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    1 Comment for this article
    Physician-level studies of quality measurement require physician-level data
    Alan M. Zaslavsky, Marc N. Elliott | Harvard Medical School, RAND Corporation
    We strongly suspect that the findings of the study by Fenton et al. have been overinterpreted. The main limitation is that it relies on the MEPS, a population-based survey that typically obtains only one patient from any doctor. Thus, the analysis could not distinguish between physician-level and patient-level associations. Whether for patient assessments, outcomes, or health care utilization, variation at the individual patient level is almost universally much greater than that at the physician level. Consequently, the associations found in a study with one patient per physician are dominated by patient-level effects and might be better characterized as follows: patients who are bigger users of health care and have (on the average) higher risk of death tend to also report getting more attention from and communication with their physicians. The letter by Friedberg et al. suggests one set of potential reasons for these associations. These data, however, say nothing about associations of these reports with physician practice patterns, and it is the conjectured influence of providing ratings on how physicians practice that Fenton et al. propose to be a potential policy concern.  In fact, we don't know which of the patients in this study were treated by physicians who received patient assessments or were paid in part based on them.

    The converse issue -- interpretation of an ecological (regional) relationship as driven by relationships at the level of subsidiary units, compounded by the numerous confounding social, epidemiological and health system differences among regions -- arises with respect to interpretation of the Dartmouth Atlas studies of Fisher et al.,  cited in the letter by Fenton et al.  Furthermore, our studies have found that the associations of utilization with a variety of patient assessment measures are more various and complex than were suggested.(1)

    Nonetheless, we are in fundamental agreement with Dr. Fenton and coauthors on " the need for careful appraisal of the nexus between greater health care consumption and a subjectively better health care experience" and development of "more nuanced patient experience measures."  Such work has been underway and will contribute to understanding the characteristics of an effective and patient-centered health care system.

    (1) Mittler JN, Landon BE, Cleary PD, Fisher E, Zaslavsky AM. Market variations in intensity of Medicare service use and beneficiary experiences with care.  Health Services Res 2010;45(3):647-669.

    Original Investigation
    Mar 12, 2012

    The Cost of Satisfaction: A National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality

    Author Affiliations

    Author Affiliations: Department of Family and Community Medicine and Center for Healthcare Policy and Research, University of California–Davis, Sacramento.

    Arch Intern Med. 2012;172(5):405-411. doi:10.1001/archinternmed.2011.1662

    Background Patient satisfaction is a widely used health care quality metric. However, the relationship between patient satisfaction and health care utilization, expenditures, and outcomes remains ill defined.

    Methods We conducted a prospective cohort study of adult respondents (N = 51 946) to the 2000 through 2007 national Medical Expenditure Panel Survey, including 2 years of panel data for each patient and mortality follow-up data through December 31, 2006, for the 2000 through 2005 subsample (n = 36 428). Year 1 patient satisfaction was assessed using 5 items from the Consumer Assessment of Health Plans Survey. We estimated the adjusted associations between year 1 patient satisfaction and year 2 health care utilization (any emergency department visits and any inpatient admissions), year 2 health care expenditures (total and for prescription drugs), and mortality during a mean follow-up duration of 3.9 years.

    Results Adjusting for sociodemographics, insurance status, availability of a usual source of care, chronic disease burden, health status, and year 1 utilization and expenditures, respondents in the highest patient satisfaction quartile (relative to the lowest patient satisfaction quartile) had lower odds of any emergency department visit (adjusted odds ratio [aOR], 0.92; 95% CI, 0.84-1.00), higher odds of any inpatient admission (aOR, 1.12; 95% CI, 1.02-1.23), 8.8% (95% CI, 1.6%-16.6%) greater total expenditures, 9.1% (95% CI, 2.3%-16.4%) greater prescription drug expenditures, and higher mortality (adjusted hazard ratio, 1.26; 95% CI, 1.05-1.53).

    Conclusion In a nationally representative sample, higher patient satisfaction was associated with less emergency department use but with greater inpatient use, higher overall health care and prescription drug expenditures, and increased mortality.