Patient experience surveys are a cornerstone of public reporting and pay-for-performance initiatives. Some healthcare providers, payers, and other stakeholders have expressed concerns about declining response rates and representativeness of these surveys [pdf], especially for underserved groups. Increasing response rates is an important goal. Several strategies have been proposed to increase response rates, including administering surveys via the web, on mobile devices, or at the point of care, offering monetary incentives, and reducing survey length [pdf].
Here’s what peer-reviewed, randomized experiments—the highest-quality research evidence—say about each of these strategies for increasing response rates.
Web-based survey administration
Administering surveys using only web-based modes results in consistently lower response rates than administering by mail or telephone. The most effective strategy for achieving high response rates to patient surveys is to administer them in sequential mixed modes. (In sequential mixed modes, a survey is administered first in one mode, then in another mode to those who haven’t responded yet. In simultaneous mixed modes, a choice of modes is offered from the start.) Mail with telephone follow-up results in response rates 13 percentage points higher than mail-only or telephone-only modes. Adding a web mode first can further increase the response rates achieved by mail-telephone by 2-5 percentage points. Simultaneous mixed modes do not increase response rates and sometimes decrease them.
Administering patient surveys first by web (with invitation by text or email) in a sequential mixed mode may reduce costs because web outreach is cheaper than mail or telephone. This approach may also reduce the time before survey responses are received, potentially increasing their usefulness for quality improvement.
Web administration can increase response from younger adults while including telephone in a sequential mixed mode approach promotes greater representation by patient age, insurance status, and race and ethnicity.
Administering Patient Surveys at the Point of Care
Surveying patients at the point of care offers the potential advantage of capturing experiences when they are most salient. It also eliminates the need for accurate and comprehensive patient contact information. However, studies show that in-person administration of paper surveys following outpatient and emergency room visits yields lower response rates than mail surveys that include follow-up with non-responders.
It can be challenging to ensure that a representative sample of eligible patients is invited to participate in point-of-service surveys. When healthcare staff are responsible for recruiting respondents, they may intentionally or unintentionally bias who is sampled and how they respond. A number of studies have shown that patients invited to participate in a survey by clinical staff at the point of service give more favorable responses than patients responding via other modes.
In contrast, one study of tablet-based survey administration while parents awaited their child’s discharge from a children’s hospital showed improved response rates and representativeness of respondents. High response rates in this setting may be due to the extended waiting period during hospital discharge. Patients and families may have fewer competing demands during this time than they do when they are invited to complete a survey at home.
Incentives
Offering monetary incentives to patients who complete surveys can result in 7-20 percentage point increases in response rates. Incentives provided with the initial mail survey invitation yield higher response rates than those provided conditionally upon receipt of completed surveys. Patients generally prefer cash over other types of incentives, such as gift cards. There are a number of reasons that survey sponsors may be reluctant to offer incentives, though. These include legal prohibitions for some surveys, cost constraints, worry that incentives may be perceived as coercion by respondents, and concern that over time, the incentives may erode patients’ intrinsic motivation to complete surveys.
Reducing Survey Length
Despite its intuitive appeal, there is limited evidence on the effects of survey length on response rates to patient surveys. The complexity of the survey matters as much as its length. For example, one study found similar response rates for a 16-page, more complex survey and a 36-page, less complex survey. When administering surveys of similar complexity and interest to potential respondents, shorter survey lengths can result in somewhat higher response rates.
The potential response rate benefit is related to the difference in survey length (e.g., comparing survey length of 4 pages to 7 pages rather than 4 pages to 5 pages). Prior research on patient surveys collected from Medicare beneficiaries in mail-telephone mixed mode found that surveys that are 12 questions shorter are associated with response rates that are 2.5 percentage points higher. But reducing the number of questions on patient surveys results in a loss of information. Reducing complexity helps to increase response rates without losing information that may be useful for quality improvement.
The Takeaway
In sum:
- Strategies focused solely on reducing burdens, such as very short surveys or web-only administration, may result in the loss of important information.
- Sequential mixed-mode survey administration promotes the highest response rates to patient surveys. It also increases the representation of hard-to-reach and underserved populations in assessments of patient care.
- Including telephone follow-up in mixed-mode administration enhances response among those with historically lower response rates. However, it has a relatively higher cost.
- Including web-based modes in mixed-mode administration may increase response among those with web access at a relatively low cost.
- Other promising strategies include:
- In-person survey administration during hospital discharge,
- Minimizing the complexity of survey wording,
- Special mail delivery
- Sending a prenotification letter prior to survey administration, and
- Provision of incentives (where permissible).
Rebecca Anhang Price
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