Patient satisfaction as measured by the patient-provider communication composite score. The vertical lines indicate 95% CIs.
aP = .002.
bP < .001.
eTable 1. Comparison of Sociodemographic and Clinical Characteristics of Adults With Psoriasis Reporting Psychological Distress Symptoms With Complete vs Incomplete Data From the MEPS
eTable 2. Comparison of Sociodemographic and Clinical Characteristics of Adults With Psoriasis Reporting Depression Symptoms With Complete vs Incomplete Data From the MEPS
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Read C, Armstrong AW. Association Between the Mental Health of Patients With Psoriasis and Their Satisfaction With Physicians. JAMA Dermatol. 2020;156(7):754–762. doi:10.1001/jamadermatol.2020.1054
Is the mental health of patients with psoriasis associated with their satisfaction with physicians?
This analysis of the medical records of 652 US adult patients with psoriasis (weighted total, 8 876 767 patients) found that patients with symptoms of psychological distress and depression reported lower satisfaction with their physicians than patients with no or fewer such symptoms.
Because patients’ baseline mental health may be associated with their perception of the physician, clinicians need to be adaptable and supportive when communicating with patients with mental health comorbidities.
How patients’ mental health is associated with their satisfaction with physicians is rarely studied among adults with skin conditions.
To examine the association between mental health comorbidities in patients with psoriasis and their satisfaction with physicians.
Design, Setting, and Participants
This retrospective survey analysis used 14 years of nationally representative longitudinal data on adults in the United States with psoriasis from the 2004-2017 Medical Expenditure Panel Survey. Statistical analysis was performed from October 1, 2018, to December 1, 2019. Mental health comorbidities were measured by performance on the Kessler 6-Item Psychological Distress Scale (score range, 0-24, where a score ≥13 is considered an indicator of a serious mental illness and significant psychological distress) and the Patient Health Questionnaire 2 (score range, 0-6, where a score ≥3 is considered a positive screening result for a depressive disorder).
Main Outcomes and Measures
Patient satisfaction with physician, measured by the patient-physician communication composite score.
A weighted total of 8 876 767 US adults with psoriasis (unweighted total, 652 patients) (weighted; 54% women; mean [SEM] age, 52.1 [0.7] years) were analyzed; 27% of adults had moderate or severe symptoms of psychological distress, and 21% had moderate or severe symptoms of depression. Patients with moderate or severe psychological distress symptoms were less satisfied with their clinicians compared with those with no or mild psychological distress symptoms (mean Kessler 6-Item Psychological Distress Scale scores for no or mild symptoms, 14.3 [95% CI, 14.2-14.4]; moderate symptoms, 13.2 [95% CI, 13.0-13.4]; and severe symptoms, 13.1 [95% CI, 12.5-13.7]; P < .001). In addition, compared with patients with no or mild psychological distress symptoms, patients with moderate psychological distress symptoms were 2.8 times more likely to report low patient satisfaction (adjusted odds ratio, 2.8 [95% CI, 1.5-4.9]; P = .001), and patients with severe psychological distress symptoms were 2.3 times more likely to report low patient satisfaction (adjusted odds ratio, 2.3 [95% CI, 1.1-4.7]; P = .03). Furthermore, patients with moderate or severe depression symptoms were less satisfied with their clinicians compared with those with no or mild depression symptoms (mean Patient Health Questionnaire 2 scores for no or mild symptoms, 14.3 [95% CI, 14.2-14.4]; moderate symptoms, 13.2 [95% CI, 12.9-13.6]; and severe symptoms, 13.0 [95% CI, 12.6-13.4]; P = .002). In addition, compared with patients with no or mild depression symptoms, patients with moderate depression symptoms were 4.6 times more likely to report low patient satisfaction (adjusted odds ratio, 4.6 [95% CI, 2.1-10.0]; P < .001).
Conclusions and Relevance
This study suggests that patients with greater psychological distress and depression report lower satisfaction with their clinicians than those without such mental health symptoms. Clinicians need to be adaptable and supportive when communicating with patients with mental health comorbidities. Evaluating clinician performance solely based on patient satisfaction can be problematic and incomplete.
