Should satisfaction scores be risk adjusted?
Some patients are hard to please. The chronically ill are less satisfied with their care. But so are young healthier patients. In fact, satisfaction ratings tend to rise with age until patients reach their early 70s, when along with their overall health status, satisfaction with care declines.
"If you view satisfaction as being a balance between patients’ expectations of care and what was actually delivered to them, it may be that there are certain patients who systematically rate their care lower than other patients," says Gary Rosenthal, MD, associate professor of medicine at Case Western Reserve University and research associate with the Department of Veterans Affairs, both in Cleveland.
So if your practice treats a high percentage of young people or the very elderly, should you expect lower patient satisfaction scores? Should health plans, report cards, and other provider profiling take that into consideration?
That question engenders debate and controversy. But some organizations concur that, in some circumstances, patient satisfaction should be risk adjusted.
For example, the Cleveland Health Quality Choice program, which mails 18,000 patient satisfaction surveys for 27 hospitals each year and publishes provider report cards, adjusts the statistics for age and patient-perceived health status.
"We have found certain patient characteristics do impact on their satisfaction rates," says Dwain Harper, DO, president of the Cleveland Health Quality Choice program. "We want to compare different institutions on institutional differences, not patient differences.
"By far the most important variables are the patients’ ages and their perceived health status," he says. "Gender and the kind of disease [they have] do have a relationship to it. But it’s not significant enough that it’s worth adjusting for."
The decision to risk adjust patient satisfaction measures was not an easy one for Harper and his colleagues. "We are committed to risk adjusting in Cleveland," he says. "But there are just as many experts that feel you shouldn’t do it."
In fact, when Harper polled 10 vendors of patient satisfaction measurement systems, about half said they did not feel the data should be adjusted.
Critics of risk adjustment argue that it devalues the opinions of some patients whose disapproving voices should be heard. "[Critics say] you shouldn’t set up different standards for different types of patients," says Rosenthal.
Yet Rosenthal, who has worked as a consultant for Cleveland Health Quality Choice, supports the use of risk adjustment in some circumstances.
"Failing to consider some of these factors could lead to results that could unduly characterize one provider as being better or worse than another provider," he says.
That is especially true if the patient populations vary widely in age and health status, he says. Cleveland Health Quality Choice doesn’t risk adjust obstetrical patients because they are a more homogenous group of younger women.
"The more diverse the patient populations, the more important the issue becomes," Rosenthal says.
Why aren’t they happy?
What accounts for the patient satisfaction differences? Why are younger patients less happy ones?
Rosenthal speculates that younger patients have different expectations for care. "It could be that as you age, expectations change somewhat," he says. "[Or] it could be people who were brought up in somewhat different eras have a different perception about what’s entitled to them."
It is relatively easy to adjust for age and health status, Rosenthal says. Surveys need only ask one additional question: Rate your health on a scale of poor to excellent.
Still, age and health status of patient populations can’t be used as an excuse for dramatically different patient satisfaction scores, says Harper. Those factors account for less than 10% of variation among scores, he says.
Despite differences among patient groups, patient-centered measures remain a vital source of information about health care quality, says Rosenthal. "There are certain types of information that you can only collect by asking and talking to the patient," he says.
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