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tors: predictors of voluntary disenrollment from a primary physician’s practice. J Fam Pract. 2001;50(2):130-136. Rao JK, Weinberger M, Kroenke K. Visit-specific expectations and patientcentered outcomes: a literature review. Arch Fam Med. 2000;9(10):1148-1155. Sequist TD, Schneider EC, Anastario M, et al. Quality monitoring of physicians: linking patients’ experiences of care to clinical quality and outcomes. J Gen Intern Med. 2008;23(11):1784-1790. Chang JT, Hays RD, Shekelle PG, et al. Patients’ global ratings of their health care are not associated with the technical quality of their care. Ann Intern Med. 2006;144(9):665-672. Kravitz RL, Epstein RM, Feldman MD, et al. Influence of patients’ requests for direct-to-consumer advertised antidepressants: a randomized controlled trial. JAMA. 2005;293(16):1995-2002. Macfarlane J, Holmes W, Macfarlane R, Britten N. Influence of patients’ expectations on antibiotic management of acute lower respiratory tract illness in general practice: questionnaire study. BMJ. 1997;315(7117):1211-1214. Pham HH, Landon BE, Reschovsky JD, Wu B, Schrag D. Rapidity and modality of imaging for acute low back pain in elderly patients. Arch Intern Med. 2009; 169(10):972-981. Fisher ES, Welch HG. Avoiding the unintended consequences of growth in medical care: how might more be worse? JAMA. 1999;281(5):446-453. Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending, part 2: health outcomes and satisfaction with care. Ann Intern Med. 2003;138(4):288-298. Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending, part 1: the content, quality, and accessibility of care. Ann Intern Med. 2003;138(4):273-287. Landrum MB, Meara ER, Chandra A, Guadagnoli E, Keating NL. Is spending more always wasteful? the appropriateness of care and outcomes among colorectal cancer patients. Health Aff (Millwood). 2008;27(1):159-168. Sirovich B, Gallagher PM, Wennberg DE, Fisher ES. Discretionary decision making by primary care physicians and the cost of U.S. health care. Health Aff (Millwood). 2008;27(3):813-823. Deyo RA, Mirza SK, Martin BI, Kreuter W, Goodman DC, Jarvik JG. Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA. 2010;303(13):1259-1265. Wiener RS, Schwartz LM, Woloshin S. Time trends in pulmonary embolism in the United States: evidence of overdiagnosis. Arch Intern Med. 2011;171(9): 831-837. Gerstein HC, Miller ME, Genuth S, et al; ACCORD Study Group. Long-term effects of intensive glucose lowering on cardiovascular outcomes. N Engl J Med. 2011;364(9):818-828. Jarvik JG, Hollingworth W, Martin B, et al. Rapid magnetic resonance imaging vs radiographs for patients with low back pain: a randomized controlled trial. JAMA. 2003;289(21):2810-2818. Cohen JW, Cohen SB, Banthin JS. The Medical Expenditure Panel Survey: a national information resource to support healthcare cost research and inform policy and practice. Med Care. 2009;47(7)(suppl 1):S44-S50. Centers for Disease Control and Prevention. NHIS linked mortality public-use files. http://www.cdc.gov/nchs/data_access/data_linkage/mortality/nhis_linkage_public _use.htm. Accessed May 16, 2011.
