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Predictors of patient satisfaction with hospital health care

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. Page 1 of 9 (page number not for citation purposes) BMC Health Services Research 2006, 6:102 http://www.biomedcentral.com/1472-6963/6/102 commonly studied socio-demographic variables, as well Background The number of patient satisfaction questionnaires has as the admission history and survey completion logistic proliferated over the last decades as tools to measure variables. health care from the patients' perspective [1-3]. One com- mon target group has been patients admitted to a hospi- Methods tal, because admission can be a stressful and dissatisfying Questionnaire development experience for many people and because of the high Various sources and methods were used to determine the health care costs that an admission to a health care system questions to be included in the questionnaire. First, a lit- entails. erature search was undertaken between January and April 2000, using MEDLINE and PSYCLIT databases, that As with other measurement instruments, patient satisfac- aimed to analyze the instruments that had been devised tion questionnaires must be tested for validity and relia- so far to evaluate inpatient satisfaction at the national and bility [4]. These are basic properties that researchers try to international levels. show for their instruments. Beyond these, other possible sources of bias may arise when collected data must be ana- Second, eight focus groups were conducted with patients lyzed. and two with health care professionals to explore opin- ions about the most positive and negative aspects of care Questionnaires can be completed by different methods: received during the course of a hospital stay. These focus self-reporting, face-to-face interviewing, phone interview- groups were geared towards understanding the issues and ing, or most recently by computer. The self-reporting recording expressions that could be used to develop ques- method requires that the questionnaire is given to the tions to be included in the questionnaire. patient at a specific time point, either personally, by mail, or by Internet. Although the Internet may become a fre- Thirdly, the research team developed a pool of question quent way of providing and completing questionnaires items, in relation to the literature and focus groups, to be [5], in many countries this is either rare or used by a very included in the questionnaire. These items were shown to homogeneous and different group of people from the a group of patients and health professionals, who pro- general population. This explains why mailing is still a fre- vided their opinions about the appropriateness of the quent method of delivering questionnaires to selected items and the ability to comprehend them and evaluated individuals [6]. A major problem and source of bias are the content and face validity of the questions. An initial patients who do not complete the questionnaire [7]. In version of the questionnaire was created, which was eval- order to minimize the number of missing people, uated in a pilot study, to analyze the comprehensibility researchers typically send reminders, up to two or three, and clarity of the items and features related to the psycho- after the first mailing. Additionally, they might contact by metric properties of the instrument. The results of the phone those who do not respond to try to encourage them pilot study led to an amended questionnaire, i.e., the to answer the questionnaire, although this is an addi- instrument used during the fieldwork described in the cur- tional source of bias that has already been studied [8]. rent study. Patients admitted to hospitals are generally old and in The final questionnaire included 34 questions, which fol- some cases have different handicaps or functional limita- low in chronologic order the steps from the time the tions that prevent or make it difficult for them to complete patient is admitted to hospital until discharge [10]. The a questionnaire. For this reason, the interviewed patient questionnaire included six domains: information and may enlist the help of a relative or friend to answer the communication with doctors (12 items), nursing care (8 questionnaire, and this could be a source of bias [9]. items), comfort (6 items), visiting (4 items), privacy (2 items), and cleanliness (2 items) (See Additional file 1- In 2002, we used a validated inpatient satisfaction ques- Appendix I). The response scale that we used had a varied tionnaire to evaluate the health care received by patients number of options, ranging from three to six. The scores admitted to several hospitals [10]. As an advantage over for each domain were calculated by adding the answers to other questionnaires, we had factored it into distinct all the items in each domain. A linear transformation then domains, creating a score for each to assist in the analysis was carried out, so that the scoring scale for each domain We used a self-reported version of the questionnaire deliv- was standardized between 0 and 100, with a score of 100 ered by mail and allowed patients to complete them per- indicating the highest level of satisfaction. The question- sonally or with the help of a relative or friend, with the naire also contained sociodemographic variables, includ- stipulation that they indicate who completed it. One of ing age, sex, educational level, professional status, and the purposes of this study was to determine and evaluate marital status. possible predictors of satisfaction in relation to the more Page 2 of 9 (page number not for citation purposes) BMC Health Services Research 2006, 6:102 http://www.biomedcentral.com/1472-6963/6/102 Study participants We also compared sociodemographic variables, the his- The study was conducted among patients admitted to one tory of current admissions, and survey completion logis- of four general acute hospitals in the Basque Health Care tics variables based on the time of the response to the Service. The hospitals were selected because of their differ- mailing. The Student t test, or analysis of variance ent geographic locations. (ANOVA), with the Scheffe's method for multiple com- parisons, or the Kruskal-Wallis test was used for continu- Adults 18 years and older were included if they had ous variables, and the Chi-square test or Fisher's exact remained in the hospital longer than 48 hours. Patients probability test for categorical variables. Patient satisfac- admitted to the Neurology Department were excluded tion scores were also compared by time of response to because a high percentage had pathologies of the central mailing controlling by person who responded, using the nervous system (such as cerebrovascular disease) that analysis of variance (ANOVA), with the Scheffe's method could hinder or prevent participation in the study. for multiple comparisons, or the Kruskal-Wallis test. Patients with serious physical or mental pathologies, such as terminal disease and psychosis, which could make the Finally, general linear models were used to analyse differ- comprehension and completion of the questionnaire dif- ences in satisfaction scores according to time of response ficult, also were excluded, as were patients whose destina- to mailing adjusted by the socio-demographic variables. tion after hospital discharge differed from their