What Does “Patient Satisfaction” Mean to and for Anesthesiologists?

"Patient satisfaction" and the patient experience are considered key measures of quality and performance in our increasingly value-based healthcare system. The American Society of Anesthesiologists' Committee on Performance and Outcomes Measurement (ASACPOM) has acknowledged that "monitoring of patient satisfaction has already been incorporated into payment for performance plans and will be an important component of other payer, healthcare plan affiliations. It is a given that this trend will continue and that assessment of patient satisfaction will affect payment for anesthesiologists in the near future." (White Paper on Patient Satisfaction and Experience with Anesthesia, as revised June 9, 2014.) Health plans use patient satisfaction surveys to evaluate physicians and to determine incentive compensation, and consumer web sites such as HealthGrades often report patient satisfaction ratings as the sole physician measure. Patient satisfaction surveys are also playing a growing role in medical boards' assessment of physicians' competency.

The ASA-Anesthesia Quality Institute's Qualified Clinical Data Registry (QCDR) provides for reporting of a "Composite Anesthesia Patient Experience Measure" with the following description: Percentage of patients, aged 18 and older, who were surveyed on their patient experience and satisfaction with anesthesia care (e.g. private vendor assessment of patient experience and satisfaction, Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey or S-CAHPS)."

Successful participation in Medicare's Physician Quality Reporting System (PQRS) next year will require practices of 100 or more eligible professionals (EPs)s that are participating in the Group Practice Reporting Option (GPRO) to report the CAHPS for PQRS survey data. Practices of 25-99 EPs that registered in the GPRO have the option of supplementing PQRS reporting with the CAHPS for PQRS survey. The CAHPS for PQRS survey will count for three of the requisite nine measures and one National Quality Strategy domain.

Starting in 2016, CMS plans to begin voluntary monthly data collection using the new Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) survey tool. The official OAS CAHPS survey, certified by the Agency for Healthcare Research and Quality, includes 37 questions that assess patient experience measures for hospital-based outpatient surgery departments or free-standing ambulatory surgery centers. The survey, to be administered by Press Ganey, will include questions about the check-in process, the facility environment, the patient's experience communicating with administrative staff and clinicians, attention to comfort, pain control, how well pre- and post-surgery care information is provided, the patient's overall experience and patient characteristics.

For all that the measurement of patient satisfaction is a now fact of our professional lives, its value is not fully accepted. Many anesthesiologists "question whether assessment of patient satisfaction with anesthesia services is meaningful or can improve quality," as the ASACPOM stated in the Introduction to its White Paper.

In The Cost of Satisfaction: A National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality (J. Fenton et al., Arch Intern Med. 2012;172(5): 405-411), a study involving a nationally representative sample, the authors found that higher patient satisfaction was associated with greater inpatient use, higher overall health care and prescription drug expenditures, and increased mortality, albeit with less emergency department use. The most satisfied patients also had statistically significantly greater mortality risk compared with the least satisfied patients. The disadvantages of using patient satisfaction as a proxy for quality include the facts that physicians whose compensation is more closely linked with patient satisfaction are more likely to deliver discretionary services, such as advanced imaging for acute low back pain, and that discretionary services may lead to iatrogenic harm via overtreatment, labeling or other causal pathways. At a minimum, reviewing the data leads to the conclusion "that we do not fully understand what drives patient satisfaction as now measured or how these factors affect health care use and outcomes."

The authors of a recent article published in the Hastings Report ("Patient-Satisfaction Surveys on a Scale of 0 to 10: Improving Health Care, or Leading It Astray?," Hastings Center Report 45, no. 3 (2015): 43-51), argue that the surveys could eventually compromise the quality of care and raise health care costs. "The pursuit of high patient-satisfaction scores may actually lead health professionals and institutions to practice bad medicine by honoring patient requests for unnecessary and even harmful treatments," they write. "Patient satisfaction is important, especially when it is a response to being treated with dignity and respect, and patient-satisfaction surveys have a valuable place in evaluating healthcare. Nonetheless, some uses and consequences of these surveys may actively mislead health care."

On the other hand, as the ASA CPOM observes in the White Paper cited above, measuring patient satisfaction may be associated with fewer adverse consequences in anesthesiology:

While higher patient satisfaction has generally been associated with increased testing, hospitalizations and invasive procedures, assessments of specific inpatient experiences may prove to be a notable exception. Using the Hospital Compare database, a recent study found an inverse relationship between patient experience and complication rates when assessing specific inpatient admissions, suggesting that lower complications are associated with improved experience and potentially vice versa. Thus, patient satisfaction scores may hold increased relevance for perioperative practitioners.
Perhaps the best strategy for anesthesiologists, given the ubiquity of patient satisfaction reporting requirements—as well as the QCDR percentage-of-patients-surveyed measure—is simply to be able to recognize good methodologies and to seek to steer one's practice, institution and even payers to the best available instruments. Barnett et al. (Patient Satisfaction Measures in Anesthesia: Qualitative Systematic Review. Anesthesiology 2013; 119:452–78) undertook a systematic review of a very large number of studies and found a large number of well-developed tools to measure satisfaction with perioperative anesthesia care, but commented that "Perhaps our most significant finding is that the vast majority of anesthesia-related studies do not use validated tools to measure satisfaction, where this outcome is thought to be of importance." The authors were unable to recommend any single survey or tool.

The ASA CPOM, however, has developed recommendations for a set of survey questions for use by anesthesia practices to report to the Anesthesia Quality Institute; the Committee "will also use these recommendations to engage both CMS and the AHRQ [Agency for Healthcare Research and Quality] in the revision of existing survey or development of new surveys that report on patient experience with anesthesia." The recommendations cover four collection categories:

General information about the survey and the surgical procedure, e.g., survey type and method of administration, time between procedure and survey response, primary anesthesia type;
Patient demographic information, used for case-mix adjustment;
"Questions for a short form version of an anesthesia satisfaction survey intended to be added to another survey of patient satisfaction that does not assess satisfaction with anesthesia services," and
Questions for a long form, stand-alone anesthesia satisfaction survey instrument.
The Appendices to the White Paper contain sets of questions in each of these categories. The White Paper is an important summary of and contribution to the literature on anesthesia patient satisfaction surveys. It should be very helpful to any anesthesia practitioner or researcher who wishes to understand the current tools available for assessing patient satisfaction or the open questions that will be resolved in the near future.