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Gastroenterology practice evaluations: Can patients get satisfaction?
Although largely untouched by the first and second industrial revolutions in the 18th and 20th centuries, the practice of medicine in the 21st century is increasingly susceptible to the vast transformative power of the third – and rapidly approaching fourth – industrial revolutions. New technological advances and their associated distribution of knowledge and connectedness have allowed patients unprecedented access to health care information. The salutary effects of this change is manifest in a diversity of areas, including registries that facilitate participation in state of the art research such as ClinicalTrials.gov and the ability to track nascent trends in infectious diseases with Google searches.1
Although the stakes may seem lower when patients go online to choose a practitioner, the reality demonstrates just how important those search results can be. With parallels of similar trends in other sectors, there is an increasing emphasis on ranking health care facilities, practitioners, and medical experiences. This phenomenon extends beyond private Internet sites into government scorecards, which has significant implications. But even with widespread access to information, there is frequently a lack of context for interpreting these data. Consequently, it is worth exploring why measuring satisfaction can be important, how patients can rate practitioners, and what to do with the available information to improve care delivery.
The idea to measure patient satisfaction of delivered health care began in earnest during the 1980s with Irwin Press and Rodney Ganey collaborating to create formal processes for collecting data on the “salient aspects of ... health care experience, [involving] the interaction of expectations, preferences, and satisfaction with medical care.”2,3 The enthusiasm for collecting these data has grown greatly since that time. More recently, the federal government began obtaining data in 2002 when the Centers for Medicaid & Medicare Services and the Agency for Healthcare Research and Quality (AHRQ) collaborated to develop a standardized questionnaire for hospitalized patients known as the Hospital Consumer Assessment of Healthcare Providers and Systems, or HCAHPS.4 Subsequently, standardized survey instruments have been developed for nearly every phase of care, including outpatient care (CG-CAHPS), emergency care (ED-CAHPS), and ambulatory surgery care (OAS-CAHPS). These instruments are particularly relevant to gastroenterologists, with questions querying patients about preprocedure instructions, surgery center check-in processes, comfort of procedure and waiting rooms, friendliness of providers, and quality of postprocedure information.
The focus on rating satisfaction intensified in 2010 after the passage of the Affordable Care Act (ACA). Around this time, patient satisfaction and health outcomes became more deeply integrated concepts in health care quality. As part of a broader emphasis in this area, CMS initiated the hospital value-based purchasing (VBP) program, which tied incentive payments for Medicare beneficiaries to hospital-based health care quality and patient satisfaction. Within this schema, 25% of performance, and its associated economic stakes, is measured by HCAHPS scores.5 Other value programs such as the Merit-Based Incentive Payment Program (MIPS) include CAHPS instruments as optional assessments of quality.
Given the financial risks linked to satisfaction rankings and their online visibility, many argue that patient satisfaction is prioritized in organizations above more clinically meaningful metrics. Studies have shown, however, that high levels of patient satisfaction can lead to increased patient loyalty, treatment adherence, patient retention, staff morale, and personal and professional satisfaction.6,7 In fact, not surprisingly, there is an inverse correlation between patient satisfaction and the rates of malpractice lawsuits.7-10
Despite the growing relevance of patient perceptions to clinical practice, measuring satisfaction remains a challenge. While current metrics are particular to an individual patient’s experiences, underlying health conditions influence opinions of these episodes of care. Specifically, patients with depression and anxiety are, in general, less satisfied with the care they receive.11,12 Similarly, patients with chronic diseases on multiple medications and those with more severe symptoms are commonly less satisfied with their care than are patients with acute issues2 and with milder symptoms.3 As gastroenterologists, seeing sicker patients with chronic conditions is not uncommon, and this could serve as a disadvantage when compared with peers in other specialties because scores are not typically adjusted.
