High Satisfaction Rating by Users of Private-for-profit Healthcare Providers—evidence from a Cross-sectional Survey Among Inpatients of a Private Tertiary Level Hospital of North India

Abstract

Background:

Evaluation of outcomes can help improve the quality of provision of services within a healthcare setting. There is limited report on patient satisfaction in private-sector in India although they provide three-quarters of healthcare services.

Aim:

The study was designed to report the level of satisfaction among inpatients of a private tertiary care hospital in India.

Materials and Methods:

A total of 102 participants were recruited and their socio-demographic, health-seeking behavior, and satisfaction rating on various aspects of healthcare were elicited. A five item Likert scale was used to obtain the satisfaction rating. Data analysis was done with the help of Stata version-9. Proportions for the discrete variables and means with Standard Deviation for the continuous variables were obtained.

Results:

All the participants were urban and from upper-middle or upper socio-economic strata. The participants reported a high level of overall satisfaction (93%) as well as high satisfaction with physicians (95%), the doctor's interpersonal skills (99%), nursing-care (93%), general services (94%), and pharmacy (88.1%).

Conclusion:

There was a high level of satisfaction reported by the participants at this tertiary level hospital. This might reflect the actual good quality services being provided by the provider or the nonannoying response, which cannot be ruled out.

Introduction

The usual measures of healthcare outcomes are changes in mortality and morbidity rates after treatment by the service provider, complication rates after treatment or surgeries and patient satisfaction with the care provided, etc.[1] Patient satisfaction is regarded as an important outcome of care and has been demonstrated to influence health-related behavior.[2–6] The evaluation of outcomes may help improve upon the quality of provision of healthcare services. Economic development and urbanization has transformed people in becoming more assertive and demanding.

In developed countries, the use of patient satisfaction as an outcome measure of health care has increased considerably over the past decade. Medical group decisions regarding physician employment and compensation are increasingly being based on patient satisfaction ratings.[7,8] Patients’ perception of the quality of a physician office visit can be affected both by the quality of the physician's care directly and that of the organizational system.[9] Part of observed differences in satisfaction rates can be ascribed to patients’ demographic characteristics such as diversity of their cultural backgrounds, and the expectations among different social strata.[10] The differences in the quality of health care reflected in patient satisfaction due to cultural diversity also emerge within the same health care system.[11–15]

Increasing life-expectancy, growth of economy, medical innovation, and globalization has ushered the age of ‘degenerative diseases’ and problems of aging.[16] Patient satisfaction as an outcome measure of health care has not been systematically examined in India especially in private healthcare facilities although an estimated 81% of all outpatient and 46% of inpatient care are provided by them.[17] A study among the inpatients reported 74.1% satisfaction with the overall care received.[18] The current study was undertaken to evaluate the level of satisfaction and its determinants among the inpatients of a tertiary care private hospital of north India.

Materials and Methods

The study was undertaken in the internal medicine department of a 250 bedded, multispecialty private-for-profit tertiary-level hospital of India. The hospital serves people from nearby areas as well as from abroad. The patients visiting the institute are from the higher economic groups as well as those belonging to medium- and low-income groups and having medical insurance.

Sampling issues

The patient satisfaction level recently reported in a study from a tertiary-level government hospital in India was between 70% and 80%.[18] Although the profile of patients at this institute is expected to differ from our study site, we could not find any reported study from a private tertiary-care hospital in India. We considered 75% as the anticipated satisfaction level of inpatients at the study site chosen. At a confidence level of 95% and with 12% relative precision, our primary outcome (overall satisfaction level) can be expected to lie between 66% and 84%. We got a sample size of 89 with the above criteria. It was proposed to recruit 100 participants for the study to account for anticipated 90% response rate.

