AANS Neurosurgeon | Volume 28, Number 4, 2019

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Point: Patient Satisfaction Surveys: Measuring Patient Contentment with Health-care Service, Not Quality and Value of Neurosurgical Care

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Editor’s Note: To read another perspective on measuring patient satisfaction, read “Counterpoint: Patient Surveys are Good.

The unsustainable cost of health care in the U.S. has led to an unprecedented shift towards value-based reform. Central to this reform era is adoption of quality measurement and profiling with the aim to incentivize and reward patient-centered, high-quality care. While all stakeholders agree on the merits of placing the patient experience at the center of health-care delivery, accurately measuring and identifying health-care value and quality remains a bigger challenge.

Defining and Measuring Patient Satisfaction
Value (quality/cost) measurement has taken center stage in profiling hospitals, physician groups and individual practitioners in an attempt to steer care towards high-value care. Health-care value in its truest sense is the net health benefit achieved per net-cost over time. Unfortunately, the challenge to measure longitudinal health benefits over time via validated patient-reported measures of safety and effectiveness of care has left the value-based reform era relying on assumed proxies to serve as the numerator in the value equation. In a rush to measure overall quality and value of care, patient satisfaction measures have filled this gap. While patient satisfaction surveys serve an important role in promoting patient-centered health-care services and bringing transparency to a consumer market in search of a positive health-care experience, the expansion of their use beyond their valid applications is a concern. Patient-satisfaction measures are paramount in order to measure patient contentment with health-care service and interaction, but are not accurate measures of overall quality, safety, effectiveness or value of neurosurgical care.

Per the Institute of Medicine (IOM), health-care quality is defined by safe, effective, patient-centered, equitable and timely care. In neurosurgery, patients seek our care and payers purchase our care for the chief deliverable of positive net health benefit (safe, effective, timely). Patient-reported outcome (PRO) questionnaires have become the standard measure for treatment effectiveness after medical interventions. The most commonly used PRO questionnaires for neurosurgery and spine surgery include pain scales (VAS/NRS, Rolland Morris) [1,2], physical disability scales (ODI) [3,4], quality of life scales (SF-12 and -36) [5] and preference-based health states (EQ-5D) [6,7]. Due to the time and cost burden of PROs, patient satisfaction with care has emerged in the health-care marketplace as a proxy for quality due to its feasibility of collection. Chow et al. [13] have defined patient satisfaction as “the degree to which patients feel they have received high-quality health care.” Patient satisfaction scales are being used with increasing frequency by health-maintenance organizations and health insurance companies in price negotiations when purchasing health care [8–12]. Furthermore, health-care systems are often judged and ranked on patient-satisfaction statistics, with an implied association with overall quality of care [13].

The Joint Commission on Accreditation of Healthcare Organizations has suggested patient satisfaction be built into the accreditation process for health-care organizations [14]. Similarly, the U.S. Department of Veterans Affairs (VA) also includes patient satisfaction within its strategic plan for patient care. The aim of the largest health insurer in the U.S., Centers of Medicare and Medicaid Services (CMS), is to provide ‘‘better care for individuals, better health for populations and lower costs.’’ Reimbursement of health-care providers is increasingly based on their performance on selected patient-centered measures [12]. Recently, ‘‘The Hospital Consumer Assessment of Health care Providers and Systems Survey’’ (HCAHPS) has been developed by CMS, and, under Medicare’s value-based purchasing policy, one percent of hospital payments will now be withheld to reward those health-care institutions and hospitals that score high on this patient satisfaction survey. This number is expected to increase to two percent by 2017 [15,16]. Thus, the focus of health-care providers and institutions has shifted to improving patient satisfaction. Comprehensive and accurate measurement of health-care quality and value is lagging.

Adjusting the Way Patient Satisfaction is Interpreted
There are several methodological issues associated with interpretation of satisfaction as an outcome measure [11]. The concept of measuring patient satisfaction is underdeveloped because patient satisfaction is a complex and multidimensional construct. It is entirely subjective and influenced by many factors including patient demographics, socioeconomic factors, lifestyle, physical health, expectations and mental health; all of which are not incorporated into their risk-adjusted analysis [13,9,11]. Thus, the results obtained from satisfaction questionnaires are highly sensitive to the choice of patient population, the timing of survey, the type of questionnaire used and the way the survey is conducted.

Patient satisfaction should be interpreted in a more socially relevant and scientifically meaningful and adjusted way [9]. In fact, Fenton et al. [10] recently found that higher satisfaction scores are associated not only with greater use of hospital resources and increased cost, but also with higher morbidity rate. This may be particularly relevant in spine care, as patients with chronic-pain conditions are frequently afflicted with confounding depression and somatic anxiety that greatly influence their reported satisfaction. Furthermore, narcotic use is common in neurosurgical spine patients. Often, aggressive weaning of narcotic use represents the best and highest quality of chronic pain care, but frequently at the cost of patient satisfaction. Thus, it is important to answer the question: Should health-care providers really focus on what patients want, rather than what patients need, merely to increase patient satisfaction? Most physicians across all specialties agree that costly care that does not improve the patient’s health — or is not safe — is of low quality regardless of whether patients are satisfied with their health-care service and experience.

In a recent prospective longitudinal cohort study by our research team, 422 patients undergoing elective cervical or lumbar degenerative spine surgery were followed throughout the three-month global period, the typical window of hospital-based and payer-based patient satisfaction administration. [17] Patient-reported outcome instruments (NRS, ODI, NDI, SF-12, EQ-5D, Zung depression scale, and MSPQ anxiety scale), return to work and patient satisfaction with provider care were recorded at baseline and three months after treatment. In ROC analyses, extent of improvement in quality of life and physical disability (effectiveness of care, health benefit) differentiated satisfaction versus dissatisfaction with care with very poor accuracy (AUC: 0.49–0.69). In regression analysis, 90-day surgical morbidity, hospital re-admission, improvement in quality of life and in general health were also not independently associated with satisfaction of care. In fact, no validated measure of safety or effectiveness of care, predicted at the individual or group level, correlated with patient-reported satisfaction of care [17]. 

These results suggest that patient-satisfaction metrics should not be expanded in their use to represent anything more than what they measure: the patient’s contentment with their health-care service experience.

Placing Safety and Effectiveness of Care as Highest Priority
There is no doubt that the use of patient satisfaction metrics represents an important movement toward patient-centered care and can help drive demand for a specific health-care entity in a consumer-driven market. However, patient-satisfaction scores should not be used alone to represent the overall quality of medical or surgical care. High patient satisfaction in the setting of compromised safety and effectiveness of care can potentially undermine the aims of the value-based quality improvement movement. It is important for neurosurgeons to first place patient-centered safety and effectiveness of care as their highest priority, while then doing their best to deliver health care with satisfactory perceived service.

Patient satisfaction is not a valid measure of overall quality, safety, effectiveness or value of neurosurgical care. Patient-satisfaction metrics represent the patient’s subjective contentment with their health-care services, a distinct aspect of care. Satisfaction metrics are an important, patient-centered measure of health-care services that should be embraced to measure and improve the patient experience, but should not be used as a proxy for overall quality, safety or effectiveness of neurosurgical care. Patient-reported measures of safety and health outcome in the context of cost should be the driving metric in value-based reform, not patient satisfaction.

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