Patient Satisfaction – An Unreliable and Dangerous Measure

Many of you have heard me criticize our dependence on patient satisfaction scores as a quality measure.

Back in 2012, researchers at the University of California-Davis published a study demonstrating that higher patient satisfaction was associated with less emergency department use, but with greater inpatient use, higher overall health care and prescription drug expenditures, and increased mortality.

And now there is new research to support this contention. A new study was recently released that once again supports my viewpoint. A group of orthopedic surgeons at Stanford Medicine randomized almost 1,500 patients who were having elective hip or knee replacement.

After they went home, half of the patients received a personal thank-you card from the surgeon along with a bouquet of flowers, and half did not. All of the patients received their usual post-surgery Press Ganey survey.

And as you can guess, the scores from the patients who received flowers were statistically higher than those who did not. Interestingly, the patients who received flowers not only rated their physician higher, but also the hospital experience. Think about that: same physicians, same nurses, same hospital, but better scores simply because they received flowers after discharge.

If a study showing increased mortality didn’t sway those who support patient satisfaction surveys, then one showing the influence of a bouquet of flowers is unlikely to change that. So maybe those with low scores just need to start sending flowers and get that additional quality money from the payers and a higher star rating to advertise.

Now, do not get me wrong here. I do think patients deserve quality care, and to be treated properly. But I think we need a way to measure patient engagement and use that, rather than these dangerous and imprecise measures of satisfaction.

Moving on, I talk often of the utility of online discussion groups in our work. Posts about hard cases, regulatory questions, and more abound. But remember that what you read on the Internet is not always correct.

There was a recent discussion on a Facebook case manager forum that illustrates this. A case manager asked: “Are total hip and knee revisions coded as inpatient, or can they be coded as outpatient procedures?” One respondent wrote “usually outpatient in a bed,” and another wrote “same-day surgery.” Another wrote “used to be IPO (inpatient only), but changed about two years ago.” Another wrote “TKA are always outpatient unless there is a complication.” That person went on to say, “none of my hips get out in less than two midnights.”

What’s wrong here? Well first, until we have Medicare for All, or some variation thereof, there are a myriad of payers, all with their own rules. So, was this referring to Medicare or commercial patients? We don’t know, because they did not specify.

But from the responses, most assumed Medicare, and sadly, most responses were wrong. Revision surgery is still on the inpatient-only list, so it is inpatient only for Medicare and Medicare Advantage, and is not proposed to change for 2025.

Then, even if referring to first-time surgery, the statement about “outpatient unless a complication” is wrong. The Medicare case-by-case exception allows inpatient admission prior to surgery due to risk. And what about the hospital where all hip replacements stay two days, where others go home the same day? How is that appropriate in 2024?

I love online forums, but please “trust but verify.”