Jon Christianson, PhD, Caroline Carlin, PhD, Patricia Keenan, PhD, and Michael Finch, PhD, are the senior authors of this research study. Judy Jou prepared this brief as a class assignment for Public Health 8802, Health Policy Applications taught by Lynn Blewett, Ph.D, professor, and Sarah Gollust, Ph.D, assistant professor.
Background
Patient satisfaction is an important measure of health care quality. In recent years, organizations such as the Institute of Medicine (IOM) and Robert Wood Johnson Foundation (RWJF) have increasingly recommended using patient satisfaction scores as one indicator of provider quality.
Patients today have access to a wide range of consumer satisfaction reports when selecting their providers. Health payment systems that use a pay-for-performance (P4P) or tiered benefit design structure can also use satisfaction metrics to calculate provider rewards. One potential problem is that providers within these systems may try to improve their performance scores by turning away patients who are likely to report low satisfaction. Identifying contributors to patient satisfaction can help address this concern.
One factor that can influence patient satisfaction is illness complexity. Research in this area is inconclusive, with some suggesting that patients with more complex conditions may report lower satisfaction with care regardless of actual provider quality, while others indicate no significant association between patient condition and satisfaction with care.
To shed more light on this issue, Carlin and colleagues examined the effects of illness complexity on the association between three aspects of provider performance known to be associated with patient satisfaction: 1) quality of interaction with the provider, 2) provider support for self-management of illness, and 3) patients’ understanding of their own conditions and treatments.
Study Design
The authors used data collected from a random-digit telephone survey administered by RWJF as part of its Aligning Forces for Quality (AF4Q) initiative, which aims to improve the treatment of chronic illnesses through building alliances between health care stakeholders. U.S. adults were screened for at least one of five chronic diseases: asthma, coronary artery disease, depression diabetes, and hypertension, then asked to complete the survey between June 2007 and June 2008. A total of 7,337 respondents were included in the study.
Illness complexity was defined as the number of chronic conditions each respondent had (1, 2, or 3+). Respondents who did not have at least one of diabetes, heart disease, or hypertension were excluded. Satisfaction was based on a 10-point scale taken from the RAND Corporation’s Improving Chronic Illness Care Evaluation (ICICE) project, which was condensed into 4 points (10, 9, 8, and 7–). The authors conducted structural equation analyses for each level of illness complexity using LISREL by SSI, Inc.
Key Findings
- Patients with higher levels of illness complexity report higher satisfaction with care. Patients with only one chronic illness were, on average, less satisfied with their care than patients with two or more chronic illnesses. This finding contrasts with earlier research suggesting that higher illness complexity is associated with lower patient satisfaction.
- The relationship between provider performance and patient satisfaction was also different for patients with varying levels of illness complexity. Positive interactions with providers and provider support for self-management of illness were associated with higher patient satisfaction for those with one or two chronic illnesses, but not for those with three or more chronic illnesses.
- Patients’ understanding of their own conditions and treatment leads to higher care satisfaction for those with one chronic illness, but for those with two or more chronic illnesses, higher understanding is associated with lower satisfaction. Carlin and colleagues suggest that patients with higher levels of illness complexity may become distressed at understanding more about their own conditions, leading to lower satisfaction.
- Overall, positive experiences with provider interaction lead to higher patient satisfaction levels across all levels of illness complexity. Provider support for self-management of illness contributes to both positive provider interaction and better patient understanding of their own conditions and illnesses.
- Women report higher levels of patient satisfaction, but this effect is smaller for women with three or more chronic conditions. Both obese and non-Hispanic black patients report lower care satisfaction at lower levels of illness complexity (1 or 2 chronic conditions), but those with three or more chronic conditions report slightly higher satisfaction.
- Patients with higher levels of education report lower levels of care satisfaction across all levels of illness complexity.
Policy Implications
This study shows that illness complexity can affect how provider performance and demographic characteristics contribute to patient satisfaction with care. Using their results, Carlin and colleagues identify ways that care providers can improve patient satisfaction while being sensitive to illness complexity.
First, policy can be used to support positive interactions between providers and patients. One approach is to adopt payment systems that provide incentive for quality of care—which includes patient satisfaction ratings—rather than for the number of patients seen by each provider.
Another recommendation is for providers to consider illness complexity when interacting with patients, so as to design an appropriate program of care based on patient characteristics. With patients who have lower levels of illness complexity, providers should emphasize patient self-management and understanding, while more sensitivity should be used when educating patients at higher levels of illness complexity about their conditions and treatments.
One way to support this on a policy level is to incorporate illness complexity into existing medical education on bedside manner and patient-provider interactions. Adding research knowledge into medical school curricula can give providers the information they need to interact successfully with patients at all levels of illness complexity.
Finally, this study has implications for payment structures based on provider quality. With patient satisfaction becoming an increasing measure of quality care, policymakers should invest more into research that explores the sources of patient satisfaction and the best ways to maximize it. More accurate measures of patient satisfaction can help prevent providers from refusing patients with higher levels of illness complexity in order to preserve their satisfaction scores.
This study highlights the role of one patient characteristic—illness complexity—that can moderate the association between provider performance and patient satisfaction. Knowing more about the factors that contribute to patient satisfaction can help policymakers design health care delivery and payment systems that incentivize quality care from the perspective of both provider and patient.
For full text of the research article: Chronic Illness and Patient Satisfaction, Health Services Research, Volume 47, Issue 6, pages 2250-2272, December 2012.