23. Agency for Healthcare Research and Quality. CAHPS: surveys and tools to advance patient-centered care. 2011. https://www.cahps.ahrq.gov/default.asp. Accessed March 10, 2011. 24. Hargraves JL, Hays RD, Cleary PD. Psychometric properties of the Consumer Assessment of Health Plans Study (CAHPS) 2.0 adult core survey. Health Serv Res. 2003;38(6, pt 1):1509-1527. 25. Ware J Jr, Kosinski M, Keller SD. A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care. 1996; 34(3):220-233. 26. Ware JE Jr, Kosinski M, Bayliss MS, McHorney CA, Rogers WH, Raczek A. Comparison of methods for the scoring and statistical analysis of SF-36 health profile and summary measures: summary of results from the Medical Outcomes Study. Med Care. 1995;33(4)(suppl):AS264-AS279. 27. Kadam UT, Schellevis FG, Lewis M, et al. Does age modify the relationship between morbidity severity and physical health in English and Dutch family practice populations? Qual Life Res. 2009;18(2):209-220. 28. DeSalvo KB, Fan VS, McDonell MB, Fihn SD. Predicting mortality and healthcare utilization with a single question. Health Serv Res. 2005;40(4):12341246. 29. Fleishman JA, Cohen JW, Manning WG, Kosinski M. Using the SF-12 health status measure to improve predictions of medical expenditures. Med Care. 2006; 44(5)(suppl):I54-I63. 30. Kravitz RL, Cope DW, Bhrany V, Leake B. Internal medicine patients’ expectations for care during office visits. J Gen Intern Med. 1994;9(2):75-81. 31. Kravitz RL, Bell RA, Azari R, Krupat E, Kelly-Reif S, Thom D. Request fulfillment in office practice: antecedents and relationship to outcomes. Med Care. 2002; 40(1):38-51. 32. Marple RL, Kroenke K, Lucey CR, Wilder J, Lucas CA. Concerns and expectations in patients presenting with physical complaints: frequency, physician perceptions and actions, and 2-week outcome. Arch Intern Med. 1997;157(13):14821488. 33. Bertakis KD, Azari R. Patient-centered care is associated with decreased health care utilization. J Am Board Fam Med. 2011;24(3):229-239. 34. Epstein RM, Franks P, Shields CG, et al. Patient-centered communication and diagnostic testing. Ann Fam Med. 2005;3(5):415-421. 35. Stewart M, Brown JB, Donner A, et al. The impact of patient-centered care on outcomes. J Fam Pract. 2000;49(9):796-804. 36. Peck BM, Ubel PA, Roter DL, et al. Do unmet expectations for specific tests, referrals, and new medications reduce patients’ satisfaction? J Gen Intern Med. 2004;19(11):1080-1087. 37. Deyo RA, Diehl AK, Rosenthal M. Reducing roentgenography use: can patient expectations be altered? Arch Intern Med. 1987;147(1):141-145. 38. Davis K, Schoenbaum SC, Audet AM. A 2020 vision of patient-centered primary care. J Gen Intern Med. 2005;20(10):953-957. 39. Flocke SA, Miller WL, Crabtree BF. Relationships between physician practice style, patient satisfaction, and attributes of primary care. J Fam Pract. 2002;51(10): 835-840. 40. Audet AM, Davis K, Schoenbaum SC. Adoption of patient-centered care practices by physicians: results from a national survey. Arch Intern Med. 2006; 166(7):754-759.
INVITED COMMENTARY
ONLINE FIRST
How to Feed and Grow Your Health Care System
N
ot long before the editorial deadline for this Invited Commentary, I headed off on vacation to warmer climes (this is not difficult when leaving from northern New England). But would a week in tropical paradise be worth the frustration and indignity of commercial air travel? It turns out I was lucky. The lead flight attendant ran a
Scan for Author Audio Interview
tight ship, assuring us an orderly, safe, and comfortable trip. Maybe I should plan more discretionary travel. According to the findings of a study published in this issue of the Archives, had my recent shoulder surgery gone more smoothly, I might instead be planning more discretionary health care.