usual In all cases, we considered the first mail respondents as residence, given the difficulties associated with locating the reference group. them. In all analyses, P < 0.05 was considered statistically signif- All study participants signed a consent form. The study icant. All statistical analyses were performed using SAS for was in compliance with the Helsinki Declaration and the Windows statistical software, version 8.0. Research Committees of the participant hospitals gave approval to the study. Results The mean age of the participants was 62.2 years old; Survey 54.3% were men, 68.3% were married or cohabitating, A random sample of 650 patients who had been dis- and 54.1% had only a primary education level. Of the charged between February and March 2002 was contacted 73.5% that participated in the study, 52.4% responded to for each hospital. Two weeks after discharge, the selected the first mailing, 27.2% to the first reminder, and 20.4% patients received the questionnaire with a prepaid return to the second reminder (Table 1). Those who did not envelope. A cover letter also was attached that explained respond were a mean of 63 years old and 48.3% were the reasons for conducting the survey, encouraged their women, but these differences were not significantly differ- participation, and guaranteed data confidentiality. A fol- ent. We found non-respondents significantly more likely low-up letter was sent to non-responders 2 weeks later. If to be emergency admissions in medical, rather than surgi- they still had not returned the questionnaire 15 days after cal, specialties, discharged to a place other than their nor- the first reminder, they received a third letter with a new mal residence, and a with a higher mean length of stay The copy of the questionnaire. The response rate obtained univariate analysis of the selected variables showed their using this method was 73.5%. relationship with the scores of our satisfaction question- naire (Table 2). We found that age was statistically corre- Statistical analysis lated with all domains except the visiting domains, with Descriptive statistics, including frequencies, percentages, higher satisfaction scores related to increasing age. Gender means and standard deviations (SDs), were calculated for was related to comfort, visiting and intimacy, with men the socio-demographic variables. For comparisons expressing higher satisfaction. Level of education was only between respondents and non-respondents on those vari- related to comfort and cleanliness, with higher satisfac- ables where we had information, we used a Chi-square tion among those with no schooling or a primary educa- test for categorical variables and a t-test or the non-para- tion level of studies. Marital status was correlated with the metric Wilcoxon for continuous variables. information, human care, intimacy, and cleanliness domains, with those married or cohabitating having In the univariate analysis, we studied the relationships higher scores except for the cleanliness domain. Shorter among the selected sociodemographic variables, the his- length of stay showed more satisfaction with visiting and tory of current and previous admissions, and survey com- cleanliness. Those admitted previously showed lower sat- pletion logistics variables with the six dimensions of the isfaction with human care, comfort and cleanliness. st questionnaire. Patients who responded to the 1 mailing expressed nd higher satisfaction than those who responded to the 2 or rd 3 mailings, with Information, Human Care, Comfort Page 3 of 9 (page number not for citation purposes) BMC Health Services Research 2006, 6:102 http://www.biomedcentral.com/1472-6963/6/102 Table 1: Sociodemographic data of the total sample Variables Responders n = 1910 Non-Responders n = 703 P value n% n % Age (years) ± SD 62.2 16.6 63.0 19.1 0.35 7.6 5.9 8.5 7.4 <0.05 Length of stay (days) x ± SD Sex 0.23 Men 1,026 54.3 361 51.7 Women 862 45.7 337 48.3 Admission service <0.001 Medical 1,084 56.8 452 64.6 Surgical 826 43.2 248 35.4 Admission type <0.001 Urgent 755 62.4 320 78.8 Planned 456 37.6 86 21.2 Marital status Single 232 12.6 Married/cohabitating 1,261 68.3 Separated/divorced 48 2.6 Widowed 304 16.5 Education level No education 288 15.9 Primary studies 982 54.1 High school/secondary education 395 21.8 University 148 8.2 Occupation Employed full time 330 18.8 Employed part time 58 3.3 Homemaker 313 17.8 Unemployed 56 3.2 Student 19 1.1 Retired 825 47.0 Disabled 155 8.8 Time of response* st 1 mailing 1,001 52.4 nd 2 mailing 520 27.2 rd 3 mailing 389 20.4 Previous admission Yes 1,509 82.1 No 330 17.9 No. previous admissions <= 2 542 39.3 3–4 437 31.7 >4 400 29.0 Who completed the questionnaire Patient 1026 55.6 Someone else 818 44.4 The sample size in each question differs because not all subjects answered all questionnaire items. *The response rate is calculated on the basis of the total number of questionnaires returned. Frequencies and percentages are presented, except for age and length of hospital stay, where the means and SDs are presented. and Intimacy. Finally, the variable "who responds to the and who completed the questionnaire; i.e. later response questionnaire" revealed that those who responded alone was more likely by older patients, widowed and those expressed higher satisfaction with information, human who needed help to answer the questionnaire. There were care, comfort and intimacy. no discernible differences by gender, level of studies, or working status. We checked whether there were differences by time of response to the mailing for different variables (Table 3) When evaluating the questionnaire satisfaction scores and we found this was significant for age, marital status based on the time of response to the mailings and who Page 4 of 9 (page number not for citation purposes) BMC Health Services Research 2006, 6:102 http://www.biomedcentral.com/1472-6963/6/102 Table 2: Univariate analysis by relevant variable Variables Patient satisfaction questionnaire domains Information Human Care Comfort Visiting Intimacy Cleanliness x (SD) x (SD) x (SD) x (SD) x (SD) x (SD) Age (years) <= 50 77.3 (19.8) 75 (21.3) 61.4 (17.7) 77.9 (20.3) 88 (21.4) 87.1 (17.7) 51–65 83.9 (17.7) 80.2 (20.2) 66 (18.5) 79.7 (18.7) 91.8 (18.4) 88.7 (17.4) >65 82.3 (18.2) 78.8 (20.9) 69.5 (17.7) 80.2 (18) 90.9 (20.1) 90 (17.1) P value <0.001 <0.001 <0.001 0.31 <0.01 <0.01 Gender Men 81.5 (18.9) 78.6 (20.7) 67.9 (18.2) 80.6 (18.1) 92.4 (18.1) 89.6 (16.8) Women 81.5 (18.3) 77.7 (21) 65.2 (18) 78.3 (19.5) 88 (22.1) 88.2 (18) P value 0.52 0.29 <0.001 <0.01 <0.001 0.09 Education level No studies/primary 81.8 (18.1) 78.4 (20.8) 67.3 (17.6) 80.2 (17.9) 90.7 (19.6) 89.5 (16.9) Secondary/university 80.8 (19.6) 78.2 (20.8) 64.8 (18.8) 78.1 (20.3) 89.6 (21.4) 87.8 (17.8) P value 0.80 0.80 <0.01 0.25 0.57 <0.05 Marital status Single/divorced 77.9 (20.5) 75.9 (22.6) 66.6 (17.5) 80.7 (18.9) 88.0 (21.5) 91.0 (16.5) Widowed 80.7 (18.0) 76.4 (21.1) 66.1 (18.4) 78.6 (18.6) 89.1 (21.4) 88.3 (18.4) Married/cohabitating 82.4 (18.3) 79.1 (20.4) 66.6 (18.2) 79.4 (18.8) 91.3 (19.3) 88.6 (17.3) P value <0.001 <0.05 0.79 0.11 <0.05 <0.05 Length of hospital stay (days) <4 81.8 (18.5) 78.9 (20.2) 67.4 (18.6) 82.2 (17.8) 90.2 (20.4) 91.1 (15.4) 4–7 81.5 (18.3) 78.5 (20.6) 66.7 (18.2) 79.6 (18.7) 91.4 (19.3) 88.8 (17.5) >7 81.6 (18.8) 77.7 (21.6) 66.3 (18.1) 77.9 (19.2) 90.0 (20.3) 87.9 (18.2) P value 0.89 0.84 0.47 <0.001 