The authors have declared that no competing interests exist.
Conceived and designed the experiments: BND RAW MCRB TPG. Analyzed the data: BND RAW WCB. Wrote the paper: BND.
Analogous to the business model of customer satisfaction and retention, patient satisfaction could serve as an innovative, patient-centered focus for increasing retention in HIV care and adherence to HAART, and ultimately HIV suppression.
To test, through structural equation modeling (SEM), a model of HIV suppression in which patient satisfaction influences HIV suppression indirectly through retention in HIV care and adherence to HAART.
We conducted a cross-sectional study of adults receiving HIV care at two clinics in Texas. Patient satisfaction was based on two validated items, one adapted from the Consumer Assessment of Healthcare Providers and Systems survey (“Would you recommend this clinic to other patients with HIV?) and one adapted from the Delighted-Terrible Scale, (“Overall, how do you feel about the care you got at this clinic in the last 12 months?”). A validated, single-item question measured adherence to HAART over the past 4 weeks. Retention in HIV care was based on visit constancy in the year prior to the survey. HIV suppression was defined as plasma HIV RNA <48 copies/mL at the time of the survey. We used SEM to test hypothesized relationships.
The analyses included 489 patients (94% of eligible patients). The patient satisfaction score had a mean of 8.5 (median 9.2) on a 0- to 10- point scale. A total of 46% reported “excellent” adherence, 76% had adequate retention, and 70% had HIV suppression. In SEM analyses, patient satisfaction with care influences retention in HIV care and adherence to HAART, which in turn serve as key determinants of HIV suppression (all p<.0001).
Patient satisfaction may have direct effects on retention in HIV care and adherence to HAART. Interventions to improve the care experience, without necessarily targeting objective clinical performance measures, could serve as an innovative method for optimizing HIV outcomes.
Over 1.1 million people in the United States (US) live with HIV infection
The business world offers a framework for increasing retention by focusing on customer satisfaction. Marketing studies clearly show that high satisfaction levels have a positive impact on customer loyalty, repeat patronage, and more extensive and favorable referrals
Analogous to the business model of customer satisfaction and retention, patient satisfaction could serve as an innovative focus for increasing retention in HIV care and adherence to HAART. Suppression of HIV replication represents the most important prognostic indicator for long-term survival with HIV infection. We sought to understand if patient satisfaction is related to suppression of HIV replication through its effects on retention in HIV care and adherence to HAART. We hypothesize that patient satisfaction positively impacts retention in HIV care and adherence to HAART, which in turn impact HIV suppression.
We used data from a cross-sectional study of patients receiving outpatient HIV primary care at Thomas Street Health Center (TSHC) and the Michael E. DeBakey Veterans Affairs Medical Center (VAMC) in Houston, Texas. This study took place within the context of a primary study to identify the drivers of overall satisfaction in patients receiving HIV primary care. A full description of the study design is described elsewhere
Due to limited study staff, we could not recruit all eligible patients concurrently. As such, we decided a priori to systematically sample patients from a list of eligible patients who had arrived at the clinic and checked in. Patients with the most recent check-in time at the time of study staff availability were approached for enrollment. The survey, available in English and Spanish, was administered prior to the HIV provider visit and took about 10 minutes to complete.
The survey instrument included 2 questions about overall care received in the clinic 1) “Overall, how do you feel about the care you got at this clinic in the past 12 months?” and 2) “Would you recommend this clinic to other patients with HIV?” These questions were adapted from validated patient self-report survey instruments
A validated, single-item measure assessed adherence to HAART. The item stated, “Many patients find it hard to take HIV medicines as their doctor prescribes them. In the past 4 weeks, how would you rate your ability to take all your HIV medicines as your doctor prescribed?” The 6-point response scale ranged from “very poor” to “excellent”
Since 2011, the US Department of Health and Human Services has recognized that patients with HIV suppression and a CD4 cell count well above the threshold for risk of opportunistic infection may need less intensive monitoring (e.g. clinicians may extend the interval for HIV RNA monitoring to every 6 months)
HIV suppression was defined as a plasma HIV RNA <48 copies/mL±30 days from the date of survey completion. Lab values were obtained from electronic medical records.
Participants self-reported their gender, race, ethnicity, education, income, health status and incarceration history. The health status item was based on a validated, widely used question, “In general, how would you rate your overall health?”
We compared overall patient satisfaction scores between participants with adequate versus inadequate retention in HIV care, “excellent” versus non-“excellent” adherence to HAART, and suppressed versus unsuppressed HIV replication using the Wilcoxon Rank-Sum Test.