Study participants and data collection

All the participants aged 18–60 years and admitted for at least 24 hours were approached consecutively at the time of discharge. Only literate participants who could self-administer the study questionnaire were recruited. The study instrument had closed-ended questions. Satisfaction was graded using a five-item Likert scale. The instrument consisted of two sections to elicit responses on selected socio-demographic variables and satisfaction ratings, respectively. We recruited participants admitted between January and February 2011.

Ethical issues

Written permission was obtained from the director of the study hospital. Informed consent was elicited from the participants. Confidentiality and privacy of participants were ensured by excluding identification details from the study instrument.

Statistical analysis

Data analysis was done with the help of statistical software Stata version 9 (StataCorp, College Station, Texas). Proportions with confidence intervals for the discrete variables and means and Standard Deviation for the continuous variables were calculated.

Results

A total of 102 participants were recruited for the current study. All the participants resided within urban areas. Table 1 depicts the selected characteristics of the study participants. There was no statistical significance in difference observed between both sexes across different age groups and educational-qualification. The modified Kuppuswamy scale was used to report the socio-economic status of the participants.[19] Information on socio-economic status, family type and marital status was not available for two participants. Of the total participants, 65 (63.7%) belonged to nuclear families and 35 (34.3%) stayed in joint families. The majority of the unmarried participants (20, 19.6%) were male (80%). Sixty-nine (67.6%) participants were currently married. Six participants reported being either divorced, separated, or being widowed and not remarried. Five participants reported their status as ‘others’. The majority of participants (86, 84.3%) identified themselves as Hindu, 2 were Muslim, 9 Sikh and 5 reported their religion as ‘others’. Three participants were foreigners, while the rest were of Indian origin. Among participants reporting Indian origin, 64 (64.6%) had no history of international exposure or travel while 35 reported so.

Table 1.

Characteristics of the study participants (n = 102)

Mean hospital stay of the participants was 4 days (95% CI 3.2, 4.8 days). Mean hospital stay was similar in both sexes (males—4 days, 95% CI 3.1, 4.8 days; females—4 days, 95% CI 2.5, 5.4 days). Participants residing locally reported statistically insignificant longer stay (4.2 days 95% CI 3.2, 5.2 days) compared with outsiders (mean 3.3 days and 95% CI 2.1, 4.6 days).

A high 99% of participants reported that the treatment helped them either a great deal (86, 84.5%) or helped quite a bit (15, 14.7%). The satisfaction ratings by the participants were high for all the parameters except for prior information about expensive investigation, visit by junior doctors, and prior information about visit of referral physician [Table 2]. Females reported marginally higher satisfaction with these parameters although the differences were not significant. The overall satisfaction with the treating physician was reported as very good or excellent by 62.7% and 16.6% of participants, respectively. None of the participants reported poor satisfaction with their treating physician or nursing staff [Table 3]. All the participants were reported to be satisfied with the willingness of nursing staff to listen to their questions and problems.

Table 2.

Level of satisfaction with the physician and nursing services (n = 102) [Grading – Yes/No, only affirmative responses reported here]

Table 3.

Perception about overall interpersonal skills and satisfaction with treating physician as well as Perception about listening skills of nursing staff (n = 102)

Table 4 reports the five-point Likert scale satisfaction ratings of the participants different types of care received. Only one participant did not agree that the hospital provided better service and care as compared with past experience. Compared with other parameters, participants were more likely to be less satisfied with the cost of treatment at the hospital. Of the 19 (18.7%) participants not comfortable with cost of treatment, 14 had paid for the hospital expenses out of pocket as compared with 5 participants who had either medical policy or work cover. The majority of the participants agreed that the doctors gave them appropriate courtesy and respect and they would recommend their doctor to their family or friends. The explanation of side-effects of medicines elicited some disagreements as did explanation of pre-investigation instructions. All other parameters elicited a high level of satisfaction rating [Table 4]. The satisfaction with the overall services of the hospital was 93%.

Table 4.

