Does patient satisfaction drive volumes in outpatient MRI?

Corresponding Author Amna A. Ajam, MD, Department of Radiology, The Ohio State University College of Medicine, 395 W. 12 th Ave., Suite 486, Columbus, OH 43210, Phone: 614-293-8315, Fax: 614-293-6935, ude.cmuso@maja.anma

Abstract

Objective:

To help quantify the potential microeconomic impact of patient satisfaction in radiology, we tested the hypothesis that patient volume trends reflect patient satisfaction trends in outpatient MRI.

Methods:

Patient visits (N = 39,595) at distinct outpatient MRI sites within a university-affiliated hospital system during a one-year period were retrospectively analyzed. Individual sites were grouped as having “decreasing,” “stable,” or “increasing” volume using an average quarterly volume change threshold of 5%. Based on Press Ganey outpatient services surveys, changes in satisfaction scores from the baseline quarter were calculated. Mood’s median tests were applied to assess statistical significance of differences in satisfaction score improvements among the three volume trend designations during the 3 post-baseline fiscal quarters.

Results:

Quarterly volume was stable at 6 sites, increased at 1 site (by 18%), and decreased at 2 sites (by 20–24%). There was a statistically significant association between volume trend and net change in satisfaction scores for all 5 domains assessed on the Press Ganey survey: Overall assessment (p<0.0001), Facilities (p=0.026), Personal issues (p=0.013), Registration (p=0.0004), and Test or treatment (p<0.0001), with median score changes generally higher at facilities with higher volume trends.

Discussion:

It can be inferred that patient satisfaction drives volume in this scenario, whereas the converse relationship of volume adversely affecting satisfaction is not observed. Patient satisfaction and volume at MRI sites are interrelated, and patient experiences or perceptions of quality may influence decisions regarding what imaging sites are preferentially utilized.

Keywords: Imaging utilization, Volume trends, Patient experience, Press Ganey outpatient services survey, Magnetic resonance imaging

Introduction

Patient satisfaction has evolved as an increasingly important measure of quality in health care and determinant of reimbursements under value-based payment models, including the Hospital Value-Based Purchasing program and the implementation of MACRA [Medicare Access and Children’s Health Insurance Program (CHIP) Reauthorization Act of 2015] [1, 2]. In non-radiology settings, patient satisfaction has been associated with willingness to return and/or to recommend medical services [3–7]. Extrapolating to diagnostic imaging services, however, can be problematic because factors affecting patients’ perception of quality potentially differ from other types of clinical encounters. Patients typically neither choose nor meet their physician provider in person and, in the case of MRI, the need to remain motionless in a confined enclosed space can enhance the emotional stresses already prevalent in radiology waiting rooms [8]. Furthermore, whether satisfaction with services and expressions of willingness to return or recommend, as gathered in surveys, actually manifest as increased patient volume has not been quantified in the non-radiology literature nor in the few studies addressing patient satisfaction in radiology [1, 9–14].

The paucity of studies assessing the interrelation of patient satisfaction and patient volume is understandable since several conditions should be met to allow assessment. Volume and/or satisfaction scores should vary demonstrably over the sampling time and across a series of sites to be compared. Secondly, conditions in the local healthcare market should be sufficiently favorable to consumers to allow patients to make voluntary choices of where they wish to have their imaging performed within reasonable constraints related to insurance status. Thirdly, the same validated satisfaction surveys should be used at all study sites and administered in the same fashion. We found these prerequisites met when we noted considerable variations in patient volume among some, but not all, hospital-based outpatient MRI facilities over a 1-year period in a healthcare system. We used this opportunity to perform a retrospective analysis of all sites in the system and test the hypothesis that trends in patient volumes reflect trends in patient satisfaction.

Methods

Outpatient MRI volume assessment

This IRB-approved, HIPAA-compliant study was performed at a university-affiliated hospital system during a 1-year period during which system-wide MRI volume gradually declined (April 2015 through March 2016). This decline followed a peak in volume occurring in the fourth quarter of fiscal year 2015 (April 1, 2015 to June 30, 2015), which is designated the baseline quarter Q0 ( Figure 1 ). Outpatient MRI studies were offered at 10 distinct physical sites within the same metropolitan area. There was no overlap of clerical or technological personnel at the sites. Patients were scheduled via a central scheduling system that incorporated their preferences in matching appointment requests with availability. Total numbers of completed MRI exams were obtained retrospectively by location for each fiscal quarter beginning with the baseline quarter to obtain study volume.

