Patient and hospital characteristics associated with patient assessments of hospital obstetrical care

Measuring Patient Experience and Patient Satisfaction—How Are We Doing It and Why Does It Matter? A Comparison of European and U.S. American Approaches

(1) Background: Patients’ experiences and satisfaction with their treatment are becoming increasingly important in the context of quality assurance, but the measurement of these parameters is accompanied by several disadvantages such as poor cross-country comparability and methodological problems. The aim of this review is to describe and summarize the process of measuring, publishing, and utilizing patient experience and satisfaction data in countries with highly developed healthcare systems in Europe (Germany, Sweden, Finland, Norway, the United Kingdom) and the USA to identify possible approaches for improvement. (2) Methods: Articles published between 2000 and 2021 that address the topics described were identified. Furthermore, patient feedback in social media and the influence of sociodemographic and hospital characteristics on patient satisfaction and experience were evaluated. (3) Results: The literature reveals that all countries perform well in collecting patient satisfaction and experience data and making them publicly available. However, due to the use of various different questionnaires, comparability of the results is difficult, and consequences drawn from these data remain largely unclear. (4) Conclusions: Surveying patient experience and satisfaction with more unified as well as regularly updated questionnaires would be helpful to eliminate some of the described problems. Additionally, social media platforms must be considered as an increasingly important source to expand the range of patient feedback.

Association of Hospital Teaching Status with Neurosurgical Outcomes: An Instrumental Variable Analysis

BACKGROUND

The interpretation of the results of prior studies on the association of hospital teaching status with surgical outcomes is limited by selection bias. We investigated whether undergoing surgical operations in teaching hospitals is associated with improved outcomes.

METHODS

We performed a cohort study of all patients undergoing spine and cranial operations who were registered in the New York Statewide Planning and Research Cooperative System database from 2009 to 2013. We examined the association of teaching status (defined as academic affiliation for the primary analysis) with inpatient case fatality, discharge to a facility, and length of stay (LOS). An instrumental variable analysis was used to control for unmeasured confounding and to simulate the effect of a randomized trial.

RESULTS

During the study period, 186,483 patients underwent surgical operations that met the inclusion criteria. Instrumental variable analysis demonstrated that hospitalization in teaching hospitals was associated with higher rates of case fatality (adjusted difference, 25%; 95% confidence interval [CI], 4%-46%), discharge to a facility (adjusted difference, 5.7%; 95% CI, 4.5%-7.0%), and longer LOS (adjusted difference, 31.4%; 95% CI, 16.0%-46.1%) in comparison with nonteaching hospitals. The same associations were present in propensity score adjusted mixed effects models. These persisted in prespecified subgroups stratified on particular operations and for different definitions of teaching hospitals.

CONCLUSIONS

Using a comprehensive all-payer cohort of surgical patients in New York State, we identified an association of treatment in teaching hospitals with increased case fatality, rate of discharge to rehabilitation, and longer LOS. Further research into the factors contributing to superior outcomes in nonteaching institutions is warranted.

Differences between Proxy and Patient Assessments of Cancer Care Experiences and Quality Ratings

OBJECTIVE

To assess the impact of proxy survey responses on cancer care experience reports and quality ratings.

DATA SOURCES/STUDY SETTING

Secondary analysis of data from Cancer Care Outcomes Research and Surveillance (CanCORS). Recruitment occurred from 2003 to 2005.

STUDY DESIGN

The study was a cross-sectional observational study. The respondents were patients with incident colorectal or lung cancer or their proxies.

DATA COLLECTION/EXTRACTION METHODS

Analyses used linear regression models with an independent variable for proxy versus patient responses as well as study site and clinical covariates. The outcomes were experiences with medical care, nursing care, care coordination, and care quality rating. Multiple imputation was used for missing data.

PRINCIPAL FINDINGS

Among 6,471 respondents, 1,011 (16 percent) were proxies. The proportion of proxy respondents varied from 6 percent to 28 percent across study sites. Adjusted proxy scores were modestly higher for medical care experiences (+1.28 points [95 percent CI:+ 0.05 to +2.51]), but lower for nursing care (-2.81 [95 percent CI: -4.11 to -1.50]) and care coordination experiences (-2.98 [95 percent CI: -4.15 to -1.81]). There were no significant differences between adjusted patient and proxy ratings of quality.

CONCLUSIONS

Proxy responses have small but statistically significant differences from patient responses. However, if ratings of care are used for financial incentives, such differences could be exaggerated across practices or areas if proxy use varies.