We performed bivariate analyses between potential control variables (demographic, health status, behavioral characteristics, and clinic utilization variables listed in
Characteristics | |
Age, years – mean (±SD) | 48 (±11) |
Gender – (%) | |
Male | 71 |
Female | 29 |
Race ethnicity – (%) | |
Non-Hispanic black | 61 |
Non-Hispanic white | 15 |
Hispanic | 21 |
Other | 3 |
Survey mode – (%) | |
Self-administered | 85 |
Interviewer-administered | 15 |
Education – (%) | |
Some high school or less | 22 |
High school graduate or equivalent | 35 |
Some college of higher | 43 |
Household income – (%) | |
≤$10K | 54 |
>$10K and ≤$30K | 36 |
>$30K | 10 |
Depression screen, positive – (%) | 43 |
Alcohol screen, positive – (%) | 42 |
Illegal or Rx drug abuse screen, positive – (%) | 19 |
Health status – (%) | |
Poor/fair | 20 |
Good/very good | 65 |
Excellent | 15 |
HIV risk factor – (%) | |
IVDA | 16 |
MSM, no IVDA | 33 |
Heterosexual sex, no IVDA | 50 |
Transfusion | <1 |
Currently prescribed HAART – (%) | 94 |
Duration enrolled in clinic, years – mean (±SD) | 7.6 (±4.5) |
CD4 count |
449 (276, 665) |
SD indicates standard deviation; IVDA intravenous drug abuse; MSM, men who have sex with men.
Value closest to date of survey completion, ±30 days; CD4 cell count available for 85% of participants.
We used structural equation modeling (SEM) to examine hypothesized relationships between patient satisfaction, retention in HIV care, adherence to HAART, and HIV suppression. SEM is a multivariate statistical method that: 1) inputs empirical data and qualitative causal assumptions from theory-based models, 2) allows for the simultaneous evaluation of direct, indirect and total effects of multiple variables, and 3) accounts for measurement error in the process of modeling relationships between latent variables (i.e. variables that are not directly observed, but estimated from directly measured ones).
Spearman's partial correlation coefficients were calculated for all measures in the structural modeling by controlling for age, race, ethnicity, depression and health status. These computations parcel out the shared variance between each control variable and pair of measures. The resulting partial correlation matrix was used as the input for the structural model estimation (
1 | 2 | 3 | 4 | 5 | ||
1 | Likelihood of recommending clinic | 1.00 | ||||
2 | Feelings about care | 0.53 |
1.00 | |||
3 | Adherence to HAART | 0.11 |
0.17 |
1.00 | ||
4 | Retention in HIV care | 0.17 |
0.08 | 0.12 |
1.00 | |
5 | HIV suppression | 0.11 |
0.09 | 0.26 |
0.26 |
1.00 |
Partial correlations controlling for age, race ethnicity, depression, and health status.
p<0.05;
p<0.01.
We first assessed the relationship between retention in HIV care, adherence to HAART and HIV suppression, controlling for age, race, ethnicity, depression and health status. This constituted the baseline model. Next, we included overall patient satisfaction as a predictor latent variable to determine its effect on the relationship between retention, adherence, and, ultimately, HIV suppression. We tested the hypothesized models using SPSS AMOS 19.0 statistical software (
We performed hypothesis testing by examining parameter estimates. The retention in HIV care and HIV suppression constructs were measured with single indicators. Since HIV RNA copies is the accepted standard measure of HIV suppression, the measurement loading for HIV suppression was set to 1.00 (i.e. no measurement error). Since no studies of reliability have been reported for the retention in HIV care construct and the construct is measured objectively, its measurement error was assumed to be 0 and the measurement loading was set to 1.00. The adherence to HAART construct has an estimated reliability of 0.67 (personal communication, Y. Lee, 2012). This was incorporated into the model by setting the measurement loading to 0.82 (the square root of the reliability 0.67) and the measurement error to 0.33 (1 minus the reliability 0.67).
Model goodness-of-fit was evaluated using 3 widely used indexes: chi-square test (χ2), the Comparative Fit Index (CFI) and Root Mean Square Error of Approximation (RMSEA)
The Institutional Review Board (IRB) for Baylor College of Medicine and Affiliated Institutions approved this study. The IRB waived the need for written informed consent because this research involves no more than minimal risk to the participants. We collected verbal informed consent and documented the procedure. All data were de-identified and analyzed anonymously.
The study sample includes 489 patients (94% of eligible patients approached; 388 from TSHC and 101 from VAMC). As shown in
Patients reported high levels of overall satisfaction with HIV care (mean = 8.5, SD = 1.7, median 9.2, range 0.8–10.0). Over 90% would “probably” (23.4%) or “definitely” (69.8%) “recommend this clinic to other patients with HIV,” and over 80% felt “mostly satisfied” (26.7%) or “completely satisfied” (57.3%) with their HIV care.
In the year before enrollment, 76% of participants had adequate retention in HIV care and 24% had inadequate retention. Participants with adequate retention were significantly more satisfied with their HIV care than patients with inadequate retention (median patient satisfaction score 9.17 versus 8.47, respectively; p = 0.02).
A total of 94% were “taking or supposed to be taking HIV medicines.” Among those prescribed HAART, 46%, 28%, 16%, 6%, 2% and 2% reported “excellent,” “very good,” “good,” “fair,” “poor,” and “very poor” adherence, respectively. Participants who reported “excellent” adherence were significantly more satisfied with their HIV care than patients who did not (median patient satisfaction score 10.00 versus 8.61, respectively; p<.0001).