(a) Total system-wide quarterly outpatient MRI volume over time. The time period selected for this study is the one-year period encompassing a gradual decline in MRI volume (Q0 through Q3). Q-1 and Q-2 refer to the quarters 3 and 6 months prior to the baseline quarter, respectively. (b) Quarterly MRI study volume for each of the 9 included outpatient MRI sites, color-coded based on volume trend (stable, increasing, or decreasing).

A plot of the average (mean) quarterly volume for the 9 sites is also shown.

For each site, the slope of a regression line of study volume across the 4 quarters, beginning with Q0, was computed to obtain the average net change in study volume per quarter and expressed as a percent of the baseline volume. Sites with average quarterly change in volume of 5% or less were assigned a volume trend designation of “stable,” and those with average quarterly increases or decreases above 5% were designated as “increasing” or “decreasing,” respectively.

Patient Satisfaction Assessment

The institution contracted with an independent third party, Press Ganey, Inc. (Wakefield, MA), for assessment of patient satisfaction. One site was relatively new, having been instated only a few months prior to the study period, and did not have patient satisfaction data for the baseline quarter; it was excluded from the satisfaction data analysis. A fixed number of randomly selected outpatients at each included MRI site were mailed a survey form with a pre-stamped return envelope through Press Ganey. Press Ganey also collected and transmitted the survey responses on a monthly basis to the institution. In addition to a few background questions and space for free-text comments, the survey contains 21 Likert items soliciting responses on a 5-point rating scale ranging from 1 (very poor) to 5 (very good) and asks the respondent to answer questions as they relate to the specific visit and location referenced in the survey [1]. The Likert items are grouped in five domains:

Registration, Facilities, Test or treatment, Personal issues, and Overall assessment ( Table 1 ). Likert item responses for each survey were converted to a linear scale from 0 to 100 and averaged within each domain to produce a domain score. Net changes in domain scores from baseline were obtained by first computing baseline mean domain scores in the baseline quarter for each site and subsequently subtracting this from each individual survey domain score to obtain the net change from baseline. In this way, each site is evaluated relative to its own baseline, thereby emphasizing each site’s quality improvement efforts during the study period and minimizing effects of intrinsic inter-site differences such as location and physical building attributes that are relatively fixed during the 1-year study period. Surveys with incomplete or missing responses were included in the study, and a survey without a recorded response in a given domain was excluded only for analyses pertaining to the specific domain.

Table 1.

Constituents of the five domains of the Press Ganey outpatient services survey

The patient satisfaction survey also includes two questions requesting the patient’s assessment of waiting time in the form of a three-digit numerical response for waiting time in minutes. One question addresses the length of time from the scheduled appointment time to being called to the test or treatment area, and the second asks for the time spent waiting in the test or treatment area before the test or treatment began.

Statistical Analysis

Nonparametric statistics (Mood’s median tests) were applied to assess statistical significance of differences among the three volume trend designations during the 3 post-baseline fiscal quarters using JMP Pro 11.0.0 (SAS Institute, Inc., Cary, NC) at an alpha of 0.05. Mood’s median test was used instead of the Kruskal-Wallis test because of lack of homoscedasticity of the data and the test’s greater robustness against outliers. Results are presented as medians and interquartile ranges (i.e., the range between the 25 th and 75 th percentiles).

Results

Outpatient MRI Volume

A total of 42,236 outpatient MRI examinations were performed across 10 sites during the study period, with total volume declining gradually over this one-year period by approximately 5.5% from the baseline quarter, corresponding to a quarterly decline of 1.8% ( Figure 1A ). Exclusion of data from 1 site that lacked baseline satisfaction data due to its relatively new status resulted in 39,595 studies across 9 sites. Volume decreased at 2 included sites by 20 and 24% per quarter. Volume remained stable at 6 of the 9 sites (mean changes of −1.3% per quarter) and increased at 1 site by 18% per quarter ( Figure 1B ). The majority of the MRI studies (73%) in the study period were at sites with stable volume (28,987 / 39,595). The site with increasing volume accounted for 17% of studies (6744 / 39,595), and the decreasing-volume sites had 10% (3864 / 39,595).

