Patient assessment of treatment satisfaction: methods and practical issues

Diagnosis and management of non-erosive reflux disease--the Vevey NERD Consensus Group

BACKGROUND/AIMS

Although considerable information exists regarding gastroesophageal reflux disease with erosions, much less is known of non-erosive reflux disease (NERD), the dominant form of reflux disease in the developed world.

METHODS

An expert international group using the modified Delphi technique examined the quality of evidence and established levels of agreement relating to different aspects of NERD. Discussion focused on clinical presentation, assessment of clinical outcome, pathobiological mechanisms, and clinical strategies for diagnosis and management.

RESULTS

Consensus was reached on 85 specific statements. NERD was defined as a condition with reflux symptoms in the absence of mucosal lesions or breaks detected by conventional endoscopy, and without prior effective acid-suppressive therapy. Evidence supporting this diagnosis included: responsiveness to acid suppression therapy, abnormal reflux monitoring or the identification of specific novel endoscopic and histological findings. Functional heartburn was considered a separate entity not related to acid reflux. Proton pump inhibitors are the definitive therapy for NERD, with efficacy best evaluated by validated quality-of-life instruments. Adjunctive antacids or H(2) receptor antagonists are ineffective, surgery seldom indicated.

CONCLUSIONS

Little is known of the pathobiology of NERD. Further elucidation of the mechanisms of mucosal and visceral hypersensitivity is required to improve NERD management.

Validation of an abbreviated Treatment Satisfaction Questionnaire for Medication (TSQM-9) among patients on antihypertensive medications

Background

The 14-item Treatment Satisfaction Questionnaire for Medication (TSQM) Version 1.4 is a reliable and valid instrument to assess patients' satisfaction with medication, providing scores on four scales – side effects, effectiveness, convenience and global satisfaction. In naturalistic studies, administering the TSQM with the side effects domain could provoke the physician to assess the presence or absence of adverse events in a way that is clinically atypical, carrying the potential to interfere with routine medical care. As a result, an abbreviated 9-item TSQM (TSQM-9), derived from the TSQM Version 1.4 but without the five items of the side effects domain was created. In this study, an interactive voice response system (IVRS)-administered TSQM-9 was psychometrically evaluated among patients taking antihypertensive medication.

Methods

A total of 3,387 subjects were invited to participate in the study from an online panel who self-reported taking a prescribed antihypertensive medication. The subjects were asked to complete the IVRS-administered TSQM-9 at the start of the study, along with the modified Morisky scale, and again within 7 to 14 days. Standard psychometric analyses were conducted; including Cronbach's alpha, intraclass correlation coefficients, structural equation modeling, Spearman correlation coefficients and analysis of covariance (ANCOVA).

Results

A total of 396 subjects completed all the study procedures. Approximately 50% subjects were male with a good racial/ethnic mix: 58.3% white, 18.9% black, 17.7% Hispanic and 5.1% either Asian or other. There was evidence of construct validity of the TSQM-9 based on the structural equation modeling findings of the observed data fitting the Decisional Balance Model of Treatment Satisfaction even without the side effects domain. TSQM-9 domains had high internal consistency as evident from Cronbach's alpha values of 0.84 and greater. TSQM-9 domains also demonstrated good test-retest reliability with high intraclass correlation coefficients exceeding 0.70. As expected, the TSQM-9 domains were able to differentiate between individuals who were low, medium and high compliers of medication, with moderate to high effect sizes. There was evidence of convergent validity with significant correlations with the medication adherence scale.

Conclusion

The IVRS-administered TSQM-9 was found to be a reliable and valid measure to assess treatment satisfaction in naturalistic study designs, in which there is potential that the administration of the side effects domain of the TSQM would interfere with routine clinical care.

Development and validation of the patient and clinician sedation satisfaction index for colonoscopy and upper endoscopy

BACKGROUND & AIMS

Recent increases in gastrointestinal endoscopic procedures and sedation options show a need for better sedation evaluation. This article describes the development and validation of 2 instruments: the Patient Satisfaction with Sedation Instrument (PSSI) and the Clinician Satisfaction with Sedation Instrument (CSSI) for assessing satisfaction in patients undergoing outpatient upper endoscopy and colonoscopy.