0.32 <0.05 Previous admissions 0 82.1 (17.0) 81.0 (18.8) 68.2 (18.1) 80.5 (18.5) 89.5 (20.8) 90.9 (16.0) 1–4 81.5 (19.3) 78.8 (20.5) 66.7 (18.0) 80.0 (18.6) 90.7 (20.1) 88.9 (17.3) >4 79.9 (18.5) 75.1 (21.5) 64.3 (17.7) 78.6 (19.3) 90.6 (19.4) 87.1 (18.3) P value 0.07 <0.001 <0.01 0.23 0.51 <0.01 Response to mailing st 1 mailing 83.4 (17.6) 80.9 (19.9) 68.0 (18.6) 79.3 (19.0) 91.8 (18.6) 89.4 (16.6) nd 2 mailing 80.9 (19.4) 77.6 (21.1) 67.3 (17.5) 79.8 (18.0) 90.3 (19.6) 89.3 (17.6) rd 3 mailing 77.8 (19.2) 72.4 (21.9) 62.6 (17.9) 79.8 (19.2) 87.8 (23.1) 87.5 (18.8) P value <0.001 <0.001 <0.001 0.71 <0.05 0.34 Responded to questionnaire With help 79 (19.1) 75.8 (21.3) 65.7 (17.4) 80 (18.1) 88.6 (21.3) 88.4 (17.8) Alone 83.4 (18.1) 80.2 (20.4) 67.5 (18.6) 79.1 (19.3) 92 (18.8) 89.4 (17) P value <0.001 <0.001 <0.05 0.85 <0.001 0.28 Student t test, or analysis of variance (ANOVA) with the Scheffe's method for multiple comparisons, or the Kruskal-Wallis test performed. responded to them, we observed that those who com- We also studied the effect of the previous variables on the pleted the questionnaire with help systematically had satisfaction scores after adjustment by all variables (Table lower scores than those who responded themselves (Table 5) in a multivariate model. Age was significantly related to 4). Statistically significant differences differences were all domains with higher scores increasing with age. Gen- found in the three mailings and for the information, der showed similar results as in the univariate analyses. human care, comfort, and intimacy domains but not for The level of education was related to visiting, intimacy, the visiting and cleanliness domains either for those who and cleanliness, with those with no education or primary responded themselves or with help. A trend toward higher studies having higher scores. Marital status was related to satisfaction was found for those who responded early and information, with higher scores for married patients; sin- a trend toward lower satisfaction was found for those who gle or divorced individuals had higher scores for comfort, responded later for those who responded themselves or visiting, and cleanliness. Length of stay related to comfort, with help. visiting and cleanliness, with lower scores for those with Page 5 of 9 (page number not for citation purposes) BMC Health Services Research 2006, 6:102 http://www.biomedcentral.com/1472-6963/6/102 Table 3: Descriptive statistics by mailing Variable Time of response to mailing st nd rd 1 mailing n = 1001 2 mailing n = 520 3 mailing n = 389 P value Age (years) <0.05 ≤50 239 (24.0) 95 (18.5) 97 (25.1) 51–65 261 (26.2) 146 (28.4) 87 (22.5) >65 496 (49.8) 274 (53.2) 202 (52.3) Gender 0.53 Men 532 (53.6) 289 (56.5) 205 (53.4) Women 460 (46.4) 223 (43.6) 179 (46.6) Education level <0.05 None/primary school 642 (67.3) 358 (73.2) 270 (73.0) Secondary/university 312 (32.7) 131 (26.8) 100 (27.0) Work status 0.11 Working/homemaker 382 (41.4) 169 (36.1) 150 (41.1) Unemployed 34 (3.7) 11 (2.4) 11 (3.0) Retired/disabled 499 (54.1) 279 (59.6) 202 (55.3) Student 8 (0.9) 9 (1.9) 2 (0.6) Marital status <0.01 Married/cohabitating 693 (71.5) 333 (66.9) 235 (62.2) Single/divorced 142 (14.7) 78 (15.7) 60 (15.9) Widowed 134 (13.8) 87 (17.5) 83 (22.0) Who fulfill the questionnaire <0.001 Alone 586 (60.6) 258 (51.8) 182 (48.0) With help 381 (39.4) 240 (48.2) 197 (52.0) Data are given as frequency (percentage). nd rd st longer length of stay. Previous admissions related to infor- to the 2 and 3 mailings, compared with the 1 mailing, mation, human care, comfort, visiting and cleanliness, for Information and Human Care, and specifically from rd st with lower scores for those with more than four previous the 3 mailing compared with the 1 mailing for Com- admissions. Lower scores were also found for respondents fort, Intimacy and Cleanliness. In all cases, a decrease in Table 4: Mean patient satisfaction scores by response to mailing times and person who responds Time of response to mailing st nd rd Variables 1 mail n = 967 2 mail n = 498 3 mail n = 379 P value n = 586 n = 258 n = 182 Responded alone Information 84.9 (17.1) 82.4 (20.0) 80.2 (17.5) <0.01 Human care 82.3 (19.4) 79.5 (20.5) 74.5 (21.9) <0.001 Comfort 69.1 (18.9) 68.3 (17.1) 61.3 (18.4) <0.001 Visit 78.8 (19.8) 79.2 (17.9) 79.9 (19.6) 0.46 Intimacy 92.9 (17.5) 91.3 (19.7) 90.3 (21.4) 0.48 Cleanliness 89.5 (16.7) 90.9 (14.9) 86.8 (20.3) 0.22 Responded with help n = 381 n = 240 n = 197 Information 80.8 (18.3) 79.4 (18.9) 75.0 (20.3) <0.01 Human care 78.6 (20.6) 76.1 (21.1) 70.0 (21.8) <0.001 Comfort 66.3 (17.8) 66.8 (16.9) 63.3 (16.9) 0.07 Visit 80.2 (17.4) 80.3 (18.4) 79.1 (19.0) 0.84 Intimacy 90.1 (20.2) 89.1 (19.6) 85.4 (24.6) 0.10 Cleanliness 89.1 (16.4) 87.7 (20.1) 87.9 (17.5) 0.80 The total number of patients does not match previous tables since there was missing information for those who responded to the "response with/ out help" variable. Page 6 of 9 (page number not for citation purposes) BMC Health Services Research 2006, 6:102 http://www.biomedcentral.com/1472-6963/6/102 Table 5: Multivariate analysis by relevant variables Variables Patient satisfaction questionnaire domains Information Human Care Comfort Visiting Intimacy Cleanliness β Coef. P value β Coef. P value β Coef. P value β Coef. P value β Coef. P value β Coef. P value R 0.063 0.062 0.084 0.028 0.039 0.034 Age (years) <= 50 ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- 51–65 7.10 <0.001 6.35 <0.001 6.30 <0.001 2.52 0.08 3.95 <0.05 3.21 <0.05 >65 7.66 <0.001 8.18 <0.001 11.65 <0.001 4.07 <0.01 3.54 0.06 4.99 <0.001 Gender Men vs. women -1.19 0.23 -0.58 0.58 1.91 <0.05 2.01 <0.05 3.44 <0.01 1.34 0.14 Education level No studies/primary ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- Secondary/university -1.67 0.15 -1.13 0.37 -1.90 0.08 -2.85 <0.05 -2.87 <0.05 -2.31 <0.05 Marital status Single/divorced -2.85 <0.05 -0.96 0.53 3.95 <0.01 3.38 <0.05 -1.64 0.35 4.37 <0.001 Widowed -0.67 0.64 -1.37 0.37 0.003 0.99 -0.75 0.60 0.48 0.78 1.25 0.34 Married/cohabitating ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- Length of hospital stay (days) <4 ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- 4–7 -0.77 0.53 -0.42 0.75 -1.56 0.16 -3.42 <0.01 0.88 0.57 -2.81 <0.05 >7 -0.27 0.82 -1.22 0.36 -2.33 <0.05 -5.50 <0.001 -0.35 0.82 -3.82 <0.001 Previous admissions 0 ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- 1–4 -1.53 0.22 -2.78 <0.05 -2.40 <0.05 -1.35 0.28 0.21 0.89 -2.60 <0.05 >4 -3.3 <0.05 -6.72 <0.001 -5.16 <0.001 -2.92 <0.05 0.10 0.96 -4.41 <0.01 Response to mailing st 1 mailing ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- nd 2 mailing -2.35 <0.05 -3.10 <0.01 -1.32 0.19 -0.03 0.98 -1.57 0.25 -0.08 0.93 rd 3 mailing -4.34 <0.001 -6.66 <0.001 -5.39 <0.001 1.06 0.38 -4.10 <0.01 -1.75 0.12 Responded to questionnaire With help vs. alone -7.37 <0.001 -6.31 <0.001 -4.45 <0.001 0.02 0.98 -5.57 <0.001 -2.20 <0.05 β Coef.: Beta coefficient from the lineal general model, after adjustment by all relevant variables. Positive values indicate more satisfaction on that domain for that category; negative values indicate less satisfaction compared with the reference category, which is blank or indicated as "versus". nd rd the scores is seen from the 2 to the 3 mailing. Finally, the questionnaire and if the patient completed the ques- those who responded with help had lower scores on infor- tionnaire