Satisfaction

Satisfaction with the Process of Care

We do a lot of research and patients are happy on average to give us some time to complete some questionnaires (1).

Our early studies of patient satisfaction addressed the psychological determinants of health.  Greater symptoms of depression are associated with lower satisfaction, but much of the variation in satisfaction was not accounted for (2-4).

Pre-operative and pre-visit expectations don’t seem to effect satisfaction (5, 6, 6B). Met expectations is likely the same construct as satisfaction.  They seem to related to met expectations with respect to communication and a good relationship between clinician and patient—which relates to measures of empathy. Pre-visit expectations and post-visit met expectations correlate with psychological determinants of illness (6B).

Discordance between a patient’s explanatory model and expert advice was associated with greater symptoms and limitations (7), which relate to the psychological and social determinants of illness.  Discussions about the psychosocial aspects of illness and discrepancies between patient and expert sense of what is going on are difficult discussions that may lead to low perceived empathy and dissatisfaction.

In a randomized trial, we found that—on average—using feedback about patient reported outcome measures led to more frequent discussion of the psychological and social determinants of illness without decreasing satisfaction (8).  The lesson here was that, while some patients are offended by these discussions, most are open to them.  And specific techniques may make this easier for clinicians and patients.

Perceived empathy correlates so well with satisfaction that they are probably measuring the same construct (9).  Some satisfaction measures have questions similar to empathy measures. We studied one 21 question measure that had several items similar to the CARE measure of empathy and it had a small correlation with an 11-point ordinal single question measure of satisfaction(9B)  Existing empathy measures and satisfaction measures both have very high ceiling effects (most people give the highest possible scores).

Longer visits don’t create more satisfaction or perceived empathy (10, 11). It seems to be a matter of quality, not quantity.  Spanish-speaking patients seeing an English-speaking surgeon ask fewer questions (12) and are less satisfied (12B). It’s important to ask people what they are thinking or say “tell me your questions” rather than “do you have any questions”.

Collection of patient satisfaction data is difficult and costly.  We found that peer impressions about attention to quality and safety correlate with patient impressions of communication effectiveness (13).  It can be more feasible and less costly to get feedback from one’s peers.

Warmth and competence seem to be the key ingredients of activation of a patient’s inner health physiology (the placebo effect), but we did not see a change in patient-reported outcomes during a single specialist visit when the rating of perceived empathy was high (14).

Our consortium of Austin area orthopedic surgeons in collaboration with our network of research volunteers is helping with some rapid cycle learning trying to advance our knowledge and skills. In a randomized trial, we found that the content of questionnaires (positively vs. negatively framed) used to assess the psychological determinants of illness did not affect perceived empathy and satisfaction measured at the end of the visit (15).

We also measured satisfaction immediately after the visit and then measured it again 2 weeks later (consistent with how most surveys and independent parties assess satisfaction) and found minimal differences suggesting that the more practical method of measuring immediately after the visit is representative.

Our current research is focusing largely on perceived empathy since that seems to be the key elements associated with satisfaction with the process of care.  Measurement of satisfaction with the outcome is discouraged—it’s better to measure the impact on symptoms and limitations (16).

We are doing both qualitative and quantitative studies to develop improved measures of satisfaction with the process of care.  We are looking for a measure distinct from measures of perceived empathy so that we can better study how perceived empathy impacts satisfaction with the process of care.  We also need measures of satisfaction and perceived empathy with fewer ceiling effects (ratings of optimal satisfaction) so we can learn more about how to improve the processes of care. The censoring (lack of distinction at the highest levels of satisfaction) makes it more difficult to learn and improve.

References:

  1. Barber LA, Hageman MG, King JD, Bekkers S, Bot AG, Ring D. The influence of patients’ participation in research on their satisfaction. J Hand Surg Am. 2014 Aug;39(8):1591-4.e3. doi: 10.1016/j.jhsa.2014.04.032. Epub 2014 Jun 2. PubMed PMID: 24881898.
  2. Lozano Calderón SA, Paiva A, Ring D. Patient satisfaction after open carpal tunnel release correlates with depression. J Hand Surg Am. 2008 Mar;33(3):303-7. doi: 10.1016/j.jhsa.2007.11.025. PubMed PMID: 18343281.
  3. Vranceanu AM, Ring D. Factors associated with patient satisfaction. J Hand Surg Am. 2011 Sep;36(9):1504-8. doi: 10.1016/j.jhsa.2011.06.001. Epub 2011 Jul 27. PubMed PMID: 21794990.
  4. Bot AG, Bossen JK, Herndon JH, Ruchelsman DE, Ring D, Vranceanu AM. Informed shared decision-making and patient satisfaction. Psychosomatics. 2014 Nov-Dec;55(6):586-94. doi: 10.1016/j.psym.2013.12.013. Epub 2014 Jan 3. PubMed PMID: 24836165.
  5. Kadzielski J, Malhotra LR, Zurakowski D, Lee SG, Jupiter JB, Ring D. Evaluation of preoperative expectations and patient satisfaction after carpal tunnel release. J Hand Surg Am. 2008 Dec;33(10):1783-8. doi: 10.1016/j.jhsa.2008.06.019. PubMed PMID: 19084178.
  6. Hageman MG, Briët JP, Bossen JK, Blok RD, Ring DC, Vranceanu AM. Do previsit expectations correlate with satisfaction of new patients presenting for evaluation with an orthopaedic surgical practice? Clin Orthop Relat Res. 2015 Feb;473(2):716-21. doi: 10.1007/s11999-014-3970-6. Epub 2014 Oct 1. PubMed PMID: 25269531; PubMed Central PMCID: PMC4294929. 6B. Briet JP, Hageman MG, Overbeek CL, Mudgal C, Ring DC, Vranceanu AM. Factors Associated With Met Expectations in Patients With Hand and Upper Extremity Disorders: A Pilot Study. Psychosomatics. 2016 Apr 12. pii: S0033-3182(16)00014-1. doi: 10.1016/j.psym.2016.02.004. [Epub ahead of print] PubMed PMID: 27080458.
  7. Strooker JA, Nota SP, Hageman MG, Ring DC. Patients with greater symptom intensity and more disability are more likely to be surprised by a hand surgeon’s advice. Clin Orthop Relat Res. 2015 Apr;473(4):1478-83. doi: 10.1007/s11999-014-3971-5. Epub 2014 Oct 4. PubMed PMID: 25280552; PubMed Central PMCID: PMC4353519.
  8. Mellema JJ, O’Connor CM, Overbeek CL, Hageman MG, Ring D. The effect of feedback regarding coping strategies and illness behavior on hand surgery patient satisfaction and communication: a randomized controlled trial. Hand (N Y). 2015 Sep;10(3):503-11. doi: 10.1007/s11552-015-9742-2. PubMed PMID: 26330786; PubMed Central PMCID: PMC4551630.
  9. Menendez ME, Chen NC, Mudgal CS, Jupiter JB, Ring D. Physician Empathy as a Driver of Hand Surgery Patient Satisfaction. J Hand Surg Am. 2015 Sep;40(9):1860-5.e2. doi: 10.1016/j.jhsa.2015.06.105. Epub 2015 Jul 29. PubMed PMID: 26231482. 9B. van Berckel MM, Bosma NH, Hageman MG, Ring D, Vranceanu AM. The Correlation Between a Numerical Rating Scale of Patient Satisfaction With Current Management of an Upper Extremity Disorder and a General Measure of Satisfaction With the Medical Visit. Hand (N Y). 2017 Mar;12(2):202-206. doi: 10.1177/1558944716662019. Epub 2016 Aug 19. PubMed PMID: 28344535; PubMed Central PMCID: PMC5349416
  10. Teunis T, Thornton ER, Jayakumar P, Ring D. Time Seeing a Hand Surgeon Is Not Associated With Patient Satisfaction. Clin Orthop Relat Res. 2015 Jul;473(7):2362-8. doi: 10.1007/s11999-014-4090-z. Epub 2014 Dec 5. PubMed PMID: 25475717; PubMed Central PMCID: PMC4457762.
  11. Parrish RC 2nd, Menendez ME, Mudgal CS, Jupiter JB, Chen NC, Ring D. Patient Satisfaction and its Relation to Perceived Visit Duration With a Hand Surgeon. J Hand Surg Am. 2016 Feb;41(2):257-62.e1-4. doi: 10.1016/j.jhsa.2015.11.015. Epub 2015 Dec 22. PubMed PMID: 26718069.
  12. Menendez ME, van Hoorn BT, Mackert M, Donovan EE, Chen NC, Ring D. Patients With Limited Health Literacy Ask Fewer Questions During Office Visits With Hand Surgeons. Clin Orthop Relat Res. 2016 Oct 28. [Epub ahead of print] PubMed PMID: 27796802 12BMenendez ME, Loeffler M, Ring D. Patient Satisfaction in an Outpatient Hand Surgery Office: A Comparison of English- and Spanish-Speaking Patients. Qual Manag Health Care. 2015 Oct-Dec;24(4):183-9. doi: 10.1097/QMH.0000000000000074. PubMed PMID: 26426319.
  13. Hageman MG, Ring DC, Gregory PJ, Rubash HE, Harmon L. Do 360-degree feedback survey results relate to patient satisfaction measures? Clin Orthop Relat Res. 2015 May;473(5):1590-7. doi: 10.1007/s11999-014-3981-3. PubMed PMID: 25287521; PubMed Central PMCID: PMC4385380.
  14. Kootstra TJM, Wilkens SC, Menendez ME, Ring D. Is Physician Empathy Associated With Differences in Pain and Functional Limitations After a Hand Surgeon Visit? Clin Orthop Relat Res. 2018 Apr;476(4):801-807. doi: 10.1007/s11999.0000000000000077. PubMed PMID: 29481341.
  15. Keulen MHF, Teunis T, Vagner GA, Ring D, Reichel LM. The Effect of the Content of Patient-Reported Outcome Measures on Patient Perceived Empathy and Satisfaction: A Randomized Controlled Trial. J Hand Surg Am. 2018 Jun 8. pii: S0363-5023(17)31732-X. doi: 10.1016/j.jhsa.2018.04.020. [Epub ahead of print] PubMed PMID: 29891272.
  16. Ring D, Leopold SS. Editorial-Measuring Satisfaction: Can It Be Done? Clin Orthop Relat Res. 2015 Oct;473(10):3071-3. doi: 10.1007/s11999-015-4485-5. Epub 2015 Jul 31. PubMed PMID: 26228896; PubMed Central PMCID: PMC4562933.

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