Since patient-centered metrics are likely to remain relevant in the future, and with the unique challenges this can present to practicing gastroenterologists, achieving higher degrees of patient satisfaction remains both aspirational and difficult. We will be asked to reconcile and manage not only clinical conundrums but also seemingly conflicting realities of patient preferences. For example, it has been shown that, among patients with irritable bowel syndrome (IBS), more testing led to higher satisfaction only until that testing was performed within the context of a gastroenterologist’s care.13 In contrast, within the endoscopy setting, a preprocedure diagnosis of IBS did not increase the risk for procedure-related dissatisfaction, provided patients were not prescribed chronic psychotropic medication, nervous prior to the procedure, distressed or in pain during the procedure, or had unmet physical or emotional needs during the procedure.14 Furthermore, there is poor correlation between endoscopic quality measures with strong evidence – such as adenoma detection rate, withdrawal time, and cecal intubation rate – and patient satisfaction.15
So, when considering these conflicting findings and evidence that patients’ global rating of their health care is not reliably associated with the quality of the care they receive,16 should we emphasize experience over outcome? As clinicians practicing in an increasingly transparent and value-based health care environment, we are subject to many priorities contending for our attention. We strive to provide care that is at once patient centric, evidence based, and low cost; however, achieving these goals often requires different strategies. At the end of the day, our primary aim is to provide consistently excellent patient care. We believe that quality and experience are not competing principles. Patient satisfaction is relevant and important, but it should not preclude adherence to our primary responsibility of providing high-quality care.
When trying to make clinical decisions that may compromise one of these goals for another, it can be helpful to recall the “me and my family” rule: What kind of care would I want for myself or my loved ones in this situation?
Acknowledgement
We thank Dr. Ziad Gellad (Duke University, Durham, N.C.) for his assistance in reviewing and providing feedback on this manuscript.
1. Proc Natl Acad Sci U S A. 2015;112(47):14473-8. 2. Am J Manag Care. 1997;3(4):579-94.
3. Gut. 2004;53(SUPPL. 4):40-4.
4. Virtual Mentor. 2013;15(11):982-7.
5. J Hosp Med. 2013;8(5):271-7.
6. Int J Health Care Qual Assur. 2011;24(4):266-73.
7. J Cutan Aesthet Surg. 2010;3(3):151-5.
8. Am J Med. 2005;118(10):1126-33.
9. JAMA. 2002;287(22):2951-7. 10. JAMA. 1994;272(20):1583-7.
11. J Diabetes Metab. 2012;3(7):1000210.
12. Am Heart J. 2000;140(1):105-10.
13. J Clin Gastroenterol. 2018;52(7):614-21.
14. Dig Dis Sci. 2005;50(10):1860-71.15. Am J Gastroenterol. 2014;109(7):1089-91.
16. Ann Intern Med. 2006;144(9):665-72.
Dr. Finn is a gastroenterologist with the Palo Alto Medical Foundation, Mountain View, Calif.; Dr. Leiman is assistant professor of medicine, director of esophageal research and quality in the division of gastroenterology, Duke University, Duke Clinical Research Institute, and chair-elect of the AGA Quality Committee.
Although largely untouched by the first and second industrial revolutions in the 18th and 20th centuries, the practice of medicine in the 21st century is increasingly susceptible to the vast transformative power of the third – and rapidly approaching fourth – industrial revolutions. New technological advances and their associated distribution of knowledge and connectedness have allowed patients unprecedented access to health care information. The salutary effects of this change is manifest in a diversity of areas, including registries that facilitate participation in state of the art research such as ClinicalTrials.gov and the ability to track nascent trends in infectious diseases with Google searches.1
Although the stakes may seem lower when patients go online to choose a practitioner, the reality demonstrates just how important those search results can be. With parallels of similar trends in other sectors, there is an increasing emphasis on ranking health care facilities, practitioners, and medical experiences. This phenomenon extends beyond private Internet sites into government scorecards, which has significant implications. But even with widespread access to information, there is frequently a lack of context for interpreting these data. Consequently, it is worth exploring why measuring satisfaction can be important, how patients can rate practitioners, and what to do with the available information to improve care delivery.