METHODS

A total of 118 patients who underwent outpatient colonoscopy or esophagogastroduodenoscopy and 22 physicians were recruited across 5 US gastroenterology practices. Physicians completed the CSSI and patients completed the PSSI after each procedure. Patients completed the SF-12 Health Survey, Patient Satisfaction Questionnaire, and Socially Desirable Response Scale; clinicians completed the Observer's Assessment of Alertness Scale after procedures.

RESULTS

Study patients were mostly women (59%), white (88%), had a mean age of 57.5 +/- 15.7 years, and had a colonoscopy (70%). Internal consistency reliabilities assessed result consistencies across test items. Coefficients greater than 0.70 indicate good reliability; greater than 0.85 indicate excellent reliability. Internal consistency reliabilities of the PSSI and CSSI total and subscale scores were greater than 0.76. Correlations were assessed using Pearson product moment correlation. PSSI and CSSI scores were correlated (P < .05). PSSI totals scores were correlated significantly with the SF-12 Health Survey (P < .05), the Patient Satisfaction Questionnaire (P < .05), and CSSI total scores were correlated with the Observer's Assessment of Alertness Scale (P < .01) and a visual analogue scale (P < .01). PSSI scores were not correlated with the Socially Desirable Response Scale (P > .05).

CONCLUSIONS

The PSSI and CSSI provide for feasible, reliable, and valid assessment of procedural sedation satisfaction for outpatient colonoscopy and esophagogastroduodenoscopies and can be used for future sedation studies.

Association between response to pentosan polysulfate sodium therapy for interstitial cystitis and patient questionnaire-based treatment satisfaction

OBJECTIVE

To evaluate the relationship between symptom reduction and satisfaction with pentosan polysulfate sodium (PPS) therapy in subjects with interstitial cystitis (IC).

METHODS

A secondary analysis was conducted in 128 subjects treated with PPS 300 mg/day (US Food and Drug Administration-approved dose) from a 32-week multicenter, randomized, double-blind study of 380 subjects with IC who were treated with PPS 300 mg/day, 600 mg/day, or 900 mg/day. Self-rated outcome measures included the O'Leary-Sant Interstitial Cystitis Symptom Index (ICSI) and a treatment satisfaction questionnaire. Treatment responders were defined as subjects having > or =30% reduction in ICSI from baseline to study end point.

RESULTS

A reduction in IC symptoms was associated with significantly higher satisfaction with PPS (p < 0.05). Compared with nonresponders, subjects achieving a > or = 30% reduction in ICSI were more likely to be pleased with PPS for IC symptoms, to have benefited from PPS for their IC symptoms, to recommend PPS for IC symptoms to others with the same condition, and to say that PPS provides better relief, based on prior experience with other IC treatments. Among all subjects at week 32, 75% said they would recommend PPS therapy for IC symptoms to others with the condition.

CONCLUSION

Despite limitations (lack of placebo control, use of a nonvalidated instrument), this analysis demonstrated significantly increased treatment satisfaction with PPS therapy among treatment responders versus nonresponders. There was a significant positive correlation between ICSI scores and response on the treatment satisfaction questionnaire. Treatment response and patient satisfaction with treatment are important clinical considerations in the management of patients with IC.

Validation of the Revised Patient Perception of Migraine Questionnaire (PPMQ-R): Measuring Satisfaction with Acute Migraine Treatment in Clinical Trials

This study was aimed to evaluate in clinical trial settings the psychometric properties of the revised Patient Perception of Migraine Questionnaire (PPMQR), a satisfaction measure for acute migraine treatment. The PPMQ-R was administered 24 h post dosing in 1304 migraineurs randomized to two identical Phase 3, single-attack trials. Reliability, concurrent and construct validity and known-groups validity were evaluated using Cronbach's α, Pearson correlations and analysis of variance, respectively. PPMQ-R scale and Total scores (Efficacy, Functionality and Ease of use) showed very good internal consistency reliability (α 0.84-0.99). Efficacy, Functionality and Total PPMQ-R scores showed large, inverse relationships with migraine pain severity, number of migraine symptoms and work ability ( r = −0.62 to −0.75; all P < 0.0001). All scales discriminated among migraine pain severity levels (all P < 0.001). The PPMQ-R has sufficient evidence of validity and reliability for measuring patient satisfaction, an important benchmark of quality and effective care.

