Beyond surveys and payments, better physician–patient communication, trust lead to improved care delivery

The words “patient satisfaction” elicit a wide variety of emotions in emergency physicians. Some immediately become angry and feel like the entire concept has been foisted upon them by hospital administrators only interested in market share and the bottom line. Some feel victimized by the move on the part of the federal government and third-party payers to tie payment to quality and patients’ perceptions of their experience. Others feel that the push for patient satisfaction leads to physicians acquiescing to patients and giving them whatever they ask for, including opiate medication prescriptions or advanced imaging studies such as CTs or MRIs, when those prescriptions and diagnostic studies are truly not in patients’ best interests. For some, it is not the concept of patient satisfaction but rather how it is measured and then used as a quality metric to judge physicians that creates concern. However, others believe that patient satisfaction and clinical quality are intimately interdependent and so patient satisfaction is part and parcel of being an outstanding physician.

All of the above feelings have merit and should be addressed by our specialty as we continue to promote excellence in what we do. I have heard my colleagues say the following:

“Clinical quality is the real deal; this customer service stuff is the fluff stuff.”

“I am an excellent physician, highly trained and skilled at procedures; I can move patients; and my RVUs are among the highest in my group—why do I have to pay attention to this?”

“These patient-satisfaction surveys are poorly devised, do not measure quality, and are not statistically valid.”

“My patients are different. We are a different kind of hospital (inner city with angry patients/suburban hospital with patients with high expectations/trauma center with a lot of homeless and drug-seeking patients) and should not be measured as others are.”

What does the literature say about the connection between patients’ perceptions of care and clinical outcomes? In a study published in the Archives of Internal Medicine in 2012 titled “The Cost of Satisfaction,” the authors concluded, “In a nationally representative sample, higher patient satisfaction was associated with less emergency department use but with greater inpatient use, higher overall healthcare and prescription drug expenditures, and increased mortality.”¹

This article has been used by naysayers of patient satisfaction to suggest that the entire concept is misguided, and some quote a Forbes article based on that study published online in January 2013, “Why Rating Your Doctor Is Bad for Your Health.”² The conclusion is that physicians are paying more attention to satisfying their patients than to treating them in an evidence-based manner and consequently their care costs more and they die more. This study, however, has serious methodological flaws: 1) They studied patient satisfaction only in the year 2000 (year 0) and never in the years when they studied cost and outcomes. 2) Prescription drug expenditures and hospital visits and admissions (cost) were studied only in 2001 (year 1) and never again, and mortality was studied in years 2001–2006 (years 1–6), during which years they never studied patient satisfaction or cost. Their conclusions have no legitimacy.

On the other hand, there are multiple articles in the literature that come to far different conclusions. In a review published in 2009, it was found that physician communication correlates strongly with patient adherence rates to treatment recommendations in acute and chronic disease.³ The authors noted that there were, at that time, more than 100 observational and 20-plus experimental studies published demonstrating the correlation of communication (patient satisfaction) with compliance. Compliance with treatment regimens has significant influence on quality measures in chronic disease and outcomes.3 In a review of the medical literature published in the British Medical Journal in 2013, patient experience was positively associated with clinical effectiveness and patient safety in 77.8 percent of studies, no association was found in 22 percent of studies, and a negative association was found in only one study (0.2 percent).⁴ Academic Medicine published a study titled “Physicians’ Empathy and Clinical Outcomes for Diabetic Patients,” which was based on the experience in the Department of Family & Community Medicine at Thomas Jefferson University. It found that, after removing all confounders, patients who rated their doctor’s empathy high had better clinical outcome markers, lower HgbA1C and LDL levels, than those who rated their physician’s empathy lower. The authors concluded, “Empathic engagement in patient care can contribute to patient satisfaction, trust, and compliance, which lead to more desirable clinical outcomes.”⁵ In another paper titled “Communication and Medication Refill Adherence,” published in Archives of Internal Medicine in 2012, after adjusting for potential confounders, the prevalence of poor refill adherence increased by 0.9 percent (95 percent CI, 0.2–1.7 percent, P=.01) for each 10-point decrease in CAHPS (patient satisfaction) scores.⁶

All of these studies support what, to me, is common sense: If physicians practice evidence-based medicine and communicate better with patients, and consequently patients have more trust in their physicians and better understand what they should do, patients will follow those evidence-based recommendations more often and will have better clinical outcomes. There are unfortunately no specific studies in this area in emergency medicine, and studying clinical outcomes in and of itself in emergency medicine is fraught with difficulty.

In a review of the medical literature…patient experience was positively associated with clinical effectiveness and patient safety in 77.8 percent of studies, no association was found in 22 percent of studies, and a negative association was found in only one study.

The entire issue of how the patient satisfaction surveys are then used is an entirely different matter. We do need to understand that our hospital administrators, the Centers for Medicare & Medicaid Services, and private insurers will continue to use the patient experience as a metric to measure quality, and they will then tie that value to payment, rewarding physicians and hospitals that do well and penalizing those that do not.

In the interim, let’s also be clear that achieving great patient satisfaction is not rocket science. There are simple tactics that emergency physicians can implement, most of which take no more time than we currently spend, and that lead to an improved perception of care. Those tactics include: 1) introducing ourselves and our roles and acknowledging everyone in the room; 2) sitting down at the bedside; 3) using key words to communicate our caring; 4) always estimating for patients how long the ED visit will take and saying it will take longer than we believe it will take (we create expectations that we can then exceed); 5) ending the patient interaction with, “What questions do you have for me? Is there anything you would like for me to go over again?”; and 6) calling back patients who are discharged home within 48 hours to see how they are doing clinically and to ensure that they understood their home-care instructions and are following your recommendations.

Let us not bristle at the thought of the words, “patient satisfaction.” Most of us became physicians because we want to help people and we want to have purpose in our lives and do worthwhile work. If improved communication with patients leads to improved adherence to our recommendations for treatment, and therefore to improved clinical outcomes, we should be all for it.

Dr. Kaplan is director of service and operational excellence at CEP America Emergency Physician Partners and medical director of the Studer Group. He is a member of the ACEP Board of Directors.

References

1. Fenton JJ, Jerant AF, Bertakis KD, et al. The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality. Arch Intern Med. 2012;172:405-411.
2. Falkenberg K. Why rating your doctor is bad for your health. Forbes. January 21, 2013.
3. Zolnierek KB, Dimatteo MR. Physician communication and patient adherence to treatment: a meta-analysis. Med Care. 2009;47:826-834.
4. Doyle C, Lennox L, Bell D. A systematic review of evidence on the links between patient experience and clinical safety and effectiveness. BMJ Open. 2013;3:e001570.
5. Hojat M, Louis DZ, Markham FW, et al. Physicians’ empathy and clinical outcomes for diabetic patients. Acad Med. 2011;86:359-364.
6. Ratanawongsa N, Karter AJ, Parker MM, et al. Communication and medication refill adherence: the Diabetes Study of Northern California. JAMA Intern Med. 2013;173:210- 218.