or did so with the assistance of someone else. mation, human care, comfort, intimacy and cleanliness. The R of each domain model also was estimated, and As in previous studies, we showed that older patients ranged between 0.028 (visiting) to 0.084 (comfort). tended to have higher satisfaction scores in all areas of our questionnaire [11,12]. Similarly, those with no education Discussion or only primary education had higher satisfaction scores. Our study showed that age, education level, marital status, Marital status traditionally has been included in this kind sex, work status, length of stays, and previous admissions of study [13], and usually, those married or cohabitating affected the scores of the six domains in the satisfaction tended to have higher satisfaction scores, but in our study questionnaire. Some variables had been studied previ- those who were single or divorced had higher satisfaction ously, but to the best of our knowledge, the full range of scores in the comfort, visiting, and cleanliness domains. variables included in this article had not been studied In contrast to other studies [11], our results showed that together in multivariate analyses for the different domains men tended to have higher satisfaction scores than of a validated satisfaction questionnaire and with a large women, as in others [14,15]. We also studied the influ- sample size. The validity of our satisfaction questionnaire ence of the working status of our respondents but, unlike was discussed previously and showed acceptable results. others [16], we did not find that this variable had any Nevertheless, to avoid bias we outlined two methodologic influence on our sample patient satisfaction. This can be aspects: the reminders needed before a patient answered due, in our case, to the fact that there was little variability Page 7 of 9 (page number not for citation purposes) BMC Health Services Research 2006, 6:102 http://www.biomedcentral.com/1472-6963/6/102 since most male respondents had retired and most Patient satisfaction can be measured in different ways. women were working at home. We did not evaluate if the Among them, the use of surveys has been a common way type of insurance had any influence since 100% of our of conducting patient satisfaction studies. The forms of patients were covered by the public National Health Sys- administration of the survey, that is, self-administration, tem. personnel interview, or a phone interview, have been eval- uated in different studies[6,20]. However, the effect of The longer the length of stay of the index admission stud- who completed the questionnaire has been studied less ied, the lower the satisfaction on specific domains such as often. We showed in the current study that who com- comfort, visiting, and cleanliness, which seemed logical, pleted the questionnaire has an important effect on the as in other studies [14]. However, studies of mental health results, in that a more negative satisfaction level was services have found the opposite to be true [17], and those recorded on those surveys answered by someone other seem to be areas more likely conditioned by a long stay. than the patient. In addition, we found that patients who already had had a previous hospital admission tended to be more The limitations of this study include the type of design demanding or critical and have lower satisfaction levels chosen (descriptive) and the inevitable non-responders. on relevant areas such as information or human care, As in previous studies [21,22], the R values were low, comfort, visiting, or cleanliness. indicating room for improving the prediction of patient satisfaction with other variables not included here. In Two main aspects of the logistics of a self-administered addition, the range of possible explicative variables patient questionnaire were studied here: the effect of the included in this study, although large, was not as exhaus- time when the patient responded to our mailings, with tive as we would have wished. Several other variables have those who responded to a second or third reminder hav- been evaluated previously that also showed a relationship ing lower levels of satisfaction; and who complete the with patient satisfaction, as the previous health status or questionnaire, the patient or someone else. The latter had hospital characteristics[22]. However, we would theoreti- the worse scores on all domains of the satisfaction ques- cally expect most explanation to be given by the differ- tionnaire, except for the visiting domain. These logistic ences in health care experiences, rather than the aspects also have been studied previously[6,8] not finding characteristics of the patients and their method of the later differences among delay on response and responding to a survey. patients' satisfaction, but this could be due to the small sample size included in that study compared to ours Conclusion (between 78 to 254 patients depending on the time when We concluded that, as in previous studies, there is evi- the patient responded to their mailings), little lower dence that patient sociodemographic characteristics affect response rate, the design of the study, and the use of dif- patient satisfaction levels. In addition, it is logical that pre- ferent satisfaction questions, though they found a ten- vious admissions and the length of the current admission dency similar to ours in the decline in their satisfaction also affect the patient response. Also, depending on the levels. But so many determinants of the satisfaction of manner in which the survey was administered, the mail hospitalized patients have not been studied globally interview method may obtain high response rates when together in multivariate models. The current study pro- using reminders, but those reminders affect the patient vides valuable information on the effect of all variables on responses. Finally, we must consider who completed the the different domains that constitute our patient satisfac- questionnaire, the patient or someone else. Therefore, tion tool. Therefore, we provide a more complete picture when conducting a patient satisfaction survey we must be of the determinants of the satisfaction of the various aware of the effect of many variables on the patient domains. responses and make the appropriate adjustments to pro- vide valid results. The different studies that have evaluated the effect of the previous sociodemographic variables [13], previous Competing interests admission experience [18], the length of hospitalization The author(s) declare that they have no competing inter- [14], and survey logistics showed, in some cases, contra- ests. dictory results. Authors' contributions Studies of the impact of reminders on the results of JMQ and NG conceived of the study, coordinated and par- patient satisfaction surveys are contradictory: some have ticipated in the design of the study, and drafted the man- shown that reminders affect the patients' responses [19], uscript. AE, FA, CE, JASS, ES and AT participated in the as in our study, while others did not show that effect [8]. design and helped to draft the manuscript. AB, AT per- Page 8 of 9 (page number not for citation purposes) BMC Health Services Research 2006, 6:102 http://www.biomedcentral.com/1472-6963/6/102 15. Crow R, Gage H, Hampson S, Hart J, Kimber A, Storey L, Thomas H: formed the statistical analyses and drafted the manuscript. The measurement of satisfaction with healthcare: implica- All authors read and approved the final manuscript. tions for practice from a systematic review of the literature. Health Technol Assess 2002, 6:1-244. 