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Editor's Correspondence
July 23, 2012

Satisfied to Death: A Spurious Result?

Author Affiliations

Author Affiliations: RAND Corporation and Department of Medicine, Harvard Medical School, and Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts (Drs Friedberg and Schneider); Blue Cross Blue Shield of Massachusetts, Boston (Dr Safran); Department of Medicine, Tufts University School of Medicine, Boston (Dr Safran); and Department of Health Policy and Management, Harvard School of Public Health, Boston (Dr Schneider).

Arch Intern Med. 2012;172(14):1110-1114. doi:10.1001/archinternmed.2012.2060

Fenton and colleagues1 find associations between higher patient experience scores and greater hospitalization rates, total expenditures, and mortality. Their results are puzzling because they conflict with a large literature demonstrating associations between higher patient experience ratings and a variety of favorable outcomes including better medication adherence, better performance on most clinical process measures, reduced hospital use, and lower inpatient mortality rates.2-5

Why the discrepancy? We believe that while the authors used a number of case-mix adjusters, unmeasured illness severity is likely to be a persistent confounder. Sicker patients are often deeply appreciative of clinician efforts (which they observe in relatively intensive relationships), while other patients may have more tepid or unformed views. It follows that these sicker, more grateful patients may experience worse outcomes—not because clinicians pander to them, as the authors suggest, but because of greater underlying illness.

The authors' adjustment for patients' self-reported health status can introduce a second potential source of confounding: patients' inherent rating tendencies. Patients who inherently tend to give favorable responses to survey questions will systematically underreport illness severity and overreport the quality of their experiences, leading the adjustment for patient-reported illness to introduce spurious associations between better patient experience ratings and worse outcomes (when these outcomes are not patient reported, as in the authors' analyses).

The use of Health Plan Consumer Assessment of Healthcare Providers and Systems (CAHPS) items may also underlie these unusual results. Health Plan CAHPS items ask patients about their experiences with all health care providers who have cared for them in the previous 12 months, forcing patients to create a single rating based on experiences with multiple clinicians in multiple settings. It is impossible to know whether the health care providers who figure most heavily in a patient's rating are also the providers most responsible for the outcomes evaluated. The resulting risk of mismatch makes these particular CAHPS measures ill suited to evaluating the relationships studied by the authors. Instead, the line of CAHPS surveys that asks patients to report their experiences with specifically named clinicians or care settings, coupled with outcomes attributable to these specific health care providers, would be more appropriate. Studies using these more focused designs have consistently demonstrated linkages between better patient experiences and better health outcomes.

Given these limitations, we believe the conclusions drawn from the authors' analyses should be more tempered. The weight of the evidence from methodologically stronger studies suggests that efforts to measure and improve patients' experiences of care should be redoubled, not curtailed.

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Article Information

Correspondence: Dr Friedberg, RAND Corporation, 20 Park Plaza, Ste 920, Boston, MA 02116 (mfriedbe@rand.org).

Financial Disclosure: None reported.

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