Do experiences with pregnancy, birth and postnatal care in Norway vary by the women's geographic origin? a comparison of cross-sectional survey results

BACKGROUND

A national survey was conducted to measure and benchmark women's experiences with pregnancy, birth and postnatal care in Norway. The purpose of this secondary analysis is to explore potential variation in these experiences with regard to the survey respondents' geographic origin.

METHODS

Data were collected in a national observational cross-sectional study, by a self-administered questionnaire and from registries. The questionnaire collects patient reported experience measures (PREMS) of mainly nontechnical aspects of the health-care services. While taking the clustered characteristics of the respondents into consideration, we compared the mean scores on 16 indexes between women of four different geographic origins using linear regression models.

RESULTS

The origin of the 4904 respondents were classified as Norway (n = 4028, 82%), Western Europe, North-America, Oceania (n = 233, 5%), Eastern Europe (n = 290, 6%), and Asia, Turkey, Africa, and South-America) (n = 353, 7%). The observed differences were moderate, and no consistency was present in the results in respect of direction or magnitude of the differences between the groups.

CONCLUSIONS

With some important cautions, we conclude that this study did not detect systematic differences between groups of different geographic origin, in their experiences with pregnancy and maternity care in Norway.

Patient experiences in relation to respondent and health service delivery characteristics: A survey of 26,938 patients attending 62 hospitals throughout Norway

Aims: To assess the association between patient experiences, aspects of healthcare delivery, and patient characteristics for adult somatic inpatients attending hospitals throughout Norway. Methods: The Patient Experiences Questionnaire (PEQ) was mailed to 26,938 patients attending inpatient clinics at 62 Norwegian hospitals during 2002 and 2003 within a six-week period. Reminders were mailed at four weeks. Scores for the PEQ were regressed on whether the patient felt that he/she had received incorrect treatment, had spent the night in a corridor bed, had been an emergency or routine admission, his/her number of previous admissions, hospital teaching status, hospital size and location, health status, and sociodemographic variables. Results: A total of 13,700 (50.9%) patients responded. Patients who felt that they had received incorrect treatment had significantly poorer scores for all 10 PEQ dimensions. Those spending the night in a corridor bed had significantly poorer scores for six dimensions. Emergency admissions and the previous number of inpatient stays were significantly associated with poorer experiences for 10 and 7 dimensions respectively. Hospital size and university status had negative relationships with scores for six and four dimensions respectively. Conclusions: Whether the patient felt that he/she had received the incorrect treatment had by far the strongest association with patient experiences. Future studies of patient experiences and satisfaction should include this variable. As found in previous research, patient experiences were significantly associated with age and health status.

Psychometric Properties of the Spanish Consumer Assessment of Health Plans Survey (CAHPS)

This study describes the psychometric properties of the Consumer Assessments of Health Plans Survey (CAHPS) in 279 persons who completed it in Spanish and 439 persons who completed it in English. We found negatively skewed distributions of responses and significant ceiling effects in both English and Spanish surveys. Cronbach’s alphas for English and Spanish multiple-item composites were 0.69 or higher. Correlations between the CAHPS measures and willingness of individuals to recommend their doctor and health plan to family and friends were all moderately strong and statistically significant except for one global rating. There were significant differences in the patterns of correlations between global ratings and composites for English and Spanish surveys. This study suggests that the Spanish CAHPS 2.0 core survey has acceptable psychometric properties.

Do patient, hospital, and community characteristics predict variations in overall inpatient experience scores? A multilevel analysis of hospitals in California

The purpose of this cross-sectional study was to examine how patient, hospital, and community characteristics explain variations in overall inpatient experience with care. We used data from the Patients’ Evaluations of Performance in California survey, the American Hospital Association annual hospital survey, and the Area Resource File. The sample consisted of 24,887 adult patients who received either medical or surgical inpatient care in 173 hospitals located in 46 California counties. A null hierarchical linear model for overall inpatient experience showed that 96.17%, 3.24%, and 0.59% of the variations were within hospitals, between hospitals, and between communities, respectively. Conditional models showed that patient characteristics (sex, age, education, health status, and service line) explained 10.95% of the within-hospital variations; hospital characteristics (teaching status, registered-nurse staffing intensity, and resources directed to patient care) explained 34.12% of the between-hospital variations; and community characteristics (hospital competition, teaching hospitals, per-capita income, and percentage of minority population) explained 99.33% of the between-community variations. These findings suggest that multilevel variations need to be considered when patient experiences are compared across hospitals. Larger future studies are needed to understand how patient experience with care may vary based on patient health-care provider communication across patient subgroups.

