Patient Satisfaction and its Relation to Perceived Visit Duration With a Hand Surgeon

Preoperative predictors of two-year satisfaction in hand and wrist surgery patients

Purpose

As stakeholders seek to improve patient outcomes while maintaining cost-effectiveness in an increasingly expensive healthcare system, metrics such as patient satisfaction are becoming more important. This present study sought to identify factors associated with and independently predictive of better surgical satisfaction two years following hand and wrist surgery.

Methods

Patients undergoing hand and wrist surgery at an urban outpatient institution were enrolled preoperatively into a surgical registry and assessed two years postoperatively. Patient satisfaction with surgery was measured at two years postoperatively with the Surgical Satisfaction Questionnaire (SSQ-8). Bivariate analysis determined associations between postoperative satisfaction and patient demographics, injury specifiers, medical history, and multiple patient-reported outcomes (PROs). Multivariable analysis determined independent predictors of two-year postoperative satisfaction following hand and wrist surgery.

Results

Better surgical satisfaction was associated with having never smoked, no preoperative opioid use, lack of an accompanying legal claim, lack of a workers compensation claim, no clinical history of depression/anxiety, less comorbidities, and higher preoperative expectations.Various PROs relating to function, pain, activity, and general health at both baseline and two years demonstrated associations with postoperative satisfaction. Multivariable analysis confirmed that never smoking, lack of a legal claim, and better preoperative Brief Michigan Hand Questionnaire scores were independently predictive of better surgical satisfaction two years following hand and wrist surgery.

Conclusion

At two years following hand and wrist surgery, better patient satisfaction was best predicted by never smoking, no related legal claim, and better baseline Brief Michigan Hand Questionnaire scores.

Level of evidence

III.

Interactional competencies in medical student admission- what makes a "good medical doctor"?

Doctors' interactional competencies play a crucial role in patient satisfaction, well-being, and compliance. Accordingly, it is in medical schools' interest to select candidates with strong interactional abilities. While Multiple Mini Interviews (MMIs) provide a useful context to assess such abilities, the evaluation of candidate performance during MMIs is not always based on a solid theoretical framework. The newly developed selection procedure "Interactional Competencies - Medical Doctors (IC-MD)" uses an MMI circuit with five simulation patient scenarios and is rated based on the theoretically and empirically grounded construct of emotional availability. A first validation study with N = 70 first-semester medical students took place in 2021. In terms of convergent validity, IC-MD ratings showed strong correlations with simulation patients' satisfaction with the encounter (r =.57) but no association with emotional intelligence measures. IC-MD ratings were not related to high school performance or a cognitive student aptitude test, indicating divergent validity. Inter-rater reliability (ICC = 0.63) and generalizability (Eρ2 = 0.64) were satisfactory. The IC-MD proved to be fair regarding participants' age and gender. Participants with prior work experience in healthcare outperformed those without such experience. Participant acceptance of the procedure were good. The IC-MD is a promising selection procedure capable of assessing interactional competencies relevant to the medical setting. Measures of interactional competencies can complement the use of cognitive selection criteria in medical student admission. The predictive validity of the IC-MD needs to be addressed in future studies.

What Patients Say About Their Orthopaedic Hand and Wrist Surgeons: A Qualitative Analysis of Negative Reviews on Yelp

Background  Patients often turn to online reviews as a source of information to inform their decisions regarding care. Existing literature has analyzed factors associated with positive online patient ratings among hand and wrist surgeons. However, there is limited in-depth analysis of factors associated with low patient satisfaction for hand and wrist surgeons. The focus of this study is to examine and characterize extremely negative reviews of hand and wrist surgeons on Yelp.com. Methods  A search was performed using the keywords "hand surgery" on Yelp.com for eight major metropolitan areas including Washington DC, Dallas, New York, Phoenix, Los Angeles, San Francisco, Boston, and Seattle. Only single-star reviews (out of a possible 5 stars) of hand and wrist surgeons were included. The complaints in the 1-star reviews were then categorized into clinical and nonclinical categories. Result  A total of 233 single-star reviews were included for analysis, which resulted in 468 total complaints. Of these complaints, 81 (18.8%) were clinically related and 351 (81.3%) were nonclinical in nature. The most common clinical complaints were for complication (24 complaints, 6%), misdiagnosis (16 complaints, 4%), unclear treatment plan (16 complaints, 4%), and uncontrolled pain (15 complaints, 3%). The most common nonclinical complaints were for physician bedside manner (93 complaints, 22%), financially related (80 complaints, 19%), unprofessional nonclinical staff (61 complaints, 14%), and wait time (46 complaints, 11%). The difference in the number of complaints for surgical and nonsurgical patients was statistically significant ( p  < 0.05) for complication and uncontrolled pain. Clinical Relevance  Patient satisfaction is dependent on a multitude of clinical and nonclinical factors. An awareness of online physician ratings is essential for hand and wrist surgeons to maintain and improve patient care and patient satisfaction. We believe the results of our study could be used to further improve the quality of care provided by hand and wrist surgeons.

An examination of negative one-star patient reviews for foot and ankle orthopedic surgery: A retrospective analysis

BACKGROUND

Despite the questionable validity of online-based physician review websites (PRWs), negative reviews can adversely affect a provider's practice. Several investigations have explored the effect of extremely negative "one-star" reviews across subspecialties such as adult reconstruction, sports medicine, and orthopaedic traumatology; however, to date, no study has explored one-star reviews in foot and ankle surgery. The goal of this study was to characterize factors that contribute to extremely negative, one-star reviews for foot and ankle surgeons on Vitals.com.

METHODS

A retrospective analysis of negative one-star reviews with corresponding patient complaints for foot and ankle surgeons (both orthopaedic surgeons as well as podiatrists) in the United States. Physicians included were selected within a 10-mile radius of the top ten largest cities in the United States. Data was stratified by patient type (e.g., those receiving surgery and those not undergoing surgical intervention) and binned according to type of patient complaint, as previously described.

RESULTS

Of the 2645 foot and ankle surgeons identified in our initial query, 13.8% of surgeons contained one-star reviews eligible for analysis. Patient complaints related to bedside manner and patient experience are the causative factors accounting for 41.5% of the one-star reviews of foot and ankle surgeons for nonsurgical-related complaints. Surgical complications and other outcomes-related factors comprised roughly 50% of the complaints related to surgical patients.

CONCLUSION

In conclusion, complaints related to bedside manner and patient experience are the causative factors accounting for 41.5% of the one-star reviews of foot and ankle surgeons for nonsurgical-related complaints. Surgical complications and other outcomes-related factors comprised roughly half of the complaints related to surgery. This data serves to inform practicing foot and ankle surgeons as to the influences behind patients leaving extremely negative reviews on PRWs.

LEVEL OF CLINICAL EVIDENCE

IV.

The ebbs and flows of empathy: a qualitative study of surgical trainees in the UK

BACKGROUND

Empathy is widely recognised as an important element of medical practice contributing to patient outcomes and satisfaction. It is also an important element of collaborative work in a healthcare team. However, there is evidence to suggest that empathy towards patients declines over time, particularly in surgical specialities. There is little qualitative research on this decline in surgical trainees, particularly in the UK. Therefore, the aim of this study was to explore how trainee surgeons experience empathy over the course of their career, both towards patients and colleagues and how they perceive it in others.

METHODS

10 semi-structured interviews were carried out with surgical trainees of different grades and specialties in January and February 2022. Framework analysis was used to interpret the data.

RESULTS

Participants experienced an evolution in empathy over their career as their personal and professional experience was added to. They drew a distinction between desensitisation and actual decline in empathy and identified more with experiencing the former in their careers. Participants also felt interprofessional relationships require empathy, and this could be improved upon. Finally, they highlighted specific impacts of the COVID-19 pandemic upon their training, including reduced theatre time.

CONCLUSIONS

Participants felt training could be improved in regard to accessing training opportunities and relationships with colleagues, although many felt empathy between colleagues is better than it has been in the past. This project highlighted areas for future research, such as with surgeons in later stages of their careers, or mixed-methods projects.

Missed Short-term Follow-up After Arthroscopic Rotator Cuff Surgery: Analysis of Surgical and Demographic Factors

INTRODUCTION

Few current studies have examined loss to follow-up after rotator cuff-related shoulder arthroscopy. Understanding the demographic and surgical factors for missed follow-up would help identify patients most at risk and potentially mitigate the onset of complications while maximizing clinical outcomes.

METHODS

A retrospective review of consecutive rotator cuff arthroscopic procedures with a minimum of 12-month follow-up done by a single, fellowship-trained surgeon was undertaken from February 2016 through January 2022. Demographic patient and surgical data, including age, sex, marital status, self-identified race, and body mass index, were collected. Follow-up at ≤3, 6 weeks, 3, 6, and 12 months was determined. Patient-related and surgical predictors for missed short-term follow-up, defined as nonattendance at the 6 and 12-month postoperative visits, were identified.

RESULTS

There were 449 cases included, of which 248 (55%) were women. The median age was 57 years (interquartile range [IQR], 51 to 62). Patients with commercial insurance (odds ratio [OR], 0.38; 95% confidence interval [CI], 0.23 to 0.64; P < 0.001) or workers' compensation (OR, 0.15; 95% CI, 0.05 to 0.43; P < 0.001) were less likely to miss the 6-month follow-up compared with patients with Medicare, whereas increased socioeconomic deprivation (OR, 0.86; 95% CI, 0.77 to 0.97, P = 0.015) was associated with decreased odds of missing that visit. Patients who missed the ≤3 weeks (OR, 1.77; 95% CI, 1.14 to 2.74, P = 0.010) and 3-month (OR, 8.55; 95% CI, 4.33 to 16.86; P < 0.001) follow-ups were more likely to miss the 6-month follow-up. Use of a patient contact system (OR, 0.55; 95% CI, 0.35 to 0.87, P = 0.01) and increased number of preoperative visits (OR, 0.91; 95% CI, 0.84 to 0.99, P = 0.033) were associated with decreased odds of missing the 12-month follow-up. Patients who missed the 6-month follow-up were more likely to miss the 12-month follow-up (OR, 5.38; 95% CI, 3.45 to 8.40; P < 0.001).

