Outpatient satisfaction: the role of nominal versus perceived communication.

Increasingly, patient satisfaction with health care is being used as an indicator of quality of care provided by health plans and providers as recommended by the Institute of Medicine's emphasis on patient-centered care (Institute of Medicine 2001). Children's health care needs differ from those of adults; it is therefore, necessary to examine satisfaction with pediatric care separately from satisfaction with adult care. The most extensive set of information about health plan and provider performance has been developed by the Consumer Assessment of Health Care Providers and Systems (CAHPS) project, sponsored by the Agency for Health Care Research and Quality and the Center for Medicare & Medicaid Services. This core CAHPS survey instrument asks adults to rate their own health care and plans; a supplementary instrument asks parents or caregivers to rate the care their children receive. In general, ratings of children's care tend to be higher than the ratings of adult care (Zhan et al. 2002). Communication is widely recognized as a key component of patient satisfaction (Roter et al. 1997; Brown et al. 1999; Homer et al. 1999;), including in the pediatric outpatient setting (Korsch, Gozzi, and Francis 1968; Freemon, Negrette, and Davis 1971; Wasserman et al. 1984; Young et al. 1985; Howell-Koren and Tinsley 1990; Street 1991, 1992a, b; Wissow et al. 1998; Mangione-Smith et al. 1999, 2001; Jessee, Nagy, and Downs 2001; Minde, Tidmarsh, and Hughes 2001; Hasnat and Graves 2003; Robinson and Heritage 2006). Racial and ethnic minority parents report less effective provider communication and staff helpfulness in care provided to children (Weech-Maldonado et al. 2001). Hispanic and Asian parents (especially those not preferring English) reported less effective provider communication and less staff helpfulness than White parents. Language barriers appear to account for much of this pattern (Morales et al. 1999; Weech-Maldonado et al. 2001;). A number of previous studies have associated increased patient/parent satisfaction with the presence of discrete communication events as recorded by third-party observers (Korsch, Gozzi, and Francis 1968; Freemon, Negrette, and Davis 1971; Wasserman et al. 1984; Young et al. 1985; Howell-Koren and Tinsley 1990; Street 1992a,b; Wissow et al. 1998; Mangione-Smith et al. 2001; Minde, Tidmarsh, and Hughes 2001;). This approach might lead to clinical and policy recommendations to treat these communication acts as constituting a checklist (Jenkins and Fallowfield 2002) that needs only be fulfilled in a nominal and perfunctory manner given the pressure of the tightly timed outpatient setting. Other researchers have also found that communication as reported in parent surveys is also associated with parent satisfaction and several studies find that both third-party observations and parent reports are associated with parent satisfaction when considered separately. Street (1991, 1992a) previously reported that third-party quantitative observations of some classes of communication correlated positively with parent satisfaction with care, though not as strongly as did parents' global perceptions of physician communication. Our study extends prior work by using coded and parent reports about the same four specific communication events, rather than using broader-based communication measures that are not explicitly intended to measure the same communication events. Moreover, we test whether associations of coded events with satisfaction are explained by parent perceptions by examining the simultaneous associations of parent-perceived and third-party-coded communication with parent satisfaction. We consider the possibility that only those specific communication acts performed sufficiently well for patients/parents to recognize and recall them affect patient satisfaction and that previous studies reflect the indirect effect of patient-perceived communication via the proxy of third-party-coded communication. On the other hand, it is possible that acts of communication not perceived or recalled by patients nonetheless register with these patients in a way that affects their overall impression of the encounter. We test our hypothesis against this alternative using a unique dataset of standardized pediatric outpatient encounters for symptoms of upper respiratory infection in which both third-party coders viewing videotapes and parents (in a post-visit survey) were asked whether each of a series of four communication events took place during the encounter.