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Comment & Response
August 2014

Patient Satisfaction as a Quality Metric Promotes Bad Medicine—Reply

Daniella Meeker, PhD1; Mark W. Friedberg, MD, MPP2,3,4; Jeffrey A. Linder, MD, MPH3,4; et al for the Behavioral Economics and Acute Respiratory Infection Investigators
Author Affiliations
  • 1RAND Corporation, Santa Monica, California
  • 2RAND Corporation, Boston, Massachusetts
  • 3Division of General Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
  • 4Harvard Medical School, Boston, Massachusetts
JAMA Intern Med. 2014;174(8):1419. doi:10.1001/jamainternmed.2014.1594

In Reply Dr Wexler is concerned that efforts to curtail unnecessary antibiotic use may lead to lower patient satisfaction with care. Our study, which did not measure patients’ experiences of care, does not address this concern directly.1 However, the intent of our intervention was to influence clinicians and patients in a way that might improve both antibiotic stewardship and patient experience. By publicly posting clinicians’ personal commitments to provide evidence-based care, we sought to enlist patients and clinicians in support of a common goal. Public commitments justify our future actions to others, leading naturally to understanding rather than dissatisfaction.2 And, people who show consistency with their public commitments are evaluated more positively than those who do not.3

On the broader issue that Dr Wexler raises, we can offer some encouragement. First, most patients who seek care for acute respiratory tract infections state that they want a diagnosis, reassurance, and relief from symptoms—not an antibiotic.4 This is true even when patients request antibiotics discordant with guidelines. Second, even in the face of such demand, several studies have shown that satisfaction does not increase with receipt of antibiotics.5 Third, critical methodological flaws have plagued recent studies linking better patient experience to adverse health outcomes and additional costs.6

To date, the evidence suggests that efforts to improve antibiotic prescribing do not result in significantly lower patient experience ratings. Improving patients’ experiences of care need not require that we abandon sound antibiotic prescribing principles.

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Article Information

Corresponding Author: Daniella Meeker, PhD, RAND Corporation, 1776 Main St, PO Box 2138, Santa Monica, CA 90407-2138 (dmeeker@rand.org).

Conflict of Interest Disclosures: None reported.

Funding/Support: This work was funded by grant 1RC4AG039115-01 from the National Institute on Aging (NIA) as part of the American Recovery and Reinvestment Act to the University of Southern California (principal investigator, Jason N. Doctor, PhD).

Role of the Sponsor: The NIA had no role in the preparation, review, or approval of the manuscript or the decision to submit the manuscript for publication.

Behavioral Economics and Acute Respiratory Infection Investigators:RAND Corporation, Santa Monica, California: Daniella Meeker, PhD; Clinical Pharmacy and Pharmaceutical Economics and Policy, University of Southern California, Los Angeles: Tara K. Knight, PhD, and Jason N. Doctor, PhD; RAND Corporation, Boston, Massachusetts: Mark W. Friedberg, MD, MPP; Division of General Medicine and Primary Care, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts: Mark W. Friedberg, MD, MPP, and Jeffrey A. Linder, MD, MPH; Anderson School of Management, University of California, Los Angeles: Noah J. Goldstein, PhD, and Craig R. Fox, PhD; COPE Health Solutions, Los Angeles, California: Alan Rothfeld, MD; QueensCare Family Clinics, Los Angeles, California: Guillermo Diaz, MD.

References
1.
Meeker  D, Knight  TK, Friedberg  MW,  et al.  Nudging guideline-concordant antibiotic prescribing: a randomized clinical trial.  JAMA Intern Med. 2014;174(3):425-431.PubMedGoogle ScholarCrossref
2.
Cialdini  RB.  Influence: Science and Practice.Vol 4. 5th ed: Boston, MA: Allyn and Bacon; 2008.
3.
Allgeier  A, Byrne  D, Brooks  B, Revnes  D.  The waffle phenomenon: negative evaluations of those who shift attitudinally.  J Appl Soc Psychol. 1979;9(2):170-182.Google ScholarCrossref
4.
Linder  JA, Singer  DE.  Desire for antibiotics and antibiotic prescribing for adults with upper respiratory tract infections.  J Gen Intern Med. 2003;18(10):795-801.PubMedGoogle ScholarCrossref
5.
Sanchez-Menegay  C, Hudes  ES, Cummings  SR.  Patient expectations and satisfaction with medical care for upper respiratory infections.  J Gen Intern Med. 1992;7(4):432-434.PubMedGoogle ScholarCrossref
6.
Friedberg  MW, Gelb Safran  D, Schneider  EC.  Satisfied to death: a spurious result?  Arch Intern Med. 2012;172(14):1112-1113.PubMedGoogle ScholarCrossref
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