Direct and indirect measures of patient satisfaction with physicians' services

This research examines alternative measures of patient satisfaction. Three measures were compared: (1) a direct measure to evaluate how the patient felt about his own personal physician, (2) an indirect measure that assessed attitudes about physicians in general, and (3) a measure designed to be intermediate between these two. Responses to the three measures were found to differ: the levels of satisfaction increased with the directness of the measure used; indirect evidence that this relationship could not be attributed solely to a patient's reluctance to criticize his own physician is also provided.The three measures were compared in terms of their association with other assessments of outcome and with indicators of the process of care. Although none of the associations was statistically significant, high scores on the intermediate measure tended to correspond with better outcomes and higher scores on the process of care. These findings are at least compatible with the contention that an intermediate measure provides the most valid assessment of patient satisfaction.Dr. Stewart, a National Health Research Scholar, was formerly with the Department of Epidemiology and Preventive Medicine, University of Western Ontario, and is now with the Department of Preventive Medicine, Dalhousie University, Halifax, Nova Scotia, Canada, B3H 4H7. Dr. Wanklin, is Professor in the Department of Epidemiology and Preventive Medicine, University of Western Ontario. Dr. Stewart has been supported by a Fellowship from the Physician's Services Incorporated Foundation (Ontario) and by a National Health Research Scholarship from Health and Welfare Canada. The authors wish to thank Drs. W. Weston, B. Halliday, D. Fuller, A. Hegde, P. Bartlett, and the staff and patients of the Tavistock Family Health Centre for their participation in this research.     

Patient satisfaction with obstetric care

Patient satisfaction with obstetric care was studied in a cohort of postpartum women from a rural midwestern county. Birth certificate data defined the population, and satisfaction data were acquired through a mailed questionnaire. An indirect measure (satisfaction scale) was derived with acceptable construct validity and internal consistency. A direct measure (open-ended questions) elicited specific comments about each woman's recent experience with obstetric care. Satisfied women, as described by the scale, were more likely to have had good physician continuity and to have attended childbirth classes. The open-ended responses most frequently described problems relating to the physician-patient relationship. In comparing the indirect and direct measures, women with high satisfaction scores were more likely to make no critical comments about their obstetric care (chi 2 = 9.16, P less than .003). The patient's perception of the physician's attitude of concern emerged as an important issue in both measures. The data demonstrate that perceived physician concern is an important component of patient satisfaction with obstetric care.     

Determinants of Patient Satisfaction With Public Hospital Services

The aim of this research is to propose and test a model of the causal relationships among the constructs of perceived service quality, consumption emotions, and satisfaction among users of public hospital services. The conceptual model proposed in this study postulates that: (a) perceived service quality is positively related to positive emotions and negatively related to negative emotions; (b) perceived service quality is positively related to patient satisfaction; and (c) positive emotions are positively related to patient satisfaction and negative emotions are negatively related to patient satisfaction. The model was tested with data from an empirical study in the Canadian public hospital setting. Data were collected from 314 respondents. The relationships between the constructs were tested using structural equation modeling by means of the EQS software. All hypothesized relationships were supported. The results confirm that perceived service quality exerts both direct and indirect effects (through positive and negative emotions) on satisfaction. The study demonstrates that emotions play an important role in determining satisfaction with hospital services.     

The impact of visit frequency on the relationship between service quality and outpatient satisfaction: a South Korean study

OBJECTIVE: To examine the relative impact of four service quality dimensions on outpatient satisfaction and to test the invariance of the structural relationships between the service quality dimensions and satisfaction across three patient groups of varying numbers of prior visits to the same hospital as outpatients. DATA SOURCES/STUDY SETTING: Survey of 557 outpatients using a self-administered questionnaire over a 10-day period at a general hospital in Sungnam, South Korea. DATA COLLECTION: Patients answered questions related to two main constructs, patient satisfaction and health care service quality. The health care service quality measures (30 items) were developed based on the results of three focus group interviews and the SERVQUAL scale, while satisfaction (3 items) was measured using a previously validated scale. STUDY DESIGN: Confirmatory factor analysis was used to assess the construct validity of the service quality scale by testing convergent and divergent validity. A structural equation model specifying the four service quality dimensions as exogenous variables and patient satisfaction as an endogenous variable was estimated to assess the relative impact of each of the service quality dimensions on satisfaction. This was followed by a multigroup LISREL analysis that tested the invariance of structural coefficients across three groups with different frequencies of outpatient visits to the hospital. PRINCIPAL FINDINGS: Findings support the causal relationship between service quality and satisfaction in the context of the South Korean health care environment. The four service quality dimensions showed varying patterns of impact on patient satisfaction across the three different outpatient groups. CONCLUSION: The hospital management needs to be aware of the relative importance of each of the service quality dimensions in satisfaction formation of outpatients, which varies across different hospital utilization groups, and use this in strategic considerations.     