A retrospective evaluation of the impact of the Planetree patient-centered model of care on inpatient quality outcomes

OBJECTIVE

This retrospective quasi-experimental study evaluated the Planetree patient-centered model of care on inpatient quality outcomes. The research questions to be addressed were: What is the impact of the Planetree patient-centered model of care (1) on patient satisfaction, (2) on clinical outcomes (length of stay and readmission), and (3) on the cost of providing care (cost per case and productive nursing hours per patient day)?

BACKGROUND

Patients and their families have described a more patient-centered approach as key to meeting their needs. The Planetree model of care provides a framework and operational guidance on how to implement programs targeting these key areas. The link between patient-centered care and quality outcomes such as patient satisfaction, length of stay, readmission, cost per case, and productive nursing hours per patient day has been postulated; however, to date little to no research has been conducted examining this issue.

METHODS

This was a retrospective, nonexperimental comparison study evaluating units with the same types of patients and the same skill mix, and with standardized organizational pay rates, supply costs, policies, procedures, contracts, and a regulatory compliance program. This provided a unique opportunity to evaluate the impact on inpatient quality outcomes of the Planetree patient-centered model of care as practiced in the Planetree unit. Data were analyzed using a 2 × 5 analysis of variance (ANOVA) and logistic regression (readmission only). This was a study of five separate cohorts grouped by calendar year rather than a study of repeated measures.

RESULTS

No differences in demographic profiles were noted between the two groups. The patient satisfaction composite mean score evaluation, length-of-stay evaluation, and the cost-per-case evaluation demonstrated that the Planetree group was different from the comparison group (p = <.05 with Eta squared = >.01). This evidence validates that the Planetree patient-centered model of care had a positive impact on patient satisfaction, length of stay, and cost per case.

CONCLUSIONS

This evaluation of 869 hospitalized adults undergoing elective total-knee or total-hip joint replacement surgery indicated that the Planetree patient-centered model of care positively affected patient satisfaction, length of stay, and cost per case. Nursing and hospital administrators seeking to improve the inpatient hospital experience should consider implementation of the Planetree patient-centered model of care. Hospitals and healthcare organizations seeking an evidence-based approach to the implementation of patient-centered care will benefit from the information in this study.

Psychometric Testing of a Comprehensive Patient Satisfaction Survey in Arabic

Background and Purpose: Although patient satisfaction is an important indicator of the quality of care received in hospitals, no reliable and valid Arabic comprehensive inpatient satisfaction survey has been published. The purpose of this study was to evaluate the psychometric properties of an Arabic patient satisfaction survey. Methods: A cross-sectional design was used where 1,339 randomly selected patients were interviewed by phone. The questionnaire was adopted and from the Hospital Consumer Assessment of Healthcare Providers and Systems survey, refined and tested over a 4-year period. Results: Item–item correlations for the 22 items on the survey ranged from .52 to .92, and the Cronbach’s alpha coefficient was .87. Construct and predictive validity were also adequate. Conclusion: The survey is recommended for use in hospitals in Lebanon and other Middle Eastern countries to facilitate benchmarking and quality improvement.

Contemporary performance of U.S. teaching and nonteaching hospitals

PURPOSE

To compare the performance of U.S. teaching and nonteaching hospitals using a portfolio of contemporary, publicly reported metrics.

METHOD

The authors classified acute care general hospitals filing a Medicare Institutional Cost Report according to teaching intensity: nonteaching, teaching, or Council of Teaching Hospitals member. They compared aggregate results across categories for Hospital Compare process compliance, mortality, and readmission rates (acute myocardial infarction [AMI], heart failure, pneumonia); Surgical Care Improvement Project (SCIP) performance; compliance with Leapfrog standards; patient experience; patient services and key technologies; safety (computerized physician order entry, intensive care unit staffing, National Quality Forum safe practices, hospital-acquired conditions); and cost/resource utilization (Medicare-adjusted expense per case; Leapfrog efficiency and resource use standards).

RESULTS

Availability of patient services and advanced technologies were associated with teaching intensity (P < .0001), as were most hospital safety metrics. Teaching intensity was favorably associated with SCIP performance, AMI and heart failure process scores, and mortality (P < .0001). It was unfavorably associated with higher AMI and pneumonia readmission rates (P < .0001) and lower scores for individual patient satisfaction measures. Costs per case were similar (P = .4194) across hospital categories after correction for federally allowed adjustments (case mix, wages, and low-income patient care).

