Contented but Not Better: Problems With Satisfaction

In this issue McCrone and colleagues present the results of a cost analysis of assertive community treatment (ACT) teams in London. Cost data were linked to a primary outcome of client satisfaction. The authors used satisfaction because it was the only measure on which ACT teams differed from standard community treatment teams in the authors' original study. Use of satisfaction as a primary outcome measure raises two important issues: the precision of satisfaction as a concept and its utility for policy decisions.

Satisfaction is a measure of a person's reaction to care. Such a reaction combines the individual's comparison to some standard and an emotional component. The problem is that people may not use the same standard for comparison, and emotional reactions differ based on life experiences. Thus it is difficult to develop precise measures that are replicable across populations. Use of a global assessment of satisfaction, although attractive in its simplicity, is fraught with problems. It is not clear whether the score represents satisfaction with overall care or with a particular aspect of it. Measuring specific components of care is critical to obtaining a more accurate picture of what is contributing to a person's satisfaction. One doesn't want to win a popularity contest at the expense of quality of care and improvement in clinical and functional status.

A measure of satisfaction is essential to understanding clients' preferences and providing feedback to professionals and managers. However, as a single measure for policy purposes it has significant limitations. It is often unclear which components of satisfaction are critical and which can be affected by changes in the system or in providers' behavior. Multidimensional measures of satisfaction should be used, and specific components that are most important for policy decisions should receive the highest weights. However, policy makers should not rely solely on satisfaction as an indicator of the utility of a given intervention. Information about other factors, such as clinical and functional status, quality of life, and adherence to treatment regimens, is necessary to understand the utility of an intervention, and these other factors may deserve more emphasis.

It doesn't seem prudent to use limited health care funds to improve general satisfaction when it is not clear what one is paying to improve and whether improved satisfaction results in a better life for those who receive the care. What if people are satisfied because they have more contact with staff? This implies that one should shift funding to lower-cost health care providers who will meet more frequently with clients. However, clinical and functional status may worsen as a result, and such a decision may lead to far greater costs over the long term.