Patient Satisfaction and Surgical Quality
Original Investigation Research
Invited Commentary
Public Reporting of Patient Satisfaction vs Objective Quality Measures Why Must We Choose? Can Patients Have Both? Elliott R. Haut, MD, PhD
As physicians and surgeons, we believe patients are fully rational human beings who make the same health care decisions we would if they had optimal data. Unfortunately, this is not the case. We all know patients, colleagues, friends, family members, and even ourselves who continue to smoke tobacco, drink alcohol in exRelated article page 858 cess, abuse drugs, avoid exercise, and eat unhealthy diets. Roughly 40% of all deaths in the United States are related to patient behavioral choices.1 Patients may not make scientifically valid choices; however, in the rubric of patient-centered care, that is okay. Patients should individualize their medical care based on personal priorities, beliefs, and preferences. One may think it is irrational to have a pancreaticodoudenenctomy or esophagectomy at a low-volume hospital or performed by a low-volume surgeon because the data are overwhelming that important outcomes (eg, mortality or complications) are dramatically worse. But what about the patient’s perspective? How difficult is it to travel 400 miles for multiple pre- and postoperative visits? Who will watch the patient’s children if his wife wants to stay with him after surgery? How lonely will he be during recuperation if no family or friends visit? What are the added out-of-pocket costs for outof-network hospitals and surgeons? What about the financial implications of travel, hotels, and meals? Are these measures (hard outcomes vs patient satisfaction) aligned? Are they mutually exclusive? To help answer ARTICLE INFORMATION Author Affiliations: The Armstrong Institute for Patient Safety and Quality, Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Health Policy and Management, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland. Corresponding Author: Elliott R. Haut, MD, PhD, Department of Surgery, Anesthesiology/Critical Care Medicine, Emergency Medicine, and Health Policy and Management, The Armstrong Institute
these questions, Sacks and colleagues2 offer a statistical analysis of the relationship between objective quality measures and patient satisfaction scores. Although their study is well done, I have a few specific methodological and philosophical concerns. First, a higher proportion of emergency operations correlates with lower patient satisfaction scores. I wonder if the relationship holds in the subgroup of patients undergoing elective surgery in which patients have a choice of hospital. Second, the authors suggest a correlation along the entire spectrum of scores. However, I respectfully disagree. There is no biological gradient or dose response with stepwise better outcomes in the higher satisfaction quartiles. The hospitals in the lowest patient satisfaction quartile clearly also have the lowest quality in almost every domain reported. My takeaway is that the lowest quartile is the problem in both regards. Third, what about reverse causality? Are patients treated at higherquality hospitals more satisfied because they did not die or have complications? Which comes first, the chicken or the egg? Public reporting is here to stay and we should embrace it. Many decisions are not black and white. Knowing patients’ preferences is key. Sacks et al2 suggest that a positive correlation means that reporting both may be redundant. But which should we drop? Patient satisfaction? Mortality? Complications? Reporting only 1 implies the others are less important. I favor continuing to provide all independent domains of quality and patient satisfaction. It is our responsibility to optimize the public reporting of meaningful data. Patients are counting on us to empower them to make their own personal decisions.
for Patient Safety and Quality, The Johns Hopkins University School of Medicine, Sheikh Zayed 6107C, 1800 Orleans St, Baltimore, MD 21287 (ehaut1 @jhmi.edu). Published Online: June 24, 2015. doi:10.1001/jamasurg.2015.1347. Conflict of Interest Disclosures: Dr Haut is the primary investigator on contract CE-12-11-4489 from the Patient-Centered Outcomes Research Institute project Preventing Venous Thromboembolism: Empowering Patients and Enabling Patient-Centered Care via Health Information Technology, receives royalties from Lippincott Williams & Wilkins for the book Avoiding
jamasurgery.com
Common ICU Errors, and is a paid consultant for the Preventing Avoidable Venous Thromboembolism– Every Patient, Every Time VHA IMPERATIV Advantage Performance Improvement Collaborative. REFERENCES 1. McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA. 1993;270(18):2207-2212. 2. Sacks GD, Lawson EH, Dawes AJ, et al. Relationship between hospital performance on a patient satisfaction survey and surgical quality [published online June 24, 2015]. JAMA Surg. doi:10 .1001/jamasurg.2015.1108.