The idea to measure patient satisfaction of delivered health care began in earnest during the 1980s with Irwin Press and Rodney Ganey collaborating to create formal processes for collecting data on the “salient aspects of ... health care experience, [involving] the interaction of expectations, preferences, and satisfaction with medical care.”2,3 The enthusiasm for collecting these data has grown greatly since that time. More recently, the federal government began obtaining data in 2002 when the Centers for Medicaid & Medicare Services and the Agency for Healthcare Research and Quality (AHRQ) collaborated to develop a standardized questionnaire for hospitalized patients known as the Hospital Consumer Assessment of Healthcare Providers and Systems, or HCAHPS.4 Subsequently, standardized survey instruments have been developed for nearly every phase of care, including outpatient care (CG-CAHPS), emergency care (ED-CAHPS), and ambulatory surgery care (OAS-CAHPS). These instruments are particularly relevant to gastroenterologists, with questions querying patients about preprocedure instructions, surgery center check-in processes, comfort of procedure and waiting rooms, friendliness of providers, and quality of postprocedure information.
The focus on rating satisfaction intensified in 2010 after the passage of the Affordable Care Act (ACA). Around this time, patient satisfaction and health outcomes became more deeply integrated concepts in health care quality. As part of a broader emphasis in this area, CMS initiated the hospital value-based purchasing (VBP) program, which tied incentive payments for Medicare beneficiaries to hospital-based health care quality and patient satisfaction. Within this schema, 25% of performance, and its associated economic stakes, is measured by HCAHPS scores.5 Other value programs such as the Merit-Based Incentive Payment Program (MIPS) include CAHPS instruments as optional assessments of quality.
Given the financial risks linked to satisfaction rankings and their online visibility, many argue that patient satisfaction is prioritized in organizations above more clinically meaningful metrics. Studies have shown, however, that high levels of patient satisfaction can lead to increased patient loyalty, treatment adherence, patient retention, staff morale, and personal and professional satisfaction.6,7 In fact, not surprisingly, there is an inverse correlation between patient satisfaction and the rates of malpractice lawsuits.7-10
Despite the growing relevance of patient perceptions to clinical practice, measuring satisfaction remains a challenge. While current metrics are particular to an individual patient’s experiences, underlying health conditions influence opinions of these episodes of care. Specifically, patients with depression and anxiety are, in general, less satisfied with the care they receive.11,12 Similarly, patients with chronic diseases on multiple medications and those with more severe symptoms are commonly less satisfied with their care than are patients with acute issues2 and with milder symptoms.3 As gastroenterologists, seeing sicker patients with chronic conditions is not uncommon, and this could serve as a disadvantage when compared with peers in other specialties because scores are not typically adjusted.
Since patient-centered metrics are likely to remain relevant in the future, and with the unique challenges this can present to practicing gastroenterologists, achieving higher degrees of patient satisfaction remains both aspirational and difficult. We will be asked to reconcile and manage not only clinical conundrums but also seemingly conflicting realities of patient preferences. For example, it has been shown that, among patients with irritable bowel syndrome (IBS), more testing led to higher satisfaction only until that testing was performed within the context of a gastroenterologist’s care.13 In contrast, within the endoscopy setting, a preprocedure diagnosis of IBS did not increase the risk for procedure-related dissatisfaction, provided patients were not prescribed chronic psychotropic medication, nervous prior to the procedure, distressed or in pain during the procedure, or had unmet physical or emotional needs during the procedure.14 Furthermore, there is poor correlation between endoscopic quality measures with strong evidence – such as adenoma detection rate, withdrawal time, and cecal intubation rate – and patient satisfaction.15
So, when considering these conflicting findings and evidence that patients’ global rating of their health care is not reliably associated with the quality of the care they receive,16 should we emphasize experience over outcome? As clinicians practicing in an increasingly transparent and value-based health care environment, we are subject to many priorities contending for our attention. We strive to provide care that is at once patient centric, evidence based, and low cost; however, achieving these goals often requires different strategies. At the end of the day, our primary aim is to provide consistently excellent patient care. We believe that quality and experience are not competing principles. Patient satisfaction is relevant and important, but it should not preclude adherence to our primary responsibility of providing high-quality care.
When trying to make clinical decisions that may compromise one of these goals for another, it can be helpful to recall the “me and my family” rule: What kind of care would I want for myself or my loved ones in this situation?