Level of satisfaction reported (n = 102) [Figures in parentheses are percentages unless specified]

Discussion

There are only limited studies available on patient satisfaction among inpatients in developing countries, especially India.[18,20] More organized attempts have been made to measure quality of care from patients’ view point in Americas and Europe.[21–23] Studies usually report satisfaction level among outpatients at different levels of healthcare.[24] All the participants in the current study were from either upper-middle or upper socio-economic class. Considering the cost of treatment at private-for-profit health institutions, this was not surprising. A considerable number of participants reported having either medical policy or work cover to take care of their hospital expenses. Medical insurance and risk pooling are not very common practices in India. The Government of India has recently introduced Rashtriya Swasthya Bima Yojana (RSBY). Below Poverty Line (BPL) families can access out-patient/inpatient care or investigations worth Indian National Rupee (INR) 30000 from public or private-empanelled hospitals by paying INR 30 as annual premium.[25] Previous studies have reported that insured hospitalized patients did not have significantly higher levels of satisfaction compared with uninsured hospitalized patients.[26] Moreover, poor patients from developing countries tend to receive care from less qualified providers.[27] The model of insurance-based healthcare can go a long way in provision of quality healthcare to other sections of the society only after proper planning and better negotiation by policy makers and public health managers with the empanelled providers.

Participants reported high overall satisfaction and satisfaction with treating physician, nursing, and support staff as well as for other services like general services, cleanliness, pharmacy, food, and catering, etc. Although the possibility of selection bias could not be ruled out owing to nonavailability of the details of patients who refused participation in the study, refusal was reported to be negligible by the floor coordinators. The study was restricted to internal medicine inpatients. The patient profile might be different here compared with other specialities. Level of satisfaction from out-patient departments is usually reported to be lower due to longer waiting time and shorter consultation time. The expectations of patients are prompt care and listening to their side of ‘sickness-story’. Moreover, as the study was conducted on participants getting discharged, socially appropriate responses cannot be ruled out. Patients admitted for shorter duration are usually not suffering from life-threatening conditions necessitating invasive and inconvenient treatment modalities. In our study, the mean duration of hospital stay was only 4 days. Studies have demonstrated that client satisfaction has cultural connotations and provider behavior might be more predictive of patient satisfaction than technical competence.[28,29] The patients usually prefer private providers who are considered more accessible even though the public health-care is mostly free or highly subsidized in India.[30] Similar findings have been reported from other parts of the world with higher client satisfaction with private providers owing to greater attention and sensitivity to client's need even in the face of similar technical quality of service provided.[31]

Our study had high proportion (91.2%) of participants reporting that they would recommend the hospital to their family or friends which was comparable (95% report) to a similar study from a tertiary public hospital of Srinagar in India.[32] Special mention can be made of concern shown to the elderly in explanation of the need of medications and their potential side effects by nursing staff, etc. These need to be explored in more details by doing further research. None of the study variables were significant predictor of overall satisfaction with the hospital services. This might be because the study was not powered enough to undertake subgroup analysis.

Patient-centric surveys should be undertaken at frequent intervals in health-care facilities providing inpatient care so that services can be appropriately improved.[33] This is one of the few attempts at measuring the satisfaction level of inpatients at a private tertiary level health facility. Analysis of already completed client satisfaction surveys has reported little evidence of reliability and validity.[34] The authors did not attempt to establish these due to a shortage of time and other resources. The instrument used is more of a feedback elicitation than a standardized client satisfaction scale and needs further refinement. Measurement of client or patient satisfaction is highly complex and many times the whole exercise might seem to be futile. Developed countries usually utilize mail surveys to get the responses which would be difficult to replicate in India owing to lower level of functional literacy.

Conclusion

The current study reported high level of satisfaction among inpatients of a private tertiary care hospital in India. This might reflect the actual good quality services being provided by the provider or the non-annoying response, which cannot be ruled out. With the current impetus growing on medical tourism and showcasing India's efforts in hospitality and patient care, this report vindicates the notion of private healthcare providers of their patient-friendly services.