HIV RNA values at the time of survey completion ±30 days were available for 84% of participants (N = 409). Seventy percent of these patients achieved HIV suppression. Participants who achieved HIV suppression were significantly more satisfied with their HIV care than patients who did not (median patient satisfaction score 9.17 versus 8.47, respectively; p<.01).
The baseline model evaluated the roles of retention in HIV care and adherence to HAART as independent antecedents to HIV suppression (
Values indicate standardized coefficients; * p<0.05; ** p<0.001.
B |
β | p | |
|
|||
Structural Model | |||
Retention in Care→Adherence to HAART | .147 (.062) | .147 | .02 |
Retention in Care→HIV Suppression | .220 (.049) | .220 | <.001 |
Adherence to HAART→HIV Suppression | .287 (.061) | .287 | <.001 |
|
|||
Measurement Model | |||
Patient Satisfaction→Feelings about care | 1.000 | .680 | NA |
Patient Satisfaction→Recommend Clinic | 1.149 | .778 | <.001 |
Structural Model | |||
Patient Satisfaction→Retention in Care | .266 (.094) | .181 | <.001 |
Patient Satisfaction→Adherence to HAART | .298 (.115) | .203 | <.001 |
Patient Satisfaction→HIV Suppression | .047 (.089) | .032 | .60 |
Retention in Care→Adherence to HAART | .110 (.063) | .110 | .08 |
Retention in Care→HIV Suppression | .215 (.050) | .215 | <.001 |
Adherence to HAART→HIV Suppression | .280 (.062) | .280 | <.001 |
B denotes B coefficient; β indicates beta coefficient.
Patient Satisfaction properties: composite reliability = 0.70; average variance extracted = 0.54.
Standard errors in parentheses.
Model Goodness of Fit: χ2 = 0.00,
Model Goodness of Fit: χ2 = 5.106,
NA indicates not applicable. The indicator loading is constrained to 1.0 for latent construct estimation and represents the reference item. No direct test of statistical significance is possible for the constrained indicator.
A second model evaluated the role of overall patient satisfaction in influencing retention in HIV care, adherence to HAART and HIV suppression (
Values indicate standardized coefficients; * p<0.05; ** p<0.001. Estimation requires that one of the indicator loadings of a construct be constrained to 1.0. No direct test of statistical significance is possible for this reference item. Statistical significance is determined by estimating an identical second model, with the indicator constraint of 1.0 moved to a different indicator. Thus, all standardized coefficients can be tested for significance, even though one item must always be constrained in any single estimation.
Similar to the baseline model, the direct effects of retention in HIV care and adherence to HAART on HIV suppression were significant (standardized coefficient = 0.215, p<.0001 and standardized coefficient = 0.280, p<.0001, respectively) (
In this study of 489 participants receiving outpatient HIV primary care, overall patient satisfaction with care is positively related to retention in HIV care and adherence to HAART, which in turn serve as key determinants of HIV suppression. The data suggest that patient satisfaction may provide a way to improve HIV outcomes through its positive influences on adherence to HAART and retention in HIV care. This finding suggests that patient-centered interventions designed to improve the care experience could serve as an innovative method for optimizing HIV outcomes.
The National Council on Patient Information and Education's report,
Retention in HIV care is a critical step for achieving long-term survival with HIV infection
Patient satisfaction represents an innovative focus for retention and adherence intervention efforts. Its innovation derives from applying the business model of customer satisfaction to improve patient adherence to care. Additionally, interventions to improve patient satisfaction with the overall care experience are not directly dependent on efforts to explicitly change patient behavior. Patient satisfaction reflects the patient's perception of the entire care process, and improving satisfaction metrics lies within the power of a clinic or institution.
Research indicates that provider and organizational factors play a large role in how patients evaluate their provider and overall clinic care
The development of successful interventions to improve retention in HIV care and adherence to HAART requires a better understanding of how patient satisfaction impacts those constructs. The exact mechanisms explaining the linkages between these constructs remain unclear. Additionally, it remains unclear which component or components of the care experience most strongly influence retention and adherence. Several studies, including a previous study based on this dataset, have reported that patients' evaluation of their provider correlates the strongest with their overall satisfaction
This study has several methodological strengths. Our practice-based model incorporates the business model of customer satisfaction with the clinical end point of HIV suppression. The study took place at 2 clinic sites. It primarily included a low-income minority population, which often has low rates of adherence to care and worse clinical outcomes
This study has certain limitations. Although our study supports the proposed causal linkages between overall patient satisfaction, retention in HIV care, adherence to HAART, and HIV suppression, correlational data cannot provide definitive evidence of causality. Emerging consensus, however, suggests that such data, when examined through structural equation modeling, can help researchers articulate, clarify and evaluate causal explanations between constructs of interest
This study identified retention in HIV care and adherence to HAART as intervening constructs through which patient satisfaction influences HIV outcomes. Our data raises the intriguing possibility that interventions aimed at improving the patient care experience by improving contextual components of care (i.e. who, where and how care is provided) could affect outcomes without actually targeting objective clinical performance measures. Our findings suggest that patient satisfaction could serve as an innovative target for interventions to improve HIV outcomes.
The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.