Acknowledgement
We thank Dr. Ziad Gellad (Duke University, Durham, N.C.) for his assistance in reviewing and providing feedback on this manuscript.
1. Proc Natl Acad Sci U S A. 2015;112(47):14473-8. 2. Am J Manag Care. 1997;3(4):579-94.
3. Gut. 2004;53(SUPPL. 4):40-4.
4. Virtual Mentor. 2013;15(11):982-7.
5. J Hosp Med. 2013;8(5):271-7.
6. Int J Health Care Qual Assur. 2011;24(4):266-73.
7. J Cutan Aesthet Surg. 2010;3(3):151-5.
8. Am J Med. 2005;118(10):1126-33.
9. JAMA. 2002;287(22):2951-7. 10. JAMA. 1994;272(20):1583-7.
11. J Diabetes Metab. 2012;3(7):1000210.
12. Am Heart J. 2000;140(1):105-10.
13. J Clin Gastroenterol. 2018;52(7):614-21.
14. Dig Dis Sci. 2005;50(10):1860-71.15. Am J Gastroenterol. 2014;109(7):1089-91.
16. Ann Intern Med. 2006;144(9):665-72.
Dr. Finn is a gastroenterologist with the Palo Alto Medical Foundation, Mountain View, Calif.; Dr. Leiman is assistant professor of medicine, director of esophageal research and quality in the division of gastroenterology, Duke University, Duke Clinical Research Institute, and chair-elect of the AGA Quality Committee.
Although largely untouched by the first and second industrial revolutions in the 18th and 20th centuries, the practice of medicine in the 21st century is increasingly susceptible to the vast transformative power of the third – and rapidly approaching fourth – industrial revolutions. New technological advances and their associated distribution of knowledge and connectedness have allowed patients unprecedented access to health care information. The salutary effects of this change is manifest in a diversity of areas, including registries that facilitate participation in state of the art research such as ClinicalTrials.gov and the ability to track nascent trends in infectious diseases with Google searches.1
Although the stakes may seem lower when patients go online to choose a practitioner, the reality demonstrates just how important those search results can be. With parallels of similar trends in other sectors, there is an increasing emphasis on ranking health care facilities, practitioners, and medical experiences. This phenomenon extends beyond private Internet sites into government scorecards, which has significant implications. But even with widespread access to information, there is frequently a lack of context for interpreting these data. Consequently, it is worth exploring why measuring satisfaction can be important, how patients can rate practitioners, and what to do with the available information to improve care delivery.
The idea to measure patient satisfaction of delivered health care began in earnest during the 1980s with Irwin Press and Rodney Ganey collaborating to create formal processes for collecting data on the “salient aspects of ... health care experience, [involving] the interaction of expectations, preferences, and satisfaction with medical care.”2,3 The enthusiasm for collecting these data has grown greatly since that time. More recently, the federal government began obtaining data in 2002 when the Centers for Medicaid & Medicare Services and the Agency for Healthcare Research and Quality (AHRQ) collaborated to develop a standardized questionnaire for hospitalized patients known as the Hospital Consumer Assessment of Healthcare Providers and Systems, or HCAHPS.4 Subsequently, standardized survey instruments have been developed for nearly every phase of care, including outpatient care (CG-CAHPS), emergency care (ED-CAHPS), and ambulatory surgery care (OAS-CAHPS). These instruments are particularly relevant to gastroenterologists, with questions querying patients about preprocedure instructions, surgery center check-in processes, comfort of procedure and waiting rooms, friendliness of providers, and quality of postprocedure information.
The focus on rating satisfaction intensified in 2010 after the passage of the Affordable Care Act (ACA). Around this time, patient satisfaction and health outcomes became more deeply integrated concepts in health care quality. As part of a broader emphasis in this area, CMS initiated the hospital value-based purchasing (VBP) program, which tied incentive payments for Medicare beneficiaries to hospital-based health care quality and patient satisfaction. Within this schema, 25% of performance, and its associated economic stakes, is measured by HCAHPS scores.5 Other value programs such as the Merit-Based Incentive Payment Program (MIPS) include CAHPS instruments as optional assessments of quality.