(Reprinted) JAMA Surgery September 2015 Volume 150, Number 9
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: by a United Arab Emirates University User on 10/24/2017
865
Original Investigation Research
Invited Commentary
Public Reporting of Patient Satisfaction vs Objective Quality Measures Why Must We Choose? Can Patients Have Both? Elliott R. Haut, MD, PhD
As physicians and surgeons, we believe patients are fully rational human beings who make the same health care decisions we would if they had optimal data. Unfortunately, this is not the case. We all know patients, colleagues, friends, family members, and even ourselves who continue to smoke tobacco, drink alcohol in exRelated article page 858 cess, abuse drugs, avoid exercise, and eat unhealthy diets. Roughly 40% of all deaths in the United States are related to patient behavioral choices.1 Patients may not make scientifically valid choices; however, in the rubric of patient-centered care, that is okay. Patients should individualize their medical care based on personal priorities, beliefs, and preferences. One may think it is irrational to have a pancreaticodoudenenctomy or esophagectomy at a low-volume hospital or performed by a low-volume surgeon because the data are overwhelming that important outcomes (eg, mortality or complications) are dramatically worse. But what about the patient’s perspective? How difficult is it to travel 400 miles for multiple pre- and postoperative visits? Who will watch the patient’s children if his wife wants to stay with him after surgery? How lonely will he be during recuperation if no family or friends visit? What are the added out-of-pocket costs for outof-network hospitals and surgeons? What about the financial implications of travel, hotels, and meals? Are these measures (hard outcomes vs patient satisfaction) aligned? Are they mutually exclusive? To help answer ARTICLE INFORMATION Author Affiliations: The Armstrong Institute for Patient Safety and Quality, Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Health Policy and Management, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland. Corresponding Author: Elliott R. Haut, MD, PhD, Department of Surgery, Anesthesiology/Critical Care Medicine, Emergency Medicine, and Health Policy and Management, The Armstrong Institute
these questions, Sacks and colleagues2 offer a statistical analysis of the relationship between objective quality measures and patient satisfaction scores. Although their study is well done, I have a few specific methodological and philosophical concerns. First, a higher proportion of emergency operations correlates with lower patient satisfaction scores. I wonder if the relationship holds in the subgroup of patients undergoing elective surgery in which patients have a choice of hospital. Second, the authors suggest a correlation along the entire spectrum of scores. However, I respectfully disagree. There is no biological gradient or dose response with stepwise better outcomes in the higher satisfaction quartiles. The hospitals in the lowest patient satisfaction quartile clearly also have the lowest quality in almost every domain reported. My takeaway is that the lowest quartile is the problem in both regards. Third, what about reverse causality? Are patients treated at higherquality hospitals more satisfied because they did not die or have complications? Which comes first, the chicken or the egg? Public reporting is here to stay and we should embrace it. Many decisions are not black and white. Knowing patients’ preferences is key. Sacks et al2 suggest that a positive correlation means that reporting both may be redundant. But which should we drop? Patient satisfaction? Mortality? Complications? Reporting only 1 implies the others are less important. I favor continuing to provide all independent domains of quality and patient satisfaction. It is our responsibility to optimize the public reporting of meaningful data. Patients are counting on us to empower them to make their own personal decisions.
for Patient Safety and Quality, The Johns Hopkins University School of Medicine, Sheikh Zayed 6107C, 1800 Orleans St, Baltimore, MD 21287 (ehaut1 @jhmi.edu). Published Online: June 24, 2015. doi:10.1001/jamasurg.2015.1347. Conflict of Interest Disclosures: Dr Haut is the primary investigator on contract CE-12-11-4489 from the Patient-Centered Outcomes Research Institute project Preventing Venous Thromboembolism: Empowering Patients and Enabling Patient-Centered Care via Health Information Technology, receives royalties from Lippincott Williams & Wilkins for the book Avoiding
jamasurgery.com
Common ICU Errors, and is a paid consultant for the Preventing Avoidable Venous Thromboembolism– Every Patient, Every Time VHA IMPERATIV Advantage Performance Improvement Collaborative. REFERENCES 1. McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA. 1993;270(18):2207-2212. 2. Sacks GD, Lawson EH, Dawes AJ, et al. Relationship between hospital performance on a patient satisfaction survey and surgical quality [published online June 24, 2015]. JAMA Surg. doi:10 .1001/jamasurg.2015.1108.
(Reprinted) JAMA Surgery September 2015 Volume 150, Number 9
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: by a United Arab Emirates University User on 10/24/2017
865
