Abstract
Background
Patient satisfaction is associated with increased compliance, improved treatment outcomes, and decreased risk of litigation. Factors such as patient understanding and psychological well-being are recognized influences on satisfaction. Less is known about the relationship between previsit expectations and satisfaction.
Questions/purposes
(1) Are there correlations among previsit expectations, met expectations, and patient satisfaction? (2) What are the categories of expectations, and which one(s) correlate with satisfaction?
Methods
Eighty-six new patients presenting to a hand surgery practice of a tertiary referral hospital with 70% direct primary care referrals, mostly with elective concerns, indicated their previsit expectations (Patient Intention Questionnaire [PIQ]). Immediately after the visit, the same patients rated the degree to which their previsit expectations were met (Expectation Met Questionnaire [EMQ]) and their satisfaction level (Medical Interview Satisfaction Scale). These tools have been used in primary care office settings and claim good psychometric properties, and although they have not been strictly validated for responsiveness and other test parameters, they have good face validity. We then conducted a multivariable backward linear regression to determine whether (1) scores on the PIQ; and (2) scores on the EMQ are associated with satisfaction.
Results
Satisfaction correlated with met expectations (r = 0.36; p < 0.001) but not with previsit expectations (r = −0.01, p = 0.94). We identified five primary categories of previsit expectations that accounted for 50% of the variance in PIQ: (1) “Information and Explanation”; (2) “Emotional and Understanding”; (3) “Emotional Problems”; (4) “Diagnostics”; and (5) “Comforting”. The only category of met expectations that correlated with satisfaction was Information and Explanation (r = 0.43; p < 0.001).
Conclusions
Among patients seeing a hand surgeon, met expectations correlate with satisfaction. In particular, patients with met expectations regarding information and explanation were more satisfied with their visit. Efforts to determine the most effective methods for conveying unexpected information warrant investigation.
Level of Evidence
Level II, prognostic study.
Electronic supplementary material
The online version of this article (doi:10.1007/s11999-014-3970-6) contains supplementary material, which is available to authorized users.
Introduction
Patient satisfaction measures are increasingly used to evaluate the quality of medical service [11]. Patient satisfaction is associated with increased compliance, improved treatment outcomes across a variety of medical settings [22], decreased risk of litigation [10], and patient ratings of the quality of their care. Patient satisfaction is affected by patient understanding of their own health and psychological well-being [9]. Sociodemographic factors can also affect patient satisfaction [5, 7, 8, 14, 24, 27].
It is likely, however, that other factors–as yet unexplored–may influence patient satisfaction with a medical encounter. Met expectations are associated with better patient satisfaction in population surveys and primary care settings [3, 23, 27]. However, the relationship between previsit or preoperative expectations and satisfaction is inconsistent [3, 12]. A study among primary care patients found that previsit expectations (whether they were realistic or unrealistic) were not associated with satisfaction [3]. Research among orthopaedic patients undergoing surgery for lower back pain found that higher previsit expectations of pain relief were associated with lower satisfaction, whereas higher previsit expectations of improved function were associated with higher satisfaction [12]. Because of the inconsistencies across studies in terms of the association between previsit expectations and satisfaction [3, 12] as well as the paucity of research on met expectations outside of primary care settings, we sought to evaluate the relationships among previsit expectations, met expectations, and satisfaction with a hand surgery outpatient visit. Specifically, we aimed to identify (1) patient previsit expectations (level and type) for a hand surgery office visit; and (2) the association of previsit expectations and met expectations with satisfaction.
Study Questions
This study attempts to answer the following questions: (1) Are there correlations among previsit expectations, met expectations, and patient satisfaction? (2) What are the categories of expectations, and which one(s) correlate with satisfaction?
Patients and Methods
Study Design and Setting
This was an observational cross-sectional study. Between September 2012 and December 9, 2012, adult, English-speaking patients presenting to the practice of one of three orthopaedic hand surgeons (JJ, CM, DCR) for an initial evaluation were invited to enroll under a protocol approved by our Human Research Committee. The study was described in detail and the treating physician/study staff obtained informed consent.
