Predicting Patient Satisfaction

Customer satisfaction is a fairly useful metric for business. Most business owners will say that the relationship between a positive customer experience and profit is evident. In the health care industry, many will argue that patient satisfaction is directly associated with better outcomes and health status. Satisfied patients will be more likely to follow recommended treatments and maintain a positive relationship with their health care practitioner. But, if dissatisfied, patients may make services less effective, either by neglecting to seek care when needed or refusing to comply with a prescribed course of treatment. Because patient satisfaction can influence both the efficacy of care and the perceived outcomes of treatment, a solid understanding of the determinants of patient satisfaction is needed.

Satisfaction can be measured from a number of different perspectives. For patients, a distinction is usually made between satisfaction with their medical care and satisfaction with their symptoms. As a measure of care, satisfaction is a patient’s rating of the quality of the medical care process. This will include an evaluation of the patient-practitioner relationship, the location and accessibility of services, continuity of care, and costs. As a measure of treatment outcome, satisfaction is the patient’s rating of their health status or symptoms after a particular treatment intervention. This will incorporate the physical, emotional, and social outcomes of treatment.

In a recent analysis, we aimed to determine predictors of satisfaction with care and symptoms in patients with acute low back pain (LBP), 1 year after presenting to primary care (Henschke et al. 2013). The study was a secondary analysis of a cohort of 1343 patients presenting with LBP to primary care. Logistic regression models were used to predict satisfaction with care and satisfaction with symptoms at the 12-month follow-up. We found that 12 months after visiting their primary care practitioner, most patients were highly satisfied with the care received (76%) but only a smaller proportion with their symptoms (55%). Interestingly, no differences in patient satisfaction were found with respect to the 3 different primary care professions (GPs, physios, and chiropractors). Patients who reported poor general health and who had more symptoms of depression at the initial visit were less likely to be satisfied with their symptoms at the 12-month follow-up. After controlling for pain intensity, higher satisfaction with medical care was more likely in patients born in Australia, who were older, and who had fewer symptoms of depression.

Research into patient satisfaction is growing, with one recent systematic review reporting that features contributing to high satisfaction with physiotherapy care include the skill, knowledge, professionalism, and communication provided by the therapist (Hush et al. 2011). When considered with the results of our study, the importance of the patient-practitioner relationship and the influence of pre-existing cultural (i.e. country of birth), demographic (i.e. age), and psychological barriers (i.e. depression) is highlighted. To improve service delivery in primary care, it is important that practitioners are aware of these barriers and their potential to influence a patient’s satisfaction with medical care.

About Nicholas Henschke

nicholas HenschkeNicholas is originally from Sydney, where he studied physiotherapy and completed his PhD on acute low back pain. After two years enjoying life as a post-doc in Amsterdam (following a year off to travel), he returned to work at the George Institute in Sydney.

Having an interest in epidemiology and global health, he has recently taken a research position in the Institute of Public Health at the University of Heidelberg, Germany. Along with musculoskeletal pain conditions, Nicholas also researches stroke rehabilitation and social determinants of health.

References

Henschke N, Wouda L, Maher CG, Hush JM, & van Tulder MW (2013). Determinants of patient satisfaction 1 year after presenting to primary care with acute low back pain. Clinical Journal of Pain, 29 (6), 512-7 PMID: 23448866

Hush JM, Cameron K, Mackey M. (2011). Patient satisfaction with musculoskeletal physical therapy care: a systematic review. Phys Ther., 91 (1), 25-36 DOI: 10.2522/ptj.20100061

 

Comments

  1. I should, then, feel more optimistic when a 68yo gentleman with a smile on his face walks through the clinic door!

    I had always assumed that the oft quoted ‘80%’ was the true number of people that recover spontaneously (i.e. no matter whether their back’s cracked or their legs are pulled) from an episode of LBP. I checked against the literature and there have been some recent findings of not so promising figures, with a systematic review by Itz et al (2013) suggesting that only a third of people with acute LBP have recovered (no pain at 1 year). The review did include studies which had people with back and leg pain, rather than just back pain alone. I guess the primary factor explaining the difference between the 33% and 55% is that your study looked at the satisfaction that people had with their symptoms, rather than the presence of pain only. I see that you also included people presenting with leg pain, and both studies looked at people presenting to primary care. I have realised from this I probably need to be more careful when I reassure someone that ‘you’ll get better’. I wonder too what the findings would be if we looked at the time course of symptoms in people who don’t seek the advice of primary care practitioners? Or whether we really did have a higher rate of recovery years ago?