CONCLUSION

Implementing an electronic patient contact system while increasing focus on patients with few preoperative visits and who miss the 6-month follow-up can reduce the risk of missed follow-up at 12 months after shoulder arthroscopy.

The Relationship Between Patient-Reported Outcomes and Patient Satisfaction With Ligament Reconstruction Tendon Interposition

PURPOSE

Achieving the minimal clinically important difference (MCID) on an outcomes instrument and reporting satisfaction with surgical outcomes are not equivalent. We hypothesized that improvement exceeding the QuickDASH and PROMIS UE CAT MCID is associated with a greater likelihood of reporting satisfaction with ligament reconstruction tendon interposition (LRTI) treatment. Our secondary hypothesis was that a subset of patients failing to meet MCID would still be satisfied.

METHODS

Patients ≥1 year after LRTI at one academic tertiary institution were included. QuickDASH and UE CAT v1.2 scores were obtained before and after surgery. Postoperative satisfaction and levels of improvement in pain and function were also obtained.

RESULTS

A total of 93 patients completed the QuickDASH, and of those, 90 also completed the UE CAT. At a mean of 2.6 ± 1.0 years after surgery, QuickDASH and UE CAT score improvement exceeded the previously published MCID estimates of 8.8 and 4.8. Although 90% (84/93) of the patients reported satisfaction, only 85% (72/93) and 72% (59/90) achieved MCID on the QuickDASH and UE CAT, respectively. Using the MCID estimate of 8.8, 96% (72/75) of the patients meeting the MCID were satisfied with their treatment. Those failing to achieve MCID reported significantly less physical function and pain improvement; however, most were satisfied nonetheless (68% [13/19] for QuickDASH, 77% [23/30] for UE CAT).

CONCLUSIONS

Achieving published MCID thresholds on the QuickDASH and PROMIS UE CAT v1.2 was predictive of patients reporting general satisfaction with their LRTI outcome ≥1 year after surgery. Most patients failing to achieve MCID still reported satisfaction with their LRTI. Achieving MCID thresholds alone should not be used as a surrogate for patient satisfaction with their treatment. Patient satisfaction is a complicated construct that is potentially very different from that of high-quality care.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Creation and Validation of the Select Medical Patient Reported Experience Measure for Physical and Occupational Therapy Outpatient Clinics

OBJECTIVE

This study describes the creation and examination of the internal consistency, content validity, construct/structural validity, and criterion/concurrent validity of the Select Medical Patient Reported Experience Measure (SM-PREM).

DESIGN

Observational study design.

SETTING

1054 Outpatient physical and occupational therapy locations in North America.

PARTICIPANTS

The study included 89,205 patients with various musculoskeletal disorders (N=89,205).

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Content validity was described, and internal consistency, construct/structural validity (factor analysis), and criterion/concurrent validity were analyzed, with concurrent validity compared against patient reported outcomes (PROM), the Net Promoter Scale, and the Orebro Musculoskeletal Screening Questionnaire-12.

RESULTS

Exploratory and confirmatory factor analysis of the SM-PREM yielded 3 dimensions, each with a very strong internal consistency (>.850). The SM-PREM yielded statistically significant results in all areas, with values that reflected minimal to fair association with PROMs.

CONCLUSION

The SM-PREM appears to capture a unique construct compared to PROMs. The 11-item tool has 3 definitive dimensions and exhibits strong internal consistency. The tool may be useful in examining patient experience in patients with musculoskeletal injuries seen by physical and occupational therapists.

Preoperative Expectations in Hand Surgery Patients

Introduction  Studies have shown a link between patients' preoperative expectations and their postoperative satisfaction. However, limited studies exist concerning patient factors associated with higher preoperative expectations in the hand surgery population. This study analyzed preoperative expectation scores of patients undergoing hand surgery and aimed to determine associated patient characteristics. Materials and Methods  A total of 418 elective hand surgery patients aged 15 years and older enrolled in a prospectively collected orthopaedic registry from June 2015 to December 2018 were analyzed. Patients were administered preoperative questionnaires including six Patient-Reported Outcome Measurement Information System domains and other activity and pain scales. Expectation scores were measured using the six domains of the Musculoskeletal Outcomes Data Evaluation and Management System expectations questionnaire. Bivariate and multivariable analyses were conducted to identify independent predictors of higher expectations. Results  Overall, patients had high expectations (≥ 80.0) of their hand surgery. Higher mean expectation scores were seen with females, college graduates, better baseline health status, and fewer prior hand surgeries ( p  < 0.05 for all). No significant associations were found among the Common Procedural Terminology codes and expectations. Multivariable analysis confirmed that college degree ( p  = 0.023) and less pain ( p  = 0.008) were predictive of higher baseline expectations. Conclusion  In sum, more educated patients with less pain at baseline and better baseline health status have higher expectations of their hand surgery. Hand surgeons can use these results to help focus their preoperative counseling and expectation management.

When Musculoskeletal Clinicians Respond to Empathetic Opportunities, do Patients Perceive Greater Empathy?

BACKGROUND

Patient use of verbal and nonverbal communication to signal what is most important to them can be considered empathetic opportunities. Orthopaedic surgeons may have mixed feelings toward empathetic opportunities, on one hand wanting the patient to know that they care, and on the other hand fearing offense, prolonged visit duration, or discussions for which they feel ill prepared. Evidence that action about empathetic opportunities does not harm the patient's experience or appreciably prolong the visit could increase the use of these communication tactics with potential for improved experience and outcomes of care.

QUESTIONS/PURPOSES

Using transcripts from musculoskeletal specialty care visits in prior studies, we asked: (1) Are there factors, including clinician attentiveness to empathetic opportunities, associated with patient perception of clinician empathy? (2) Are there factors associated with the number of patient-initiated empathetic opportunities? (3) Are there factors associated with clinician acknowledgment of empathetic opportunities? (4) Are there factors associated with the frequency with which clinicians elicited empathetic opportunities?

METHODS

This study was a retrospective, secondary analysis of transcripts from prior studies of audio and video recordings of patient visits with musculoskeletal specialists. Three trained observers identified empathetic opportunities in 80% (209 of 261) of transcripts of adult patient musculoskeletal specialty care visits, with any uncertainties or disagreements resolved by discussion and a final decision by the senior author. Patient statements considered consistent with empathetic opportunities included relation of emotion, expression of worries or concerns, description of loss of valued activities or loss of important roles or identities, relation of a troubling psychologic or social event, and elaboration on daily life. Clinician-initiated empathetic opportunities were considered clinician inquiries about these factors. Clinician acknowledgment of empathetic opportunities included encouragement, affirmation or reassurance, or supportive statements. Participants completed post-visit surveys of perceived clinician empathy, symptoms of depression, and health anxiety. Factors associated with perceived clinician empathy, number of empathetic opportunities, clinician responses to these opportunities, and the frequency with which clinicians elicited empathetic opportunities were sought in bivariate and multivariable analyses.

RESULTS

After controlling for potentially confounding variables such as working status and pain self-efficacy scores in the multivariable analysis, no factors were associated with patient perception of clinician empathy, including attentiveness to empathetic opportunities. Patient-initiated empathetic opportunities were modestly associated with longer visit duration (correlation coefficient 0.037 [95% confidence interval 0.023 to 0.050]; p < 0.001). Clinician acknowledgment of empathetic opportunities was modestly associated with longer visit duration (correlation coefficient 0.06 [95% CI 0.03 to 0.09]; p < 0.001). Clinician-initiated empathetic opportunities were modestly associated with younger patient age (correlation coefficient -0.025 [95% CI -0.037 to -0.014]; p < 0.001) and strongly associated with one specific interviewing clinician as well as other clinicians (correlation coefficient -1.3 [95% CI -2.2 to -0.42]; p = 0.004 and -0.53 [95% CI -0.95 to -0.12]; p = 0.01).

CONCLUSION

Musculoskeletal specialists can respond to empathic opportunities without harming efficiency, throughput, or patient experience.

CLINICAL RELEVANCE

Given the evidence that patients prioritize feeling heard and understood, and evidence that a trusting patient-clinician relationship is protective and healthful, the results of this study can motivate specialists to train and practice effective communication tactics.

Patient-Centered Communication Tools for the Patch Test Clinic

Patient-centered communication positively impacts the clinical encounter. Multiple strategies exist to improve communication between providers and their patients; the application and impact of these strategies have been studied in multiple specialties, though little exists regarding communication best practices in the patch test clinic. Because the procedural components of patch testing often span the course of an entire week, effective communication with patients during the patch testing visit is important for not only technical success, but also patient understanding and experience. In this study, we highlight the value of beginning the patch testing visit with clear introductions and agenda setting, improving patient understanding and engagement through methods such as teach backs and cycles of questions and answers that create patient-provider dialogue, and using communication techniques to make expressions of empathy. We provide detailed examples regarding the application of these techniques to the patch testing process, aimed at enhancing the patch testing experience and improving clinical outcomes. Our review exemplifies how dermatologists can leverage communication tools to improve patient satisfaction and outcomes during patch testing.

Patient Satisfaction with Virtual Clinic Encounters: Analysis of Factors that Impact the Press Ganey Survey in the Hand Surgery Population

Purpose

Our purpose was to identify patient characteristics and visit components that affect patient satisfaction with virtual new patient visits in an outpatient hand surgery clinic as measured by the Press Ganey Outpatient Medical Practice Survey (PGOMPS) total score (primary outcome) and provider subscore (secondary outcome).

Methods

Adult patients evaluated through virtual new patient visits at a tertiary academic medical center between January 2020 and October 2020 who completed the PGOMPS for virtual visits were included. Data regarding demographics and visit characteristics were collected via chart review. Factors associated with satisfaction were identified using a Tobit regression model on the continuous score outcomes (Total Score and Provider Subscore) to account for substantial ceiling effects.

