patient satisfaction, Press-Ganey, surveys

Are we taking patient satisfaction too far?

“Patient satisfaction” has become quite the buzzword for us in the medical care field.  Of course we want our patients to be healthy, and if possible we would also like them to be happy.  However, sometimes the two are mutually exclusive, or at least mutually elusive.  Patient satisfaction is even starting to be factored into how we’re paid- starting last year, Medicare started making incentive payments to hospitals based on how they did on surveys.  Some doctors are even having part of their salary based on how they score in surveys.

On the surface, this sounds like a pretty good idea, right?  If someone is satisfied, they must have gotten good care.

Not so fast.  Press-Ganey is the largest company involved in making patient satisfaction surveys.  But even they admit that the response rate on surveys is so low that it does not produce meaningful results.  Even more disturbing is that physicians who are a minority race are more likely to receive low scores.

And the worst part of this whole thing?  Patients who are more satisfied have worse outcomes.  They have more hospitalizations, more health care expenses, and a higher death rate!    If you think about it, it’s easy to see why.  A patient wants a stress test, just to “make sure” his heart is OK.  It’s not indicated, as he has no cardiac risk factors and no chest pain.  If he doesn’t get it, he’s unsatisfied.  If he does get it, he’s happy.  But what if the stress test is positive?  Then he gets a cardiac catheterization- a procedure with definite risks.  The cath is normal.  So, now this patient has added at least $10,000 to the nation’s health care tab.  He had a risky procedure.  Luckily, there was no permanent harm done.  The patient is satisfied, and thinks, “I’m so glad we made sure everything was okay!”  But in reality, he received bad, expensive, and risky medical care.

Anyway, this is what has triggered this little rant of mine.  It’s an article on NPR written by an emergency physician, detailing a patient’s experience.  In a nutshell, the patient had a heart attack at a restaurant.  He refused an ambulance and his wife drove him to the ER.  Once there, he received exemplary, fast care.  He had an EKG within 3 minutes, an immediate diagnosis of a heart attack and was taken to the cath lab.  In 22 minutes, the clogged artery in his heart was opened with a balloon a stent was placed.  The patient recovered perfectly- so perfectly, in fact, that he was back at work and exercising again in 2 weeks.

But the story doesn’t end there.  The patient and his wife then lodged a complaint with the hospital that there was no communication and he didn’t even know that he had a heart attack until his second day in the hospital.

Well.  I have to say that I find this pretty hard to believe.  The husband signed a consent.  Unfortunately, the anesthesia given can often cause amnesia for the events preceding it.  As for the wife, I would venture to say that given the panic of the situation her recall might not be that great.

In my experience, when I was doing hospital medicine, I would always introduce myself to patients.  I’d see them, examine them, and review the plan with them. And often, a few hours later, a nurse would page me and ask when I was coming to see the patient.  I’d already seen the patient, but they  thought that I was the nurse or a therapist, even though I had introduced myself.  Or they just forgot the visit all together.  A hospital is a disorienting place to be, and that can be made worse by medications and illness.

But let’s say that in this particular case of the heart attack patient, the patient and his wife are correct.  The ER staff didn’t explain to them what was happening.  They treated the disease only.  But was their sin so bad?  Seconds count in a heart attack.  Every second wasted is more dead heart muscle.  This story makes me wonder if we’ve gotten so used to the every day miracles that modern medicine performs that we have forgotten how things used to be.  Heart disease deaths in the United States peaked in 1968.  Since then, we’ve added 6.6 years of life expectancy, and 70% of this increase is due to a decrease in heart disease.  The estimate is that 1.7 million lives are saved in the USA annually that would otherwise be lost to heart disease.  1.7 million.

I’m sorry the patient and his wife were unhappy.  But, I have to say, I also think they are terribly ungrateful, and I’m more sorry for the doctors and nurses who had to deal with the inevitable fall out from the complaint.  They busted their butts and saved that patient’s life, and for their amazing efforts they were called on the carpet.

For me, personally, if it comes down to a life-or-death situation, I want a doctor who can kick ass, not kiss ass.  Niceties and hand-holding be damned.

coding, ICD-10, insurance insanity

Well, I stand corrected.

I recently posted about the absurdity of the new ICD-10 coding system, which features various crucial codes, such as “bitten by orca” and “sucked into jet engine.”  In my usual sarcastic manner, I pointed out how silly the level of detail of the coding system is.

Well, I stand corrected after reading this article today.  It appears that Harrison Ford was injured on the set of the new Star Wars film, when the hydraulic door of the Millennium Falcon starship fell on his ankle.  Poor guy.  He was airlifted to the hospital and is expected to do ok (and I must say that Harrison Ford is looking mighty good at 71).

But now we’re left with a conundrum.  How should we code this encounter?  See, using ICD 9, I would code it as 928.21 (crush injury, ankle).  But now…there are so many choices!  How about… W23.0XXA (Caught, crushed or pinched between inanimate objects).  Oh, but wait.  That code excludes inanimate mechanical forces involving military or war operations, so that’s out.  I mean, the is Han Solo we’re talking about, and he’s fighting the forces of the Empire.  So….Y36.101 (war operations involving destruction of an aircraft, civilian)?  Maybe…

Wait!  I’ve got it!  V95.40XA (unspecified spacecraft accident injuring occupant, initial encounter)!!!

Whew.  That was close.  Thank heavens for ICD-10!