Patients evaluate dermatologists and other dermatology clinicians on how well we communicate about their skin diseases and treatment plans. In the field of dermatology, dermatologists and dermatology clinicians generally receive high patient satisfaction ratings.1-4 However, dermatologists sometimes receive disparate evaluations by different patients. Why do some patients rate their dermatology clinicians poorly when most other patients rate the same clinicians highly?
Traditional factors relevant to dermatology patients’ satisfaction with health care professionals include confidence in the clinician, provision of individualized care, and the quality of information provided.5-15 However, to our knowledge, the association between a patient’s baseline psychological state and his or her perception of the quality of patient-clinician interactions is unknown. So, are unhappy patients more likely than happy patients to rate lower patient satisfaction with their clinicians regardless of the actual quality of patient-clinician interactions? Understanding whether mental health comorbidities may be associated with patient satisfaction is important because greater patient satisfaction is associated with better practice and better patient outcomes.2,16-20
A critical knowledge gap exists in this area. Addressing this knowledge gap enables dermatology clinicians to be more cognizant of the psychological factors that may be associated with patient satisfaction. In addition, addressing this knowledge gap will be foundational to improve our approaches to increase patient satisfaction, from enhancing communication styles to directly addressing patients’ underlying psychological state.
This study aims to evaluate whether an association exists between a patient’s psychological state and the perception of patient-clinician encounters using nationally representative data collected with validated instruments. We chose to examine this question for patients with psoriasis owing to the chronicity of psoriasis, the varied psychological and mood states among patients with psoriasis, and the overall large disease burden.21-23
This retrospective survey analysis used longitudinal data from the 2004-2017 Household Component of the Medical Expenditure Panel Survey (MEPS). The MEPS is a publicly available database that uses a stratified, multistaged probability design to provide a nationally representative, noninstitutionalized sample of US adults that is followed up for approximately 2 consecutive years.24 The survey collects deidentified information on health care use, health care expenditures, and sociodemographic characteristics as well as physical and mental health comorbidities. This study was determined to be exempt by the University of Southern California Institutional Review Board because the MEPS comprises deidentified, publicly available data. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines.
The study population included all adults (≥18 years) alive during the calendar year who reported a diagnosis of psoriasis, reported patient satisfaction with their clinician, and completed the Kessler 6-Item Psychological Distress Scale (K6) and/or the Patient Health Questionnaire 2 (PHQ2). We used the Medical Conditions data file to identify patients who had a diagnosis of psoriasis identified by the International Classification of Diseases, Ninth Revision (ICD-9) code 696 or the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) code L40. The MEPS database had been used previously to evaluate patients with psoriasis.25,26 We used the Full-Year Consolidated data file to obtain mental health comorbidity and patient satisfaction data. For analysis, we included patients who had complete data on demographic and clinical characteristics of interest.
The dependent variable was patient satisfaction as measured by the patient-physician communication composite score, a validated instrument that assesses a patient’s perception of the quality of patient-clinician communication.27,28 This measure collects patients’ responses to the following 4 patient-clinician communication domains: (1) listening carefully to patients, (2) explaining diagnoses and management in ways patients could understand, (3) showing respect for patients’ perspective, and (4) spending enough time with patients. Patients’ responses were scored using a 4-point Likert scale (1-4, where 1 indicates never and 4 indicates always). Global scores range from 4 to 16. Based on existing literature, the patient-physician composite scores were categorized into the following 3 groups: (1) low patient satisfaction (patient-physician composite score, 4-9), (2) medium patient satisfaction (patient-physician composite score, 10-15), and (3) high patient satisfaction (patient-physician composite score, 16).29-33
The independent variable (indicator) was mental health comorbidities as measured by the presence of psychological distress or depression symptoms. We favored the use of K6 and PHQ2 rather than ICD codes for anxiety and depression because the K6 and PHQ2 provided granular information regarding patients’ mental health symptoms and pertain only to patients exhibiting symptoms.