Results

A total of 95 patients were included: 54% were men and the mean age was 54 ± 16 years. Mean area deprivation index was 32 ± 18, and the mean driving distance to the clinic was 97 ± 188 mi. Common diagnoses include compressive neuropathy (21%), hand arthritis (19%), hand mass (12%), and fracture/dislocation (11%). Treatment recommendations included small joint injection (20%), in-person evaluation (25%), surgery (36%), and splinting (20%). Multivariable Tobit regressions showed notable differences in satisfaction by the provider on the Total Score but not on the Provider Subscore. Other factors known to affect the PGOMPS scores for in-person visits were not notably associated with the Total or Provider Sub-Scores for virtual visits (area deprivation index, age, and offer of surgery or injection) other than the body mass index.

Conclusions

Virtual clinic visit satisfaction was affected by the provider. Wait time strongly affects satisfaction with in-person visits but is not accounted for by the PGOMPS scoring system for virtual visits, which is a limitation of their survey. Further work is required to determine how to improve the patient experience with virtual visits.

Type of study/level of evidence

Prognostic IV.

There is Little or No Association Between Independently Assessed Communication Strategies and Patient Ratings of Clinician Empathy

BACKGROUND

Quality of care is increasingly assessed and incentivized using measures of patient-reported outcomes and experience. Little is known about the association between measurement of clinician communication strategies by trained observers and patient-rated clinician empathy (a patient-reported experience measure). An effective independent measure could help identify and promote clinician behaviors associated with good patient experience of care.

QUESTIONS/PURPOSES

(1) What is the association between independently assessed clinician communication effectiveness and patient-rated clinician empathy? (2) Which factors are associated with independently assessed communication effectiveness?

METHODS

One hundred twenty adult (age > 17 years) new or returning patients seeking musculoskeletal specialty care between September 2019 and January 2020 consented to video recording of their visit followed by completion of questionnaires rating their perceptions of providers' empathy levels in this prospective study. Patients who had operative treatment and those who had nonoperative treatment were included in our sample. We pooled new and returning patients because our prior studies of patient experience found no influence of visit type and because we were interested in the potential influences of familiarity with the clinician on empathy ratings. We did not record the number of patients or baseline data of patients who were approached, but most patients (> 80%) were willing to participate. For 7% (eight of 120 patients), there was a malfunction with the video equipment or files were misplaced, leaving 112 records available for analysis. Patients were seen by one provider among four attending physicians, four residents, or four physician assistants or nurse practitioners. The primary study question addressed the correlation between patient-rated clinician empathy using the Jefferson Scale of Patient Perceptions of Physician Empathy and clinician communication effectiveness, independently rated by two communication scholars using the Liverpool Communication Skills Assessment Scale. Based on a subset of 68 videos (61%), the interrater reliability was considered good for individual items on the Liverpool Communication Skills Assessment Scale (intraclass correlation coefficient [ICC] 0.78 [95% confidence interval (CI) 0.75 to 0.81]) and excellent for the sum of the items (that is, the total score) (ICC = 0.92 [95% CI 0.87 to 0.95]). To account for the potential association of personal factors with empathy ratings, patients completed measures of symptoms of depression (the Patient-Reported Outcome Measurement Information System depression computerized adaptive test), self-efficacy in response to pain (the two-item Pain Self-Efficacy Questionnaire), health anxiety (the five-item Short Health Anxiety Inventory), and basic demographics.

RESULTS

Accounting for potentially confounding variables, including specific clinicians, marital status, and work status in the multivariable analysis, we found higher independent ratings of communication effectiveness had a slight association (odds ratio [OR] 1.1 [95% CI 1.0 to 1.3]; p = 0.02) with higher (dichotomized) ratings of patient-rated clinician empathy, while being single was associated with lower ratings (OR 0.40 [95% CI 0.16 to 0.99]; p = 0.05). Independent ratings of communication effectiveness were slightly higher for women (regression coefficient 1.1 [95% CI 0.05 to 2.2]); in addition, two of the four attending physicians were rated notably higher than the other 10 participants after controlling for confounding variables (differences up to 5.8 points on average [95% CI 2.6 to 8.9] on a 36-point scale).

CONCLUSION

The observation that ratings of communication effectiveness by trained communication scholars have little or no association with patient-rated clinician empathy suggests that either effective communication is insufficient for good patient experience or that the existing measures are inadequate or inappropriate. This line of investigation might be enhanced by efforts to identify clinician behaviors associated with better patient experience, develop reliable and effective measures of clinician behaviors and patient experience, and use those measures to develop training approaches that improve patient experience.

LEVEL OF EVIDENCE

Level I, prognostic study .

Factors Associated With Patient Satisfaction Measured Using an Iterative Scale

BACKGROUND AND OBJECTIVES

Patient experience measures tend to have notable ceiling effects that make it difficult to learn from gradations of satisfaction to improve care. This study tested 2 different iterative satisfaction measures after a musculoskeletal specialty care visit in the hope that they might have less ceiling effect. We measured floor effects, ceilings effects, skewness, and kurtosis of both questionnaires. We also assessed patient factors independently associated with the questionnaires and the top 2 possible scores.

METHODS

In this cross-sectional study, 186 patients completed questionnaires while seeing 1 of 11 participating orthopedic surgeons in July and August 2019; the questionnaire measured: (1) demographics, (2) symptoms of depression, (3) catastrophic thinking in response to nociception, (4) heightened illness concerns, and (5) satisfaction with the visit on 2 iterative satisfaction scales. Bivariate and multivariable analyses sought associations of the explanatory variable with the satisfaction scales.

RESULTS

There is a small correlation between the 2 scales ( r = 0.27; P < .001). Neither scale had a floor effect and both had a ceiling effect of 45%. There is a very small correlation between greater health anxiety and lower satisfaction measured with one of the scales ( r = -0.16; P = .05).

CONCLUSION

An iterative satisfaction questionnaire created some spread in patient experience data, but could not limit ceiling effects. Additional strategies are needed to remove ceiling effects from satisfaction measures.

Moderators and Mediators of the Relationship of Shared Decision-Making and Satisfaction

Background:Evidence suggests that health literacy, perceived availability of information and guidance to adapt to challenges (informational support), and symptoms of depression all have the potential to mediate or moderate the relationship between patient-rated involvement in decisions and satisfaction with care. If so these could be useful targets for improving patient experience. Methods: We prospectively enrolled 130 new adult patients visiting an orthopedic surgeon over a 4-month period. All patients were asked to complete measures of satisfaction with care (21-item Medical Interview Satisfaction Scale), perceived involvement in decisions (9-item Shared Decision-Making Questionnaire), symptoms of depression (the Patient-Reported Outcomes Measurement Information Scale [PROMIS] Depression Computerized Adaptive Test [CAT]), perceived availability of information and guidance to adapt to challenges (PROMIS Informational Support CAT), and the Newest Vital Sign test of health literacy. Results: The strong correlation between satisfaction with care (ρ = 0.60, P < .001) and perceived involvement in decisions was neither mediated nor moderated by health literacy, perceived availability of information and guidance, and symptoms of depression. Conclusions: The observation that patient-rated shared decision-making is strongly related to satisfaction with an office visit, independent of health literacy, perceived support, and symptoms of depression, is consistent with evidence that various measures of patient experience tend to correlate and emphasizes the importance of the patient-clinician relationship. Level of Evidence: Level II, prospective study.

Examining how physician factors influence patient satisfaction during clinical consultations about cancer prognosis and pain

Objective

Patient-physician communication affects cancer patients' satisfaction, health outcomes, and reimbursement for physician services. Our objective is to use machine learning to comprehensively examine the association between patient satisfaction and physician factors in clinical consultations about cancer prognosis and pain.

Methods

We used data from audio-recorded, transcribed communications between physicians and standardized patients (SPs). We analyzed the data using logistic regression (LR) and random forests (RF).

Results

The LR models suggested that lower patient satisfaction was associated with more in-depth prognosis discussion; and higher patient satisfaction was associated with a greater extent of shared decision making, patient being black, and doctor being young. Conversely, the RF models suggested the opposite association with the same set of variables.

Conclusion

Somewhat contradicting results from distinct machine learning models suggested possible confounding factors (hidden variables) in prognosis discussion, shared decision-making, and doctor age, on the modeling of patient satisfaction. Practitioners should not make inferences with one single data-modeling method and enlarge the study cohort to help deal with population heterogeneity.

Innovation

Comparing diverse machine learning models (both parametric and non-parametric types) and carefully applying variable selection methods prior to regression modeling, can enrich the examination of physician factors in characterizing patient-physician communication outcomes.

Validation and Translation of the Relational Aspect of Care Questionnaire into the Malay Language (RAC-QM) to Evaluate the Compassionate Care Level of Healthcare Workers from the Patient's Perspective

BACKGROUND

Compassionate care has been increasingly highlighted in the past few decades worldwide, including in Malaysia. Despite acknowledging its importance, Malaysia still lacks a validated tool that can be used to assess the level of compassionate care from the patient's perspective. Therefore, this study aims to validate and translate the Relational Aspect of Care Questionnaire (RAC-Q) into the Malay language.

METHODS

Permission to use and translate the original RAC-Q into the Malay language was obtained. The RAC-Q was then translated into the Malay language following the 10 steps proposed for the translation of a patient-reported outcome questionnaire. A pretest was conducted based on 30 inpatients to assess the appropriateness and clarity of the finalized translated questionnaire. A cross-sectional study was performed based on 138 inpatients from six adult wards of a teaching hospital so as to validate the translated questionnaire. The data were analyzed using R software version 4.1.3 (R Core Team, Vienna, Austria, 2020). The results were presented descriptively as numbers and percentages or means and standard deviations. A confirmatory factor analysis was performed using robust estimators.

RESULTS

The analysis showed that the measurement model of the RAC-Q Malay version (RAC-QM) fits well based on several fit indices: a standardized factor loading range from 0.40 to 0.73, comparative fit index (CFI) of 0.917, Tucker-Lewis fit index (TLI) of 0.904, root mean square error of approximation (RMSEA) of 0.06, and a standardized root mean square residual (SRMR) of 0.073. It has good reliability, with a Cronbach's alpha of 0.857 and a composite ratio of 0.857.

CONCLUSION

The RAC-QM demonstrated good psychometric properties and is valid and reliable based on the confirmatory analysis, and it can thus be used as a tool for evaluating the level of compassionate care in Malaysia.

