesting that patient satisfaction is associated with higher rates of adherence.

The picture isn’t so clear, however, with respect to health outcomes. A group of investigators from the Department of Family and Community Medicine and the Center for Healthcare Policy and Research at the University of California – Davis have been examining this matter. One of their investigations, published in the Archives of Internal Medicine in 2012, found that while patients with higher satisfaction were less likely to use emergency departments, they were more likely to have been hospitalized and had higher prescription drug costs. Of particular note, they had higher mortality rates. The investigators have more recently found that patients report higher satisfaction with discretionary (elective) hospitalizations than with emergent hospitalizations.

The UC – Davis group has also reported that while there is an association between higher patient satisfaction and adherence to preventive care (recommended screenings and immunizations), further analysis reveals that patient satisfaction appears to be more due to patient characteristics than to the health care received. Higher satisfaction is associated with older age, residing in the Northeast or Midwest, having higher health status and higher self-rated health, having private insurance, and identification as a non-Hispanic white. Lower satisfaction is associated with the converse of these variables, as well as having more skepticism about medical care.

While there are critics of the research conducted by this UC-Davis group, there are reasons why higher levels of satisfaction can be associated with poorer outcomes. Patients, and physicians, tend to have a bias toward action rather than watchful waiting. Unfortunately, poor health outcomes can be associated with interventions based on false-positive test results, complications of treatments for conditions that are not life-threatening, or the unnecessary use of antibiotics that increases the development of antibiotic-resistant organisms. For example, while a parent may be more satisfied when a physician prescribes an antibiotic for the child’s upper respiratory ailment, what is overlooked is that the illness likely would have run its course without treatment. And the unnecessary treatment  contributes to the problem of antibiotic resistance. It is also noteworthy that even patients who experience adverse outcomes of excessive medical care are generally found to be satisfied. Of course, there are systemic ways in which physicians are rewarded for excess care and penalized if they opt for doing less…because of how they are reimbursed, malpractice liability, ratings of clinical performance, and patient satisfaction.

It is interesting and important to mention that other research has found that patients who take more responsibility for their health tend to be more satisfied. This is an encouraging finding, given that the chronic illnesses which are most responsible for morbidity and mortality in the United States require lifestyle changes for the most effective management.

With respect to patient satisfaction, the adage, “be careful what you wish for,” may be on target. What makes me happy may not make me healthy. I might be happier to have a side of French fries rather than broccoli, but the vegetable is certainly the healthier choice. Physician decisions to not prescribe a medication, order a test, or pursue a procedure contrary to patient preference may not result in higher patient satisfaction, but in the long term may result in better health outcomes.

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