Quantitative comparison of measurements of urgent care service quality

ABSTRACT

Service quality and patient satisfaction are essential to health care organization success. Parasuraman, Zeithaml, and Berry introduced SERVQUAL, a prominent service quality measure not yet applied to urgent care. We develop an instrument to measure perceived service quality and identify the determinants of patient satisfaction/ behavioral intentions. We examine the relationships among perceived service quality, patient satisfaction and behavioral intentions, and demonstrate that urgent care service quality is not equivalent using measures of perceptions only, differences of expectations minus perceptions, ratio of perceptions to expectations, and the log of the ratio. Perceptions provide the best measure of urgent care service quality.     

A prospective cohort study found that provider and information continuity was low after patient discharge from hospital

ObjectiveContinuity of care is composed of provider and information continuity and can change value over time. Most studies that have quantitatively associated continuity of care and outcomes have ignored these characteristics. This study is a detailed examination of continuity of care in patients discharged from hospital that simultaneously measured separate components of continuity over time or determined the factors with which they are associated.Design SettingMulticenter, prospective cohort study of patients discharged to the community after elective or emergent hospitalization. For all physician visits during 6 months after discharge, we identified the physician and the availability of particular information (including hospital discharge summary and any information from previous physician visits). Four physician continuity scores (preadmission; hospital admitting; hospital consultant; and postdischarge) and two information continuity scores (discharge summary and postdischarge visit information) were calculated for all patients (range: 0–1, where 0 is perfect discontinuity and 1 is perfect continuity).ResultsFour thousand five hundred fifty-three people were followed for a median of 175 days. Both provider (range of median values: 0–0.410) and information (range: 0.220–0.427) continuity scores were low and varied extensively over time. With a few exceptions, continuity measures were independent of each other. The influence of patient factors on continuity varied extensively between the continuity measures with the most influential factors being admission urgency, admitting service, and the number of physicians who regularly treated the patient.ConclusionBoth provider and information continuity was low in patients discharged from hospital. Continuity measures can change extensively over time, which are usually independent of each other, and are associated with patient and admission characteristics. Future studies should measure multiple components of provider and information continuity over time to completely capture continuity of care.     

Patient satisfaction and ethnic identity among American Indian older adults

Work in the field of culturally competent medical care draws on studies showing that minority Americans often report lower satisfaction with care than White Americans and recommends that providers should adapt care to patients' cultural needs. However, empirical evidence in support of cultural competence models is limited by reliance upon measurements of racial rather than ethnic identity and also by a near-total neglect of American Indians. This project explored the relationship between ethnic identity and satisfaction using survey data collected from 115 chronically ill American Indian patients >or=50 years at a Cherokee Nation clinic. Satisfaction scores were high overall and comparable to those found in the general population. Nevertheless, analysis using hierarchical linear modeling showed that patients' self-rated American Indian ethnic identity was significantly associated with satisfaction. Specifically, patients who rated themselves high on the measure of American Indian ethnic identity reported reduced scores on satisfaction with health care providers' social skill and attentiveness, as compared to those who rated themselves lower. Significant associations remained after controlling for patients' sex, age, education, marital status, self-reported health, wait time, and number of previous visits. There were no significant associations between patients' American Indian ethnic identity and satisfaction with provider's technical skill and shared decision-making. Likewise, there were no significant associations between satisfaction and a separate measure of White American ethnic identity, although a suggestive trend was observed for satisfaction with provider's social skill. Our findings demonstrate the importance of including measures of ethnic identity in studies of medical satisfaction in racial minority populations. They support the importance of adapting care to patient's cultural needs, and they highlight the particular significance of interpersonal communication for patient satisfaction among American Indians. Results will be of special interest to health researchers, clinicians, and policy makers working in fields related to minority health.     

Hospital efficiency and patient satisfaction.