Which Factors Are Associated With Satisfaction With Treatment Results in Patients With Hand and Wrist Conditions? A Large Cohort Analysis

BACKGROUND

Satisfaction with treatment results is an important outcome domain in striving for patient-centered and value-based healthcare. Although numerous studies have investigated factors associated with satisfaction with treatment results, most studies used relatively small samples. Additionally, many studies have only investigated univariable associations instead of multivariable associations; to our knowledge, none have investigated the independent association of baseline sociodemographics, quality of life, improvement in pain and function, experiences with healthcare delivery, and baseline measures of mental health with satisfaction with treatment results.

QUESTIONS/PURPOSES

(1) What factors are independently associated with satisfaction with treatment results at 3 months post-treatment in patients treated for common hand and wrist conditions? (2) What factors are independently associated with the willingness to undergo the treatment again at 3 months post-treatment in patients treated for common hand and wrist conditions? Among the factors under study were baseline sociodemographics, quality of life, improvement in pain and function, experiences with healthcare delivery, and baseline measures of mental health.

METHODS

Between August 2018 and May 2020, we included patients who underwent carpal tunnel release, nonsurgical or surgical treatment for thumb-base osteoarthritis, trigger finger release, limited fasciectomy for Dupuytren contracture, or nonsurgical treatment for midcarpal laxity in one of the 28 centers of Xpert Clinics in the Netherlands. We screened 5859 patients with complete sociodemographics and data at baseline. Thirty-eight percent (2248 of 5859) of these patients had complete data at 3 months. Finally, participants were eligible for inclusion if they provided a relevant answer to the three patient-reported experience measure (PREM) items. A total of 424 patients did not do this because they answered "I don't know" or "not applicable" to a PREM item, leaving 31% (1824 of 5859) for inclusion in the final sample. A validated Satisfaction with Treatment Result Questionnaire was administered at 3 months, which identified the patients' level of satisfaction with treatment results so far on a 5-point Likert scale (research question 1, with answers of poor, moderate, fair, good, or excellent) and the patients' willingness to undergo the treatment again under similar circumstances (research question 2, with answers of yes or no). A hierarchical logistic regression model was used to identify whether baseline sociodemographics, quality of life, change in outcome (patient-reported outcome measures for hand function and pain), baseline measures of mental health (including treatment credibility [the extent to which a patient attributes credibility to a treatment] and expectations, illness perception, pain catastrophizing, anxiety, and depression), and PREMs were associated with each question of the Satisfaction with Treatment Result Questionnaire at 3 months post-treatment. We dichotomized responses to our first question as good and excellent, which were considered more satisfied, and poor, moderate, and fair, which were considered less satisfied. After dichotomization, 57% (1042 of 1824) of patients were classified as more satisfied with the treatment results.

RESULTS

The following variables were independently associated with satisfaction with treatment results, with an area under the curve of 0.82 (95% confidence interval 0.80 to 0.84) (arranged from the largest to the smallest standardized odds ratio [SOR]): greater decrease in pain during physical load (standardized odds ratio 2.52 [95% CI 2.18 to 2.92]; p < 0.001), patient's positive experience with the explanation of the pros and cons of the treatment (determined with the question: "Have you been explained the pros and cons of the treatment or surgery?") (SOR 1.83 [95% CI 1.41 to 2.38]; p < 0.001), greater improvement in hand function (SOR 1.76 [95% CI 1.54 to 2.01]; p < 0.001), patients' positive experience with the advice for at-home care (determined with the question: "Were you advised by the healthcare providers on how to deal with your illness or complaints in your home situation?") (SOR 1.57 [95% CI 1.21 to 2.04]; p < 0.001), patient's better personal control (determined with the question: "How much control do you feel you have over your illness?") (SOR 1.24 [95% CI 1.1 to 1.40]; p < 0.001), patient's more positive treatment expectations (SOR 1.23 [95% CI 1.04 to 1.46]; p = 0.02), longer expected illness duration by the patient (SOR 1.20 [95% CI 1.04 to 1.37]; p = 0.01), a smaller number of symptoms the patient saw as part of the illness (SOR 0.84 [95% CI 0.72 to 0.97]; p = 0.02), and less concern about the illness the patient experiences (SOR 0.84 [95% CI 0.72 to 0.99]; p = 0.04). For willingness to undergo the treatment again, the following variables were independently associated with an AUC of 0.81 (95% CI 0.78 to 0.83) (arranged from the largest to the smallest standardized OR): patient's positive experience with the information about the pros and cons (determined with the question: "Have you been explained the pros and cons of the treatment or surgery?") (SOR 2.05 [95% CI 1.50 to 2.80]; p < 0.001), greater improvement in hand function (SOR 1.80 [95% CI 1.54 to 2.11]; p < 0.001), greater decrease in pain during physical load (SOR 1.74 [95% CI 1.48 to 2.07]; p < 0.001), patient's positive experience with the advice for at home (determined with the question: "Were you advised by the healthcare providers on how to deal with your illness or complaints in your home situation?") (SOR 1.52 [95% CI 1.11 to 2.07]; p = 0.01), patient's positive experience with shared decision-making (determined with the question: "Did you decide together with the care providers which care or treatment you will receive?") (SOR 1.45 [95% CI 1.06 to 1.99]; p = 0.02), higher credibility the patient attributes to the treatment (SOR 1.44 [95% CI 1.20 to 1.73]; p < 0.001), longer symptom duration (SOR 1.27 [95% CI 1.09 to 1.52]; p < 0.01), and patient's better understanding of the condition (SOR 1.17 [95% CI 1.01 to 1.34]; p = 0.03).

CONCLUSION

Our findings suggest that to directly improve satisfaction with treatment results, clinicians might seek to: (1) improve the patient's experience with healthcare delivery, (2) try to influence illness perception, and (3) boost treatment expectations and credibility. Future research should confirm whether these suggestions are valid and perhaps also investigate whether satisfaction with treatment results can be predicted (instead of explained, as was done in this study). Such prediction models, as well as other decision support tools that investigate patient-specific needs, may influence experience with healthcare delivery, expectations, or illness perceptions, which in turn may improve satisfaction with treatment results.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Recommendation of Surgery and Other Interventions Is Associated With Increased Patient Satisfaction With Orthopedic Outpatient Visits

The primary goal of our study was to determine whether satisfaction with orthopedic surgery outpatient visits is affected by a recommendation for surgery compared with a recommendation for nonoperative treatment, as measured by the Press Ganey Outpatient Medical Practice Survey (PGOMPS). Secondarily, we evaluated the effect of offering an injection, therapy, or any intervention (surgery, injection, therapy, immobilization, aspiration, or radiation therapy) on PGOMPS scores. To investigate this relationship, we reviewed new orthopedic outpatient visits at a tertiary academic center during a single year (2018). Patient satisfaction was defined as a PGOMPS score greater than the 33rd percentile. Univariate and multivariate binary logistic regression was conducted to determine the effect of a surgical recommendation and the effect of recommending an injection, therapy, or any intervention on the PGOMPS total score and provider subscore. Of the 1217 included patients, multivariate analysis showed that a surgical recommendation was significantly and independently associated with satisfaction on the PGOMPS total score and provider subscore. Multivariate analysis also showed that being offered an injection, therapy, or any intervention was significantly associated with higher PGOMPS total scores compared with not being offered those interventions. Patients who were offered surgery or other interventions were significantly more likely to be satisfied with their encounter and the surgeon. Patients who were offered surgery were significantly more likely to be satisfied with their encounter and the surgeon than those who were not offered surgery. Additionally, patients who were offered any intervention were significantly more likely to be satisfied with their encounter than those who were not offered an intervention. [Orthopedics. 2022;45(3):187-191.].

Does Adjusting for Social Desirability Reduce Ceiling Effects and Increase Variation of Patient-Reported Experience Measures?

Social desirability bias (a tendency to underreport undesirable attitudes and behaviors) may account, in part, for the notable ceiling effects and limited variability of patient-reported experience measures (PREMs) such as satisfaction, communication effectiveness, and perceived empathy. Given that there is always room for improvement for both clinicians and the care environment, ceiling effects can hinder improvement efforts. This study tested whether weighting of satisfaction scales according to the extent of social desirability can create a more normal distribution of scores and less ceiling effect. In a cross-sectional study 118 English-speaking adults seeking musculoskeletal specialty care completed 2 measures of satisfaction with care (one iterative scale and one 11-point ordinal scale), a measure of social desirability, and basic demographics. Normality of satisfaction scores was assessed using Shapiro-Wilk tests. After weighting for social desirability, scores on the iterative satisfaction scale had a more normal distribution while scores on the 11-point ordinal satisfaction scale did not. The ceiling effects in satisfaction decreased from 47% (n = 56) to 2.5% (n = 3) for the iterative scale, and from 81% (n = 95) to 2.5% (n = 3) for the ordinal scale. There were no differences in mean satisfaction when the social desirability was measured prior to completion of the satisfaction surveys compared to after. The observation that adjustment for levels of social desirability bias can reduce ceiling effects suggests that accounting for personal factors could help us develop PREMs with greater variability in scores, which may prove useful for quality improvement efforts.

"We're All Time Poor": Experienced Clinicians' and Students' Perceptions of Challenges Related to Patient Communication

PHENOMENON

Communication is a complex and essential element of clinical practice. It is widely accepted that communication skills can be taught and learned, but challenges remain for clinicians in achieving effective communication with patients. This study explored the patient-communication challenges faced by both medical students and experienced clinicians.

APPROACH

Semi-structured interviews were conducted with twenty medical students and nineteen experienced clinicians from a range of medical disciplines. Interviews were recorded and transcribed, and transcriptions subjected to thematic analysis and coding to quantify the challenges discussed.

FINDINGS

There was remarkable consistency in the challenges described by both groups of participants, with eight predominant challenges identified: time constraints and chaotic environments, rapport building, patient characteristics, reluctance, omissions, assumptions, decision-making, and keeping conversations focused.

INSIGHTS

Medical curricula often focus on communication challenges associated with complex or sensitive clinical situations, but many of the challenges identified occur in routine consultations. Both pre-service and post-graduate medical training should adopt strategies to help build students' and clinicians' skills in managing these challenges from the outset of training.

