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Assessing Patient Satisfaction in Behavioral Health: The Influence of Socioeconomic Status
Patient satisfaction level and net promoter score (likelihood to recommend) ratings of psychiatric care facilities are 2 metrics that facilitate monitoring and improving the quality of service delivery. Higher patient satisfaction increases adherence to treatment and is associated with a greater decrease of symptoms at discharge (e.g., Skar-Froding et al., 2021; Katsakou et al., 2010). Moreover, patients with greater satisfaction in the first 2 days of a psychiatric stay benefit more from care (Priebe at al., 2011). Finally, higher satisfaction ratings and net promoter scores demonstrate to referral sources some level of quality, and patients who need repeat or step-down care are likely to return or help attract future patients. Therefore, a positive patient experience is crucial, as it is associated with better patient outcomes, drives referral source growth, and increases revenue.
Studies have demonstrated that patient satisfaction is influenced by a complex interaction of factors related to provider of care performance and patient characteristics (for a review, Stamboglis & Jacobs, 2020). Socioeconomic status (SES) has been identified as a predictor of patient satisfaction. SES refers to the social class of an individual, which is often based on one’s occupation, education, income, wealth, and where someone lives. Research investigating participants’ experiences with healthcare in general in the United States consistently shows individuals with lower SES are less satisfied with coverage, access, and interactions with medical staff at healthcare facilities (Caballo et al., 2021; Chen et al., 2019; Haviland et al., 2005). For satisfaction with psychiatric care specifically, satisfaction in European countries has been found to be positively correlated with being employed, but negatively correlated with having a higher education level (Bird et al., 2019). Other studies found no associations between education level nor employment status and satisfaction with psychiatric care (Bucci et al., 2017, Fortin et al., 2018; Woodward et al., 2017; Krupchanka et al., 2017).
Currently available research does not address the influence of SES specifically on psychiatric hospital patient satisfaction or likelihood to recommend (net promoter score) in the US. Knowing whether SES affects patient experience in psychiatric care is key as it can add context to satisfaction scores that allows administrators to better meet the needs of individuals from different SES backgrounds. For this analysis, we aimed to test whether patient SES has a relationship with patient satisfaction and/or likelihood to recommend the psychiatric care facility.
Analysis Methods
Participants. Data were collected from 553,671 patients who received inpatient (acute) care from 149 psychiatric facilities across the US, discharged in the years 2021-22. Patients completed the satisfaction survey at discharge. Patient completion was voluntary, with a completion rate of 62.3%.
Measures. Demographic data were obtained from patient registration data at the psychiatric facility, and included age, gender, race, length of stay at the care facility, and zip code.
SES was evaluated using a publicly available index score based on zip codes. The US Census and American Community Survey has developed an index value of area-based SES, ranging from 1 to 100, where higher scores indicate an overall higher social/economic status of the area. The following metrics are used by the American Community Survey to calculate the index score of each zip code area: median household income, median home value, occupation status, educational status, and family type status. Area-based SES index scoring is shown to perform relatively as well as self-reported SES indicators (Berkowitz et al., 2015).
The 2 satisfaction metrics of interest for this study, average satisfaction and net promoter category, were assessed with a 17-item patient satisfaction survey developed for internal use in these psychiatric facilities (Nowlin & Brown, 2021). The survey measures patient satisfaction with different components of care, with 16 items rated from 1 (‘strongly disagree’) to 5 (‘strongly agree’). These 16 items are averaged to arrive at the average satisfaction metric. The final item, referred to as the net promoter item, asks the patient how likely they are to recommend the facility to others, rated from 0 (‘not at all likely’) to 10 (‘extremely likely’). A patient’s response to the net promoter item categorizes them as either a promoter (responses of 9 or 10), passive (7 or 8), or detractor (0-6). A facility’s net promoter score is calculated as the difference between % promoters-% detractors, where a higher net promoter score can be achieved by increasing the percent of patients that are promoters (converting detractors or passives into promoters) or decreasing the percent of patients that are detractors (converting detractors into passives or promoters). Therefore, each patient’s net promoter category impacts the facility’s net promoter score.
Results
Demographic characteristics and patient satisfaction metrics are presented in table 1.
>> VIEW Table 1: Demographic characteristics and patient satisfaction metrics
Socioeconomic status and patient satisfaction. A linear hierarchical regression analysis was performed to examine if socioeconomic index score predicted average satisfaction with care, controlling for the effect of patients’ age and race to address potential confounding (Woodward, Berry & Bucci, 2017). The socioeconomic index score had a statistically significant but very small relationship with average satisfaction, where a higher socioeconomic index score was associated with lower Average Satisfaction scores. A multinominal logistic regression was used to create a model of the relationship between socioeconomic index score and membership in the categories of detractor, passive, or promoter. Similarly, a higher socioeconomic index score was associated with a very slightly higher likelihood to be a detractor, or a passive than a promoter.
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Although our data suggests higher SES is associated with lower satisfaction in psychiatric facilities, this association was very small. Similarly, individuals with higher SES are slightly less likely to recommend the facility to others (i.e., to be a promoter compared to a detractor or passive). These findings are in line with the Bird et al (2019) study that found having a higher education level was weakly associated with less satisfaction with psychiatric care. Perhaps, individuals with higher SES are slightly more demanding of the care facility or more vocal about their dissatisfaction, however the difference is notably small and, in practical terms, not likely driving a facility’s average satisfaction or net promoter scores.
In contrast, previous studies reported individuals with lower SES are less satisfied with healthcare in general in the US (Caballo et al., 2021; Chen et al., 2019; Haviland et al., 2005). Patients with lower SES may have less access to or coverage for care and medical procedures, and may fail to develop a meaningful relationship with their provider as they may not have a regular and reliable source of care (Caballo et al., 2021). Compared to other sectors of healthcare, psychiatric care requires a personal connection with patients, and therapy may be more uniform especially during inpatient care, hence resulting in small associations between SES and patient satisfaction. Previous studies have also assessed satisfaction with healthcare retrospectively, and patients may have reported their satisfaction in terms of both scope of access and the quality of received care (Chen et al., 2019; Haviland et al., 2005) while the current study assessed only the quality of the episode of care at the time of discharge.
The findings of this study should be interpreted alongside several limitations:
- Although area-based socioeconomic compositive scores are found to be a good proxy of individual socioeconomic status (Berkowitz et al., 2015), it is still likely that having more detailed data on socioeconomic indicators would yield refined results.
- The study did not assess satisfaction with psychiatric care in general (e.g., waiting time prior to admission, cost, or coverage), but only the patient experience with the individual episode of care.
- We did not analyze the qualitative feedback provided by patients, which could be included in future research.
This study identifies a small negative association between socioeconomic status and 2 metrics of patient satisfaction. Though a statistically significant relationship was found, it is likely not large enough to be a key driver of patient satisfaction. Psychiatric facilities seeking to improve performance on satisfaction metrics should instead focus on other patient characteristics with more meaningful impacts as well as the quality of clinical care they are providing.
Fortesa Kadriu, PhD, and Sarah K. Brown, DrPH, are data scientists with Mental Health Outcomes.
The views expressed in Perspectives are solely those of the authors and do not necessarily reflect the views of Behavioral Healthcare Executive, Addiction Professional, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.
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