Participants/Study Subjects
One hundred two patients were enrolled in the study. Of these, six were excluded as a result of lack of English proficiency, three declined participation after enrollment, and seven patients did not complete the second part of the questionnaire after their medical appointment, most claiming lack of time. Analyses were done on a final sample of 86 patients (Table 1).
Table 1.
Patients’ demographics (n = 86)
| Demographic | Mean | SD | Range |
|---|---|---|---|
| Age (years) | 44 | 16 | 19–77 |
| Education | 16 | 3 | 10–22 |
| Overall health (SD) | 8 | 2 | 2–10 |
| Number | Percent | ||
|---|---|---|---|
| Sex | |||
| Men | 43 | 50 | |
| Women | 43 | 50 | |
| Race | |||
| White | 72 | 84 | |
| Black | 4 | 5 | |
| Asian | 4 | 5 | |
| American Indian or Alaskan Native | 0 | 0 | |
| More than one race | 1 | 1 | |
| Other or unknown | 5 | 6 | |
| Diagnosis | |||
| Acute injuries | 48 | 56 | |
| Nonspecific arm pain | 7 | 8 | |
| Carpal tunnel syndrome | 1 | 1 | |
| Ganglion | 5 | 6 | |
| Dequervain | 4 | 5 | |
| Trigger finger | 4 | 5 | |
| Dupuytren | 2 | 2 | |
| Osteoarthritis | 1 | 1 | |
| Other | 14 | 16 | |
| Work status | |||
| Working full-time | 56 | 65 | |
| Working part-time | 8 | 9 | |
| Homemaker | 0 | 0 | |
| Retired | 9 | 10 | |
| Unemployed, able to work | 5 | 6 | |
| Unemployed, unable to work | 5 | 6 | |
| Workers compensation | 1 | 1 | |
| Currently on sick leave | 1 | 1 | |
| Marital status | |||
| Single | 33 | 39 | |
| Living with partner | 3 | 3 | |
| Married | 43 | 50 | |
| Separated/divorced | 6 | 7 | |
| Widowed | 1 | 1 | |
| Physician | |||
| Surgeon 1 | 3 | 4 | |
| Surgeon 2 | 77 | 90 | |
| Surgeon 3 | 6 | 7 | |
Variables, Outcome Measures, Data Sources, and Bias
Before the medical encounter with the hand specialist, patients completed the Patient Intentions Questionnaire (PIQ) [20] and a demographics and medical profile questionnaire. After the encounter patients, completed the Expectations Met Questionnaire (EMQ) [25] and the Medical Interview Satisfaction Scale (MISS) [13, 18, 26].
Measures
The PIQ [20] consists of 34 equally weighted statements measuring a patient’s previsit expectations and specific goals for a primary care medical visit [25]. Examples include: “I want my GP [general practitioner] to understand the problem”; “I want the GP to explain my emotional problems.” All items in the PIQ were scored on a 3-point Likert scale (agree, uncertain, or disagree). We modified the term “GP” to “doctor” in the PIQ questions to match the study setting (Appendix 1 [Supplemental materials are available with the online version of CORR®.]). The PIQ score represents the percentage of expectations endorsed before the visit divided by the total potential previsit expectations.
The EMQ [25] consists of the same 34 statements on the PIQ aimed to determine if a patient’s expectations were met after the visit. For example, “The doctor understood the problem”; “The doctor explained my emotional problems.” Comparable with the PIQ, all items in the EMQ were scored on a 3-point Likert scale (agree, uncertain, or disagree). The EMQ was scored as percentage of met expectation per item in the PIQ as initially endorsed by the patient.
The results of the PIQ and EMQ were divided into three groups according to low previsit and met expectation (0%–35%), moderately and uncertain previsit and met expectation (36%–80%), and highly previsit and met expectation (81%–100%), consistent with previously developed methodology [27].