In Orthopaedic Speciality Care, Longer Explanations Are Not More Caring or More Satisfying

BACKGROUND

Research consistently documents no correlation between the duration of a musculoskeletal specialty care visit and patient experience (perceived empathy of the specialist and satisfaction with care). Based on a combination of clinical experience and other lines of research, we speculate that longer visits are often related to discordance between specialist and patient interpretation of symptoms and weighting of available test and treatment options. If this is true, then the specific duration of time discussing the specialist's interpretations and options with the patient (expertise transfer) might correlate with satisfaction with care and perceived empathy of the clinician even if the total visit time does not.

QUESTIONS/PURPOSES

(1) What demographic or mental health factors are associated with the duration of expertise transfer? (2) What factors, including the duration of expertise transfer, are associated with the patient's satisfaction with the visit and perceived clinician empathy?

METHODS

In a cross-sectional study, 128 new and returning English-speaking adult outpatients seeking care from one of three orthopaedic specialists in two urban practices between September and November 2019 were enrolled and agreed to audio recording of the visit. A total of 92% (118) of patients completed the questionnaire and had a usable recording. Participants completed a sociodemographic survey, the Patient-Reported Outcome Measure Information System Depression computer adaptive test (PROMIS Depression CAT; a measure of symptoms of depression), the Short Health Anxiety Index (SHAI-5; a measure of symptoms of hypochondriasis, a form of symptoms misinterpretation), the Pain Catastrophizing Scale (PCS-4; a measure of misinterpretation of symptoms), an ordinal measure of patient satisfaction (dichotomized into satisfied or not because of strong ceiling effects), and the Jefferson Scale of Patient Perception of Physician Empathy (JSPPPE; a measure of perceived clinician empathy). The duration of expertise transfer and the total duration of the visit were measured by two raters with acceptable reliability using software that facilitates segmentation of the visit audio recording. To determine factors associated with the duration of expertise transfer, satisfaction, and empathy, we planned a multivariable analysis controlling for potential confounding variables identified in exploratory bivariable analysis. However, there were insufficient associations to merit multivariable analysis.

RESULTS

A longer duration of expertise transfer had a modest correlation with catastrophic thinking (r = 0.24; p = 0.01). Complete satisfaction with the visit was associated with less health anxiety (6 [interquartile range 5 to 7] for complete satisfaction versus 7 [5 to 7] for less than complete satisfaction; p = 0.02) and catastrophic thinking (4 [1 to 7] versus 5 [3 to 11]; p = 0.02), but not with the duration of expertise transfer. Greater perceived clinician empathy had a slight correlation with less health anxiety (r = -0.19; p = 0.04).

CONCLUSION

Patients with greater misinterpretation of symptoms experience a slightly less satisfying visit and less empathetic relationship with a musculoskeletal specialist despite a longer duration of expertise transfer. This supports the concept that directive strategies (such as teaching healthy interpretation of symptoms) may be less effective then guiding strategies (such as nurturing openness to alternative, healthier interpretation of symptoms using motivational interviewing tactics, often over more than one visit or point of contact).

LEVEL OF EVIDENCE

Level II, therapeutic study.

A Review of the Evidence and Recommendations on Communication Skills and the Patient-Provider Relationship: A Rome Foundation Working Team Report

BACKGROUND & AIMS

Over several decades, changes in health care have negatively impacted meaningful communication between the patient and provider and adversely affected their relationship. Under increasing time pressure, physicians rely more on technology than face-to-face time gathering data to make clinical decisions. As a result, they find it more challenging to understand the illness context and fully address patient needs. Patients experience dissatisfaction and a diminution of their role in the care process. For patients with disorders of gut-brain interaction, stigma leads to greater care dissatisfaction, as there is no apparent structural basis to legitimize the symptoms. Recent evidence suggests that practical communication skills can improve the patient-provider relationship (PPR) and clinical outcomes, but these data are limited.

METHODS

The Rome Foundation convened a multidisciplinary working team to review the scientific evidence with the following aims: a) to study the effect of communication skills on patient satisfaction and outcomes by performing an evidence-based review; b) to characterize the influence of sociocultural factors, health care system constraints, patient perspective, and telehealth on the PPR; c) to review the measurement and impact of communication skills training on these outcomes; and d) to make recommendations to improve communication skills training and the PPR.

RESULTS

Evidence supports the fact that interventions targeting patient-provider interactions improve population health, patient and provider experience, and costs. Communication skills training leads to improved patient satisfaction and outcomes. The following are relevant factors to consider in establishing an effective PPR: addressing health care system constraints; incorporating sociocultural factors and the role of gender, age, and chronic illness; and considering the changing role of telehealth on the PPR.

CONCLUSIONS

We concluded that effective communication skills can improve the PPR and health outcomes. This is an achievable goal through training and system change. More research is needed to confirm these findings.

Missed Empathic Opportunities During Hand Surgery Office Visits

Background: Empathy (conveyance of an understanding of a patient's situation, perspective, and feelings) deepens the therapeutic alliance and leads to better health outcomes. We studied the frequency and nature of empathic opportunities and physician responses in patients visiting a hand surgeon. We also sought patient characteristics associated with the number of patient-initiated-clues and missed opportunities by surgeons. Methods: For this prospective cohort study, we enrolled 83 new, adult patients visiting 1 of 3 hand surgeons during a period of 4 months. All visits were audio-recorded, and empathic opportunities (patient-initiated emotional or social clues) and physician responses were categorized using the model of Levenson et al. Before the visit, patients completed the Newest Vital Sign health literacy test; 3 Patient-Reported Outcomes Measurement Information System-based questionnaires: Upper-Extremity function, Pain Interference, and Depression questionnaires; and a sociodemographic survey. Results: Empathic opportunities were present in 70% of hand surgery office visits. Surgeons responded empathically to about half of the opportunities. Patients with limited health literacy and greater symptoms of depression (small correlation; r = -0.29) were less likely to receive a positive response. Response to an empathic opportunity did not affect visit duration. Conclusions: Hand surgeons often miss empathic opportunities. Future research might address the influence of training physicians to address empathic opportunities on trust, adherence, satisfaction, and outcomes.

Determinants of caregiver satisfaction in pediatric orthopedics

This study investigates determinants of pediatric orthopedic surgery patients' parent or guardian (caregiver) satisfaction with the physician in an outpatient office setting. This was a cross-sectional survey study of 200 English-speaking caregivers of pediatric patients that checked into the pediatric orthopedic clinic at the authors' institution from 1 March 2017 to 1 November 2018. Questionnaires given in clinic include the Newest Vital Sign and The Literacy in Musculoskeletal Problems survey to measure general and musculoskeletal health literacy, respectively, demographic information, expected/estimated wait time, Consultation and Relational Empathy Measure, and Consumer Assessment of Healthcare Providers and Systems Clinician and Group. After multivariate regression, only perceived physician empathy as measured by the Consultation and Relational Empathy Measure score was significantly correlated with caregiver satisfaction (P < 0.0001), accounting for 56% of the variability of caregiver satisfaction scores. The odds of a satisfaction score of at least 9 out of 10 were 21% higher for every unit increase of the Consultation and Relational Empathy Measure score [odds ratio = 1.21 (P < 0.0001)]. After logistic regression, the caregiver's gender was also correlated with patient satisfaction and the odds of a patient satisfaction score ≥9 for males was less than 1/4th that of females [odds ratio = 0.16 (P = 0.040)]. The most important determinant of caregiver satisfaction with the physician in an outpatient pediatric orthopedic setting is perceived physician empathy. This accounts for the majority of the caregiver's satisfaction. This is the first study to determine this relationship in pediatric orthopedic surgery.

Clinician Factors Rather Than Patient Factors Affect Discussion of Treatment Options

BACKGROUND

Shared decision-making aims to combine what matters most to a patient with clinician expertise to develop a personalized health strategy. It is a dialogue between patient and clinician in which preferences are expressed, misconceptions reoriented, and available options are considered. To improve patient involvement, it would help to know more about specific barriers and facilitators of patient-clinician communication. Health literacy, the ability to obtain, process, and understand health information, may affect patient participation in decision-making. If the patient is quiet, deferential, and asks few questions, the clinician may assume a more paternalistic style. A patient with greater agency and engagement could be the catalyst for shared decisions.

QUESTIONS/PURPOSES

We assessed (1) whether effective clinician communication and effort is related to patient health literacy, and (2) if there are other factors associated with effective clinician communication and effort.

METHODS

We combined a prospective, cross-sectional cohort of 86 audio-recorded visits of adult patients seeking specialist hand care for a new problem at an urban community hospital in the Netherlands with a cohort of 72 audio-recorded hand surgery visits from a tertiary hospital in the United States collected for a prior study. The American cohort represents a secondary use of data from a set of patients from a separate study using audio-recorded visits and administering similar questionnaires that assessed different endpoints. In both cohorts, adult patients seeking specialist hand care for a new problem were screened. In total, 165 patients were initially screened, of which 96% (158) participated. Eight percent (13) of visits were excluded since the final diagnosis remained unclear, 8% (12) since it was not the first consultation for the current problem, 5% (8) in which only one treatment option was available, and < 1% (1) since there was a language barrier. A total of 123 patients were analyzed, 68 from the Netherlands and 55 from the United States. The Newest Vital Sign (NVS) health literacy test, validated in both English and Dutch, measures the ability to use health information and is based on a nutrition label from an ice cream container. It was used to assess patient health literacy on a scale ranging from 0 (low) to 6 (high). The 5-item Observing Patient Involvement (OPTION5) instrument is commonly used to assess the quality of patient-clinician discussion of options. Scores may be influenced by clinician effort to involve patients in decision-making as well as patient engagement and agency. Each item is scored from 0 (no effort) to 4 (maximum effort), with a total maximum score of 20. Two independent raters reached agreement (kappa value 0.8; strong agreement), after which all recordings were scored by one investigator. Visit duration and patient questions were assessed using the audio recordings. Patients had a median (interquartile range) age of 54 (38 to 66) years, 50% were men, 89% were white, 66% had a nontraumatic diagnosis, median (IRQ) years of education was 16 (12 to 18) years, and median (IQR) health literacy score was 5 (2 to 6). Median (IQR) visit duration was 9 (7 to 12) minutes. Cohorts did not differ in important ways. The number of visits per clinician ranged from 14 to 29, and the mean overall communication effectiveness and effort score for the visits was low (8.5 ± 4.2 points of 20 points). A multivariate linear regression model was used to assess factors associated with communication effectiveness and effort.

