When the Literary Digest conducted a poll to predict the winner of the 1936 presidential election, the results were clear: Alfred Landon would overwhelmingly defeat Franklin Delano Roosevelt. The Literary Digest was confident about its results: after all, they had surveyed 10 million people and received 2.4 million responses. But they could not have been more wrong. Why? Those 10 million people were drawn from a pool of Literary Digest subscribers, automobile owners, and telephone owners. In 1936, automobiles, phones, and subscriptions to the Literary Digest were available only to the rich. These selection factors skewed the results toward Landon, the choice of the wealthy.
The systemic failure of their sampling technique is cited in most introductory statistics textbooks, since it shows so clearly how bad sampling can lead to wrong conclusions. Roosevelt won in the most lopsided victory in American history.
Today, surveys of patient satisfaction are an important tool in measuring the patient experience in the ED, inpatient setting, ambulatory care center, and skilled nursing facility. Patients’ feelings about their experiences are important for many reasons. First, patient stress is antithetical to treatment because stress and anxiety have negative effects on health. Secondly, physician communication with patients helps to support patient engagement, which, in turn, has enormous effects on health outcomes.
Finally, patient satisfaction surveys are important because Medicare has started to use patient satisfaction as a criterion for a portion of reimbursement for care. Under Value Based Purchasing (VBP), “Medicare will cut or reward hospitals by 1% depending on how they fare on the Hospital Consumer Assessment of Healthcare Providers and Systems survey. The survey, given to patients after they have been discharged, was expanded to include questions such as whether their nurses and doctors treated them with courtesy and respect, the cleanliness of their rooms, and how their pain was managed.”
Beyond illustrating patient experience, patient satisfaction surveys can also expose operational inefficiencies, thereby highlighting areas a hospital needs to work on to improve its VBP score. One factor that has a very strong negative correlation with patient satisfaction is wait times – the longer patients have to wait to see a provider, the less satisfaction they report with their experience. Concentrating on throughput has enormous effects on the qualitative experience, which reverberates through the patient’s engagement.
But healthcare can be seen as behind the times in terms of attention to the experience of those they serve. As Leonard Fromer, MD writes, “It's the physician mentality that healthcare is a special thing and the only people trained well enough to really understand what's supposed to happen are the doctors. But that is absolutely prehistoric thinking. To ignore the input from the patient, to ignore the customer, to say the customer's desires are irrelevant is not living with reality.”
Clearly, we need to survey our patients. And we need to make sure we're including all patients to avoid biasing our results. An analysis of 210 published studies on patient satisfaction concluded that, “Patient satisfaction studies generally show poor awareness of the importance of methodological issues relevant to response rate. Far more attention to this aspect is needed if findings in this field are to be accepted as valid and useful.”
While the Literary Digest was making its enormous error in early 1936, George Gallup conducted a much smaller poll and was able to predict the outcome of the election with a much smaller sample. But in 2012, the Gallup organization erroneously predicted a Romney victory over Obama. Many speculate that Gallup’s difficulty in reaching cell phone users with their automatic dialing systems created a systemic bias toward older voters, who were more likely to support Romney. It is ironic because the reliance on land lines (which were a luxury in 1936) contributed to the demise of Literary Digest and the creation of Gallup’s organization; and today the reliance on land lines may contribute to the eventual demise of Gallup. Literary Digest went belly up shortly after their election survey failure, and today Gallup seems to be losing their credibility to Nate Silver, who continually re-examines sampling methodology. There is a lesson here for us.
We must make sure that our surveys reach all patients. Outreach methods for survey research must keep up with the times, or we risk introducing systemic bias that could have effects on health outcomes for future generations.