The K6 scale is a validated 6-item measure of psychological distress. It evaluates aspects of nervousness, hopelessness, restlessness, depression, apathy, and worthlessness during a 30-day reference period.34,35 Each item is scored on a 5-point Likert scale (0-5, where 0 indicates none of the time and 4 indicates all of the time). Global scores range from 0 to 24; a score of 13 or more is considered an indicator of a serious mental illness and significant psychological distress.34 A validation study of mental health comorbidity measures in the MEPS database demonstrated that all K6 items loaded strongly on the mental health factor using factor analysis.36 The K6 scores were categorized into the following 3 groups: no or mild psychological distress symptoms (K6 score, 0 to <5), moderate psychological distress symptoms (K6 score, 5 to <13), and severe psychological distress symptoms (K6 score, 13-24).37
The PHQ2 is a validated 2-item screening measure for depression.38,39 Responders are asked to report whether, during the past 2 weeks, they have been “feeling down, depressed, or hopeless” or have “little interest or pleasure in doing things.” Each item is scored on a 4-point Likert scale (0-3, where 0 indicates not at all and 3 indicates nearly every day). Global scores range from 0 to 6; a score of 3 or more is considered a positive screening result for a depressive disorder (sensitivity, 94%; specificity, 75%).39 The PHQ2 scores were categorized into the following 3 groups: no or mild depression symptoms (PHQ2 score, <1.5), moderate depression symptoms (PHQ2 sore, ≥1.5 to <3), and severe depression symptoms (PHQ2 score, 3-6).39,40
We adjusted for potential demographic confounders, including age, sex (self-reported as female or male), race, ethnicity (Hispanic or non-Hispanic), marital status, employment status (employed or unemployed), educational level, poverty level category, the year the survey was conducted, and whether the patient and clinician speak the same language.41-46 We also adjusted for potential clinical confounders, including cognitive limitations, social limitations, and comorbidities. Cognitive limitations were defined as confusion or memory loss, problems making decisions, or the requirement of supervision for safety. Social limitations were defined as any social, recreational, or family activity limitations secondary to mental or physical impairments. Comorbidities were assessed using the Charlson Comorbidity Index, excluding depression from the index owing to its collinearity with mental health comorbidity measures.47 The Charlson Comorbidity Index is a validated method of the estimated risk of mortality from comorbid disease and has been adapted for use with 3-digit ICD-9 codes.47-50 Its use in the MEPS is well described.51-54
Statistical analysis was performed from October 1, 2018, to December 1, 2019. We conducted separate analyses for each mental health comorbidity measure (K6 and PHQ2). We performed a descriptive analysis of age, sex, race, ethnicity, marital status, employment status, educational level, poverty level category, cognitive limitations, social limitations, and year the survey was conducted and calculated the Charlson Comorbidity Index. We evaluated differences in sociodemographic and clinical factors between patients with varying severities of mental health symptoms using χ2 analyses for categorical variables and analysis of variance for continuous data.
To determine whether differences exist in patient satisfaction among patients with varying severities of mental health symptoms, we performed a univariate analysis using analysis of variance. Multivariate logistic regression models were used to evaluate the outcome of patient satisfaction, which was a binomial variable.
To obtain nationally representative population sums, we applied person-level sampling weights and a variance estimation stratum. P ≤ .05 was established a priori as statistically significant for unadjusted comparisons. To address multiple hypothesis testing, P ≤ .004 was established using the Bonferroni correction (α/number of tested variables = 0.05/13 = 0.004) as statistically significant for adjusted comparisons. For all statistical analyses of the MEPS survey data, we applied the appropriate survey commands using STATA, version 13.0 (StataCorp LLC).
Among a weighted total of 13 965 002 US adults with psoriasis (unweighted, 1385 US adults with psoriasis) who reported mental health comorbidities during a 14-year period from the 2004-2017 MEPS database, approximately 36% were excluded from the analysis owing to missing data. A comparison of sociodemographic and clinical characteristics of the original population with incomplete data and the analyzed population with complete data showed overall similar population-level characteristics and are detailed in eTables 1 and 2 in the Supplement.
