Examining the link between patient satisfaction and adherence to HIV care: a structural equation model

Abstract

Introduction: 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.

Objective: 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.

Methods: 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.

Results: 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).

Conclusions: 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.

Figure 1. Baseline Model of Retention in HIV Care, Adherence to HAART and HIV Suppression (N = 489).

Values indicate standardized coefficients; * p<0.05; ** p<0.001.

Figure 2. Patient Satisfaction Model (N = 489).

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.