The objective of this study was to investigate the relationship between efficiency and patient satisfaction for a sample of general, acute care hospitals in Ontario, Canada. A measure of patient satisfaction at the hospital level was constructed using data from a province-wide survey of patients in mid-1999. A measure of efficiency was constructed using data from a cost model used by the Ontario Ministry of Health, the primary funder of hospitals in Ontario. In accordance with previous studies, the model also included measures of hospital size, teaching status and rural location. Based on the results of this study, at a 95% confidence level, there does appear to be evidence to suggest that an inverse relationship between hospital efficiency and patient satisfaction exists. However, the magnitude of the effect appears to be small. Hospital size and teaching status also appear to affect satisfaction, with lower satisfaction scores reported among non-teaching and larger hospitals. This study did not find any evidence to suggest that hospital location (rural versus urban) or religious affiliation contributed to reports of patient satisfaction in any way not explained by the other measures included in the study. The findings imply that low patient satisfaction cannot be explained by excessive management concentration on efficiency. Managers should analyse some of the underlying causes of patient dissatisfaction before reconfiguring resources. It may be beneficial in larger hospitals to study the aspects of care that patients have reported they prefer in small hospitals.     

Patient satisfaction in pay for performance programs

Concerns about both the cost and quality of health care have led to a growing interest in, and call for "pay for performance." Increasingly, as well, patient satisfaction is being viewed as an essential aspect of care that should be considered in judging performance. At the same time, there are concerns about the validity of patient satisfaction as a relevant quality measure. We argue that patient satisfaction is not only an outcome measure, but also an essential part of the process of care itself. This experiential aspect of care, however, is evaluated by patients, whereas formal processes and outcomes are recorded and evaluated by providers. As such, the 2 measures are evaluating different aspects of care that need not--but typically do--coincide. We also suggest that where patient satisfaction is utilized in pay for performance calculations, it constitutes a very small portion of the total money at stake and is unlikely to lead to "gaming" through acquiescence to patients' requests for unnecessary treatments.     

Assessing medical student effectiveness from the psychiatric patient's perspective: the Medical Student Interviewing Performance Questionnaire

This study sought to develop and pilot-test a patient-completed rating scale of medical student effectiveness while training in psychiatry. Specifically, the study focused on: (1) examining the statistical reliability and validity of a new scale; (2) using the measure to assess patient satisfaction with medical student care during the psychiatry clerkship; and (3) providing some experience-based recommendations about utilizing patient feedback when training medical students in psychiatry. Data were collected over an entire academic year and involved 35 third-year medical students and ratings of their performance provided by 102 psychiatric inpatients. Participants were recruited from three inpatient units and the rate of participation was 62.5%. Principle components analyses of the Medical Student Interviewing Performance Scale (MSIPQ) showed that the overall scale consisted of two, theoretically relevant subscales called 'Rapport' and 'Treatment Feedback.' Each subscale had adequate reliability. In addition, the two subscales were shown to each account for unique variance in two separate questions assessing the patient's overall ratings of rapport and treatment helpfulness. Finally, patients' mean ratings of medical student effectiveness were examined and showed very high levels of satisfaction with the student-patient relationship and the quality of care received. This study is among the first to examine patient satisfaction with medical student providers among a general population of psychiatric inpatients. Recommendations are made about the ways in which the MSIPQ can be used to strengthen the training of medical students in psychiatry.     

Job satisfaction in the practice of clinical pharmacy.

Two groups of pharmacists (n = 69) assigned to 35 US Army Medical Treatment Facilities were surveyed to assess job satisfaction. Pharmacists providing patient care were significantly more satisfied on intrinsic job satisfaction measures than pharmacists not providing patient care. On the other hand, no significant difference in satisfaction was found between pharmacy groups on extrinsic job satisfaction measures. The results are discussed relative to intrinsic and extrinsic sources of job satisfaction and patient care.     

Self-rated oral health as an independent predictor of self-rated general health, self-esteem and life satisfaction

Self-rated health (SRH) is a useful summary measure of people's general health and was found to predict future health outcomes. Self-rated oral health (SROH) is a similarly useful summary measure of people's oral health. Both are related to quality of life, especially at old age. The objectives of the study were: (1) to assess the independent contribution of SROH to concurrent and future SRH of elderly people, controlling for sociodemographics and health measures, and, (2) to assess whether SROH adds unique information not captured by SRH by testing their independent associations with self-esteem and life satisfaction. Participants were 850 residents of a retirement community (mean age 73) interviewed in their homes at baseline and 5 years later. The interview included single-item self-ratings of general and oral health, self-reports of medical history, recent chronic diseases, medication usage, functional disability, self-esteem and life satisfaction. Multiple regression analyses showed that SROH had an independent effect on concurrent and future SRH, controlling for age and other measures of health status. Both SRH and SROH independently explained a significant amount of variance in concurrent ratings of self-esteem and life satisfaction. SROH has a unique role in people's perceptions of their overall health yet is not fully captured by SRH. Therefore, it should be considered by general health care providers in their assessments of the health status of older adults.     