The MISS [13, 18, 26] includes 21 items measuring satisfaction with a medical encounter (eg, “The doctor seemed to take my problems seriously”). All items were scored on a 7-point Likert scale from very unsatisfied to completely satisfied. In the digital version of the MISS, question 6 (“The doctor seemed to be interested in me as a person”) was constantly skipped for all patients as a result of a mistake in how the questionnaire was adapted from the paper-based questionnaire. This question was part of the Rapport subscale, which is comprised of seven other similar questions, which represent this aspect of the visit well (eg, “The doctor seemed warm and friendly to me” and “The doctor seemed to take my problems seriously”). A mean satisfaction index score was calculated by dividing the total satisfaction score by the total number of answered questions.
The primary measures used in this study have good psychometric properties as evidenced by internal consistency reliability α between 0.84 and 0.97 [27] as well as validation in patients with back pain [6] and in primary care [13, 23, 27].
Statistical Analysis, Study Size
An a priori power analyses indicated that a sample of 84 patients total would provide 80% statistical power with α = 0.05 for a moderate effect size of 0.5 based on an analysis of variance (ANOVA).
Continuous data were presented as means when normally distributed. When data were not normally distributed, we reported the median with interquartile range. Mean imputation was used to account for missing values. Four patients skipped one question in the PIQ and four patients skipped one question in the EMQ. One patient missed one question in the MISS questionnaire.
To determine the categories of desired expectations on the PIQ, we performed a factor analysis with the help of the statistical orthogonal principal component analysis through the Varimax rotation. A question was related to a specific factor if there was a loading of minimal 0.40 or more. This method was used and validated in prior research [27].
We used the Spearman correlations to test for correlation between continuous variables. The strength of the correlation was interpreted by the following guidelines: small strength (r = 0.10–0.29), medium strength (r = 0.30–0.49), and large strength (r = 0.50–1.0) [4]. We used ANOVA to test for differences in satisfaction by categories of expectations met and by type of expectation on the PIQ. We conducted a multivariable backward linear regression to determine whether (1) score on the PIQ; and (2) score on the EMQ were associated with satisfaction. We included all variables with p < 0.10 in bivariate analysis.
Results
Correlations Among Previsit Expectations, Met Expectations, and Patient Satisfaction
Satisfaction correlated with met expectations (r = 0.36, p < 0.001) but not with previsit expectations (r = −0.01, p = 0.94). The best linear regression model for greater satisfaction included met expectations alone and explained 27% of the variance. Four (5%) patients had low previsit expectations, 74 (86%) moderate previsit expectations, and eight (9%) had high previsit expectations. The degree of met expectations was low in four patients (5%), moderate in 33 (38%), and high in 49 (57%). Preliminary bivariate analysis identified differences in satisfaction in patients with low, moderate, and high met expectations.
Categories of Expectations and Correlations With Satisfaction
Factor analysis identified five primary categories of previsit expectation that accounted for 50% of the variance in PIQ: (1) “Information and Explanation”; (2) “Emotional and Understanding”; (3) “Emotional Problems”; (4) “Diagnostics”; and (5) “Comforting”. Cronbach’s α ranged from 0.76 to 0.90 indicating overall good to excellent reliability for all factors. Patients’ goals for the visit with the hand surgeon focused more on “Information and Explanation”, “Comforting”, and “Diagnostics” than on “Emotional Understanding” and “Emotional Problems” (Table 2). The only category of met expectations that correlated with satisfaction was “Information and Explanation” (r = 0.43; p < 0.001) (Table 3). Interestingly, among the previsit expectation categories, the category “Information and Explanation” was highly met, whereas the other four factors were met to a moderate or low extent.
Table 2.
Desired and met expectations divided by categories*
| Category | Factor desired (%) |
Factor desired and met (%) |
Factor desired and not met (%) |
Factor not desired and met (%) |
Factor not desired and not met (%) |
Total (%) |
|---|---|---|---|---|---|---|
| Factor 1 (Information and Explanation) | 96 | 83 | 13 | 3 | 1 | 100 |
| Factor 2 (Emotional and Understanding) | 38 | 26 | 11 | 26 | 37 | 100 |
| Factor 3 (Emotional Problems) | 5.5 | 2 | 3 | 9 | 86 | 100 |
| Factor 4 (Diagnostics) | 61 | 33 | 27 | 20 | 19 | 100 |
| Factor 5 (Comforting) | 74 | 51 | 23 | 14 | 12 | 100 |
* Mean percentage of patients reporting their expectation as being met and not met by factor.