CONCLUSIONS

Teaching hospitals offer advanced clinical capabilities, educate the next generation of providers, care for disadvantaged urban populations, and are leaders in health care research and innovation. However, many stakeholders may be unaware of an additional value-relatively higher quality and safety in many areas, with similar adjusted costs.

Improving quality of medical treatment and care: are surgeons' working conditions and job satisfaction associated to patient satisfaction?

BACKGROUND

Over the last decades, surgeons, researchers, and health administrators have been working hard to define standards for high-quality treatment and care in Surgery departments. However, it is unclear whether patients' perceptions of medical treatment and care are related and affected by surgeons' perceptions of their working conditions and job satisfaction. The aim of this study was to evaluate patients' satisfaction in relation to surgeons' working conditions.

METHODS

A cross-sectional survey with 120 patients and 109 surgeons working in Surgery hospital departments was performed. Surgeons completed a survey evaluating their working conditions and job satisfaction. Patients assessed quality of medical care and treatment and their satisfaction with being a patient in this department.

RESULTS

Seventy percent of the patients were satisfied with performed surgeries and services in their department. Surgeons' job satisfaction and working conditions rated with moderate scores. Bivariate analyses showed correlations between patients' satisfaction and surgeons' job satisfaction and working conditions. Strongest correlations were found between kindness of medical staff, treatment outcome and overall patient satisfaction.

CONCLUSION

This study demonstrates strong associations between surgeons' working conditions and patient satisfaction. Based on these findings, hospital managements should improve work organization, workload, and job resources to not only improve surgeons' job satisfaction but also quality of medical treatment and patient satisfaction in Surgery departments.

Organizational determinants of patient-centered fertility care: a multilevel analysis

OBJECTIVE

To identify organizational determinants of positive patient experiences with fertility care, with the goal of improving patient centeredness of care.

DESIGN

Cross-sectional survey.

SETTING

One large university clinic and 12 medium-sized fertility clinics in the Netherlands.

PATIENT(S)

Three hundred and sixty-nine couples receiving medically assisted reproduction in one of the participating clinics between March and May 2008.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Organizational determinants of patients' experiences with patient centeredness in fertility care.

RESULT(S)

Of the patients during the relevant period, 78% of the women and 76% of their partners participated in the study. Infertile couples who have a lead physician, have access to an electronic personal health record, or see trained fertility nurses have more positive experiences with aspects of patient-centered care, like continuity of care and partner involvement. Moreover, receiving a treatment other than in vitro fertilization was negatively associated with the perceived patient centeredness of care. The identified determinants explained 5.1% to 22.4% of the total variance.

CONCLUSION(S)

This study provides organizational determinants of patients' experiences with fertility care on numerous facets of patient centeredness. These organizational determinants can be used as valuable tools to enable clinics to provide a more positive patient experience.

Teaching hospital status and operative mortality in the United States: tipping point in the volume-outcome relationship following colon resections?

OBJECTIVE

To compare risk- and volume-adjusted outcomes of colon resections performed at teaching hospitals (THs) vs non-THs to assess whether benign disease may influence the volume-outcome effect.

DESIGN

Retrospective data analysis examining colon resections determined by International Classification of Diseases, Ninth Revision, Clinical Modification classification performed in the United States from 2001 through 2005 using the Nationwide Inpatient Sample (NIS) and the Area Resource File (2004). Patient covariates used in adjustment included age, sex, race, Charlson Index comorbidity score, and insurance status. Hospital covariates included TH status, presence of a colorectal surgery fellowship approved by the Accreditation Council for Graduate Medical Education, geographical region, institutional volume, and urban vs rural location. County-specific surgeon characteristics used in adjustment included average age of surgeons and proportion of colorectal board-certified surgeons within each county. Environmental or county covariates included median income and percentage of county residents living below the federal poverty level.

SETTING

A total of 1045 hospitals located in 38 states in the United States that were included in the NIS.

PATIENTS

All patients older than 18 years who had colon resection and were discharged from a hospital included in the NIS.

MAIN OUTCOME MEASURES

Operative mortality, length of stay (LOS), and total charges.

RESULTS

A total of 115 250 patients were identified, of whom 4371 died (3.8%). The mean LOS was 10 days. Fewer patients underwent surgical resection in THs than in non-THs (46 656 vs 68 589). Teaching hospitals were associated with increased odds of death (odds ratio, 1.14) (P = .03), increased LOS (P = .003), and a nonsignificant trend toward an increase in total charges (P = .36).

CONCLUSIONS

With the inclusion of benign disease, colon surgery displays a volume-outcome relationship in favor of non-THs. Inclusion of benign disease may represent a tipping point.