Effects of patient demands on satisfaction with Japanese hospital care.

OBJECTIVE: The objective of this study was to detect whether there was any difference among the characteristics of patient satisfaction between two patient emphasis groups: patients demanding technical elements of hospital care and patients demanding interpersonal elements. DESIGN AND SETTING: The sample for this study was drawn from in-patients discharged from 77 voluntarily participating hospitals throughout Japan. The relationship between overall satisfaction with hospital care and patient satisfaction, and the evaluation of a hospital's reputation, was explored by stepwise multiple regression analysis of 33 variables relevant to aspects of hospital care for each patient group. RESULTS: In the interpersonal emphasis (IE) group, 'nurse's kindness and warmth' was associated significantly with overall satisfaction, while 'skill of nursing care' and 'nurse's explanation' were significant predictors of overall satisfaction in the technical emphasis (TE) group. On the other hand, 'doctor's clinical competence', 'recovery from distress and anxiety', and items pertaining to the hospital's reputation were significantly related to overall satisfaction in both emphasis groups. CONCLUSION: For overall patient satisfaction, it is essential to satisfy specific items related to the aspect of hospital care emphasized by the patient. Specific significant predictors of overall satisfaction (e.g. 'doctor's clinical competence') were indispensable measures of professional performance in hospital care, irrespective of the patients' emphasis. A positive perception of hospital reputation items might increase overall patient satisfaction with Japanese hospitals.     

Experience of services as a key outcome in amyotrophic lateral sclerosis (ALS) care: the case for a better understanding of patient experiences

People with amyotrophic lateral sclerosis (ALS) frequently express dissatisfaction with services. Patient satisfaction with services in ALS care is not always measured and service user perspectives are not usually included when evaluating the outcomes of care. There is a lack of consensus on what constitutes satisfaction for patients in ALS care. To date, health care professionals' conceptualization of outcomes in ALS care has excluded measures of patient satisfaction with services. Exploring the context of the ALS service user experience of care will identify a conceptual framework that will include the domains of satisfaction with care for patients with ALS. An instrument that draws on the ALS patient perspective of services, developed on the basis of qualitative investigation, should be used to measure satisfaction with services.     

Power calculation for the general two-sample Mendelian randomization analysis

Mendelian randomization (MR) study has become a powerful approach to assess the potential causal effect of a risk exposure on an outcome. Most current MR studies are conducted under the two-sample setting by combining summary data from two separate genome-wide association studies (GWAS), with one providing measures on associations between genetic markers and the risk exposure, and the other on associations between genetic markers and the outcome. We develop a power calculation procedure for the general two-sample MR study, allowing for the use of multiple genetic markers, and shared participants between the two GWAS. This procedure requires a few easy-to-interpret parameters and is validated through extensive simulation studies.     

Interpersonal and organizational dimensions of patient satisfaction: the moderating effects of health status.

OBJECTIVES: Based on Donabedian's structure, process, and outcome model, this study was conducted to identify the underlying dimensions of patient satisfaction for diabetic patients and determine the effects of demographic characteristics and health status on these dimensions. DESIGN: A cross-sectional analytical research design was used with a questionnaire, comprising demographic characteristics, the general and mental health items from the SF-20, and a 25-item patient satisfaction scale. SETTING AND STUDY PARTICIPANTS: The questionnaire was administered to 263 South African black diabetic outpatients from the diabetic clinics at two hospitals. There were 174 females and 89 males, aged between 16 and 89 years (mean = 53.5, sd = 13.9). The average number of years of schooling was 6.3 (sd = 4.1). Main outcome measure. A reliable and valid patient satisfaction scale. RESULTS: Factor analysis was conducted on the patient satisfaction scale and two factors, accounting for 71.6% of the variance, were extracted. The major items on Factor I were support, consideration, friendliness, and encouragement, labelled the interpersonal dimension. Factor II emphasized availability of a seat and toilet in the waiting area and cleanliness, labelled the organizational dimension. The two factors had very good reliability coefficients: 0.85 (organizational) and 0.98 (interpersonal). Multi-trait scaling showed that all items exceeded the item convergent (r > 0.40) and discriminant (Z > 1.96) validity criteria. Patients in poor general health were significantly less satisfied (P = 0.007) with the organizational quality of their care than patients in good health; patients in poor mental health were significantly less satisfied (P = 0.04) with the interpersonal quality of their care than patients in good mental health. CONCLUSIONS: The findings provided support for Donabedian's model. They demonstrated that attributes of providers and settings are major components of patient satisfaction, and showed that the scale is a reliable and valid measure of patient satisfaction for this South African population.     