Patient-reported outcomes. How important are they?

Outcome after surgical treatment has been based predominantly on objective criteria (biomedical model) and has largely ignored, until recently, the expectations, personal feelings, satisfaction, and quality of life of patients (outcomes model). The importance of this derives from considerations that the viewpoints and priorities of patients may not be the same as those of their surgeons. Furthermore, there is often little correlation between symptom severity and disease severity. Measures of quality of life and patient satisfaction are, thus, important in valid assessment of the results of surgical treatment. Global assessment based on both the biomedical and outcomes models constitutes the ideal. Questionnaires designed to measure both quality life (generic and specific) and patient satisfaction with treatment require careful development and validation by appropriate studies.

Patient-reported outcomes in a trial of exenatide and insulin glargine for the treatment of type 2 diabetes

Background

Patient-reported measures can be used to examine whether drug differences other than clinical efficacy have an impact on outcomes that may be important to patients. Although exenatide and insulin glargine appear to have similar efficacy for treatment of type 2 diabetes, there are several differences between the two treatments that could influence outcomes from the patient's perspective. The purpose of the current study was to examine whether the two drugs were comparable as assessed by patient-reported outcomes using data from a clinical trial in which these injectable medications were added to pre-existing oral treatment regimens.

Methods

Patients were randomized to either twice daily exenatide or once daily insulin glargine during a 26-week international trial. At baseline and endpoint, five patient-reported outcome measures were administered: the Vitality Scale of the SF-36, The Diabetes Symptom Checklist – Revised (DSC-R), the EuroQol EQ-5D, the Treatment Flexibility Scale (TFS), and the Diabetes Treatment Satisfaction Questionnaire (DTSQ). Change from baseline to endpoint was analyzed within each treatment group. Group differences were examined with General linear models (GLMs), controlling for country and baseline scores.

Results

A total of 549 patients with type 2 diabetes were enrolled in the trial, and current analyses were conducted with data from the 455 per protocol patients (228 exenatide and 227 insulin glargine). The sample was primarily Caucasian (79.6%), with slightly more men (55.2%) than women, and with a mean age of 58.5 years. Paired t-tests found that both treatment groups demonstrated statistically significant baseline to endpoint change on several of the health outcomes instruments including the DSC-R, DTSQ, and the SF-36 Vitality subscale. GLMs found no statistically significant differences between groups in change on the health outcomes instruments.

Conclusion

This analysis found that both exenatide and insulin glargine were associated with significant improvements in patient-reported outcomes when added to oral medications among patients with type 2 diabetes. Despite an additional daily injection and a higher rate of gastrointestinal adverse events, treatment satisfaction in the exenatide group was comparable to that of the glargine group, possibly because of weight reduction observed in patients treated with exenatide.

Psychometric evaluation of the Osteoporosis Patient Treatment Satisfaction Questionnaire (OPSAT-Q), a novel measure to assess satisfaction with bisphosphonate treatment in postmenopausal women

Background

The Osteoporosis Patient Satisfaction Questionnaire (OPSAT-Q) is a new measure of patient satisfaction with bisphosphonate treatment for osteoporosis. The objective of this study was to evaluate the psychometric characteristics of the OPSAT-Q.

Methods

The OPSAT-Q contains 16 items in four subscales: Convenience, Confidence with Daily Activities, Side Effects, and Overall Satisfaction. All four subscale scores and an overall composite satisfaction score (CSS) can be computed. The OPSAT-Q, Osteoporosis Targeted Quality of Life (OPTQoL), and sociodemographic/clinical questionnaires, including 3 global items on convenience, functioning and side effects, were self-administered to women with osteoporosis or osteopenia recruited from four US clinics. Analyses included item and scale performance, internal consistency reliability, reproducibility, and construct validity. Reproducibility was measured using the intraclass correlation coefficient (ICC) via a follow-up questionnaire completed by participants 2 weeks post baseline.