16. Beck EJ, Griffith R, Fitzpatrick R, Mandalia S, Carrier, Conlon C, Man- Additional material del B, Ong E, Pozniak A, Tang A, Tomlinson D, Williams: Patient satisfaction with HIV service provision in NPMS hospitals: the development of a standard satisfaction questionnaire. Additional file 1 NPMS Steering Group. AIDS Care 1999, 11:331-343. 17. Rosenheck R, Wilson NJ, Meterko M, Rosenheck R, Wilson NJ, Summary of the questions included in the patient satisfaction question- Meterko M: Influence of patient and hospital factors on con- naire. Short description of the data: questions included in the question- sumer satisfaction with inpatient mental health treatment. naire, for each of the six domains that were obtained in the validation Psychiatr Serv 1997, 48:1553-1561. study; these questions have been summarized and listed in the file. 18. John J: Patient satisfaction: the impact of past experience. J Click here for file Health Care Mark 1992, 12:56-64. 19. Wensing M, Mainz J, Kramme O, Jung HP, Ribacke M: Effect of [http://www.biomedcentral.com/content/supplementary/1472- mailed reminders on the response rate in surveys among 6963-6-102-S1.doc] patients in general practice. J Clin Epidemiol 1999, 52:585-587. 20. Ford RC, Bach SA, Fottler MD: Methods of measuring patient satisfaction in health care organizations. [Review] [41 refs]. Health Care Manage Rev 1997, 22:74-89. 21. Kane RL, Maciejewski M, Finch M: The relationship of patient sat- Acknowledgements isfaction with care and clinical outcomes. Med Care 1997, This study was supported by a grant from the Fondo de Investigación San- 35:714-730. 22. Finkelstein BS, Singh J, Silvers JB, Neuhauser D, Rosenthal GE: itaria (FIS 00/0129), of the thematic networks (FIS G03/202) and the Patient and hospital characteristics associated with patient Research Committee of the Galdakao hospital. The authors of this article assessments of hospital obstetrical care. Med Care 1998, wish to thank all personnel at the data-gathering units of the four hospitals. 36:AS68-AS78. References Pre-publication history 1. Rubin HR: Patient evaluations of hospital care. A review of the The pre-publication history for this paper can be accessed literature. [Review] [56 refs]. Med Care 1990, 28:S3-S9. here: 2. van Campen C, Sixma H, Friele RD, Kerssens JJ, Peters L: Quality of care and patient satisfaction: a review of measuring instru- ments. [Review] [66 refs]. Med Care Res Rev 1995, 52:109-133. http://www.biomedcentral.com/1472-6963/6/102/pre 3. Sitzia J, Wood N: Patient satisfaction: a review of issues and concepts. Soc Sci Med 1997, 45:1829-1843. pub 4. Sitzia J: How valid and reliable are patient satisfaction data? An analysis of 195 studies. Int J Qual Health Care 1999, 11:319-328. 5. Bethell C, Fiorillo J, Lansky D, Hendryx M, Knickman J: Online con- sumer surveys as a methodology for assessing the quality of the United States health care system. J Med Internet Res 2004, 6:e2. 6. Walker AH, Restuccia JD: Obtaining information on patient sat- isfaction with hospital care: mail versus telephone. Health Serv Res 1984, 19:291-306. 7. Sitzia J, Wood N: Response rate in patient satisfaction research: an analysis of 210 published studies. Int J Qual Health Care 1998, 10:311-317. 8. Gasquet I, Falissard B, Ravaud P: Impact of reminders and method of questionnaire distribution on patient response to mail-back satisfaction survey. J Clin Epidemiol 2001, 54:1174-1180. 9. Showers N, Simon EP, Blumenfield S, Holden G, Showers N, Simon EP, Blumenfield S, Holden G: Predictors of patient and proxy sat- isfaction with discharge plans. Soc Work Health Care 1995, 22:19-35. 10. Gonzalez N, Quintana JM, Bilbao A, Escobar A, Aizpuru F, Thompson A, Esteban C, Sebastian JA, de la SE: Development and validation Publish with Bio Med Central and every of an in-patient satisfaction questionnaire. Int J Qual Health Care 2005, 17:465-472. scientist can read your work free of charge 11. Hargraves JL, Wilson IB, Zaslavsky A, James C, Walker JD, Rogers G, "BioMed Central will be the most significant development for Cleary PD: Adjusting for patient characteristics when analyz- ing reports from patients about hospital care. Med Care 2001, disseminating the results of biomedical researc h in our lifetime." 39:635-641. Sir Paul Nurse, Cancer Research UK 12. Jaipaul CK, Rosenthal GE: Are older patients more satisfied with hospital care than younger patients? J Gen Intern Med 2003, Your research papers will be: 18:23-30. available free of charge to the entire biomedical community 13. Hall JA, Dornan MC: Patient sociodemographic characteristics peer reviewed and published immediately upon acceptance as predictors of satisfaction with medical care: a meta-anal- ysis [published erratum appears in Soc Sci Med cited in PubMed and archived on PubMed Central 1990;30(12):following 1368]. Soc Sci Med 1990, 30:811-818. yours — you keep the copyright 14. Thi PL, Briancon S, Empereur F, Guillemin F: Factors determining inpatient satisfaction with care. Soc Sci Med 2002, 54:493-504. BioMedcentral Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 9 of 9 (page number not for citation purposes) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Health Services Research Springer Journals

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Springer Journals
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Copyright © 2006 by Quintana et al; licensee BioMed Central Ltd.
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Medicine & Public Health; Public Health; Health Administration; Health Informatics; Nursing Management/Nursing Research
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16914046
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Abstract

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. Page 1 of 9 (page number not for citation purposes) BMC Health Services Research 2006, 6:102 http://www.biomedcentral.com/1472-6963/6/102 commonly studied socio-demographic variables, as well Background The number of patient satisfaction questionnaires has as the admission history and survey completion logistic proliferated over the last decades as tools to measure variables. health care from the patients' perspective [1-3]. One com- mon target group has been patients admitted to a hospi- Methods tal, because admission can be a stressful and dissatisfying Questionnaire development experience for many people and because of the high Various sources and methods were used to determine the health care costs that an admission to a health care system questions to be included in the questionnaire. First, a lit- entails. erature search was undertaken between January and April 2000, using MEDLINE and PSYCLIT databases, that As with other measurement instruments, patient satisfac- aimed to analyze the instruments that had been devised tion questionnaires must be tested for validity and relia- so far to evaluate inpatient satisfaction at the national and bility [4]. These are basic properties that researchers try to international levels. show for their instruments. Beyond these, other possible sources of bias may arise when collected data must be ana- Second, eight focus groups were conducted with patients lyzed. and two with health care professionals to