RESULTS

There was no correlation between health literacy and clinician communication effectiveness and effort (r = 0.087 [95% CI -0.09 to 0.26]; p = 0.34), nor was there a difference in means (SD) when categorizing health literacy as inadequate (7.8 ± 3.8 points) and adequate (8.9 ± 4.5 points; mean difference 1.0 [95% CI -2.6 to 0.54]; p = 0.20). After controlling for potential confounding variables such as gender, patient questions, and health literacy, we found that longer visit duration (per 1 minute increase: r2 = 0.31 [95% CI -0.14 to 0.48]; p < 0.001), clinician 3 (compared with clinician 1: OR 33 [95% CI 4.8 to 229]; p < 0.001) and clinician 5 (compared with clinician 1: OR 11 [95% CI 1.5 to 80]; p = < 0.02) were independently associated with more effective communication and effort, whereas clinician 6 was associated with less effective communication and effort (compared with clinician 1: OR 0.08 [95% CI 0.01 to 0.75]; p = 0.03). Clinicians' communication strategies (the clinician variable on its own) accounted for 29% of the variation in communication effectiveness and effort, longer visit duration accounted for 11%, and the full model accounted for 47% of the variation (p < 0.001).

CONCLUSION

The finding that the overall low mean communication effectiveness and effort differed between clinicians and was not influenced by patient factors including health literacy suggests clinicians may benefit from training that moves them away from a teaching or lecturing style where patients receive rote directives regarding their health. Clinicians can learn to adapt their communication to specific patient values and needs using a guiding rather than directing communication style (motivational interviewing).Level of Evidence Level II, prognostic study.

Factors Influencing Press Ganey Ambulatory Surgery Scores in Patients Undergoing Upper Extremity Procedures

We sought to determine whether patient and surgical factors are associated with the Press Ganey Ambulatory Surgery Survey (PGAS) satisfaction scores in patients undergoing outpatient upper extremity procedures.

Socioeconomic, racial and ethnic differences in patient experience of clinician empathy: Results of a systematic review and meta-analysis

INTRODUCTION

Empathy is essential for high quality health care. Health care disparities may reflect a systemic lack of empathy for disadvantaged people; however, few data exist on disparities in patient experience of empathy during face-to-face health care encounters with individual clinicians. We systematically analyzed the literature to test if socioeconomic status (SES) and race/ethnicity disparities exist in patient-reported experience of clinician empathy.

METHODS

Using a published protocol, we searched Ovid MEDLINE, PubMed, CINAHL, EMBASE, CENTRAL and PsychINFO for studies using the Consultation and Relational Empathy (CARE) Measure, which to date is the most commonly used and well-validated methodology for measuring clinician empathy from the patient perspective. We included studies containing CARE Measure data stratified by SES and/or race/ethnicity. We contacted authors to request stratified data, when necessary. We performed quantitative meta-analyses using random effects models to test for empathy differences by SES and race/ethnicity.

RESULTS

Eighteen studies (n = 9,708 patients) were included. We found that, compared to patients whose SES was not low, low SES patients experienced lower empathy from clinicians (mean difference = -0.87 [95% confidence interval -1.72 to -0.02]). Compared to white patients, empathy scores were numerically lower for patients of multiple race/ethnicity groups (Black/African American, Asian, Native American, and all non-whites combined) but none of these differences reached statistical significance.

CONCLUSION

These data suggest an empathy gap may exist for patients with low SES. More research is needed to further test for SES and race/ethnicity disparities in clinician empathy and help promote health care equity.

TRIAL REGISTRATION

Registration (PROSPERO): CRD42019142809.

Day-of-Surgery Video Calls and Phone Calls Increase Patient Satisfaction with Outpatient Surgery Experience: A Randomized Controlled Trial of Postoperative Communication Modalities

BACKGROUND

With the increasing utilization of patient satisfaction as a metric for clinical care, there is growing interest in techniques that can be used to improve satisfaction in patients undergoing surgery. The purpose of this trial was to assess the impact of day-of-surgery video and phone calls on patient satisfaction.

METHODS

We enrolled 251 patients undergoing outpatient orthopaedic surgery with 3 participating surgeons. Surgeons were randomized to 1 of 3 patient communication modalities: no contact (standard of care), phone call, or video call. Several hours following discharge on the day of surgery, the surgeons contacted patients according to their assigned treatment group. At the initial postoperative office visit, satisfaction outcomes were assessed using the Consumer Assessment of Healthcare Providers and Systems Surgical Care (S-CAHPS) survey and an additional satisfaction questionnaire.

RESULTS

Fifty-nine (97%) of 61 patients in the no-contact group, 118 (99%) of 119 patients in the phone group, and 71 (100%) of 71 patients in the video group completed follow-up assessment. The S-CAHPS top-box response rate in both the video group (0.86 ± 0.14, p < 0.001) and the phone group (0.84 ± 0.17, p < 0.001) was greater than in the no-contact group (0.68 ± 0.26). When asked to rate satisfaction with overall care, a greater proportion of patients in the video group (85.9%) gave the top-box response compared with both the phone group (71.8%, p = 0.040) and the no-contact group (60.7%, p = 0.002). Among the patients in the video group, 62.0% indicated that they would prefer a video call in future encounters with their surgeon compared with 1.8% of patients in the no-contact group (p < 0.001) and 1.7% of patients in the phone group (p < 0.001).

CONCLUSIONS

Phone and video calls following discharge are an effective way of enhancing patient satisfaction with the clinical care experience as measured by the S-CAHPS survey. In terms of satisfaction with overall care, video calls may be superior to phone calls.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

What Are the Priming and Ceiling Effects of One Experience Measure on Another?

Patient-reported experience measures have notable ceiling effects which can hinder efforts to learn and improve. This study tested whether an iterative (Guttman-style) satisfaction questionnaire combined with instructions intended to give people agency to critique us primes responses on an ordinal scale and reduces ceiling effects. Among the 161 subjects randomly assigned to complete an iterative satisfaction questionnaire before or after an ordinal scale, there was no difference in mean satisfaction (no priming). The Guttman scale was more normally distributed and had slightly less ceiling effect when compared to the ordinal scale. Iterative satisfaction scales partially mitigate ceiling effects. The absence of priming suggests that attempts to encourage agency and reflection have limited ability to reduce ceiling effects, and alternative approaches should be tested.

Reporting and utilization of Patient-Reported Outcomes Measurement Information System® (PROMIS®) measures in orthopedic research and practice: a systematic review

BACKGROUND

The Patient-Reported Outcomes Measurement Information SystemⓇ (PROMISⓇ) is a dynamic system of psychometrically sound patient-reported outcome (PRO) measures. There has been a recent increase in the use of PROMIS measures, yet little has been written about the reporting of these measures in the field of orthopedics. The purpose of this study was to conduct a systematic review to determine the uptake of PROMIS measures across orthopedics and to identify the type of PROMIS measures and domains that are most commonly used in orthopedic research and practice.

METHODS

We searched PubMed, Embase, and Scopus using keywords and database-specific subject headings to capture orthopedic studies reporting PROMIS measures through November 2018. Our inclusion criteria were use of PROMIS measures as an outcome or used to describe a population of patients in an orthopedic setting in patients ≥ 18 years of age. We excluded non-quantitative studies, reviews, and case reports.

RESULTS

Our final search yielded 88 studies published from 2013 through 2018, with 57% (50 studies) published in 2018 alone. By body region, 28% (25 studies) reported PROMIS measures in the upper extremity (shoulder, elbow, hand), 36% (32 studies) reported PROMIS measures in the lower extremity (hip, knee, ankle, foot), 19% (17 studies) reported PROMIS measures in the spine, 10% (9 studies) reported PROMIS measures in trauma patients, and 6% (5 studies) reported PROMIS measures in general orthopedic patients. The majority of studies reported between one and three PROMIS domains (82%, 73 studies). The PROMIS Computerized Adaptive Test (CAT) approach was most commonly used (81%, 72 studies). The most frequently reported PROMIS domains were physical function (81%, 71 studies) and pain interference (61%, 54 studies).

CONCLUSION

Our review found an increase in the reporting of PROMIS measures over the recent years. Utilization of PROMIS measures in orthopedic populations is clinically appropriate and can facilitate communication of outcomes across different provider types and with reduced respondent burden.

REGISTRATION

The protocol for this systematic review was designed in accordance with the PRISMA guidelines and is registered with the PROSPERO database (CRD42018088260).

Health Literacy in Surgery

Background:

Low health literacy is associated with poor health outcomes in many chronic diseases and may have an important role in determining surgical outcomes. This study aims to comprehensively review the current state of science on adult health literacy in surgery and to identify knowledge gaps for future research.

Methods:

Using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a systematic search was conducted to identify all studies from January 2002 through May 2018 that used validated instruments to assess health literacy among adult patients undergoing surgery. Studies were assessed for quality using the Newcastle-Ottawa scale and evaluated on findings by their focus on identifying health literacy levels, understanding associations with surgical outcomes, and/or developing interventions to address low health literacy.

Key Results:

There were 51 studies on health literacy with data from 22,139 patients included in this review. Low health literacy was present in more than one-third of surgical patients (34%, interquartile range 16%–50%). The most commonly used validated instrument for assessment of health literacy in the surgical population was the Newest Vital Sign. Most studies were focused on identifying the prevalence of low health literacy within a surgery population (84%, n = 43). Few studies focused on understanding the association of health literacy to surgical outcomes (12%, n = 6) and even fewer studies developed interventions to address health literacy (4%, n = 2).

Discussion:

Low health literacy is common among surgical patients. Important opportunities exist to better understand the role of health literacy in determining surgical outcomes and to develop more health literacy-sensitive models of surgical care. [HLRP: Health Literacy Research and Practice. 2020;4(1):e45–e65.]