Results

104 women with a mean age of 65.1 years participated. The majority were Caucasian (64.4%), living with someone (74%), and not currently employed (58.7%). 73% had osteoporosis and 27% had osteopenia. 80% were taking weekly bisphosphonates and 18% were taking daily medication (2% missing data). On a scale of 0–100, individual patient subscale scores ranged from 17 to 100 and CSS scores ranged from 44 to 100. All scores showed acceptable internal consistency reliability (Cronbach's alpha > 0.70) (range 0.72 to 0.89). Reproducibility ranged from 0.62 (Daily Activities) to 0.79 (Side Effects) for the subscales; reproducibility for the CSS was 0.81. Significant correlations were found between the OPSAT-Q subscales and conceptually similar global measures (p < 0.001).

Conclusion

The findings from this study confirm the validity and reliability of the OPSAT-Q and support the proposed composition of four subscales and a composite score. They also support the use of the OPSAT-Q to examine the impact of bisphosphonate dosing frequency on patient satisfaction.

Quality of life assessment in clinical practice in haemophilia treatment

The modern management of haemophilia has greatly influenced not only survival of patients, their clinical symptoms and orthopaedic outcome but also their perceived quality of life (QoL). QoL measures recently became an essential part of clinical trials being one of the most important patient-rated outcomes (PROs). Moreover, QoL assessment is essential in pharmacoeconomics. In clinical trials, not only clinical outcomes but also the so-called PROs and health-economic outcomes are included. Different types of economic evaluations may be conducted in order to describe the economic burden of a disease condition, to determine the cost of care and to assess and evaluate alternative treatments in terms of both costs and effects as well as benefits and outcomes with the aim of optimizing the use of resources. For these evaluations, the following analyses are performed: descriptive cost of illness study, incremental cost-effectiveness analysis, incremental cost-utility analysis and incremental cost-benefit analysis. By contrast, PROs are derived from direct patient reports and they allow to evaluate the impact of a disease and its treatment on patients' well-being and functioning. PROs include health-related quality of life, patient preferences/utilities, treatment satisfaction and other PROs such as functional assessment, etc. Choosing a QoL measure, study- and instrument-related aspects have to be taken into account. Finally, QoL assessment will become a part of the regular clinical assessment of persons with haemophilia, in order to provide trustworthy data of perceived well-being to be compared over time and in order to assess treatment efficacy and quality of care.

Patient-centered surgical outcomes: the impact of goal achievement and urge incontinence on patient satisfaction one year after surgery

OBJECTIVE

The purpose of this study was to assess factors that influence patient satisfaction 1 year after pelvic reconstructive surgery.

STUDY DESIGN

We previously reported the objective success, goals, and expectations of a cohort of 78 patients 3 months after surgery. A second blinded independent physician investigator contacted the same patients by phone to reassess these items 1 year after surgery. Data were analyzed with the Spearman correlation, the Mann-Whitney test, the chi-squared test of association, and the Friedman test.

RESULTS

Seventy patients (89%) of the original cohort completed the second assessment. Although group satisfaction and goal achievement were stable (P < .01), 70% of patients reported a change in their satisfaction ratings between 3 months and 1 year (rho = 0.3). Reduced satisfaction between 3 and 12 months after surgery was strongly associated with decreased goal achievement (rho = 0.47; P = .006). Fifty-six percent of patients reported urge incontinence symptoms after surgery (44% de novo and 12% persistent). Urge incontinence was the most common reason for patient dissatisfaction after surgery (P = .04).

CONCLUSION

Symptoms of urge incontinence and reduced achievement of subjective surgical goals are associated with decreased long-term patient satisfaction after reconstructive pelvic surgery.

Validation of the Revised Patient Perception of Migraine Questionnaire: Measuring Satisfaction With Acute Migraine Treatment

OBJECTIVE

To evaluate the psychometric properties of the revised Patient Perception of Migraine Questionnaire (PPMQ-R), which measures satisfaction with migraine treatment.