explore opin- ions about the most positive and negative aspects of care Questionnaires can be completed by different methods: received during the course of a hospital stay. These focus self-reporting, face-to-face interviewing, phone interview- groups were geared towards understanding the issues and ing, or most recently by computer. The self-reporting recording expressions that could be used to develop ques- method requires that the questionnaire is given to the tions to be included in the questionnaire. patient at a specific time point, either personally, by mail, or by Internet. Although the Internet may become a fre- Thirdly, the research team developed a pool of question quent way of providing and completing questionnaires items, in relation to the literature and focus groups, to be [5], in many countries this is either rare or used by a very included in the questionnaire. These items were shown to homogeneous and different group of people from the a group of patients and health professionals, who pro- general population. This explains why mailing is still a fre- vided their opinions about the appropriateness of the quent method of delivering questionnaires to selected items and the ability to comprehend them and evaluated individuals [6]. A major problem and source of bias are the content and face validity of the questions. An initial patients who do not complete the questionnaire [7]. In version of the questionnaire was created, which was eval- order to minimize the number of missing people, uated in a pilot study, to analyze the comprehensibility researchers typically send reminders, up to two or three, and clarity of the items and features related to the psycho- after the first mailing. Additionally, they might contact by metric properties of the instrument. The results of the phone those who do not respond to try to encourage them pilot study led to an amended questionnaire, i.e., the to answer the questionnaire, although this is an addi- instrument used during the fieldwork described in the cur- tional source of bias that has already been studied [8]. rent study. Patients admitted to hospitals are generally old and in The final questionnaire included 34 questions, which fol- some cases have different handicaps or functional limita- low in chronologic order the steps from the time the tions that prevent or make it difficult for them to complete patient is admitted to hospital until discharge [10]. The a questionnaire. For this reason, the interviewed patient questionnaire included six domains: information and may enlist the help of a relative or friend to answer the communication with doctors (12 items), nursing care (8 questionnaire, and this could be a source of bias [9]. items), comfort (6 items), visiting (4 items), privacy (2 items), and cleanliness (2 items) (See Additional file 1- In 2002, we used a validated inpatient satisfaction ques- Appendix I). The response scale that we used had a varied tionnaire to evaluate the health care received by patients number of options, ranging from three to six. The scores admitted to several hospitals [10]. As an advantage over for each domain were calculated by adding the answers to other questionnaires, we had factored it into distinct all the items in each domain. A linear transformation then domains, creating a score for each to assist in the analysis was carried out, so that the scoring scale for each domain We used a self-reported version of the questionnaire deliv- was standardized between 0 and 100, with a score of 100 ered by mail and allowed patients to complete them per- indicating the highest level of satisfaction. The question- sonally or with the help of a relative or friend, with the naire also contained sociodemographic variables, includ- stipulation that they indicate who completed it. One of ing age, sex, educational level, professional status, and the purposes of this study was to determine and evaluate marital status. possible predictors of satisfaction in relation to the more Page 2 of 9 (page number not for citation purposes) BMC Health Services Research 2006, 6:102 http://www.biomedcentral.com/1472-6963/6/102 Study participants We also compared sociodemographic variables, the his- The study was conducted among patients admitted to one tory of current admissions, and survey completion logis- of four general acute hospitals in the Basque Health Care tics variables based on the time of the response to the Service. The hospitals were selected because of their differ- mailing. The Student t test, or analysis of variance ent geographic locations. (ANOVA), with the Scheffe's method for multiple com- parisons, or the Kruskal-Wallis test was used for continu- Adults 18 years and older were included if they had ous variables, and the Chi-square test or Fisher's exact remained in the hospital longer than 48 hours. Patients probability test for categorical variables. Patient satisfac- admitted to the Neurology Department were excluded tion scores were also compared by time of response to because a high percentage had pathologies of the central mailing controlling by person who responded, using the nervous system (such as cerebrovascular disease) that analysis of variance (ANOVA), with the Scheffe's method could hinder or prevent participation in the study. for multiple comparisons, or the Kruskal-Wallis test. Patients with serious physical or mental pathologies, such as terminal disease and psychosis, which could make the Finally, general linear models were used to analyse differ- comprehension and completion of the questionnaire dif- ences in satisfaction scores according to time of response ficult, also were excluded, as were patients whose destina- to mailing adjusted by the socio-demographic variables. tion after hospital discharge differed from their usual In all cases, we considered the first mail respondents as residence, given the difficulties associated with locating the reference group. them. In all analyses, P < 0.05 was considered statistically signif- All study participants signed a consent form. The study icant. All statistical analyses were performed using SAS for was in compliance with the Helsinki Declaration and the Windows statistical software, version 8.0. Research Committees of the participant hospitals gave approval to the study. Results The mean age of the participants was 62.2 years old; Survey 54.3% were men, 68.3% were married or cohabitating, A random sample of 650 patients who had been dis- and 54.1% had only a primary education level. Of the charged between February and March 2002 was contacted 73.5% that participated in the study, 52.4% responded to for each hospital. Two weeks after discharge, the selected the first mailing, 27.2% to the first reminder, and 20.4% patients received the questionnaire with a prepaid return to the second reminder (Table 1). Those who did not envelope. A cover letter also was attached that explained respond were a mean of 63 years old and 48.3% were the reasons for conducting the survey, encouraged their women, but these differences were not significantly differ- participation, and guaranteed data confidentiality. A fol- ent. We found non-respondents significantly more likely low-up letter was sent to non-responders 2 weeks later. If to be emergency admissions in medical, rather than surgi- they still had not returned the questionnaire 15 days after cal, specialties, discharged to a place other than their