Association of Imaging Volume with Patient Satisfaction

A total of 1314 completed surveys were analyzed. There was a statistically significant association between volume trend and net change in satisfaction scores (from baseline) for all 5 domains assessed on the Press Ganey survey: Overall assessment, Facilities, Personal issues, Registration, and Test or treatment ( Figures 2 and ​ and3). 3 ). When comparing the decreasing-volume group with the stable-volume group, the median changes in domain scores from baseline were significantly lower in the decreasing-volume group with regard to Facilities (p=0.013), Personal issues (p=0.0075), Registration (p=0.016), and Test or treatment domains (p<0.0001), in addition to the Overall assessment score (p<0.0001). Comparing the increasing-volume site with the stable-volume sites found that the increasing-volume site scored significantly higher than the stable-volume group in the Overall assessment (p<0.0001), Registration (p=0.0008), and Test or treatment domains (p=0.024). When comparing sites with decreasing and increasing volume, all domains except for the Facilities domain showed statistically significantly higher median domain score changes for the increasing-volume site: Overall assessment (p<0.0001), Personal issues (p=0.039), Registration (p<0.0001), and Test or treatment (p=0.0002).

Overview of median satisfaction score changes (from baseline), separated by domain. For clarity of presentation, measures of dispersion are omitted here and are instead shown in Figure 3 under individual domain analyses.

Changes in satisfaction scores across volume trends as analyzed within individual domains: Overall Assessment (a), Facilities (b), Personal Issues (c), Registration (d), and Test or Treatment (e). Median values are shown, and error bars denote limits of interquartile ranges. *p

Association of Imaging Volume with Patient-Reported Wait Times

Volume trend was also associated with net change in patient-reported wait times (from baseline) for both the time spent waiting in the registration area prior to being called to the test/treatment area and the waiting time in the test/treatment area ( Figure 4 ). Recalled wait time in the registration area was, on average, 5 minutes longer than baseline in the decreasing-volume facilities and unchanged from baseline for the stable-volume and increasing-volume facilities. For this metric, the median change from baseline between the sites with decreasing volume and stable volume was statistically significant (p<0.0001). For recalled waiting time in the test/treatment area, the increasing volume group reduced the waiting time by a median of 5 minutes. This improvement was statistically significant compared to both the stable volume group (p=0.0007) and the decreasing volume group (p=0.034), both of which showed no change from baseline.

Median changes in wait time in the registration area until called to the test or treatment area (a) and in the test or treatment area (b) as reported by the patient. Data points represent medians, and error bars represent limits of interquartile ranges. *p

Discussion

The relationship between patient volume and patient satisfaction in healthcare is often challenging to analyze because of various constraints on patient choice, such as limited availability of appointment slots. During the time period examined in this study, overall MRI patient volume declined gradually, producing a supply-demand situation in which patients had relatively greater flexibility in choosing where they undergo imaging.

Although we did not systematically examine potential causes of the observed temporal changes in total system-wide MRI volume during the study period, we suspect that the observed fluctuations may be due to local factors such as competition with other local imaging practices or local changes in staffing or health care access. Under these conditions, greater positive trends in satisfaction survey responses were associated with trends towards greater patient volumes. Of note is that, with the exception of the facility assessment, all satisfaction score averages improved from the baseline in this study, albeit at different degrees. This is true even for sites showing decreasing patient volume, which may reflect ongoing institutional efforts in improving the patient experience or greater capacity to meet patient expectations in the setting of declining patient volume through easier scheduling, shorter wait times, or less hurried interactions with staff.

Given increased consumerism in healthcare, it is important to be cognizant of the economic consequences of patient satisfaction. Given that a relatively high proportion of operating costs in MRI are fixed costs, profitability at an MRI site is strongly dependent on patient volume [15, 16]. Taking patient volume as an indicator of increased profitability [17], our findings corroborate the positive association between client satisfaction, loyalty, and profitability described for inpatient care [18], the hospitality industry, and banking services [19]. For instance, a study using American Customer Satisfaction Index data on over 200 Fortune 500 companies across multiple industries demonstrated a clear impact of satisfaction on future cash flows [20]. A study of 3767 hospitals found positive patient experience to be associated with increased profitability, with an even stronger association between negative patient experience and decreased profitability [21].

Given the positive association between larger satisfaction score improvements and increasing patient volume among the sites examined in this study, it is reasonable to infer that the observed differences in volume trends among available sites reflect effects of patient preference or other variables affecting patients’ ability or willingness to visit a particular location. Conversely, one might also consider a relationship whereby patient volume potentially influences patients’ satisfaction or perception of quality of care. Although high volumes tend to have an adverse or limiting effect on satisfaction in service-based industries [22], in which consumers expect individualized attention and value face-to-face interaction, our study’s results do not support an adverse effect of higher patient volume on satisfaction scores. In fact, satisfaction metrics, including perceived wait times, at sites with growing patient volume were better than at declining-volume sites, implying that any feedback effect of volume on satisfaction is likely minor, at least under the conditions described in this study. Since recorded time spent at the various locations was based on patients’ recall and perception, the actual amount of time elapsed was not directly measured in this study. Patients’ responses regarding waiting times may therefore be influenced by their emotional state [23] or that of others in the waiting areas [24], such that happier patients may perceive time as passing less slowly. Alternatively, improvements in efficiency or staffing at a given site could impact both waiting time and volume.