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Fenton and colleagues1 followed more than 50 000 adult participants in the National Center for Health Statistics’ Medical Expenditure Panel Survey over a 2-year period (longer for mortality). Judging from patients’ reported satisfaction with their physicians after year one, the authors found that, compared with patients in the lowest quartile of satisfaction, patients in the highest quartile were subsequently less likely to be seen in an emergency department, but more likely to be hospitalized, were responsible for more prescription drug and total health care expenditures, and were more likely to die. These relationships held after controlling for numerous potential confounders, including year one health care utilization, health status, income, and health insurance. The authors infer that efforts to cater to patient satisfaction may be ill guided; by implicitly encouraging health care providers to honor requests for (or to explicitly offer) discretionary health care services, such efforts may lead to overutilization, higher costs, and worse outcomes. There is, however, reason to question the validity of the inference. One of the primary findings itself raises concern—a 26% mortality excess among the most satisfied patients, an effect size that far exceeds that for all other, more immediate, study outcomes (eg, a 12% excess in hospitalizations). While the authors have attempted to separate patient satisfaction from correlates (eg, older age, more comorbidities) that might instead be responsible for higher utilization and worse outcomes, the likelihood of an unmeasured confounder remains high. One nomination is that a patient’s strong sense of connection to the health care system, related perhaps to (unmeasured) vulnerability or frailty, might predict more satisfaction, hospitalization, and death. And yet the inference is entirely believable—and cause for concern. The direct relationship between customer satisfaction and subsequent consumption is doctrine in commerce and business.2 “The customer is always right,” a phrase likely coined by Marshall Field, the department store magnate, in the late 19th century,3 is a credo that we, as consumers, may wish we encountered more often. Is health care any different? Apparently not. But it should be. While most Americans may accurately assess how well their washing machines, their hairdressers, or even their airlines are performing, their evaluations of physicians and health care interventions may have limited validity. A dozen years ago, the New Yorker published a wonderful personal reflection by Joseph Epstein.4 Subtitled “A Healthy Man’s Nightmare,” it recounts the author’s journey from a healthy, health conscious, and physically active 62-year-old literature professor to a survivor of coronary artery bypass surgery (“a brutal piece of work”), weakened, with a lasting sense of vulnerability that he eloquently labels “heart-consciousness.”4 He wonders, one year afterwards, whether he will ever return to his previous sense of well-being. Epstein’s journey started with a “routine” physical—his gift to his wife on the occasion of his 60th birthday—that revealed a low highdensity lipoprotein cholesterol level, which in turn led directly to a stress test. Even more remarkable than the
journey is the author’s conclusion: he considers himself lucky, attributing his good fortune to his physicians, paragons of excellence. Regardless of whether one believes Mr Epstein to have been ultimately helped or harmed by his screening stress test, his satisfaction with the experience should perhaps not be as surprising as I initially found it. Satisfaction with seemingly adverse outcomes of potentially excessive medical care appears to be the norm. Numerous studies have found that patients are consistently highly satisfied with one of the most common downsides of medical care— false-positive test results and the downstream events that follow.5,6 Moreover, such patients are more likely to undergo the same (and likely other) testing in the future, dismissing their anxiety and other adverse effects as a negligible price for a good outcome. The same heuristic operates on the physician. Ransohoff et al7 proposed, a decade ago, that prostatespecific antigen (PSA) screening for prostate cancer exemplifies a system without negative feedback. Regardless of the true net effect (beneficial or harmful) of screening, a physician ordering a screening PSA receives a favorable result: he can reassure the patient with a normal PSA result; celebrate with the patient who has overcome a false positive; or (most compelling for the physician) offer potentially life-saving treatment to the patient whose prostate cancer was “caught early”— notwithstanding the likelihood that the patient’s outcome may be worse because of early detection. Regardless, the physician can feel satisfied, and more certain that ordering the next screening PSA will be the right decision, which will then appear to be the case, and so on. Positive feedback systems abound in health care, for both physicians and patients. Diagnostically, almost any unnecessary, or discretionary, test (particularly imaging) has a good chance of detecting an abnormality. Acting on that abnormality