How to Feed and Grow Your Health Care System.
A landmark study has established that patient satisfaction is correlated with mortality - in the wrong way. The more satisfied, the greater mortality. What accounts for this dynamic? And what are the implications for healthcare costs and available political options? 'One of the primary findings itself raises concern—a 26% mortality excess among the most satisfied patients, an effect size that far exceeds that for all other, more immediate, study outcomes (eg, a 12% excess in hospitalizations).' Brenda E. Sirovich, MD, MS wrote a response to the study.
The study: The Cost of Satisfaction A National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality
by Joshua J. Fenton, MD, MPH; Anthony F. Jerant, MD; Klea D. Bertakis, MD, MPH; Peter Franks, MD was published online in Arch Intern Med. February 13, 2012. doi:10.1001/archinternmed.2011.1662
Conclusion from the study:
: In a nationally representative sample, 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.
Brenda E. Sirovich, points out that the dynamics of healthcare are responsible for escalating costs and worse health outcomes:
"Positive feedback systems abound in health care, for both physicians and patients. Diagnostically, almost any unnecessary, or discretionary, test (particularly imaging) has a good chance of detecting an abnormality; acting on that abnormality has an excellent chance of producing a favorable outcome (because a good outcome was already highly likely). Having obtained an excellent outcome, ostensibly owing to a test that was seemingly unnecessary, a natural reaction would be thereafter to perform (or undergo) even more discretionary testing on (or by) patients, with an increasingly negligible likelihood of benefit and greater risk of net harm.
Consider thyroid cancer: incidence of papillary carcinoma (by far the most common type) has tripled over a 30-year period, with an abundance of very small cancers that appear nonlethal.8 The excess cases almost certainly represent pseudodisease (destined never to cause symptoms during a patient's lifetime)—patients who cannot possibly benefit from having had their cancer detected, but can be, and likely are, harmed. However, in the eyes of the patient, her loved ones (and casual acquaintances), and her physicians, she was snatched from the jaws of a premature death by a vigilant physician who thought he felt something on examination or who inexplicably ordered thyroid ultrasound examination. The lesson learned, for all, will surely be to be increasingly vigilant in the future.
Ransohoff et al7(p665) explains, "The point is that . . . decisions for aggressive intervention—screening or treatment—may be positively reinforced when patients and physicians view the decisions from the perspective of an individual person."
Even if patients and physicians were to see through this illusion, overcoming the "more is always better" fallacy of health care remains an enormous challenge. In a recent survey published in the Archives,9 we found that nearly half of US primary care physicians believed that their own patients were receiving too much medical care, and they identified potent systemic incentives encouraging aggressive practice. Practicing physicians have learned—from reimbursement systems, the medical liability environment, and clinical performance scorekeepers—that they will be rewarded for excess and penalized if they risk not doing enough.
More aggressive practice, therefore, improves not only patients' perceived outcomes, but also those of physicians (reimbursement, performance ratings, protection against lawsuits), and the positive feedback loop of health care utilization is fueled at two ends."
'A positive feedback system is not in fact positive (ie, favorable)—it represents an unstable system, one that cannot control its own growth or demise. It is time that we, as a profession and as a society, take responsibility for controlling this unrestrained system, by working to overcome the widespread misconception that more care is necessarily better care and to realign the incentives that help nurture this belief.'