Plain Language Summary:

Health literacy has not been well-studied in surgery but likely plays an important role. In this article, we reviewed all current research on health literacy in surgery to help us understand where we are at and where we need to go. We found that low health literacy is common and we need more ways to address it in surgery.

Relationship Between Orthopedic Surgeon's Empathy and Inpatient Hospital Experience Scores in a Tertiary Care Academic Institution

Studies have examined the relationship between physician empathy and patient experience, but few have explored it in surgeons. The purpose of this study was to report on orthopedic surgeon empathy in a mutlispecialty practice and explore its association with orthopedic patient experience. Patients completed the consultation and relational empathy (CARE) measure (March 2017-August 2018) and Canadian Patient Experience Survey-Inpatient Care (CPES-IC; March 2017-February 2019) to assess empathy and patient experience, respectively. Consultation and relational empathy measures were correlated to CPES-IC for 3 surgeon-related questions pertaining to respect, listening, and explaining. Surgeon CARE scores (n = 1134) ranged from 42.0 ± 9.1 to 48.6 ± 2.4 with 50.4% of patients rating their surgeon as perfectly empathic. There were no significant differences between surgeons for CPES-IC continuous and topbox scores (n = 834) for respect and correlations between CPES-IC questions. The CARE measure for both continuous and topbox scores were weak to moderate, but none were significant. Empathy was associated with surgeon respect and careful listening, despite lack of significant correlation. Possible future work could use an empathy tool more appropriate for this surgeon population.

Unmet Patient Expectations for Interventions Decrease Provider Satisfaction Scores

As health care reimbursement evolves, physicians will continue to be evaluated based on the quality of care that they provide. One measure of quality is based on patient satisfaction as reported through the Consumer Assessment of Healthcare Providers and Systems Survey (CAHPS). Although previous studies have explored expectations and their role in patient satisfaction, no studies have investigated the role of patient expectations for interventions in surgical specialty clinics. Patients (N=126) were given 2 surveys, a pre-visit and a post-visit questionnaire, with options based on the CAHPS survey. Patients were asked to select common orthopedic services that they expected to receive from their appointments, rate their physicians on Likert scales, and report the services that were actually provided. Patients who left with unmet expectations for interventions (45%) rated their physicians lower than patients who had all of their expectations met (9.0±1.4 vs 9.5± 0.8; P<.05). For most individual interventions, there was no difference in satisfaction between patients with met and unmet expectations. However, patients who expected surgery and did not have their expectations met rated their physician lower than patients whose expectations for surgery were met (9.0±1.3 vs 9.7±0.6; P<.05). No statistically significant difference was found in physician rating with increased numbers of unmet expectations, individual surgeon rating, perceptions of their providers, and wait time. This study reports that patient expectations for interventions, and particularly a recommendation for surgery, may alter a patient's reported satisfaction, particularly when surgical expectations are unmet. [Orthopedics. 2020;43(5):e378-e382.].

Impact of Consultation Length on Satisfaction in Patients with Chronic Low Back Pain: A Nationwide Multicenter Study in Japan

Introduction

Chronic low back pain (CLBP) is a major health burden worldwide and requires patient satisfaction with treatment. Consultation length can be an important factor in patient satisfaction, but few studies have investigated the impact of consultation length on satisfaction in patients with CLBP. This study tried to elucidate the impact of consultation length on clinical outcomes in patients with CLBP.

Methods

This study is part of an analysis using the database of the nationwide, multicenter cohort for CLBP performed by the Project Committee of the Japanese Society for Spine Surgery and Related Research. A total of 427 patients aged 20-85 years (median age, 73.0 years; female, 58.6%) with CLBP were prospectively followed-up monthly for 6 months. Multivariable nonlinear regression analyses were performed to assess the effect of consultation length on outcome measures including subjective satisfaction score, EuroQol 5-dimension, Japanese Orthopaedic Association (JOA) score, Roland-Morris Disability Questionnaire, JOA Back Pain Evaluation Questionnaire, visual analog scale (VAS) and Medical Outcome Survey short-form 8-item health survey that evaluated at the next phase. Furthermore, we assessed whether the effect of consultation length on patient satisfaction was modified by the baseline Brief Scale for Psychiatric Problems in Orthopaedic Patients (BS-POP) score for patient and physician versions.

Results

VAS for CLBP was the only score that correlated significantly with consultation length (P = 0.018). Satisfaction score showed a significant positive correlation with consultation length in patients with the highest baseline BS-POP scores (P < 0.2). Moreover, consultation lengths more than 7.6 min and 15.1 min offered increase of satisfaction if patients show the highest BS-POP scores on patient and physician versions, respectively.

Conclusions

These findings suggest that a sufficiently long consultation is an important factor for subjective satisfaction in the patients with CLBP, particularly in patients with psychological problems.

Factors Associated With Patient Satisfaction Measured Using a Guttman-Type Scale

Patient experience measures such as satisfaction are increasingly tracked and incentivized. Satisfaction questionnaires have notable ceiling effects that may limit learning and improvement. This study tested a Guttman-type (iterative) Satisfaction Scale (GSS) after a musculoskeletal specialty care visit in the hope that it might reduce the ceiling effect. We measured floor effects, ceiling effects, skewness, and kurtosis of GSS. We also assessed factors independently associated with GSS and the top 2 possible scores. In this cross-sectional study, 164 patients seeing an orthopedic surgeon completed questionnaires measuring (1) a demographics, (2) symptoms of depression, (3) catastrophic thinking in response to nociception, (4) heightened illness concerns, and (5) satisfaction with the visit (GSS). Bivariate and multivariable analyses sought associations of the explanatory variable with total GSS and top 2 scores of GSS. Accounting for potential confounding using multivariable analysis, lower satisfaction was independently associated with greater symptoms of depression (β: -0.03; 95% CI: -0.05 to -0.00; P = .047). The top 2 scores of the GSS were independently associated with women (compared to men: odds ratio [OR]: 2.12, 99% CI: 1.01-4.45, P = .046) and lower level of education (masters' degree compared to high school; OR: 0.16, 95% CI: 004-0.61, P = .007). The GSS had no floor effect, a ceiling effect of 38%, a skewness of -0.08, and a kurtosis of 1.3. The 38% ceiling effect of the iterative (Guttman-style) satisfaction measure is lower than ordinal satisfaction scales, but still undesirably high. Alternative approaches for reducing the ceiling effect of patient experience measures are needed.

Attempts to Limit Censoring in Measures of Patient Satisfaction

Background:

Measures of patient satisfaction are increasingly used to measure patient experience. Most satisfaction measures have notable ceiling effects, which limits our ability to learn from variation among relatively satisfied patients. This study tested a variety of single-question satisfaction measures for their mean overall score, ceiling and floor effect, and data distribution. In addition, we assessed the correlation between satisfaction and psychological factors and assessed how the various methods for measuring satisfaction affected net promoter scores (NPSs).

Methodology:

A total of 212 patients visiting orthopedic offices were enrolled in this randomized controlled trial. Patients were randomized to 1 of 5 newly designed, single-question satisfaction scales: (a) a helpfulness 11-point ordinal scale from 0 to 10, (b) a helpfulness ordinal 11-point scale from 0 to 5 (ie, with 1.5, 2.5, etc), (c) a helpfulness 100-point slider, (d) a satisfaction 11-point ordinal scale from 0 to 10, and (e) a willingness to recommend 11-point ordinal scale from 0 to 10. Additionally, patients completed the 2-item Pain Self-Efficacy Questionnaire (PSEQ-2), 5-item Short Health Anxiety Inventory (SHAI-5) Scale, and Patient-Reported Outcomes Measurement Information System (PROMIS) Depression. We assessed mean and median score, ceiling and floor effect, and skewness and kurtosis for each scale. Spearman’s correlation tests were used to test correlations between satisfaction and psychological status. Finally, we assessed the NPS for the various scales.

Results:

Ceiling effects ranged from 29% to 68%. The 11-point ordinal helpfulness scale from 0 to 10 had the least ceiling effect (29%). All of the scales were asymmetrically distributed, with the 11-point ordinal scale from 0 to 5 having the most Gaussian distribution (skew = 0.64 and kurtosis = 2.3). Satisfaction scores did not correlate with psychological factors: PSEQ-2 (r = 0.04; P = .57), SHAI-5 (r = 0.01; P = .93), and PROMIS Depression (r = −0.04; P = .61). Net promoter scores varied substantially by scale design, with higher scores corresponding with greater ceiling effects.

Conclusions:

Variations in scale types, text anchors, and lead-in statements do not eliminate the ceiling effect of single-question measures of satisfaction with a visit to an orthopedic specialist. Further studies might test other scale designs and labels.

Level of Evidence:

Diagnostic; Level II

The Association Between Symptoms of Depression and Office Visits in Patients With Nontraumatic Upper-Extremity Illness

PURPOSE

Because psychological and social factors increase symptoms and limitations, it is possible that they are also related to higher use of care.

METHODS

We used a database of an academic outpatient orthopedic department in which patient-reported outcome measures were routinely collected and identified 3,620 patients with de Quervain tendinopathy, ganglion, trapeziometacarpal arthritis, trigger digit, or carpal tunnel syndrome who remained in care at least 3 months. At every office visit, patients completed the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Computerized Adaptive Test (CAT), PROMIS Pain Interference CAT, and PROMIS Depression CAT. We conducted multivariable Poisson regression analysis of factors associated with the total number of office visits, accounting for PROMIS scores at the first office visit, age, surgical treatment, sex, diagnosis, and clinician team.

RESULTS

Operative treatment had the greatest influence on the number of office visits. Other variables associated with the number of visits were female sex, younger age, higher PROMIS Depression scores, and higher Pain Interference scores.

CONCLUSIONS

Treatment choice had the greatest influence on the number of subsequent visits for atraumatic conditions. The fact that the total number of office visits is associated with greater symptoms of depression and greater pain interference, independent of treatment choice, suggests a relation between mental health and resource use.

CLINICAL RELEVANCE

Quality improvement efforts and future research might address whether adding strategies to decrease symptoms of depression and optimize coping strategies (to reduce pain interference) might improve upper-extremity health more efficiently than standard treatment alone.