    Itz, C. J., Geurts, J. W., van Kleef, M., & Nelemans, P. (2013). Clinical course of non-specific low back pain: a systematic review of prospective cohort studies set in primary care. Eur J Pain, 17(1), 5-15. doi: 10.1002/j.1532-2149.2012.00170.x

  2. Julia Hush says:

    To add to the patient satisfaction story, we recently asked whether there are different factors that influence patient satisfaction with musculoskeletal physiotherapy care in different cultures: Australia and Korea (Hush, et al., 2013). Consistent with the findings described by Nick and other international data, we found that the interpersonal aspects of patient care, namely effective communication and respect from the therapist, seem to be a universal factor determining patient satisfaction across cultures. However, we also found a factor that was unique to the Korean culture: the expectation of courtesy and propriety throughout the process of care. An unexpected finding in both Australian and Korean cohorts was that global patient satisfaction was only weakly correlated with the outcome of treatment, so patients could be satisfied with care even if their symptoms didn’t improve much.

    The clinical implication of these results is that effective communication and other inter-personal skills are critical for patient satisfaction, even when treatment outcomes are not perceived as optimal. Patient satisfaction can be further enhanced if therapists understand and address additional features of care that uniquely contribute to patient satisfaction in the cultural context in which they are working.

    Prue – to answer your question about the course of LBP in those not necessarily seeking treatment, have a look at the recently published data from the HUNT study (Vasseljen, et al., 2013). The results are rather sobering and provide pretty solid evidence that our previous notions about 90% of acute back pain recovering, were in fact wishful thinking. This study shows, in a large cohort of patients in Norway, that while pain does reduce substantially in the first 2 months after onset, only 1/3 have recovered at that point, and there is little improvement after that.

    Clearly we need to better understand the factors contributing to resilience on the one hand, and vulnerability on the other, for the development of chronic back pain. In the meantime, if we can work on our interpersonal and communication skills, at least we can keep our patients happy.

    Hush, J. M., Lee, H., Yung, V., Adams, R., Mackey, M., Wand, B. M., et al. (2013). Intercultural comparison of patient satisfaction with physiotherapy care in Australia and Korea: an exploratory factor analysis. Journal of Manual & Manipulative Therapy, 21(2), 103-112.
    Vasseljen, O., Woodhouse, A., Bjørngaard, J. H., & Leivseth, L. (2013). Natural course of acute neck and low back pain in the general population: The HUNT study. Pain.

  3. At the risk of coming across as contrary, I wonder what place measurement of satisfaction with care has in healthcare practice. If patient satisfaction (with care) is not especially well related to clinical outcome, as mentioned by Julia, then why are we interested in it? It makes sense within a pure business model, as per Nick’s comments at the start of the article but is that the same for healthcare?
    The downside of patient satisfaction could conceivably be an increase in healthcare utilisation, i.e. if someone is happy with the service, then they’ll probably want more of it. This is pretty much what was found in a large US study published last year (Fenton et al. Arch Intern Med. 2012;172(5):405-411). They found that increased satisfaction 1 year after study entry was associted with higher total healthcare expenditure and drug usage in the following year.
    They also found that higher satisfaction was associated with increased mortality, but unfortunately resisted the temptation to title the study; “Satisfaction kills”.

    Julia Hush Reply:

    Good question Steve! I think the fact that communication comes out as the number one factor for satisfaction really tells us a lot. Our patients really value being empowered with knowledge about their condition, what to expect regarding prognosis, strategies to self-manage and prevent recurrence etc. These are valuable aspects of physiotherapists’ clinical care that can contribute to high patient satisfaction. There are many conditions that physiotherapists treat (eg chronic pain) where there may be little improvement in symptoms over time, but these other aspects of care can make a difference to quality of life, self-efficacy etc. As usual it comes back to what you measure and how.

    Regarding the Fenton study – which was about physician visits – t’s not surprising that more satisfied patients had higher drug usage, since most patients see their GP expecting drugs to be prescribed. The correlation with higher mortality is interesting. Maybe they were just older and more likely to die (older patients are more satisfied with their healthcare (McKinnon 2001)). Still, I don’t know how they resisted that title!

    McKinnon AL. (2001). Client Satisfaction with Physical Therapy Services: Does Age Make a Difference? Physical & Occupational Therapy In Geriatrics, 19(2), 23-37.

    steve k Reply:

    I think this is interesting within the current paradigm that places a high value on self-management, espcially for chronic disorders. To some extent I would think more self-management should (on average) correspond to decreased contact with healthcare providers. If this is so, is there a danger, as clinical providers in optimising our product to increase satisfaction? Maybe this has the effect of increasing contact/reliance, rather than increasing self-management?