An interesting article in Medscape tells us something which most doctors already know: patient satisfaction does not always equate to quality healthcare - in fact, if this study is correct, the most satisfied patients are also the ones who "have the highest mortality rate and the highest hospital admission and healthcare expenditure rates".
In case you can't access the article, here are some abstracts:
"[A]n overemphasis on patient satisfaction could have unintended adverse effects on health care utilization, expenditures, and outcomes," write Joshua J. Fenton...
The prospective cohort study followed-up 51,946 respondents to the 2000 through 2007 Medical Expenditure Panel Survey (MEPS) and included 2 consecutive annual surveys for each patient. ... Mortality outcomes during a mean follow-up of 3.9 years were available for a subset of 36,428 respondents.
Patient satisfaction was assessed with the Consumer Assessment of Health Plans Survey; specifically, with 4 items pertaining to physician communication (which is strongly correlated with global satisfaction) and a fifth item that allowed patients to rate their care from all physicians and healthcare providers.
After adjusting for sociodemographics, health behaviors, healthcare access, propensity to use healthcare, and health status, the authors determined that the odds of any ED visit were lower among patients in the more satisfied quartiles (adjusted odds ratio [aOR], 0.92; 95% confidence interval [CI], 0.84 - 1.00; P = .06), whereas the odds of inpatient admission were higher among the most satisfied patients (aOR, 1.12; 95% CI, 1.02 - 1.23; P = .02).Similarly, patients who were the most satisfied had 8.8% more health expenditures (95% CI, 1.6% - 16.6%; P = .02) in the second year, as well as 9.1% more drug expenditures (95% CI, 2.3% - 16.4%; P = .01) and a 26% greater mortality risk (adjusted hazard ratio, 1.26; 95% CI, 1.05 - 1.53; P = .02), compared with patients who were least satisfied.
...
... the authors... suggest a possible explanation for the findings.
"Physicians whose compensation is more strongly linked with patient satisfaction are more likely to deliver discretionary services," they write, adding that "discretionary services may lead to iatrogenic harm via overtreatment, labeling, or other causal pathways."
"The authors infer that efforts to cater to patient satisfaction may be ill guided," writes Brenda Sirovich, MD... "There is, however, reason to question the validity of the inference," she continued. "[T]he likelihood of an unmeasured confounder remains high. One nomination is that a patient's strong sense of connection to the health care system, related perhaps to (unmeasured) vulnerability or frailty, might predict more satisfaction, hospitalization, and death.
"And yet, the inference is entirely believable — and cause for concern," she adds.
"Practicing physicians have learned — from reimbursement systems, the medical liability environment, and clinical performance scorekeepers — that they will be rewarded for excess and penalized if they risk not doing enough.... It is time that we, as a profession and as a society, take responsibility for controlling this unrestrained system, by working to overcome the widespread misconception that more care is necessarily better care and to realign the incentives that help nurture this belief."
The authors of this blog will not be surprised at all by these findings - in fact, some have warned against such a phenomenon. Fact is, healthcare is a confidence goods, and what you want (or think you want), what makes you feel good, is oftentimes not what *is* good for you.
Until patients and payers (the "scorekeepers") alike wise up to the fact that it is not the criteria they set but the ones the clinicians set which are likely to have real health outcome significance, and until they are willing to incentivise clinicians for doing what the clinicians *know* and not they (the "customers") *think* is right, the situation will persist.
31 comments:
Life is sad. You see a doctor to get a better quality of life, yet you cannot choose the one you agree with. Cheers everyone.
But seeing a doctor doesn't get you a better quality of life.
Better health = better quality of life. Well that's how the fairytale goes.
Even if you accept that equation, "seeing" a doctor doesn't give you better health.
From the study findings, it certainly does not seem to be the case.
Well, the study showed that some people who "saw" doctors had better health than others who also "saw" doctors - what do you think accounts for the difference?
No comments. Not a member of Medscape.
@Anon
Assuming you have no medical education/background, would you rather see a doctor who does not agree with you (you being an untrained layman) but delivers quality, evidence based care, OR see one that agrees with, and follows your layman-opinion on how healthcare should be just to keep you satisfied and deliver care that is unnecessary for you (or worse, potentially harmful)?
The major determinant of how 'healthy' you are is really almost entirely based on how you choose to live a healthy lifestyle, not on which doctor you see (unless you see a quack la).
I didn't read the entire article, but in the local context, the patient satisfaction equation is simple: short waiting time + friendly / outwardly caring ( even if incompetent / hypocritical ) doctor + good service ( SMILE! ) = happy patient.