Table 3.
Correlation of percentage of met expectations with satisfaction
| Patient satisfaction (MISS) | ||
|---|---|---|
| Pearson rho | 95% CI | |
| Percentage of met expectations | ||
| Factor 1 (Information and Explanation) | 0.43 | 0.238–0.587 (p < 0.01) |
| Factor 2 (Emotional and Understanding) | 0.15 | −0.059 to 0.355 (p = 0.15) |
| Factor 3 (Emotional Problems) | 0.04 | −0.174 to 0.249 (p = 0.72) |
| Factor 4 (Diagnostics) | 0.04 | −0.173 to 0.250 (p = 0.71) |
| Factor 5 (Comforting) | 0.19 | −0.021 to 0.388 (p = 0.07) |
MISS = Medical Interview Satisfaction Scale; CI = confidence interval.
Discussion
Patient satisfaction is an important measure, because it is associated with increased compliance, improved treatment outcomes, and decreased risk of litigation. Many factors play into satisfaction, including patient’s understanding of their own health and patient’s rating of the quality of their care and perhaps expectations. We therefore investigated how previsit and met expectations affect satisfaction and looked for categories of expectations that influence satisfaction. We found that high previsit expectations did not correlate with satisfaction with a hand surgery outpatient visit but met expectations did. Patients had the highest expectations about information and explanation followed by diagnostics and comforting, both of which were endorsed more that emotional support.
This study should be considered in light of its shortcomings. One limitation of this study is that the PIQ was developed for primary care practice. Little is known about the repeatability, responsiveness, and the floor/ceiling effects. The clinical situation in a primary care practice may be different when a patient is rating their primary doctor with whom they are quite familiar as opposed to a specialist they have never met. Nevertheless, the high Cronbach α values give us confidence in the methodology described by Williams et al [23] using the factor analysis, which is also a reliable method in other settings including orthopaedic practices. Additional validation of these questionnaires in an orthopaedic practice is merited. Another limitation is the absence of question 6 from the MISS, but we think there is sufficient overlap with other questions evaluating rapport that this probably has little or no effect on the results.
In our study, there was no association between level of previsit expectations and patient satisfaction. The association between previsit expectations and satisfaction appears to depend on setting, patient population, and type of previsit expectations [3, 12, 21]. The fact that the majority of patients in this sample had moderate previsit expectations (few had low or high expectations) may have limited our ability to test the association of previsit expectations and satisfaction. The finding that met expectations correlate with satisfaction in patients with upper extremity illness is consistent with prior studies in other populations [3, 23, 27]. For instance, satisfaction and expectations were strongly correlated in studies of patients undergoing THA [16, 17]. This may be a foregone conclusion because measures of met expectations and measures of patient satisfaction may be assessing the same construct. Future research should replicate these findings with a larger sample of patients, perhaps with one or more diagnoses associated with a greater rate of high expectations.
As one might expect, the previsit expectations reported by patients undergoing hand surgery focused more on “Information and Explanation”, “Comforting”, and “Diagnostics” than on “Emotional Understanding” and “Emotional Problems”. The only category of previsit expectation that correlated with satisfaction was “Information and Explanation”. As a result, attempts to improve patient satisfaction might focus on establishing appropriate previsit expectations perhaps by corresponding directly with the primary care doctor (“curbside consult”), providing evidenced-based information in an understandable and meaningful form (eg, decision aids) before the visit, and even previsit triage and education.
It has been more difficult to determine factors associated with patient satisfaction than factors associated with other aspects of the illness experience such as symptoms and disability. Collective research suggests that satisfaction relates to factors like patient understanding, depression, pain intensity [1, 15, 19] as well as effective communication [2], but there is not a strong relationship with previsit expectations. Given the sense of many physicians that previsit expectations do seem to lead to disappointment, future research regarding previsit expectations might benefit from a focus on a specific paradigm where unrealistically high expectations are common while accounting for psychological factors, effective communication skills, time spent waiting for the doctor, and time spent with the doctor.