Patient satisfaction questionnaire and quality achievement in hospital care: the case of a Greek public university hospital

The scope of this research has been to investigate the satisfaction of Greek patients hospitalized in a tertiary care university public hospital in Alexandroupolis, Greece, in order to improve medical, nursing and organizational/administrative services. It is a cross-sectional study involving 200 patients hospitalized for at least 24 h. We administered a satisfaction questionnaire previously approved by the Greek Health Ministry. Four aspects of satisfaction were employed (medical, hotel facilities/organizational, nursing, global). Using principal component analysis, summated scales were formed and tested for internal consistency with the aid of Cronbach's alpha coefficient. The non-parametric Spearman rank correlation coefficient was also used. The results reveal a relatively high degree of global satisfaction (75.125%), yet satisfaction is higher for the medical (89.721%) and nursing (86.432%) services. Moreover, satisfaction derived from the hotel facilities and the general organization was found to be more limited (76.536%). Statistically significant differences in participant satisfaction were observed (depending on age, gender, citizenship, education, number of previous admissions and self-assessment of health status at the first and last day of patients' stay) for the medical, nursing and hotel facilities/organizational dimension, but not for global satisfaction. The present study confirms the results of previously published Greek surveys.

Organizational influences on patient perceptions of symptom management

We tested a theoretical model of the relationships of hospital context, nursing unit structure, and patient characteristics to patients' perceptions of the extent to which nurses met their expectations for management of troubling symptoms. In our sample of 2,720 patients randomly selected from 278 nursing units in 143 hospitals, we found that patient age was positively associated with patients' perceptions of symptom management. The proportion of registered nurses as caregivers on the unit was not a significant predictor of symptom management, but better work conditions on the unit (nurses' autonomy, participation in decision-making, and collaboration with other disciplines [relational coordination]) significantly contributed to patients' perceptions of better symptom management.

The Effect of Hospital Size and Teaching Status on Patient Experiences With Hospital Care

BACKGROUND

Hospitals rapidly change structure and organization. Little research has been conducted that documents whether hospital size and teaching status is associated with patient experiences.

OBJECTIVES

We sought to assess the effect of hospital size and teaching status on patient experiences with hospital care.

METHODS

We undertook a cross-sectional survey of patients discharged from somatic hospitals in Norway. Multilevel regression analysis was used to assess the effect of interest. A total of 21,445 patients from 50 hospitals, categorized as small (36-85 beds, n=17), medium-sized (88-218 beds, n=17), large, nonteaching hospitals (226-725 beds, n=10), and large, teaching hospitals (380-997 beds, n=6) were studied. We used the Patients' Experiences Questionnaire (PEQ), which contains 10 scales measuring different aspects of hospital care.

RESULTS

In general, the 10,626 respondents (50% response) rated their experiences as positive. Intraclass correlation ranged from 0.23% (Scale Information About Examinations) to 6.5% (Scale Hospital and Equipment), indicating that a small to modest proportion of the variance was at the hospital level. On 5 of the 10 PEQ scales, a statistically significant part of the variance between hospitals was attributed to hospital category. Small hospitals received the highest ratings and large, teaching hospitals the lowest. Patient characteristics and hospital category contributed together to a proportional reduction in variance ranging from 7.6% (Hospital and Equipment scale) to 53.1% (Hospital Organization scale).

CONCLUSION

The effect of hospital category on patient experiences with hospital care was small. Hospital category was not a major determinant of patient experiences during hospitalization.

Determinants of patient satisfaction in oncology settings from European and Asian countries: Preliminary results based on the EORTC IN-PATSAT32 questionnaire

The aim of this study was to identify factors associated significantly with hospitalised cancer patients' satisfaction with care. Patients were recruited from four geographical/cultural groups, including five European countries and Taiwan. They rated their level of satisfaction by completing the EORTC IN-PATSAT32 questionnaire at home. Additionally, data were collected on the sociodemographic and clinical characteristics and the quality of life of the patients, as well as on institutional characteristics. Of 762 patients recruited, 647 (85%) returned a completed questionnaire. The number of nurses and doctors per bed, institution size, geo-cultural origin, ward setting, teaching/non-teaching setting, treatment toxicity, global health status, participation in clinical trials and education level were all associated significantly at the multivariate level with satisfaction with doctor and nurse interpersonal skills, information provision, availability, and/or overall satisfaction. A number of patient-, institutional- and culture-related factors are associated with the perceived quality of cancer care. Future studies, with appropriate sampling frames and stratification procedures, are needed to better understand cross-national and cross-cultural differences in cancer patient satisfaction.