Most don't want a barrage of tests performed ( can't speak for the private sector though ). Over-ordering is, in my opinion, usually due to the defensive medicine mentality rather than compensation-driven.
The administrators use satisfaction surveys presumably to gauge each institution's "performance" in terms of service quality.
Personally, I find them useless and distracting. What we need are "staff satisfaction" surveys to drive much needed changes in the public healthcare system.
Of course, this will never happen. Doesn't hurt to hope. :)
Medical treatment involves staff and patients. Its a chicken and egg relationship. Personally I feel they should have surveys for both parties.
@Anon.
Are you implying that all doctors who deliver evidence-based care have zero satisfied patients ? I personally want a doctor who agrees and acknowledges the concern of a patient and still able to deliver evidence-based care. I know and despise a greedy lazy doctor when I see one. Apparently from the study, there are more of such doctors.
"I know and despise a greedy lazy doctor when I see one."
Sure you do. Apparently from the study most people don't.
Must be nice to be special.
Yes, from the study, somehow that seems to be the case.
I am nothing special. Perhaps when I am at my most frail state, I would add to that statistic as well.
No, many of them have many satisfied patients; because as you pointed out, I feel that (as of now) most of our local doctors both acknowledge their patients' concerns and practice evidence based care too.
But acknowledging patients' concerns and agreeing with them are 2 different things. The doctor may acknowledge that you are concerned you have a rare, rapidly lethal disease (because maybe your relative has it too), but can disagree that you require a battery of expensive tests to diagnose said condition because in his experience he feels you are unlikely to have it.
I think the point the article is trying to make is that with evolving patient expectations of doctors' 'service' and healthcare delivery, patient satisfaction is no longer as simple as just acknowledging concerns. It is much easier to just perform the battery of tests (and profit from them as well), rather than stand by the 'evidence' and risk facing a law suit (and its associated headaches) if by a stroke of luck the 0.001% chance of you having the disease comes true.
You can call this greed or immorality or unethical behavior, but when your career is on the line, wouldn't you protect yourself first too?
And echoing what angry doc has said; if you are a layman, how on earth would you know whether your doctor is practicing evidence based medicine or not? Or do you base your assessment of the 'greed and laziness' of a doctor entirely on the amount he charges you and the length of your consultation?
Zhou, you have raised a good point. How should a layman assess whether a doctor is practising evidence based medicine or not ?
I'm sure many of the veteran readers/authors here will have better points, but here's my opinion;
The first, and most practical way is simply to ask. 'Can I ask why you are not giving me antibiotics for this cold?', 'Why do you think I don't require further treatment/investigations regarding this?', 'Why don't you think I have cancer?', 'What are the alternatives besides this treatment and what are the pros and cons?'
All competent doctors will/should have fully satisfactory answers to these simple questions. And it is perfectly within the patient's right to know the answer to these questions.
If your doctor seems unsure about what he's doing, or gives an answer that sounds dubious; then please seek a 2nd opinion to verify what he has said.
Having received answers from your doctor, I guess the next (and harder) step is to actually believe him. Antibiotics are not required for a large proportion of common colds, but a lot of patients still want to be prescribed a course. For some conditions early surgery may have been shown to result in better outcomes, so don't dismiss the suggestion, but ask more about it.
As our population's general level of education rises, it'll be nice if the patient-doctor relationship took a step in this direction of mutual cooperation (not to mention respect and understanding) in the care of the patient, instead of 'Hey, do you know where I work? At some big-time law firm okay' complete with a 'you better watch out' glare.
I also feel that the government/health ministry could do more in this aspect. While publishing average costs for hospitalization/procedures across both restructured and private hospitals is indeed useful to patients, it has inadvertently placed the emphasis of care on things that do matter, but should not matter the most. Not sure if it is the chicken or the egg, but it definitely has something to do with patients judging doctors and hospitals based on cost, waiting times, and hospitalization lengths.
Clinical practice guidelines published by the health ministry are useful in standardizing care, but they are aimed towards physicians and not the layman. Perhaps it will not help the layman directly in assessing whether his doctor is practicing EBM, but having a written standard of care is useful in promoting practice of EBM in the healthcare community.
Again, these are my humble views, whether from the senior physicians or concerned public, please feel free to add yours.
But according to the study, if the patients questions the doctor and receives (what he thinks is) a satisfactory answer and is thus satisfied, then there is actually a higher chance of him having a poorer outcome.
If on the other hand he receives an answer that he is not satisfied with, chances are he will have a better health outcome.