Electronic supplementary material
Acknowledgments
We thank Drs Chaitanya Mudgal and Jesse Jupiter for allowing us to enroll their patients.
Footnotes
One of the authors (MGJSH) was supported by “Marti kuning Eckhardt fonds,” a nonmedical study grant, “Spinoza fonds,” a nonmedical study grant, and a “AnnaFonds Travel grant” (Dutch orthopaedic travel grant). One of the authors (RDB) was supported by “Spinza fonds,” a nonmedical study grant.
All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research ® editors and board members are on file with the publication and can be viewed on request.
Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.
References
- 1.Archer KR, Castillo RC, Wegener ST, Abraham CM, Obremskey WT. Pain and satisfaction in hospitalized trauma patients: the importance of self-efficacy and psychological distress. J Trauma Acute Care Surg. 2012;72:1068–1077. doi: 10.1097/TA.0b013e3182452df5. [DOI] [PubMed] [Google Scholar]
- 2.Bartlett EE, Grayson M, Barker R, Levine DM, Golden A, Libber S. The effects of physician communications skills on patient satisfaction; recall, and adherence. J Chronic Dis. 1984;37:755–764. doi: 10.1016/0021-9681(84)90044-4. [DOI] [PubMed] [Google Scholar]
- 3.Bowling A, Rowe G, McKee M. Patients’ experiences of their healthcare in relation to their expectations and satisfaction: a population survey. J R Soc Med. 2013;106:143–149. doi: 10.1258/jrsm.2012.120147. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Cohen JW. Statistical Power Analysis for Behavioral Sciences. 2. Hillsdale, NJ, USA: Lawrence Erlbaum Associates; 1988. pp. 79–81. [Google Scholar]
- 5.Fox JG, Storms DM. A different approach to sociodemographic predictors of satisfaction with health care. Soc Sci Med A. 1981;15:557–564. doi: 10.1016/0271-7123(81)90079-1. [DOI] [PubMed] [Google Scholar]
- 6.Georgy EE, Carr EC, Breen AC. Back pain management in primary care: development and validity of the Patients’ and Doctors’ Expectations Questionnaire. Qual Prim Care. 2013;21:113–122. [PubMed] [Google Scholar]
- 7.Greene JY, Weinberger M, Mamlin JJ. Patient attitudes toward health care: expectations of primary care in a clinic setting. Soc Sci Med Med Psychol Med Sociol. 1980;14A:133–138. doi: 10.1016/0160-7979(80)90026-0. [DOI] [PubMed] [Google Scholar]
- 8.Hall JA, Feldstein M, Fretwell MD, Rowe JW, Epstein AM. Older patients’ health status and satisfaction with medical care in an HMO population. Med Care. 1990;28:261–270. doi: 10.1097/00005650-199003000-00006. [DOI] [PubMed] [Google Scholar]
- 9.Hardy GE, West MA, Hill F. Components and predictors of patient satisfaction. Br J Health Psychol. 1996;1:65–85. doi: 10.1111/j.2044-8287.1996.tb00492.x. [DOI] [Google Scholar]
- 10.Hickson GB, Clayton EW, Entman SS, Miller CS, Githens PB, Whetten-Goldstein K, Sloan FA. Obstetricians’ prior malpractice experience and patients’ satisfaction with care. JAMA. 1994;272:1583–1587. doi: 10.1001/jama.1994.03520200039032. [DOI] [PubMed] [Google Scholar]
- 11.Hudak PL, Wright JG. The characteristics of patient satisfaction measures. Spine (Phila Pa 1976). 2000;25:3167–3177. [DOI] [PubMed]
- 12.Iversen MD, Daltroy LH, Fossel AH, Katz JN. The prognostic importance of patient pre-operative expectations of surgery for lumbar spinal stenosis. Patient Educ Couns. 1998;34:169–178. doi: 10.1016/S0738-3991(97)00109-2. [DOI] [PubMed] [Google Scholar]