Factors determining client satisfaction with hospital-based perinatal care in Sri Lanka

OBJECTIVES

To describe mothers' satisfaction with perinatal care received during hospitalization for delivery, and to identify sociodemographic and health-care-related factors associated with satisfaction.

METHOD

A cross-sectional study of 446 mother-newborn pairs from five hospitals in Puttalam district, Sri Lanka, was carried out by stratified randomization. Client satisfaction was measured using a 16-item survey instrument with high internal consistency (Cronbach's alpha=0.81), through exit interview.

RESULTS

The proportion of mothers who were fully satisfied varied from 10.8% to 31.4% for interpersonal aspects, and from 10.1% to 28.9% for technical aspects of care. The satisfaction rates were lower with physical environment (6.1-10.1%) and higher with outcome of care (41.0-48.0%). Multivariate analyses indicated that mothers were more satisfied with the services available from lower level hospitals. Multiparae were more satisfied than primiparae. Determinants of satisfaction included providing immediate mother-newborn contact, information after examination and counselling on family planning. Higher satisfaction with the physical environment was associated with being Moor or Tamil as opposed to Sinhalese and with lower family income.

CONCLUSIONS

The factors associated with client satisfaction identified in this study may be helpful in improving quality of care. Hospital staff should ensure that these are addressed and develop interpersonal relationships, especially with the first-time mothers and in higher level hospitals. Maternity units of lower level institutions should be upgraded with essential facilities.

Predictors of patient satisfaction with hospital health care

BACKGROUND

We used a validated inpatient satisfaction questionnaire to evaluate the health care received by patients admitted to several hospitals. This questionnaire was factored into distinct domains, creating a score for each to assist in the analysis. We evaluated possible predictors of patient satisfaction in relation to socio-demographic variables, history of admission, and survey logistics.

METHODS

Cross-sectional study of patients discharged from four acute care general hospitals. Random sample of 650 discharged patients from the medical and surgical wards of each hospital during February and March 2002. A total of 1,910 patients responded to the questionnaire (73.5%). Patient satisfaction was measured by a validated questionnaire with six domains: information, human care, comfort, visiting, intimacy, and cleanliness. Each domain was scored from 0 to 100, with higher scores indicating higher levels of patient satisfaction.

RESULTS

In the univariate analysis, age was related to all domains except visiting; gender to comfort, visiting, and intimacy; level of education to comfort and cleanliness; marital status to information, human care, intimacy, and cleanliness; length of hospital stay to visiting and cleanliness, and previous admissions to human care, comfort, and cleanliness. The timing of the response to the mailing and who completed the questionnaire were related to all variables except visiting and cleanliness. Multivariate analysis confirmed in most cases the previous findings and added additional correlations for level of education (visiting and intimacy) and marital status (comfort and visiting).

CONCLUSION

These results confirm the varying importance of some socio-demographic variables and length of stay, previous admission, the timing of response to the questionnaire, and who completed the questionnaire on some aspects of patient satisfaction after hospitalization. All these variables should be considered when evaluating patient satisfaction.

Development and validation of an in-patient satisfaction questionnaire

OBJECTIVE

To develop a psychometrically sound, hospital patient satisfaction questionnaire to be administered to patients discharged from medical and surgical services.

DESIGN

Cross-sectional survey in Spanish.

SETTING

Four acute care general hospitals of the Basque Health Service.

STUDY PARTICIPANTS

Random samples of 650 discharged patients from each hospital during February and March 2002. A total of 1910 patients responded to the questionnaire (73.5%).

MAIN OUTCOME MEASURES

Overall perceived quality of health care and perceived health improvement.

RESULTS

No sociodemographic differences were found between respondents and non-respondents. Six dimensions were identified from the factor analysis, explaining 50% of the variance. All items, except two, revealed loadings above 0.4. Cronbach's alpha exceeded 0.7 for all dimensions, except privacy. Comfort was the dimension with the lowest level of patient satisfaction, whereas privacy was the most satisfactory. The interscale correlations never exceeded the internal consistency of each scale. The analysis of the dimensions with two items of global assessment showed a positive correlation.

CONCLUSIONS

The results obtained from the development and validation of the questionnaire provide evidence of its psychometric properties, although it would be useful to carry out further analyses to assess time-based properties of reliability. We found a positive relation between the degree of patient satisfaction and overall evaluation of the quality of health care, providing evidence of the ability of the questionnaire to correlate with other concepts. The in-patient satisfaction questionnaire could become a useful instrument in quality-of-care assessment.