BACKGROUND

The original version of the PPMQ was developed prior to the introduction of newer migraine treatments, which may have attributes that influence treatment satisfaction.

METHODS

Literature review, patient focus groups, and one-on-one patient interviews guided revisions to the original PPMQ. The revised questionnaire was tested in 200 migraine patients visiting neurologists and primary care clinics. At baseline, all subjects completed the PPMQ-R, a migraine-specific quality-of-life measure, and a migraine experience questionnaire; and 125 subjects completed assessments 24 hours after each migraine attack and within 30 days post-baseline. Factor analysis was performed to inform the development of a scoring algorithm, and reliability, validity, and responsiveness of the PPMQ-R were evaluated.

RESULTS

Factor analyses confirmed that the revised questionnaire has five domains measuring satisfaction with efficacy, functionality, ease of use, medication cost, and bothersomeness of medication side effects. A total score can be created by taking the average of efficacy, functionality, and ease of use scores. The PPMQ-R scale scores and Total score demonstrated internal consistency reliability (Cronbach's alpha: 0.80 to 0.98) and test-retest reliability (intra-class correlation coefficient: 0.79 to 0.91). Except for the Cost domain, the PPMQ-R scores discriminated among migraine pain severity levels (all P < .05) and levels of impairment in ability to work and perform usual activities (all P < .05). Except for the Ease of Use and Cost domains, mean PPMQ-R scores were significantly higher among patients with no change in treatment and whose pain improved between two consecutive migraine attacks (all P < .01).

CONCLUSION

The PPMQ-R is a reliable and valid measure of patient satisfaction with acute migraine treatment in women with frequent migraine attacks.

Development and validation of the Gastroesophageal Reflux Disease Treatment Satisfaction Questionnaire

There is growing recognition of the importance of assessing patient perceptions of treatment, especially patient satisfaction. The Gastroesophageal Reflux Disease (GERD) Treatment Satisfaction Questionnaire (GTSQ) was developed to assess satisfaction with GERD medication. A web-based survey, which included the GTSQ and the GERD Symptom Assessment Scale (GSAS), was administered in September 2003 to 2511 subjects taking prescription GERD medication, identified as H2-receptor antagonists (H2RAs) and proton pump inhibitors (PPIs). Results showed excellent reliability of the GTSQ subscales (from 0.82-0.95) and validity with respect to two GSAS subscales. Rabeprazole (Aciphex) subjects taking 1 pill per day were statistically more satisfied than those taking 2 pills per day for all subscales except "Daytime Relief" and "Quick and Long-Lasting." Those who stayed on rabeprazole therapy longer showed statistically significant greater satisfaction on the "Daytime Relief" and "Health-Related Quality of Life" scales. The GTSQ has high reliability and can be used to assess aspects of satisfaction with GERD medication.

Review article: towards the optimization of symptom evaluation in reflux disease

A recent workshop has taken stock of the processes used for the evaluation of reflux disease symptoms. Such evaluations are vital both for routine clinical practice and for the critical assessment and comparison of therapeutic options. The workshop endorsed the importance of the assessment of symptom patterns for the diagnosis of reflux disease. Patient self-report symptom questionnaires were considered to be potentially valuable instruments, but have been researched relatively little in reflux disease. On the basis of a survey of the literature and data from generic methodological research, the workshop concluded that virtually all trials of the therapy of reflux disease have used too few response options for a sensitive definition of symptom status, and recommended that six to seven response options be used. Modified Likert scales with defined individual response options and structured patient self-report, rather than physician assessment, were considered to be the best approaches. These views on symptom status assessment are not reflected fully in the current practice of reflux disease clinical trials. Furthermore, the terminology used to describe symptom status is frequently ambiguous or tautological. Quality of life measures were acknowledged as valid and useful secondary measures of therapeutic benefit. By contrast, evaluation of the state of the art of assessment of patient satisfaction with therapy led to the conclusion that the methodology for this particular assessment was still in its infancy. The outputs of the workshop revealed many aspects of the assessment of reflux disease that would benefit from further research and development. A report on the detailed outputs of the workshop has been published recently.