- 13.Kinnersley P, Stott N, Peters T, Harvey I, Hackett P. A comparison of methods for measuring patient satisfaction with consultations in primary care. Fam Pract. 1996;13:41–51. doi: 10.1093/fampra/13.1.41. [DOI] [PubMed] [Google Scholar]
- 14.Like R, Zyzanski SJ. Patient satisfaction with the clinical encounter: social psychological determinants. Soc Sci Med. 1987;24:351–357. doi: 10.1016/0277-9536(87)90153-5. [DOI] [PubMed] [Google Scholar]
- 15.Lozano Calderon SA Paiva A, Ring D. Patient satisfaction after open carpal tunnel release correlates with depression. J Hand Surg Am. 2008;33:303–307. doi: 10.1016/j.jhsa.2007.11.025. [DOI] [PubMed] [Google Scholar]
- 16.Mancuso CA, Jout J, Salvati EA, Sculco TP. Fulfillment of patients’ expectations for total hip arthroplasty. J Bone Joint Surg Am. 2009;91:2073–2078. doi: 10.2106/JBJS.H.01802. [DOI] [PubMed] [Google Scholar]
- 17.Mancuso CA, Salvati EA, Johanson NA, Peterson MG, Charlson ME. Patients’ expectations and satisfaction with total hip arthroplasty. J Arthroplasty. 1997;12:387–396. doi: 10.1016/S0883-5403(97)90194-7. [DOI] [PubMed] [Google Scholar]
- 18.Meakin R, Weinman J. The ‘Medical Interview Satisfaction Scale’ (MISS-21) adapted for British general practice. Fam Pract. 2002;19:257–263. doi: 10.1093/fampra/19.3.257. [DOI] [PubMed] [Google Scholar]
- 19.O’Toole RV, Castillo RC, Pollak AN, MacKenzie EJ, Bosse MJ, Group LS Determinants of patient satisfaction after severe lower-extremity injuries. J Bone Joint Surg Am. 2008;90:1206–1211. doi: 10.2106/JBJS.G.00492. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Salmon P, Sharma N, Valori R, Bellenger N. Patients’ intentions in primary care: relationship to physical and psychological symptoms, and their perception by general practitioners. Soc Sci Med. 1994;38:585–592. doi: 10.1016/0277-9536(94)90255-0. [DOI] [PubMed] [Google Scholar]
- 21.Soroceanu A, Ching A, Abdu W, McGuire K. Relationship between preoperative expectations, satisfaction, and functional outcomes in patients undergoing lumbar and cervical spine surgery: a multicenter study. Spine (Phila Pa 1976). 2012;37:E103–108. [DOI] [PubMed]
- 22.Williams B. Patient satisfaction: a valid concept? Soc Sci Med. 1994;38:509–516. doi: 10.1016/0277-9536(94)90247-X. [DOI] [PubMed] [Google Scholar]
- 23.Williams S, Weinman J, Dale J, Newman S. Patient expectations: what do primary care patients want from the GP and how far does meeting expectations affect patient satisfaction? Fam Pract. 1995;12:193–201. doi: 10.1093/fampra/12.2.193. [DOI] [PubMed] [Google Scholar]
- 24.Williams SJ, Calnan M. Key determinants of consumer satisfaction with general practice. Fam Pract. 1991;8:237–242. doi: 10.1093/fampra/8.3.237. [DOI] [PubMed] [Google Scholar]
- 25.Williams SW. J. Dale, J. Newman, S. Patient expectations: what do primary care patients want from the GP and how far does meeting expectations affect patient satisfaction. Fam Pract. 1995;12:9. doi: 10.1093/fampra/12.2.193. [DOI] [PubMed] [Google Scholar]
- 26.Wolf MH, Putnam SM, James SA, Stiles WB. The Medical Interview Satisfaction Scale: development of a scale to measure patient perceptions of physician behavior. J Behav Med. 1978;1:391–401. doi: 10.1007/BF00846695. [DOI] [PubMed] [Google Scholar]
- 27.Zebiene E, Razgauskas E, Basys V, Baubiniene A, Gurevicius R, Padaiga Z, Svab I. Meeting patient’s expectations in primary care consultations in Lithuania. Int J Qual Health Care. 2004;16:83–89. doi: 10.1093/intqhc/mzh006. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.