I have taken a brief look through the survey used to assess patient satisfaction in the study; out of 20 questions that directly pertain to the delivery of healthcare, only 2 relate to the explanation of treatment/care plans to the patient, and even then the questions were 'how often did the provider explain things in a way that was easy to understand' and 'how often did the provider give you easy to understand information about these health questions or concerns'. The rest of the questions pertain to after hours consultations, waiting times, sufficient actual consultation times, and respect.
So I don't really think that you can conclude that the satisfaction of the patient as assessed in this study pertains to the satisfaction of the patient with the doctor's actual clinical competence? Correct me if I'm wrong..
But anyhow, what then does angry doc think is a good way for laymen to assess their healthcare providers and to tell the bad from the good then, if we want to move away from cost and waiting times and consultation times..?
Well, the article states that "[p]atient satisfaction was assessed with the Consumer Assessment of Health Plans Survey; specifically, with 4 items pertaining to physician communication (which is strongly correlated with global satisfaction) and a fifth item that allowed patients to rate their care from all physicians and healthcare providers", so I guess communication is a major part of what is being looked at here.
I don't think I have a foolproof method of telling whether your doctor is good or bad - I don't even know which brand of butter to pick at the supermarket. But I think the study tells us that if you think you "know (and despise) a greedy lazy doctor when [you] see one", then chances are you are wrong.
Oh, and I hope you are not satisfied with my answer, because that probably means I am right.
Hmm.... based on what angry doc says, I should hire doctors, dentists, lawyers, accountants whom I am not satisfied with, cos they are most probably right.
Only doctors - it's not been shown that the same applies for dentists, lawyers, or accountants.
^ lol, touche
Better to just die than to get sick, especially for the layman.
Then why wait?
I do not want my family lose my life insurance on the grounds of suicide
Wow. If only my life was as full of purpose as yours...
Angry doc apparently has no idea what i am trying to convey. I am so not satisfied with angry doc, he must be so right.
Correlation between higher mortality / healthcare expenditure / hospital admission with greatest patient satisfaction is Not Evidence that one or the other factors are Causes of the rest. It just means that for the sample population these factors appeared together.
We should remind ourselves to see only the data, and beware of any "conclusions" which are hypotheses or opinions.
Certainly, but it does tell us that a high patient satisfaction doesn't always equate with good 'hard outcomes', and that the reverse may be true.
You won't conclude that making patients unsatisfied makes them healtheir, but you certainly can't claim that making them satsfied does!
The point I (and the authors of the article, I believe) am trying to make is that patients aren't the best judge of what's good for them, and administrations using "satisfaction surveys" to measure the work of the clinicians may not be measuring what healthcare should be about.
But feel free to not draw any conclusion you don't want to.
i agree and disagree with both the layman and doctors.
For a 'patient' (aka me) who has been thrown from a GP to the A&E to the ward to another ward and facing lovely MOs who SMILES and tells me 'I HAVE NO CLUE WHAT IS WRONG...' and happily writes 'for PSY assessment' in my diagnosis, I honestly think I will really go CRAZY with these doctors I agree with them.
Don't get me wrong, for 30s of their precious time, I did get good service, but if I had agree to everything they had said, I would have been even more depress and anxious and be 'more sick' and likely to 'die earlier'
But to their credit, I went for a PSY assessment in private practice to make sure i was not crazy. He listened me, told me to keep a diary, and found out it was actually something I am eating that is making me sick, not some... erm, what did they say? 'PSY problems'
I like to believe that normal people do know their bodies best, and can't really explain very well in medical terms for the doctors to fully understand if they are not dead, or dying. Doctors should be train to listen to the layman as well, and not dismiss it (or for my case with the lovely NUS students and MOs) look down at the patient as though they are complete mental who do not know the difference between left and right.
It works both ways. If the doctor can very accurately tell me why he thinks I am an idiot for thinking my weakness is not due to a pinched nerve, no matter how annoyed I am, I will still believe him. But if his answer is a 'i don't know,' which is what I was told as a 'standard procedure when you have no clue what the diagnosis is, and the senior consultant is too busy to see you because you are not dying yet and we have no neuro dept so yea...' and throw me around and order ridiculous amount of tests which I cannot even agree with, then how am i suppose to believe a word you say?
Also, i think for most people, doing the tests gives them a sense of assurance, that they are not dying of cancer...or some rare sickness
I think that is what everyone wants. If the patient wants to do tests, fine, let them wait for like 3 months. But most just want an answer, so just... train the MOs and Registrars to say something else than 'i don't know'
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