Race and satisfaction in general OB/GYN clinics

BACKGROUND: The purpose of this study was to test the hypothesis that racial differences in satisfaction can be found among OB/GYN patients on a US naval base. METHODS: Cross-sectional surveys assessing satisfaction with services were obtained from 838 patients who were seen in one of the two general OB/GYN clinics (455 in the base hospital clinic and 391 in a satellite clinic). Multiple logistic regression analysis was used to identify subgroups of patients who were not very satisfied with care received. RESULTS: When the patients seen in the base hospital were analyzed separately, Asian respondents had significantly lower odds of being very satisfied relative to non-Hispanic white respondents (AOR = .33, p < .01). CONCLUSION: Asian patients may be less satisfied than others when treated at a larger facility. Patients treated at a satellite clinic tended to be more satisfied than patients seen at the base hospital.

Quality of care in teaching hospitals: a literature review

PURPOSE

To compare the quality of care in teaching hospitals with that in nonteaching hospitals.

METHOD

By performing a literature review via PubMed, the author identified and surveyed 23 studies that compared the quality of care in teaching hospitals with that in nonteaching hospitals. The studies were published from 1989-2004 and in all but one case dealt exclusively with U.S. hospitals.

RESULTS

The teaching hospitals studied had better-quality measures than did nonteaching hospitals in the predominant number of studies reviewed. Process measures were significantly better in teaching hospitals in seven of the eight studies where such measures were observed, and equal in the other study. Risk-adjusted mortality was lower in teaching hospitals in nine of the 15 studies using that measure, not significantly different in five, and significantly lower in nonteaching hospitals in one study (in pediatric intensive care units, even though the teaching hospitals had a better process of care). In nonmortality outcomes, teaching hospitals were better in one study using that measure; there were no significant differences in five other such studies. Major teaching hospitals had more favorable outcomes end points than did minor teaching hospitals in eight studies in which they were compared. Including only those six studies using clinical data for process analysis or risk adjustment, teaching hospitals had a better process in all six and lower adjusted mortality in five of seven studies where that measure was used.

CONCLUSIONS

Overall, the favorable results in teaching hospitals extended over a range of locations, conditions, and populations, including routine as well as complex conditions. However, the quality measured in these studies was not at target levels across the spectrum of hospitals. There needs to be a continuous and determined effort for improvement in all institutions. It is to be hoped that teaching hospitals will take the lead not only in continuously improving their own quality, but also in developing and evaluating ever improving methods of quality assessment.

Methodological issues in public reporting of patient perspectives on hospital quality

BACKGROUND

Increasing attention is being focused on public reporting of patient satisfaction and experience with hospital care, both nationally and at the state level. Comparative reports on hospital patient satisfaction use a standard survey, but little is known about underlying methodological approaches for reporting these quality measures.

METHODS

Literature, Web sites, and key informants were used to identify nine public reports. In-depth reviews were conducted to determine approaches to collecting, analyzing, and publicly reporting comparative data. Data were grouped into four analytic categories: survey, sampling, computation of scores, and reporting of scores.

RESULTS

The reports were similar in response rates and sampling procedures but differed in the number of hospitals included, the survey instrument, and survey procedure. The reports varied considerably in the techniques for computing hospital scores and decisions about reporting scores.

CONCLUSIONS

Reports from nine locales illustrate the decision making necessary to produce comparative reports on hospital patient satisfaction. Differences stem from decisions about the survey instrument and statistical decisions about how to interpret and report data. These issues should be clearly delineated as part of any public reporting process.

Obstetric patient satisfaction: asking patients what they like

OBJECTIVE

This study was undertaken to determine pertinent attributes of women's hospital experience related to the delivery of their children and to use open-ended responses from women to develop a taxonomy for classifying patient satisfaction in obstetrics.

STUDY DESIGN

By using clinimetric methods, we interviewed 67 obstetric patients during their postpartum hospital stays, asking open-ended questions about their satisfaction with care. Responses were transcribed, arranged into distinct groups, and organized as a taxonomy of patient satisfaction.

RESULTS

The final taxonomy derived from patient responses was divided into six main axes related to physicians, nurses, other staff, special services, hospital attributes, and personal focus; a total of 51 individual items were identified related to patient satisfaction. These items have face validity, and many are not routinely included in assessments of patient satisfaction.

CONCLUSION

A simple strategy of using open-ended questions leads to a clinically relevant and easily understood classification scheme for patient satisfaction with in-hospital obstetric services.