nor- the first reminder, they received a third letter with a new mal residence, and a with a higher mean length of stay The copy of the questionnaire. The response rate obtained univariate analysis of the selected variables showed their using this method was 73.5%. relationship with the scores of our satisfaction question- naire (Table 2). We found that age was statistically corre- Statistical analysis lated with all domains except the visiting domains, with Descriptive statistics, including frequencies, percentages, higher satisfaction scores related to increasing age. Gender means and standard deviations (SDs), were calculated for was related to comfort, visiting and intimacy, with men the socio-demographic variables. For comparisons expressing higher satisfaction. Level of education was only between respondents and non-respondents on those vari- related to comfort and cleanliness, with higher satisfac- ables where we had information, we used a Chi-square tion among those with no schooling or a primary educa- test for categorical variables and a t-test or the non-para- tion level of studies. Marital status was correlated with the metric Wilcoxon for continuous variables. information, human care, intimacy, and cleanliness domains, with those married or cohabitating having In the univariate analysis, we studied the relationships higher scores except for the cleanliness domain. Shorter among the selected sociodemographic variables, the his- length of stay showed more satisfaction with visiting and tory of current and previous admissions, and survey com- cleanliness. Those admitted previously showed lower sat- pletion logistics variables with the six dimensions of the isfaction with human care, comfort and cleanliness. st questionnaire. Patients who responded to the 1 mailing expressed nd higher satisfaction than those who responded to the 2 or rd 3 mailings, with Information, Human Care, Comfort Page 3 of 9 (page number not for citation purposes) BMC Health Services Research 2006, 6:102 http://www.biomedcentral.com/1472-6963/6/102 Table 1: Sociodemographic data of the total sample Variables Responders n = 1910 Non-Responders n = 703 P value n% n % Age (years) ± SD 62.2 16.6 63.0 19.1 0.35 7.6 5.9 8.5 7.4 <0.05 Length of stay (days) x ± SD Sex 0.23 Men 1,026 54.3 361 51.7 Women 862 45.7 337 48.3 Admission service <0.001 Medical 1,084 56.8 452 64.6 Surgical 826 43.2 248 35.4 Admission type <0.001 Urgent 755 62.4 320 78.8 Planned 456 37.6 86 21.2 Marital status Single 232 12.6 Married/cohabitating 1,261 68.3 Separated/divorced 48 2.6 Widowed 304 16.5 Education level No education 288 15.9 Primary studies 982 54.1 High school/secondary education 395 21.8 University 148 8.2 Occupation Employed full time 330 18.8 Employed part time 58 3.3 Homemaker 313 17.8 Unemployed 56 3.2 Student 19 1.1 Retired 825 47.0 Disabled 155 8.8 Time of response* st 1 mailing 1,001 52.4 nd 2 mailing 520 27.2 rd 3 mailing 389 20.4 Previous admission Yes 1,509 82.1 No 330 17.9 No. previous admissions <= 2 542 39.3 3–4 437 31.7 >4 400 29.0 Who completed the questionnaire Patient 1026 55.6 Someone else 818 44.4 The sample size in each question differs because not all subjects answered all questionnaire items. *The response rate is calculated on the basis of the total number of questionnaires returned. Frequencies and percentages are presented, except for age and length of hospital stay, where the means and SDs are presented. and Intimacy. Finally, the variable "who responds to the and who completed the questionnaire; i.e. later response questionnaire" revealed that those who responded alone was more likely by older patients, widowed and those expressed higher satisfaction with information, human who needed help to answer the questionnaire. There were care, comfort and intimacy. no discernible differences by gender, level of studies, or working status. We checked whether there were differences by time of response to the mailing for different variables (Table 3) When evaluating the questionnaire satisfaction scores and we found this was significant for age, marital status based on the time of response to the mailings and who Page 4 of 9 (page number not for citation purposes) BMC Health Services Research 2006, 6:102 http://www.biomedcentral.com/1472-6963/6/102 Table 2: Univariate analysis by relevant variable Variables Patient satisfaction questionnaire domains Information Human Care Comfort Visiting Intimacy Cleanliness x (SD) x (SD) x (SD) x (SD) x (SD) x (SD) Age (years) <= 50 77.3 (19.8) 75 (21.3) 61.4 (17.7) 77.9 (20.3) 88 (21.4) 87.1 (17.7) 51–65 83.9 (17.7) 80.2 (20.2) 66 (18.5) 79.7 (18.7) 91.8 (18.4) 88.7 (17.4) >65 82.3 (18.2) 78.8 (20.9) 69.5 (17.7) 80.2 (18) 90.9 (20.1) 90 (17.1) P value <0.001 <0.001 <0.001 0.31 <0.01 <0.01 Gender Men 81.5 (18.9) 78.6 (20.7) 67.9 (18.2) 80.6 (18.1) 92.4 (18.1) 89.6 (16.8) Women 81.5 (18.3) 77.7 (21) 65.2 (18) 78.3 (19.5) 88 (22.1) 88.2 (18) P value 0.52 0.29 <0.001 <0.01 <0.001 0.09 Education level No studies/primary 81.8 (18.1) 78.4 (20.8) 67.3 (17.6) 80.2 (17.9) 90.7 (19.6) 89.5 (16.9) Secondary/university 80.8 (19.6) 78.2 (20.8) 64.8 (18.8) 78.1 (20.3) 89.6 (21.4) 87.8 (17.8) P value 0.80 0.80 <0.01 0.25 0.57 <0.05 Marital status Single/divorced 77.9 (20.5) 75.9 (22.6) 66.6 (17.5) 80.7 (18.9) 88.0 (21.5) 91.0 (16.5) Widowed 80.7 (18.0) 76.4 (21.1) 66.1 (18.4) 78.6 (18.6) 89.1 (21.4) 88.3 (18.4) Married/cohabitating 82.4 (18.3) 79.1 (20.4) 66.6 (18.2) 79.4 (18.8) 91.3 (19.3) 88.6 (17.3) P value <0.001 <0.05 0.79 0.11 <0.05 <0.05 Length of hospital stay (days) <4 81.8 (18.5) 78.9 (20.2) 67.4 (18.6) 82.2 (17.8) 90.2 (20.4) 91.1 (15.4) 4–7 81.5 (18.3) 78.5 (20.6) 66.7 (18.2) 79.6 (18.7) 91.4 (19.3) 88.8 (17.5) >7 81.6 (18.8) 77.7 (21.6) 66.3 (18.1) 77.9 (19.2) 90.0 (20.3) 87.9 (18.2) P value 0.89 0.84 0.47 <0.001 0.32 <0.05 Previous admissions 0 82.1 (17.0) 81.0 (18.8) 68.2 (18.1) 80.5 (18.5) 89.5 (20.8) 90.9 (16.0) 1–4 81.5 (19.3) 78.8 (20.5) 66.7 (18.0) 80.0 (18.6) 90.7 (20.1) 88.9 (17.3) >4 79.9 (18.5) 75.1 (21.5) 64.3 (17.7) 78.6 (19.3) 90.6 (19.4) 87.1 (18.3) P value 0.07 <0.001 <0.01 0.23 0.51 <0.01 Response to mailing st 1 mailing 83.4 (17.6) 80.9 (19.9) 68.0 (18.6) 79.3 (19.0) 91.8 (18.6) 89.4 (16.6) nd 2 mailing 80.9 (19.4) 77.6 (21.1) 67.3 (17.5) 79.8 (18.0) 90.3 (19.6) 89.3 (17.6) rd 3 mailing 77.8 (19.2) 72.4 (21.9) 62.6 (17.9) 79.8 (19.2) 87.8 (23.1) 87.5 (18.8) P value <0.001 <0.001 <0.001 0.71 <0.05 0.34 Responded to questionnaire With help 79 (19.1) 75.8 (21.3) 65.7 (17.4) 80 (18.1) 88.6 (21.3) 88.4 (17.8) Alone 83.4 (18.1) 80.2 (20.4) 67.5 (18.6) 79.1 (19.3) 92 (18.8) 89.4 (17) P value <0.001 <0.001 <0.05 0.85 <0.001 0.28 Student t test, or analysis of variance (ANOVA) with the Scheffe's method for multiple comparisons, or the Kruskal-Wallis test performed. responded to them, we observed that those who com- We also studied the effect of the previous variables on the pleted the questionnaire with help systematically had satisfaction scores after adjustment by all variables (Table lower scores than those who responded themselves (Table 5) in a multivariate model. Age was significantly related to 4). Statistically significant differences differences were all domains with higher scores increasing with age. Gen- found in the three mailings and for the information, der showed similar results as in the univariate analyses. human care, comfort, and intimacy domains but not for The level of education was related