Are Patient Satisfaction Surveys Making People Sicker?

It’s no wonder medical providers have long protested patient satisfaction surveys.  A patient pulls up the the emergency department unable to find a parking spot.  Finally, after pulling into a cramped parking space, the door to the next car opens placing a noticeable ding in their passenger side door.  Braving the rainy weather, the patient exits their car and enters the waiting room.

Greeted by a stressed out triage nurse nearing the end of a 12 hour shift, the patient is told to take a seat, their name will be called when a room in the ED is available.  The patient proceeds to spend two hours sitting in the waiting room the sounds and smells of vomiting permeating the room.  The patient is coughed over and sneezed upon until finally called back into the emergency department…to a stretcher in the hallway.

At the end of the patient’s visit they are asked to fill out a satisfaction survey.  While their overall experience at the emergency department that day was terrible, their provider in the ED was respectful, polite and even apologized for the wait.  Tainted by an overall negative experience, the patient checks “Very Good” rather than “Excellent” when grading their medical provider on the post-visit satisfaction survey.

Meanwhile, hospital administrators have informed providers they expect a grade of “Excellent” from all patient satisfaction surveys.  “Very Good” is not acceptable and providers with anything less than an “Excellent” average will not receive their full quarterly bonus.  Realizing they need to make up for the overall negative experience coming to the hospital can be, medical providers privately feel pressured to meet patient’s requests and demands, regardless of medical necessity.  They prescribe antibiotics unnecessarily and order expensive testing like MRI’s when they aren’t warranted.  They admit patients to the hospital at their request rather than recommending less costly outpatient care.  It’s no wonder the patient satisfaction survey as a quality of care measure is coming under fire.

A recent study published in the Journal of the American Medical Association looks at patient satisfaction and its relationship to healthcare utilization, expenditures and mortality.  Their findings are interesting.  The study not surprisingly shows that physicians frequently accede to patient’s requests for discretionary services that are of little or no medical benefit.  Physicians whose compensation is more strongly tied to patient satisfaction are more likely to offer discretionary and more costly services like advanced imaging for acute low back pain.

Offering discretionary services to improve satisfaction ratings is unfortunately not a benign issue.  This leads to problems like overexposure to radiation, risk of harm from unnecessary medication use and other risks of overtreatment.  The study showed that within groups of patients with 3 different chronic illnesses, greater intensity of care was associated with higher patient satisfaction but also with higher mortality and without improvement of quality of care.  The pressure to increase patient satisfaction scores could literally be killing some patients.

Not only are health outcomes worse for patients who are overtreated, healthcare costs are higher for these patients.  Patients with the highest satisfaction scores on surveys had 8.8% greater total healthcare expenditures and 9.1% greater prescription drug expenditures.  More satisfied patients were also more likely to be admitted to the hospital from the emergency department, a costly decision.

As nurse practitioners and physician assistants, it seems we are stuck between a rock and a hard place on the issue of patient satisfaction surveys.  Our jobs, and often pay depend on how highly patients rate our care.  On the other hand, we are responsible for appropriate medical decision making.  Our patients come to us for help and advice.  We are to reduce mortality, not cause it by overtreating and overradiating.  Often, we don’t have control over the patient experience in the parking lot and waiting room, much less the attitudes of other hospital employees all of whom help shape a patient’s experience an undoubtedly influence satisfaction scores.

JAMA‘s recent study does shed a ray of light on the patient satisfaction survey when it comes to provider’s scores.  The study shows that although “patient satisfaction correlates to the extent to which physicians fulfill patient’s requests, patient satisfaction can be maintained in the absence of request fulfillment if physicians address patient concerns in a patient-centered way”.  When providers inform patients of the reasons they don’t need certain imaging studies, procedures or medications, satisfaction can be maintained and health outcomes improved.  But, as we know, these conversations take time and can be challenging to implement in the real-world.

Patient satisfaction surveys certainly have their place in medicine.  It’s important for administrators to get an idea of how well different providers are interacting with patients.  However, they shouldn’t be seen as the ultimate performance measure.  Medical providers must feel comfortable taking the risk of leaving some patients dissatisfied in order to prevent unnecessary healthcare costs and negative health outcomes.


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