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The American Journal of Managed Care October 2017
Low-Value Antibiotic Prescribing and Clinical Factors Influencing Patient Satisfaction
Adam L. Sharp, MD, MS; Ernest Shen, PhD; Michael H. Kanter, MD; Laura J. Berman, MPH; and Michael K. Gould, MD, MS
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Alison Cuellar, PhD; Amelia M. Haviland, PhD; Seth Richards-Shubik, PhD; Anthony T. LoSasso, PhD; Alicia Atwood, MPH; Hilary Wolfendale, MA; Mona Shah, MS; and Kevin G. Volpp, MD, PhD
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Anne P. Ehlers, MD, MPH; Sara Khor, MS; Amy M. Cizik, PhD, MPH; Jean-Christophe A. Leveque, MD; Neal S. Shonnard, MD; Rod J. Oskouian, Jr, MD; David R. Flum, MD, MPH; and Danielle C. Lavallee, PharmD, PhD
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Jeffrey D. Clough, MD, MBA; Michaela A. Dinan, PhD; and Kevin A. Schulman, MD
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Is Higher Patient Satisfaction Associated With Better Stroke Outcomes?
Xiao Xiang, PhD; Wendy Yi Xu, PhD, MS; and Randi E. Foraker, PhD, MA

Is Higher Patient Satisfaction Associated With Better Stroke Outcomes?

Xiao Xiang, PhD; Wendy Yi Xu, PhD, MS; and Randi E. Foraker, PhD, MA
Global patient satisfaction was positively associated with quality of stroke care and higher discharge information satisfaction may be linked to worse outcomes. Additionally, improvements in satisfactions were linked to higher costs.
Limitations and Strengths

There are several limitations to our study. First, as it is based on CMS data, our results may not be appropriate to generalize to all hospitals because the participating hospitals may be systematically different, in terms of hospital characteristics, compared with non-participating hospitals. Another limitation is the ecological design of our study. Our results can only explain the association at the hospital level, not at the patient level. Although we have adjusted for hospital size, teaching status, location, region, and disproportionate share, unobserved factors may still confound our results. For example, hospitals that discharge more patients to their home, rather than a skilled nursing facility, may have higher patient satisfaction and lower readmission rates. Nevertheless, lacking stroke severity information may not be a major confounder because the health outcome measures were risk adjusted in terms of case mix, hospital clustering effect, and comorbidities of patients.14 The risk adjustment may also explain the lack of variability of mortality and readmission rate among hospitals in our sample. Furthermore, our study cannot determine the direction of causality. HCAHPS surveys were conducted from 48 hours to 6 weeks after discharge. It could be possible that some patients reported low satisfaction because they experienced unfavorable health outcomes during the time after discharge. Finally, without an indicator of stroke severity, we can only provide the evidence of association, instead of causality, between patient satisfaction and stroke care cost.

Despite the limitations, our study also has some strengths. To extend our ability to extrapolate our conclusions to a broader definition of stroke cases, we conducted a sensitivity analysis. In those analyses, global patient satisfaction remained associated with an increased cost of care. In addition, we used both CCR and hospital charge to estimate cost. Specifically, we estimated cost by multiplying the charges for DRG 066 by hospital-specific cost-to-charge ratios. Although we do not have information of the real costs that were incurred, previous researchers have verified that using the CCR produces estimates closest to providers’ actual costs.20-22 There are many other ways to estimate cost, such as using the CMS payments or hospital charges; however, these methods are also subject to limitations. The CMS payments were the reimbursements to the hospitals after adjusting the costs by regional, hospital, and individual characteristics according to published policies.11 With hospital-level aggregated data, we were not able to disentangle policy adjustment and the real cost from the payments. The charges were the list prices marked by the hospitals, which were usually much higher than the real cost.23 Thus, standardizing charges by CCR was the best approximation of cost in this context.


Our study provided important knowledge on the relationship between patient satisfaction and healthcare quality in stroke care. Higher global patient satisfaction scores were associated with improved readmission and mortality rates while discharge information satisfaction domains produced mixed evidence. Our analysis also suggests that improving patient satisfaction will lead to higher stroke care costs and the associated improvements observed in stroke outcomes may not be cost-effective.

Author Affiliations: Department of Epidemiology and Biostatistics, School of Public Health, Peking University Science Center (XX), Beijing, China; Division of Epidemiology (XX, REF), and Division of Health Services Management and Policy (WYX), College of Public Health, The Ohio State University, Columbus, OH.

Source of Funding: None.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article. 

Authorship Information: Concept and design (XX, WYX); acquisition of data (XX); analysis and interpretation of data (XX, WYX); drafting of the manuscript (XX, WYX); critical revision of the manuscript for important intellectual content (XX, WYX, REF); statistical analysis (XX); administrative, technical, or logistic support (REF); and supervision (WYX, REF). 

Address Correspondence to: Xiao Xiang, PhD, Peking University Health Science Center, 38 Xueyuan Rd, Beijing 100191, China. E-mail: 

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20. Shwartz M, Young DW, Siegrist R. The ratio of costs to charges: how good a basis for estimating costs? Inquiry. 1995;32(4):476-481.

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