Introduction.

The use of self-reported patient evaluations as a quality measure signifies a paradigm shift in American medicine. The Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Hospital Survey, developed by the Centers for Medicare and Medicaid Services (CMS) and the Agency for Healthcare Research and Quality, represents the first standardized, nationwide measurement system for tracking patients’ perception of their care [1]. CMS reports CAHPS® Hospital Survey results publicly, and starting October 2012, Medicare will distribute value-based incentive payments for acute care services based partly on how patients rate their care experience [2].

In addition, the American Board of Internal Medicine requires recertifying physicians to complete at least one Practice Improvement Module®, one of which entails soliciting 25 patient evaluation surveys.

The focus on patient satisfaction stems from longstanding interest in the business sector, where most large firms regularly monitor the satisfaction of their customers. The emphasis on improving customer experience is based on evidence that higher levels of customer satisfaction lead to higher customer loyalty, greater repeat purchasing and more favorable referrals, all of which result in improved market share, greater revenues and higher profitability [3]. Customer satisfaction serves as a key metric for judging firm performance and informs management on how to improve customer experiences with their firm’s offerings and sales channels.

In the context of health care, patient satisfaction is an individual’s evaluation of his or her experiences in receiving health care in a specific delivery setting (e.g. hospital, primary care clinic, outpatient surgery, etc) [4]. Limited cross-sectional studies show a positive relationship between patient satisfaction and adherence to medications [5]–[9]. Likewise, adherence to medications clearly impacts clinical outcomes [10], [11]. Satisfaction also has been associated with patient switching behavior in regards to provider and insurance plans [12], [13]. Furthermore, studies using national CAHPS® Hospital Survey data show a significant albeit modest correlation between patient satisfaction and objective clinical performance measures [14], [15].

Leaders seeking to improve satisfaction typically apply the attribute model of satisfaction [16], [17]. Attribute models have been used to study satisfaction across a wide spectrum of human experience, including customer, job and life satisfaction [18], [19]. In the context of health care, this model incorporates the following concepts: 1) overall patient satisfaction describes a distinct and separate global evaluation of a set of component experiences; 2) given a set of experiences, patients weigh each experience differently in rating their overall satisfaction; 3) the stronger the association between a component experience and overall satisfaction, the greater the presumed impact of that component experience. The attribute model of satisfaction provides insight into the relative importance of different component experiences to patients and the trade-offs patients may make in exchange for excellence in other areas. Furthermore, component experiences attributed the most importance represent critical points of intervention for improving the care experience and ultimately increasing overall satisfaction.

Relatively fewer patient satisfaction studies take place in the outpatient primary care setting and in the context of chronic diseases. While the CAHPS® database of national hospital survey data provides a glimpse of patients’ hospital care experience, CMS does not require the public reporting of outpatient clinic survey data. HIV affects over 1.1 million people in the United States and represents a chronic disease well-suited for studying the drivers of overall patient satisfaction [20]. Management of HIV infection occurs mostly in the outpatient setting and requires frequent visits with a primary care provider. In this study, we seek to understand the drivers of overall patient satisfaction in a predominantly low-income, ethnic-minority population of HIV primary care patients, a group not well-represented in patient satisfaction studies. Specifically, we applied the attribute model of satisfaction to determine 1) the component experiences that contribute to patients’ evaluation of their overall satisfaction with care received, and 2) the relative contribution of each component experience in explaining patients’ evaluation of overall satisfaction.

Abstract.
Objective.

This study seeks to understand the drivers of overall patient satisfaction in a predominantly low-income, ethnic-minority population of HIV primary care patients. The study’s primary aims were to determine 1) the component experiences which contribute to patients’ evaluations of their overall satisfaction with care received, and 2) the relative contribution of each component experience in explaining patients’ evaluation of overall satisfaction.

Methods.

We conducted a cross-sectional study of 489 adult patients receiving HIV primary care at two clinics in Houston, Texas, from January 13–April 21, 2011. The participation rate among eligible patients was 94%. The survey included 15 questions about various components of the care experience, 4 questions about the provider experience and 3 questions about overall care. To ensure that the survey was appropriately tailored to our clinic population and the list of component experiences reflected all aspects of the care experience salient to patients, we conducted in-depth interviews with key providers and clinic staff and pre-tested the survey instrument with patients.

Results.

Patients’ evaluation of their provider correlated the strongest with their overall satisfaction (standardized β = 0.445, p<0.001) and accounted for almost half of the explained variance. Access and availability, like clinic hours and ease of calling the clinic, also correlated with overall satisfaction, but less strongly. Wait time and parking, despite receiving low patient ratings, did not correlate with overall satisfaction.

Conclusions.

The patient-provider relationship far exceeds other component experiences of care in its association with overall satisfaction. Our study suggests that interventions to improve overall patient satisfaction should focus on improving patients’ evaluation of their provider.