A weighted total of 8 876 767 patients (unweighted, 652 patients) were included in the analysis. The mean (SEM) age was 52.1 (0.7) years. Women comprised 54% of the population, and men comprised 46% of the population. The mean patient satisfaction score was 14.0 (95% CI, 13.8-14.2).
Regarding psychological distress, 73% of patients had no or mild symptoms, 22% had moderate symptoms, and 5% had severe symptoms (Table 1). The mean patient satisfaction score was 14.3 (95% CI, 14.2-14.4) for patients with no or mild psychological distress symptoms, 13.2 (95% CI, 13.0-13.4) for patients with moderate psychological distress symptoms, and 13.1 (95% CI, 12.5-13.7) for patients with severe psychological distress symptoms (P < .001) (Figure). Unadjusted logistic regression found that, compared with patients with no or mild psychological distress symptoms, patients with moderate psychological distress symptoms were 3.0 times more likely to report low patient satisfaction with their clinician (odds ratio [OR], 3.0 [95% CI, 1.7-5.4]; P < .001).
Multivariate logistic regression adjusting for sociodemographic and clinical characteristics found that, compared with patients with no or mild psychological distress symptoms, patients with moderate psychological distress symptoms were 2.8 times more likely to report low patient satisfaction with their clinician (adjusted OR [AOR], 2.8 [95% CI, 1.5-4.9]; P = .001), and patients with severe psychological distress symptoms were 2.3 times more likely to report low patient satisfaction with their clinicians (AOR, 2.3 [95% CI, 1.1-4.7]; P = .03) (Table 2).
Regarding depression, 79% had no or mild symptoms, 13% had moderate symptoms, and 8% had severe symptoms (Table 1). The mean patient satisfaction score was 14.3 (95% CI, 14.2-14.4) for patients with no or mild depression symptoms, 13.2 (95% CI, 12.9-13.6) for patients with moderate depression symptoms, and 13.0 (95% CI, 12.6-13.4) (P = .002) for patients with severe depression symptoms (Figure).
Unadjusted logistic regression found that, compared with patients with no or mild depression symptoms, patients with moderate depression symptoms were 3.8 times more likely to report low patient satisfaction with their clinician (OR, 3.8 [95% CI, 1.8-7.9]; P = .001), and patients with severe depression symptoms were 2.3 times more likely to report low patient satisfaction with their clinician (OR, 2.3 [95% CI, 1.2-4.2]; P = .009). Multivariate logistic regression adjusting for sociodemographic and clinical characteristics found that, compared with patients with no or mild depression symptoms, patients with moderate depression symptoms were 4.6 times more likely to report low patient satisfaction with their clinician (AOR, 4.6 [95% CI, 2.1-10.0]; P < .001) (Table 2).
This study examined a critical gap in the association between the mental health of patients with psoriasis and their perception of the quality of patient-clinician interactions. Based on this nationally representative population of adults with psoriasis spanning 14 years, compared with patients with no mental health symptoms, patients with psychological distress and depressive symptoms are more likely to report lower satisfaction with their physicians.
Specifically, patients with moderate or severe psychological distress and patients with moderate depression symptoms were more likely to report low patient satisfaction with clinicians regardless of sociodemographic factors or comorbidities. Therefore, it is possible that patients’ mental health status may be associated with their perception of the quality of interactions with health care professionals. However, further research is necessary to confirm the directionality of the findings.