has an excellent chance of producing a favorable outcome (because a good outcome was already highly likely). Having obtained an excellent outcome, ostensibly owing to a test that was seemingly unnecessary, a natural reaction would be thereafter to perform (or, for patients, undergo) even more discretionary testing in patients with an increasingly negligible likelihood of benefit—and greater risk of net harm. Consider thyroid cancer: incidence of papillary carcinoma (by far the most common type) has tripled over a 30-year period, with an abundance of very small cancers that appear nonlethal.8 The excess cases almost certainly represent pseudodisease (destined never to cause symptoms during a patient’s lifetime)—patients who cannot possibly benefit from having had their cancer detected, but can be, and likely are, harmed. However, in the eyes of the patient, her loved ones (and casual acquaintances), and her physicians, she was snatched from the jaws of a premature death by a vigilant physician who thought he felt something on examination or who inexplicably ordered a thyroid ultrasound examination. The lesson learned, for all, will surely be to be increasingly vigilant in the future. Ransohoff et al7(p665) explains, “The point is that . . . decisions for aggressive intervention—screening or treat-
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ment—may be positively reinforced when patients and physicians view the decisions from the perspective of an individual person.” Even if patients and physicians were to see through this illusion, overcoming the “more is always better” fallacy of health care remains an enormous challenge. In a recent survey published in the Archives,9 we found that nearly half of US primary care physicians believed that their own patients were receiving too much medical care, and they identified potent systemic incentives encouraging aggressive practice. Practicing physicians have learned—from reimbursement systems, the medical liability environment, and clinical performance scorekeepers—that they will be rewarded for excess and penalized if they risk not doing enough. More aggressive practice, therefore, improves not only patients’ perceived outcomes, but also those of physicians (reimbursement, performance ratings, protection against lawsuits), and the positive feedback loop of health care utilization is fueled at two ends. As any engineer will tell you (and as my father, an applied mathematician, wanted to make sure I understood as he read this over my shoulder during our tropical vacation), a positive feedback system is not in fact positive (ie, favorable)—it represents an unstable system, one that cannot control its own growth, or demise. We, as a profession and as a society, can take responsibility for controlling this unrestrained system only if we commit to overcoming the widespread misconception that more care is necessarily better care, and to realigning the incentives that help nurture this belief. Brenda E. Sirovich, MD, MS Published Online: February 13, 2012. doi:10.1001 /archinternmed.2012.62
Author Affiliations: Department of Veterans Affairs Medical Center, VA Outcomes Group, White River Junction, Vermont, and The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire. Correspondence: Dr Sirovich, Department of Veterans Affairs Medical Center, VA Outcomes Group (111B), 215 N Main St, White River Junction, VT 05009 (brenda
[email protected]). Financial Disclosure: None reported. Disclaimer: The views expressed herein do not necessarily represent the views of the Department of Veterans Affairs or the US government. Online-Only Material: Visit http://www.archinternmed .com to listen to an author interview about this article. Additional Information: Nathaniel Hochman, BA, MSc, provided valuable comments on an earlier draft of this Invited Commentary. 1. Fenton JJ, Jerant AF, Bertakis KD, Franks P. The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality [published online February 13, 2012]. Arch Intern Med. 2012;172 (5):405-411. 2. Seiders K, Voss GB, Grewal D, Godfrey AL. Do satisfied customers buy more? examining moderating influences in a retailing context. J Mark. 2005;69(4): 26-43. 3. The Phrase Finder. The customer is always right. http://www.phrases.org.uk /meanings/106700.html. Accessed December 24, 2011. 4. Epstein J. Taking the bypass: a healthy man’s nightmare. New Yorker. April 12, 1999;75:58-63. 5. McGovern PM, Gross CR, Krueger RA, Engelhard DA, Cordes JE, Church TR. False-positive cancer screens and health-related quality of life. Cancer Nurs. 2004;27(5):347-352. 6. Pisano ED, Earp J, Schell M, Vokaty K, Denham A. Screening behavior of women after a false-positive mammogram. Radiology. 1998;208(1):245-249. 7. Ransohoff DF, McNaughton Collins M, Fowler FJ. Why is prostate cancer screening so common when the evidence is so uncertain? a system without negative feedback. Am J Med. 2002;113(8):663-667. 8. Davies L, Welch HG. Increasing incidence of thyroid cancer in the United States, 1973-2002. JAMA. 2006;295(18):2164-2167. 9. Sirovich BE, Woloshin S, Schwartz LM. Too little? too much? primary care physicians’ views on US health care: a brief report. Arch Intern Med. 2011; 171(17):1582-1585.
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