Science has officially discredited a widely-shared myth about patients: receiving analgesics is not associated with overall emergency department patient satisfaction scores.
Emergency physicians have long thought that patients denied narcotics were likely to rate them poorly on patient satisfaction surveys, and sometimes wondered if fighting with patients about that was worth the blemish on a score that is increasingly used to determine their worth as providers. But a new study found that other factors were responsible.
The mean overall patient satisfaction scores for patients receiving analgesics or opioid analgesics were actually lower than for those who didn't receive them, but the study pointed to long waits and patient flow as the more likely culprits for the low scores. (Ann Emerg Med 2014;64:469.)
The link between analgesics and patient satisfaction has a long and storied history. The Press Ganey survey has many questions that try to assess the environment and interaction with the health care provider staff, said Kavita Babu, MD, an author of the study who is the fellowship director of medical toxicology and an associate professor of emergency medicine at UMass Memorial Medical Center. But few specifically ask about treatment or disease processes with the exception of pain control. “There's a specific question ... that addresses how well your pain is controlled today, and I think that led physicians to intuit a link between pain killer provisions and Press Ganey score,” she said.
It goes without saying that opioid prescribing has been a hot topic in emergency medicine circles for years, and the Annals study was an off-shoot of one such conversation about obstacles to responsible opioid prescribing that the authors had at the American College of Medical Toxicology Prescription Opioid Academy.
“If there was no link, as we found, it reinforces to physicians that they have to continue to use evidence-based practice or guideline-based practice as opposed to feeling like their opioid prescribing is going to influence their overall patient satisfaction scores,” Dr. Babu said.
Emergency physicians are, of course, acutely aware that prescribed opioids form the supply chain for 70 percent of opioid abusers, something physicians from the University of Wisconsin-Madison labeled “an epidemic of prescription drug misuse and diversion resulting in increased rates of addiction, health care utilization, and overdose deaths.” (JAMA 2012;307:1377.) Fulfilling a patient's request for opioids may save the emergency physician time, but often leaves him in moral distress, said that JAMA editorial by Aleksandra Zgierska, MD, PhD, Michael Miller, MD, and David Rabago, MD. “[M]any physicians may behave in a way even they think is questionable: write the requested opioid prescription, and move on.”
Patient satisfaction is far more complex than just writing a simple prescription. “Clinicians are experiencing increased pressure to produce positive results from their clinical activities,” with a portion of their compensation hinging on patient satisfaction targets. “Of even greater importance, a physician's job retention or ability to be promoted may be directly linked to satisfaction-related results,” Dr. Zgierska and her colleagues wrote in the JAMA editorial.
It's a tough mindset to escape, especially when physicians feel pressured by patients, said James Adams, MD. “When a patient is standing in the middle of the emergency department screaming at me because I'm not giving them narcotics, that not only colors that one encounter but all the encounters to follow. So we find that these experiences with the manipulative or hostile patients are very disconcerting and often even frightening, so doctors get bullied into prescribing. We can't just pretend that doesn't exist,” said Dr. Adams, the chair of emergency medicine and the health systems chief medical officer at Northwestern University.
Countless components seem to explain why this association between patient satisfaction and prescribing narcotics exists, but one thing is commonly acknowledged: Physicians are pressured into striving for high patient satisfaction scores. Worried about making their bonuses coupled with administration breathing down their necks, they look for shortcuts. They see giving patients what they want — often opioids — as a way to bypass improving other factors, like wait time and flow, Dr. Babu said.
High scores can be achieved by addressing issues like communication between staff and patients, the Annals study found. “[W]e have to focus on the things that matter,” Dr. Babu said. “We have to try to minimize wait times wherever possible; we have to be the best communicators we can be with patients and their families. And ... we have to discard the sort of urban legend that talks about the link between patient satisfaction and opioid prescribing because it's dangerous, and I think it encourages irresponsible prescribing on the part of emergency providers.”
Of course, it is certainly easier just to write a prescription and have the patient be on his way because it would help with long waits, which is a huge factor in determining patient satisfaction. But Gregory Moran, MD, an author of a study on prescribing antibiotics to patients with upper respiratory infections, found that those drugs weren't associated with patient satisfaction. (Ann Emerg Med 2007;50:213.) It turns out that what was pivotal was just a simple explanation of the illness.
“If physicians can just explain why antibiotics aren't indicated and give patients other recommendations for their symptoms, then they're happy,” said Dr. Moran, the acting chief of the emergency department at Olive View UCLA Medical Center.
More than that, if physicians take the time, even a brief amount of time, he said, to explain what is going on, it will reassure the patient and make the EP look caring and professional. “And the science proves it goes a much longer way than giving them a prescription just because you think they expect it,” he said.
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