These findings are informative for the following reasons. Even if clinicians delivered consistent high-quality care, some patients may perceive such care to be inferior owing, at least in part, to their baseline mental health status. For example, a patient who has depressive symptoms at baseline is more likely than another patient without depressive symptoms to rate a clinician poorly. Prior research in other chronic diseases may provide a rationale for this observation.55-58 In some patients, the “pervasiveness” of mental health illness, defined as a general negative outlook on life, may predispose them to be particularly sensitive to the suboptimal components of the patient-clinician interaction.59 In addition, cognitive impairments associated with mental health illnesses can be associated with a patient’s ability to engage with the clinician or comprehend or recall information from the encounter.60-62
Our findings corroborate and extend those from studies of other chronic diseases.63,64 For example, for patients with chronic coronary disease, depressive symptoms were strongly associated with a negative perception of their clinicians.64 Furthermore, patients with depressive symptoms are also more likely to report overall dissatisfaction with other aspects of health care delivery regardless of disease severity or comorbidities.63-66
Recognizing the association between a patient’s baseline mental health status and a patient’s satisfaction is critical in caring for patients with psoriasis because one-third of patients with psoriasis present with symptoms of depression and anxiety.67-69 Improving the patient experience among those with mental health comorbidities is important because increased patient satisfaction may be associated with greater treatment adherence and better health outcomes.2,16-20
When caring for patients with mental health symptoms, dermatology clinicians may need to be more adaptive in their communication style.20,70,71 Because depressed patients can be more sensitive to negative communication, the clinician needs to be more conscious about using a positive and supportive communication style. In addition, clinicians need to provide context when discussing the effectiveness and the potential adverse effects of treatment such that patients can evaluate the treatments accurately.
Furthermore, these study findings are especially relevant when we evaluate clinicians based on the results of patient satisfaction surveys. Patient surveys with small sample sizes, nonrandom sampling, or low response rates need to be interpreted with skepticism and caution. Also, comparing a clinician’s performance based solely on patient satisfaction is problematic because different physicians may treat different patient populations with varying baseline mental health status.
This study has some limitations, and our findings need to be interpreted in the context of the study design. The MEPS database does not collect data on physicians’ perceptions of the quality of an encounter, thereby limiting a comparison of patient and clinician perceptions. In addition, the MEPS does not capture other factors that may be associated with the mental health status of patients with psoriasis and their satisfaction with their clinician, such as psoriasis disease severity and treatment responses. Because the MEPS methods enable the calculation of national estimates, the study findings are generalizable to patients with psoriasis in the United States. The findings are mostly, but not entirely, generalizable to dermatology clinicians in the United States because the MEPS does not specify whether clinicians caring for patients with psoriasis were dermatologists. However, based on other national studies, most psoriasis clinicians are dermatologists.72,73
Our study found that psychological distress and depression symptoms were associated with lower patient satisfaction with clinicians among adults with psoriasis. A patient’s baseline mental health, at least in part, is associated with their perception of the health care professional. It is important for clinicians to be adaptable and supportive in their communication style in caring for these patients. It is also important to recognize that evaluating clinician performance solely based on patient satisfaction can be problematic and incomplete.
Accepted for Publication: March 10, 2020.
Corresponding Author: April W. Armstrong, MD, MPH, Department of Dermatology, Keck School of Medicine, University of Southern California, 1975 Zonal Ave, KAM B6, Los Angeles, CA 90089 (firstname.lastname@example.org).
Published Online: May 6, 2020. doi:10.1001/jamadermatol.2020.1054
Author Contributions: Drs Read and Armstrong had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Acquisition, analysis, or interpretation of data: Both authors.
Drafting of the manuscript: Both authors.
Critical revision of the manuscript for important intellectual content: Both authors.
Statistical analysis: Read.
Administrative, technical, or material support: Armstrong.
Conflict of Interest Disclosures: Dr Read reported receiving grants from the National Psoriasis Foundation (NPF) during the conduct of the study. Dr Armstrong reported receiving grants and personal fees from Abbvie, Bristol-Myers Squibb, Dermavant, Eli Lilly, Janssen Pharmaceuticals Inc, Leo Pharma, Novartis Pharmaceuticals Corp, Regeneron Pharmaceuticals, and UCB Pharma; personal fees from Boehringer Ingelheim, Genentech, Merck, Modernizing Medicine, Ortho Dermatologics, Pfizer Inc, Sanofi Genzyme, and Celgene; and grants from Dermira and Kyowa Hakko Kirin outside the submitted work.
Funding/Support: This study was funded by the NPF/USA.
Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Additional Information: This study was conducted with publicly available, deidentified data from the Agency for Health Care Research and Quality’s Medical Expenditure Panel Survey.