The Role of Outpatient Care Accreditation in Enhancing Foreign Patients' Perception of Colombian Medical Tourism: A Quasi-experimental Design

This study analyzes whether hospitals accredited by the Joint Commission International in outpatient medical care protocols located in Colombia achieve a higher quality perception from foreign patients compared to others treated in a non-accredited one. A t-test with Welch correction, chi-square test, correlation coefficient of Tau Kendall, pre-test, post-test, complementary questionnaire and a 2 focus groups were used in 178 foreign patients. It was observed that patients treated in accredited hospitals had a higher quality perception than the non-accredited group. However, it was found that an unbalanced application of the 3 variables negatively alters quality judgment. Findings contributes to understanding the Colombian medical tourism in depth using non-conventional instruments.

Predictors of Patient Satisfaction in Hand and Upper Extremity Clinics

Introduction  Patient satisfaction is an important clinical marker for hand/upper extremity patients. Few studies have investigated the predictors of patient satisfaction in the clinic setting. Our objective was to analyze patient satisfaction surveys to explore factors that influence patient satisfaction. Materials and Methods  We conducted a retrospective analysis assessing patient satisfaction in the hand/upper extremity clinics at our university medical center between 2012 and 2018. Patient satisfaction was assessed via Press Ganey Hospital Consumer Assessment of Healthcare Providers and Systems surveys. Patient demographics, satisfaction scores, and clinic experience questionnaire responses were evaluated. Statistical analysis was conducted to identify significant trends. Results  Between 2012 and 2018, 102 surveys were completed. Scores ranged from 5 to 10 with an average provider rating of 9.56. We found six factors significantly influenced patient satisfaction: adequate time was spent with the provider, provider showed respect, patient was seen by provider within 15 minutes of appointment time, provider listened sufficiently, patient received understandable medical instructions, and understandable medical explanations ( p < 0.05). Conclusion  Achieving patient satisfaction is an important clinical marker in hand/upper extremity clinics. Patient satisfaction has defined predictors wherein various clinical factors can influence patient satisfaction and willingness to refer their provider to other patients.

Medical visit time and predictors in health facilities: a mega systematic review and meta-analysis

Purpose

Visit time is a crucial aspect of patient–physician interaction; its inadequacy can negatively impact the efficiency of treatment and diagnosis. In addition, visit time is a fundamental demand of patients, and it is one of the rights of every patient. The purpose of this paper is to determine factors influencing the consultation length of physicians and to compare consultation length in different countries.

Design/methodology/approach

MEDLINE (PubMed), Web of Science, Cochrane, ProQuest, Scopus, and Google Scholar were searched. In addition, references of references were checked, and publication lists of individual scholars in the field were examined. We used data sources up to June 2018, without language restriction. We used a random-effects model for the meta-analyses. Meta-analyses were conducted using Comprehensive Meta-Analysis Version (CMA) 3.0.

Findings

Of 16,911 identified studies, 189 studies were assessed of which 125 cases (67 percent) have been conducted in the USA. A total of 189 studies, 164 (86.77 percent) involved face-to face-consultations. The effects of three variables, physician gender, patient gender, and type of consultation were analyzed. According to moderate and strong evidence studies, no significant difference was found in the consultation lengths of female and male doctors (Q=42.72, df=8,I2=81.27,p=0.891) and patients’ gender (Q=55.98, df=11,I2=80.35,p=0.314). In addition, no significant difference was found in the telemedicine or face-to-face visits (Q=41.25, df=5,I2=87.88,p=0.170).

Originality/value

In this systematic review and meta-analysis, all of physicians’ visits in 34 countries were surveyed. The evidence suggests that specified variables do not influence the length of consultations. Good relationship is essential to a safe and high-quality consultation and referral process. A high-quality consultation can improve decisions and quality of visits, treatment effectiveness, efficiency of service, quality of care, patient safety and physician and patient satisfaction.

Wait Times in Musculoskeletal Patients: What Contributes to Patient Satisfaction

Introduction:

The purpose of this study was to determine how wait time duration is associated with patient satisfaction and how appointment characteristics relate to wait time duration and patient satisfaction in the orthopedic surgery clinic.

Methods:

Two hundred sixty-four patients visiting one of 3 ambulatory orthopedic surgery clinics were asked to estimate their wait time and to rate their satisfaction with the visit. The associations between appointment characteristics, wait time, and satisfaction were analyzed using t tests, 1-way analysis of variance, and Pearson correlation coefficients.

Results:

Wait times were significantly different based on visit type, appointment time, whether an X-ray was required, and whether a trainee was involved (P < .001). Patients with wait times less than 30 minutes had higher satisfaction scores (P < .001). Satisfaction ratings were significantly different based on the surgeon’s management recommendation (P = .0211), but were not significantly different based on sex, age, office location, visit type, appointment time subsection, or time spent with the physician (P > .05).

Conclusion:

Wait times negatively correlated with satisfaction. New patient visits, appointment times in the later third of the day, appointments requiring an X-ray, and appointments involving a trainee had significantly longer wait times. Care should be taken to inform patients with visits involving these characteristics that they may experience longer than average wait times.

Association of waiting and consultation time with patient satisfaction: secondary-data analysis of a national survey in Peruvian ambulatory care facilities

Background

Research suggested that waiting time and consultation time are associated with overall patient satisfaction concerning health services. However, there is a lack of information regarding this subject in Latin American countries, where particular aspects of health systems and population characteristics could modify this association. Our aim was to evaluate the association of waiting time and consultation time with patient satisfaction, in Peruvian ambulatory care facilities and propose a cut-off points of waiting and consultation time based on patient satisfaction.

Methods

Cross-sectional secondary data analysis of the National Survey on User Satisfaction of Health Services (ENSUSALUD-2015), a national-wide survey with a probabilistic sample of 181 Peruvian ambulatory care facilities. Patient satisfaction, waiting time, consultation time, and sociodemographic variables were collected from the ENSUSALUD-2015. All variables were collected by survey directly to patients, from the selected ambulatory care facilities, after their consultation. Complex survey sampling was considered for data analysis. In the association analysis, we grouped the waiting time and consultation time variables, every 10 min, because for it is more relevant and helpful in the statistical and practical interpretation of the results, instead of the every-minute unit.

Results

The survey was performed in 13,360 participants. Response rate were 99.8 to 100% in the main variables. Waiting time (for every 10 min) was inversely associated with patient satisfaction (aOR: 0.98, 95% CI: 0.97–0.99), although the aOR was lower among those who reported a waiting time ≤ 90 min (aOR: 0.92, 95% CI: 0.89–0.96). Consultation time (for every 10 min) was directly associated with patient satisfaction (aOR: 1.59, 95% CI: 1.26–2.01), although the aOR was higher among those who reported a consultation time ≤ 15 min (aOR: 2.31, 95% CI: 1.66–3.21).

Conclusion

In Peruvian ambulatory care facilities, both waiting time and consultation time showed an association with overall patient satisfaction, which was stronger in the first 90 min of waiting time and in the first 15 min of consultation time. This should be taken into consideration when designing interventions to improve waiting times and consultation times in ambulatory care facilities from Peru or from similar contexts.

Satisfaction With Specific and Nonspecific Diagnoses

PURPOSE

Nonspecific upper extremity illnesses (eg,. wrist pain, forearm pain)-where no objectively verifiable pathology is detectable-are common and usually self-limiting. For some patients, a nonspecific diagnosis can contribute to mistrust and disappointment.

METHODS

This study tested the primary null hypothesis that there is no difference in mean overall satisfaction between patients given a specific compared with a nonspecific diagnosis. Second, we assessed factors associated with satisfaction and with nonspecific upper extremity diagnosis.

RESULTS

There was no significant difference between mean satisfaction with nonspecific and specific diagnoses in bivariate analysis. However, when treated as a categorical variable, 22% of the patients with a nonspecific diagnosis had a satisfaction score of 8 or lower compared with 11% of the patients given a specific diagnosis. First visit and greater pain intensity were significantly associated with a nonspecific diagnosis in bivariate analysis. In the multivariable models, no factors were independently associated with satisfaction or with nonspecific diagnoses.

CONCLUSIONS

Although nonspecific diagnoses can sometimes be frustrating for both physician and patient, in this small study using a satisfaction measure with a strong ceiling effect, they were no less satisfying to patients on average and corresponded with slightly greater pain intensity than specific diagnoses.

CLINICAL RELEVANCE

The degree to which nonspecific diagnoses (perhaps in combination with compassionate care and incremental monitoring) can be part of a satisfying treatment experience merits additional investigation.

Visit Duration Does Not Correlate with Perceived Physician Empathy

BACKGROUND

Perceived physician empathy is a strong driver of patient satisfaction. We assessed the influence of wait time, time spent with the surgeon, and surgeon stress level on the way patients rated surgeon empathy.

METHODS

One hundred and fourteen patients visiting 1 of 6 participating surgeons were prospectively enrolled in the study. We recorded patient demographics and assessed the patient rating of perceived physician empathy. Time waiting for the surgeon and time spent with the surgeon were measured with use of ambulatory tracking systems and by research assistants with stopwatches outside the patient rooms. Patient ratings of surgeon empathy were assessed with use of the Jefferson Scale of Patient's Perceptions of Physician Empathy (JSPPPE), and surgeon stress level was assessed with use of the Perceived Stress Score short form. The mean wait time was 30 ± 18 minutes, and the mean time spent with the surgeon was 8.7 ± 5.3 minutes. Two separate multilevel linear regression models were used to compare factors associated with the JSPPPE and time spent with the surgeon.

RESULTS

Neither time spent with the surgeon nor wait time was independently associated with perceived physician empathy; being male, having at least a post-college graduate degree, and higher self-reported surgeon stress levels were independently associated with less perceived empathy. More time spent with the surgeon was independently associated with lower self-reported surgeon stress levels; follow-up visits and visits for a traumatic condition were independently associated with less time spent with the surgeon.

CONCLUSIONS

The results of the present study show that improved communication strategies, rather than shorter wait time or increased time spent with the patient, may increase patient satisfaction. This should be a focus of future research.