Greater patient satisfaction with physicians was associated with increased hospitalization, higher health care expenditures, and a higher mortality risk within a few years, according to a survey of over 36,000 patients.
Some experts hold that "systematic routine measurement of patient satisfaction is a powerful quality-improvement tool for physicians and health plans," assuming that it correlates with more efficient use of the health care system, lower costs, and better results for patients. In contrast, "our data suggest that we do not fully understand what drives patient satisfaction ... or how [it] affect[s] health care use and outcomes," said Dr. Joshua J. Fenton and his associates in the department of family and community medicine and the Center for Healthcare Policy and Research, University of California–Davis.
"An overemphasis on patient satisfaction could have unintended adverse effects on health care utilization, expenditures, and outcomes," they noted. The study was published in Archives of Internal Medicine.
The researchers assessed the relationships among these factors and patient satisfaction in a prospective cohort study using data from the Medical Expenditure Panel Survey (MEPS). The MEPS is an annual, nationally representative sampling of adults who answer questionnaires pertaining to their access to, use of, and costs associated with health care.
For this study, 36,428 participants’ responses to questions about satisfaction with their physicians were assessed for the baseline year, then health care utilization and costs were assessed for the subsequent year, and mortality was assessed for up to 6 years (mean follow-up duration, 3.9 years).
The study subjects also responded to the Consumer Assessment of Health Plans Survey, which included queries about how often in the past year their physicians listened carefully, explained things in a way that was easy to understand, showed respect for what they had to say, and spent enough time with them.
The data were adjusted to account for potential confounders such as sociodemographic factors, health behaviors, access to health care, health status, insurance status, and comorbidities.
The odds that a study subject would have an inpatient admission were higher among the most satisfied patients, compared with the least satisfied (adjusted odds ratio, 1.12). And patients in the highest quartile of satisfaction showed a 9% higher total of health care expenditures and a 9% higher total of expenditures on prescription drugs, compared with those in the lowest quartile, Dr. Fenton and his colleagues said (Arch. Intern. Med. 2012;172:405-11).
In an analysis that excluded data on patients who rated their overall health as "poor" and those who had three or more chronic diseases, these associations between patient satisfaction on the one hand and health care utilization and costs on the other did not change appreciably.
During follow-up, 1,396 of the study subjects (3.8%) died. Compared with the least satisfied patients, "the most satisfied patients had a 26% greater mortality risk." This association between patient satisfaction and mortality risk remained significant in a further analysis that excluded patients who rated themselves as having "poor" health and those who had three or more chronic diseases.
Compared with the least satisfied patients, those who were most satisfied were less likely to present to the emergency department. Taken together with the other results, this finding "raises the question of whether more-satisfied patients may be differentially hospitalized for elective or less urgent indications, because nonelective urgent hospitalizations often begin with ED visits," the researchers said.
However, an alternative explanation is that people who are the least satisfied with their physicians may be more likely to seek health care at an ED rather than at their doctor’s office, they added.
This study was not designed to elucidate the reasons underlying these associations, but one possible explanation might be that patient satisfaction is a marker for illness, "identifying patients who rely more on support from their physicians and thus report higher satisfaction," Dr. Fenton and his associates said.
Overall, the study results "suggest that we may not fully understand the factors associated with patient satisfaction," they said.
"Patients typically bring expectations to medical encounters, often making specific requests of physicians, and satisfaction correlates with the extent to which physicians fulfill patient expectations." However, physicians are often required to challenge or disturb patients’ beliefs and expectations, such as when they explain the risks of requested tests or treatments and when they address lifestyle issues such as substance abuse, poor diet, or smoking.
"Relaxing patient satisfaction incentives may encourage physicians to prioritize the benefits of truthful therapeutic discourse, despite the risks of dissatisfying some patients," the investigators said.
Among the study’s limitations is that the patient satisfaction measure involved the physician and not other domains of health care, although satisfaction with one’s physician correlates with other dimensions, such as global satisfaction, the authors wrote. They also noted the possibility that patient satisfaction could differ with longer-term use and expenditure.