While statistically significant differences were present when analyzing all domains of the Press Ganey survey, the effects varied across different domains, with statistical significance highest for Overall assessment and Test or treatment and least for items inquiring about the physical facilities. Interestingly, the newest, most structurally appealing sites in this study fell in the decreasing-volume group, diminishing the argument for major design investment as means of enhancing patient volume. This may reflect the experience of a Korean study that showed patients’ perception of the structural facility having less importance than the interaction with personnel [7]. Other studies also reported the perception of staff interactions as one of the most important determinants of patient satisfaction [25–27]. Although all sites are conceivably subject to ongoing quality improvement processes as part of routine operations, one potentially notable observation was that the staff at the site with increased patient volume and at 4 of the 6 stable-volume sites had undergone advanced interpersonal skill training that included rapport-building skills and verbal communication techniques to promote patient relaxation and cooperation as previously described [28], in contrast to none of the decreasing-volume sites. This may have led to increased efficiency or increased reputation for referrals through other mechanisms. The above statements represent plausible mechanisms whereby improvements in patient satisfaction may lead to increased volume over the course of a 1-year period.

Limitations

There are several limitations to our study. First, this is a retrospective study examining satisfaction data on outpatients at a single hospital system. Associations thus cannot necessarily predict potential causal relationships between satisfaction scores and imaging volume, and there may be limited generalizability of these findings to other institutions or settings. Also, in this study, our use of a 5% threshold of quarterly change to designate sites as increasing, stable, or decreasing in volume was arbitrary. However, as depicted in Figure 1B , the three groups show distinct temporal trends that allow them to be reliably and robustly separated, such that using a threshold as low as 2% or as high as 10% would not have altered the volume trend group assignments. As with any study examining survey data, the results are subject to response bias, which previously has been described for use of Press Ganey outpatient services surveys [29]. Such bias may affect satisfaction in either direction, but it is conceivable that patients with negative experiences may be more inclined to return a survey to express their dissatisfaction compared to those with neutral or satisfactory experiences, although some patients with strongly positive experiences may be more inclined to return their surveys than those who felt more neutral or only mildly satisfied. Furthermore, the gradual decline in system-wide volume during the study period may represent a situation that allows patient preferences to have a greater impact on distribution of imaging volume than might be present when fewer scanner openings are available. While this likely improves our ability to detect effects of patient preferences on imaging volume, the results may not necessarily apply to other situations in which scanner availability is a limiting factor.

Conclusion

In conclusion, patient satisfaction and patient volume at MRI imaging sites are interrelated, and patient experiences or perceptions of quality of care have the potential to influence what imaging sites are preferentially utilized. Significant associations between favorable satisfaction survey trends and increasing MRI volume suggest that patient satisfaction is not only a quality metric but has operational importance in predicting or impacting imaging volume. As relative differences in satisfaction score changes between decreasing-volume and increasing-volume sites are lower for the Facilities domain of the survey than for the other domains, we can infer that interactions with staff may be more important than the quality or cleanliness of the physical facilities in impacting volumes in outpatient MRI. However, further studies are needed to elucidate any potential causal mechanisms behind the observed associations and the cost-effectiveness of any interventions to improve the patient experience.

Sources of Support

Elvira Lang is the recipient of a Small Business Innovation in Research (SBIR) Phase II Grant from NCCIH/NIH (R44AT006296) and is the owner of a small business (Hypnalgesics, LLC) as required by the grant mechanism. There is no other industry or government funding for the work described in this manuscript.

Footnotes

Conflicts of Interest

Xuan V. Nguyen and Amna A. Ajam declare no conflicts of interest.

Elvira V. Lang is the owner and CEO of Hypnalgesics, LLC d/b/a Comfort Talk®, a company dedicated to training frontline medical staff in improving the patient experience.

Statement of data access and integrity.

The authors declare that they had full access to all of the data in this study, and the authors take complete responsibility for the integrity of the data and the accuracy of the data analysis.

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