Patient Experience and Quality Care

Doctors are increasingly asked to address patient experience as an important  measurement.  As frontline doctors we put our patients at the center of everything we do, and understanding that a good patient experience is as important as clinical outcomes benefits not only our patients but those who interact with the patient.

While we all support improving the patient experience, it is not so simple to describe the relationship between the self reported patient experience and clinical outcomes. A 2013 study in the Annals of Family Medicine by Llanwarne et al concludes:

“Our findings support the hypothesis that although there are positive associations between clinical quality of care and measures of patient experience, these 2 domains of care quality remain predominantly distinct, with statistically significant but very low correlations. The strongest correlations are between clinical quality and access. Clinical and patient experience domains of quality need to be considered separately when assessing the overall performance of a family practice.”

A 2014 Review Article “Examining the Role of Patient Experience Surveys in measuring Health Care Quality” suggests a complicated picture.  On one hand they write “the empirical evidence indicates that it is possible for health care providers and plans to simultaneously offer better patient experiences and better clinical quality, and that positive patient experiences, best practice clinical processes, lower hospital readmissions, and desirable clinical outcomes are often positively associated across provider organizations. “ But they also explain that “Many of the studies we reviewed, however, reported null associations between patients’ care experiences and clinical processes or outcomes. Lack of association between patient experience measures and clinical outcomes is not necessarily surprising, as clinical process measures have not been demonstrated to be consistently and positively related even to one another.”

A 2014 Debate and Analysis piece in the British Journal of General Practice tries to draw a sharper line between outcomes and Patient Reported Outcomes Measures (PROMs). “However, although patient experience clearly matters, and validated PREMs (patient reported experience measure) provide an invaluable view of this, experience is distinct from outcome. Recent research suggests that the correlation between a positive experience and outcome in general practice, while statistically significant, is actually fairly low.”

 

Something deeper is being discussed when experience and outcome are juxtaposed in this way.  In the American context an underlying issue is how the patient should be viewed in the new health care landscape.  Perhaps the anxiety of using patient experience as a measure mirrors the move from patient to consumer.   Hospitals, like many brands, are worried about attracting and keeping patients.  If the patient is a consumer and the consumer is always right, what does that mean for the professional authority of the doctor?

This seems to be precisely the question in  Alexandra Robbins’ Atlantic Article “The Problem with Satisfied Patients” where the thesis is stated in the subtitle “A misguided attempt to improve healthcare has led some hospitals to focus on making people happy rather than making them well.”  He quotes a Missouri clinical instructor who said “patients can be very satisfied and dead an hour later.”  A scary idea, but does the data warrant this fear?

The reverse side of the “consumer is always right” argument is the fear that hospitals will focus on the experience of the patient and not their health.  Will the incentive move from hard outcomes to subjective experience? Robbins writes “Many hospitals seem to be highly focused on pixie-dusted sleight of hand because they believe they can trick patients into thinking they got better care.”

Of course, as Dr. Ira Nash points out in a critique of the article on KevinMD, the hospitals are not asking the patients to review everything about the quality of their hospital, only the quality and of their experience as a patient, and in this area who is a more of an expert than the patient?

There is a big difference if the challenge to professional authority comes from the hospital and insurance companies or from the patients. The first demands a strong defensive posture and the second demands empathy.  While the use of the patient experience might be manipulated to preserve a “brand”, in itself the patient experience is an important part of the healing process for the doctor to consider.  Putting the patient first is different from manipulating the patient and it is the doctor’s role to keep them separate.