The coronary heart disease in-patient experience questionnaire (I-PEQ (CHD)): results from the survey of National Health Service patients

OBJECTIVE

Analysis of data from the National Survey of Coronary Heart Disease patients to develop a core measure of patient experiences of health care. A secondary purpose was to determine whether a single summary index figure could be generated from the instrument.

DESIGN

The data reported here comes from the survey of coronary heart disease (CHD) patients, which was the second in the programme of National Surveys of National Health Service (NHS) patients. It took place during 1999. After an in-patient episode for CHD, questionnaires were mailed out to patients with a covering letter and a pre-paid stamped addressed envelope. Those patients who did not reply within two weeks of the initial mailing were sent a reminder letter and, if this elicited no reply within two weeks, they were sent another copy of the questionnaire.

SAMPLE

Of the 116,872 patients who were sent questionnaires, 3399 proved to be ineligible or out-of scope to the survey. Responses were gained from 84,310 (74.3% of eligible respondents).

RESULTS

Reliability analysis supported the existence of seven dimensions which seem to be tapping distinct underlying phenomena: hospital environment, information and communication, patient involvement, coordination of care, discharge and transition, and pain. Higher order factor analysis indicated these dimensions constituted one factor and, consequently, can be summed to create an index figure. The construct validity of the measure was assessed, and it distinguished between groups as was hypothesised.

CONCLUSIONS

The dimensions of the questionnaire have high internal reliability. Both the dimensions of the instrument and the index score were found to have high construct validity. The instrument provides a core set of issues that should be covered when assessing the quality of care for hospital patients with coronary heart disease.

Teaching hospitals and quality of care: a review of the literature

Because teaching hospitals face increasing pressure to justify their higher charges for clinical care, the quality of care in teaching and nonteaching hospitals is an important policy question. The most rigorous peer-reviewed studies published between 1985 and 2001 that assessed quality of care by hospital-teaching status in the United States provide moderately strong evidence of better quality and lower risk-adjusted mortality in major teaching hospitals for elderly patients with common conditions such as acute myocardial infarction, congestive heart failure, and pneumonia. A few studies, however, found nursing care, pediatric intensive care, and some surgical outcomes to be better in nonteaching hospitals. Some factors related to teaching status, such as organizational culture, staffing, technology, and volume, may lead to higher-quality care.

Lack of relationship between the Cleveland Health Quality Choice project and decreased inpatient mortality in Cleveland

The Cleveland Health Quality Choice (CHQC) project was previously suggested to have been responsible for declines in inpatient mortality in Cleveland hospitals during the first years of the project (1992-1993). We sought to (a) verify this decline in mortality and (b) better understand its possible relationship to CHQC. We employed regression analysis to compare mortality rate trends for Cleveland versus the rest of Ohio using Ohio Hospital Association inpatient mortality data. We found that the rate of decline in mortality in Cleveland (-.218% per 6 months; 95% confidence limits, -.278% to -.159% per 6 months) was statistically indistinguishable from that in the rest of the state (-.188% per 6 months; 95% confidence limits, -.234% to -.143% per 6 months) (P = .35). We could not demonstrate a significant beneficial effect of the CHQC project on hospital mortality in Cleveland. Inpatient mortality was simultaneously declining at a statistically indistinguishable rate throughout the state.

Adjusting for patient characteristics when analyzing reports from patients about hospital care

OBJECTIVES

To determine which patient characteristics are associated with reports and ratings of hospital care, and to evaluate how adjusting reports and ratings for hospital differences in such variables affects comparisons among hospitals.

DESIGN

A telephone survey of a sample of patients hospitalized in 22 hospitals in a single city and a statewide mail survey of hospitalized patients.

MEASURES

The surveys assessed: respect for patients' preferences, coordination of care, information exchange between patient and providers, physical care, emotional support, involvement of family and friends, and transition and continuity. The surveys also asked patients to rate their doctors, nurses, and other hospital staff.

RESULTS

The variables with the strongest and most consistent associations with patient-reported problems were age and reported health status. Patient gender and education level also sometimes predicted reports and/or ratings. Models including these variables explained only between 3% and 8% of the variation in reports and ratings.

CONCLUSIONS

The impact of adjusting for patient characteristics on hospital rankings was small, although a larger impact would be expected when comparing hospitals with more variability in types of patients. Nevertheless, we recommend adjusting at least for the most important predictors, such as age and health status. Such adjustment helps alleviate concerns about bias. It also may be useful to present data for certain groups of patients (ie, medical, surgical, obstetric) separately to facilitate interpretation and quality improvement efforts.