Given the financial risks linked to satisfaction rankings and their online visibility, many argue that patient satisfaction is prioritized in organizations above more clinically meaningful metrics. Studies have shown, however, that high levels of patient satisfaction can lead to increased patient loyalty, treatment adherence, patient retention, staff morale, and personal and professional satisfaction.6,7 In fact, not surprisingly, there is an inverse correlation between patient satisfaction and the rates of malpractice lawsuits.7-10
Despite the growing relevance of patient perceptions to clinical practice, measuring satisfaction remains a challenge. While current metrics are particular to an individual patient’s experiences, underlying health conditions influence opinions of these episodes of care. Specifically, patients with depression and anxiety are, in general, less satisfied with the care they receive.11,12 Similarly, patients with chronic diseases on multiple medications and those with more severe symptoms are commonly less satisfied with their care than are patients with acute issues2 and with milder symptoms.3 As gastroenterologists, seeing sicker patients with chronic conditions is not uncommon, and this could serve as a disadvantage when compared with peers in other specialties because scores are not typically adjusted.
Since patient-centered metrics are likely to remain relevant in the future, and with the unique challenges this can present to practicing gastroenterologists, achieving higher degrees of patient satisfaction remains both aspirational and difficult. We will be asked to reconcile and manage not only clinical conundrums but also seemingly conflicting realities of patient preferences. For example, it has been shown that, among patients with irritable bowel syndrome (IBS), more testing led to higher satisfaction only until that testing was performed within the context of a gastroenterologist’s care.13 In contrast, within the endoscopy setting, a preprocedure diagnosis of IBS did not increase the risk for procedure-related dissatisfaction, provided patients were not prescribed chronic psychotropic medication, nervous prior to the procedure, distressed or in pain during the procedure, or had unmet physical or emotional needs during the procedure.14 Furthermore, there is poor correlation between endoscopic quality measures with strong evidence – such as adenoma detection rate, withdrawal time, and cecal intubation rate – and patient satisfaction.15
So, when considering these conflicting findings and evidence that patients’ global rating of their health care is not reliably associated with the quality of the care they receive,16 should we emphasize experience over outcome? As clinicians practicing in an increasingly transparent and value-based health care environment, we are subject to many priorities contending for our attention. We strive to provide care that is at once patient centric, evidence based, and low cost; however, achieving these goals often requires different strategies. At the end of the day, our primary aim is to provide consistently excellent patient care. We believe that quality and experience are not competing principles. Patient satisfaction is relevant and important, but it should not preclude adherence to our primary responsibility of providing high-quality care.
When trying to make clinical decisions that may compromise one of these goals for another, it can be helpful to recall the “me and my family” rule: What kind of care would I want for myself or my loved ones in this situation?
Acknowledgement
We thank Dr. Ziad Gellad (Duke University, Durham, N.C.) for his assistance in reviewing and providing feedback on this manuscript.
1. Proc Natl Acad Sci U S A. 2015;112(47):14473-8. 2. Am J Manag Care. 1997;3(4):579-94.
3. Gut. 2004;53(SUPPL. 4):40-4.
4. Virtual Mentor. 2013;15(11):982-7.
5. J Hosp Med. 2013;8(5):271-7.
6. Int J Health Care Qual Assur. 2011;24(4):266-73.
7. J Cutan Aesthet Surg. 2010;3(3):151-5.
8. Am J Med. 2005;118(10):1126-33.
9. JAMA. 2002;287(22):2951-7. 10. JAMA. 1994;272(20):1583-7.
11. J Diabetes Metab. 2012;3(7):1000210.
12. Am Heart J. 2000;140(1):105-10.
13. J Clin Gastroenterol. 2018;52(7):614-21.
14. Dig Dis Sci. 2005;50(10):1860-71.15. Am J Gastroenterol. 2014;109(7):1089-91.
16. Ann Intern Med. 2006;144(9):665-72.
Dr. Finn is a gastroenterologist with the Palo Alto Medical Foundation, Mountain View, Calif.; Dr. Leiman is assistant professor of medicine, director of esophageal research and quality in the division of gastroenterology, Duke University, Duke Clinical Research Institute, and chair-elect of the AGA Quality Committee.