The development and validation of the primary care satisfaction survey for women.

Assessing patient satisfaction with health care is becoming an integral component of quality monitoring in health care systems, but existing tools typically were developed to minimize differences related to gender. This paper reports the development and psychometric properties of a new survey instrument to measure women's satisfaction with their primary care. A multisite, cross-sectional validation survey of 1,202 women receiving care in primary care settings in Michigan, North Carolina, and Pennsylvania was conducted. Item response theory (IRT) and factor analysis methods were used to identify three scales in the Primary Care Satisfaction Survey for Women (PCSSW): Communication, Administration and Office Procedures, and Care Coordination and Comprehensiveness. Internal consistency reliability is reported, as well as convergent validity in relation to two generic measures (Medical Outcomes Study [MOS] Visit Satisfaction and Consumer Assessment of Health Plans Survey [CAHPS] overall quality rating); discriminant validity in relation to groups expected to have differing satisfaction levels based on previous literature; predictive validity in relation to behavioral intentions; and explanatory power in overall satisfaction ratings. The 24-item PCSSW may be self-administered or conducted by telephone and may be used in studies to evaluate or improve the quality of primary care for women.     

Measuring quality of palliative care: Psychometric properties of the FAMCARE Scale

This study measures quality of palliative care in 181 family members (i.e. spouse, child) to cancer victims with terminal disease 1 month after the time of death. The specific aim was to explore the underlying factor structure and dimensionality of the 20 items of the FAMCARE Scale, measuring family satisfaction with health care given to the patient and to them. The results from a factor analysis, a Mokken Scaling Program analysis, and a reliability analysis, showed that 19 out of the 20 items form a strong one-dimensional scale. Since the scale is one-dimensional, the possibility of reducing the number of items should be explored in future research. Our recommendation is to measure satisfaction with care 1–2 months after the death of the patient. One should also explore the possibilities of measuring satisfaction with care prospectively as an integral part of the palliative care program.     

Does managed care restrictiveness affect the perceived quality of primary care? A report from ASPN. Ambulatory Sentinel Practice Network

BACKGROUND: The competitive managed care marketplace is causing increased restrictiveness in the structure of health plans. The effect of plan restrictiveness on the delivery of primary care is unknown. Our purpose was to examine the association of the organizational and financial restrictiveness of managed care plans with important elements of primary care, the patient-clinician relationship, and patient satisfaction. METHODS: We conducted a cross-sectional study of 15 member practices of the Ambulatory Sentinel Practice Network selected to represent diverse health care markets. Each practice completed a Managed Care Survey to characterize the degree of organizational and financial restrictiveness for each individual health care plan. A total of 199 managed care plans were characterized. Then, 1475 consecutive outpatients completed a patient survey that included: the Components of Primary Care Instrument as a measure of attributes of primary care; a measure of the amount of inconvenience involved with using the health care plan; and the Medical Outcomes Study Visit Rating Form for assessing patient satisfaction. RESULTS: Clinicians' reports of inconvenience were significantly associated (P < .001) with the financial and organizational restrictiveness scores of the plan. There was no association between plan restrictiveness and patient report of multiple aspects of the delivery of primary care or patient satisfaction with the visit. CONCLUSIONS: Plan restrictiveness is associated with greater perceived hassle for clinicians but not for patients. Plan restrictiveness seems to be creating great pressures for clinicians, but is not affecting patients' reports of the quality of important attributes of primary care or satisfaction with the visit. Physicians and their staffs appear to be buffering patients from the potentially negative effects of plan restrictiveness.     

Reliability and validity of medical outcome and patient satisfaction measures among injured workers in Washington state: A pretest

Several existing measures of medical outcomes and some newly constructed measures of patient satisfaction were tested for reliability and validity on a sample of 100 subjects who had suffered work-related injuries and illnesses in Washington State. Included in the measures of medical outcome were the SF-36 and the upper body mobility subscale of the Health Assessment Questionnaire. The newly constructed measures of patient satisfaction assessed areas such as satisfaction with the attending physician and with access to referrals. Also administered were assessments of job satisfaction, both prior to and since the injury, and a measure of chance health locus of control. The patient satisfaction and medical outcomes measures demonstrated good reliability and validity for use with this population. However, neither the measures of job satisfaction nor chance health locus of control were related to either patient satisfaction with medical care nor to medical outcomes. Am. J. Ind. Med. 31:427–434, 1997. © 1997 Wiley-Liss, Inc.