to visiting, intimacy, the visiting and cleanliness domains either for those who and cleanliness, with those with no education or primary responded themselves or with help. A trend toward higher studies having higher scores. Marital status was related to satisfaction was found for those who responded early and information, with higher scores for married patients; sin- a trend toward lower satisfaction was found for those who gle or divorced individuals had higher scores for comfort, responded later for those who responded themselves or visiting, and cleanliness. Length of stay related to comfort, with help. visiting and cleanliness, with lower scores for those with Page 5 of 9 (page number not for citation purposes) BMC Health Services Research 2006, 6:102 http://www.biomedcentral.com/1472-6963/6/102 Table 3: Descriptive statistics by mailing Variable Time of response to mailing st nd rd 1 mailing n = 1001 2 mailing n = 520 3 mailing n = 389 P value Age (years) <0.05 ≤50 239 (24.0) 95 (18.5) 97 (25.1) 51–65 261 (26.2) 146 (28.4) 87 (22.5) >65 496 (49.8) 274 (53.2) 202 (52.3) Gender 0.53 Men 532 (53.6) 289 (56.5) 205 (53.4) Women 460 (46.4) 223 (43.6) 179 (46.6) Education level <0.05 None/primary school 642 (67.3) 358 (73.2) 270 (73.0) Secondary/university 312 (32.7) 131 (26.8) 100 (27.0) Work status 0.11 Working/homemaker 382 (41.4) 169 (36.1) 150 (41.1) Unemployed 34 (3.7) 11 (2.4) 11 (3.0) Retired/disabled 499 (54.1) 279 (59.6) 202 (55.3) Student 8 (0.9) 9 (1.9) 2 (0.6) Marital status <0.01 Married/cohabitating 693 (71.5) 333 (66.9) 235 (62.2) Single/divorced 142 (14.7) 78 (15.7) 60 (15.9) Widowed 134 (13.8) 87 (17.5) 83 (22.0) Who fulfill the questionnaire <0.001 Alone 586 (60.6) 258 (51.8) 182 (48.0) With help 381 (39.4) 240 (48.2) 197 (52.0) Data are given as frequency (percentage). nd rd st longer length of stay. Previous admissions related to infor- to the 2 and 3 mailings, compared with the 1 mailing, mation, human care, comfort, visiting and cleanliness, for Information and Human Care, and specifically from rd st with lower scores for those with more than four previous the 3 mailing compared with the 1 mailing for Com- admissions. Lower scores were also found for respondents fort, Intimacy and Cleanliness. In all cases, a decrease in Table 4: Mean patient satisfaction scores by response to mailing times and person who responds Time of response to mailing st nd rd Variables 1 mail n = 967 2 mail n = 498 3 mail n = 379 P value n = 586 n = 258 n = 182 Responded alone Information 84.9 (17.1) 82.4 (20.0) 80.2 (17.5) <0.01 Human care 82.3 (19.4) 79.5 (20.5) 74.5 (21.9) <0.001 Comfort 69.1 (18.9) 68.3 (17.1) 61.3 (18.4) <0.001 Visit 78.8 (19.8) 79.2 (17.9) 79.9 (19.6) 0.46 Intimacy 92.9 (17.5) 91.3 (19.7) 90.3 (21.4) 0.48 Cleanliness 89.5 (16.7) 90.9 (14.9) 86.8 (20.3) 0.22 Responded with help n = 381 n = 240 n = 197 Information 80.8 (18.3) 79.4 (18.9) 75.0 (20.3) <0.01 Human care 78.6 (20.6) 76.1 (21.1) 70.0 (21.8) <0.001 Comfort 66.3 (17.8) 66.8 (16.9) 63.3 (16.9) 0.07 Visit 80.2 (17.4) 80.3 (18.4) 79.1 (19.0) 0.84 Intimacy 90.1 (20.2) 89.1 (19.6) 85.4 (24.6) 0.10 Cleanliness 89.1 (16.4) 87.7 (20.1) 87.9 (17.5) 0.80 The total number of patients does not match previous tables since there was missing information for those who responded to the "response with/ out help" variable. Page 6 of 9 (page number not for citation purposes) BMC Health Services Research 2006, 6:102 http://www.biomedcentral.com/1472-6963/6/102 Table 5: Multivariate analysis by relevant variables Variables Patient satisfaction questionnaire domains Information Human Care Comfort Visiting Intimacy Cleanliness β Coef. P value β Coef. P value β Coef. P value β Coef. P value β Coef. P value β Coef. P value R 0.063 0.062 0.084 0.028 0.039 0.034 Age (years) <= 50 ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- 51–65 7.10 <0.001 6.35 <0.001 6.30 <0.001 2.52 0.08 3.95 <0.05 3.21 <0.05 >65 7.66 <0.001 8.18 <0.001 11.65 <0.001 4.07 <0.01 3.54 0.06 4.99 <0.001 Gender Men vs. women -1.19 0.23 -0.58 0.58 1.91 <0.05 2.01 <0.05 3.44 <0.01 1.34 0.14 Education level No studies/primary ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- Secondary/university -1.67 0.15 -1.13 0.37 -1.90 0.08 -2.85 <0.05 -2.87 <0.05 -2.31 <0.05 Marital status Single/divorced -2.85 <0.05 -0.96 0.53 3.95 <0.01 3.38 <0.05 -1.64 0.35 4.37 <0.001 Widowed -0.67 0.64 -1.37 0.37 0.003 0.99 -0.75 0.60 0.48 0.78 1.25 0.34 Married/cohabitating ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- Length of hospital stay (days) <4 ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- 4–7 -0.77 0.53 -0.42 0.75 -1.56 0.16 -3.42 <0.01 0.88 0.57 -2.81 <0.05 >7 -0.27 0.82 -1.22 0.36 -2.33 <0.05 -5.50 <0.001 -0.35 0.82 -3.82 <0.001 Previous admissions 0 ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- 1–4 -1.53 0.22 -2.78 <0.05 -2.40 <0.05 -1.35 0.28 0.21 0.89 -2.60 <0.05 >4 -3.3 <0.05 -6.72 <0.001 -5.16 <0.001 -2.92 <0.05 0.10 0.96 -4.41 <0.01 Response to mailing st 1 mailing ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- nd 2 mailing -2.35 <0.05 -3.10 <0.01 -1.32 0.19 -0.03 0.98 -1.57 0.25 -0.08 0.93 rd 3 mailing -4.34 <0.001 -6.66 <0.001 -5.39 <0.001 1.06 0.38 -4.10 <0.01 -1.75 0.12 Responded to questionnaire With help vs. alone -7.37 <0.001 -6.31 <0.001 -4.45 <0.001 0.02 0.98 -5.57 <0.001 -2.20 <0.05 β Coef.: Beta coefficient from the lineal general model, after adjustment by all relevant variables. Positive values indicate more satisfaction on that domain for that category; negative values indicate less satisfaction compared with the reference category, which is blank or indicated as "versus". nd rd the scores is seen from the 2 to the 3 mailing. Finally, the questionnaire and if the patient completed the ques- those who responded with help had lower scores on infor- tionnaire or did so with the assistance of someone else. mation, human care, comfort, intimacy and cleanliness. The R of each domain model also was estimated, and As in previous studies, we showed that older patients ranged between 0.028 (visiting) to 0.084 (comfort). tended to have higher satisfaction scores in all areas of our questionnaire [11,12]. Similarly, those with no education Discussion or only primary education had higher satisfaction scores. Our study showed that age, education level, marital status, Marital status traditionally has been included in this kind sex, work status, length of stays, and previous admissions of study [13], and usually, those married or cohabitating affected the scores of the six domains in the satisfaction tended to have higher satisfaction scores, but in our study questionnaire. Some variables had been studied previ- those who were single or divorced had higher satisfaction ously, but to the best of our knowledge, the full range of scores in the comfort, visiting, and cleanliness domains. variables included in this article had not been studied In contrast to other studies [11], our results showed that together in multivariate analyses for the different domains men tended to have higher satisfaction scores than of a validated satisfaction questionnaire and with a large women, as in others [14,15]. We also studied the influ- sample size. The validity of our satisfaction questionnaire ence of the working status of our respondents but, unlike was discussed previously and showed acceptable results. others [16], we did not find that this variable had any Nevertheless, to avoid bias we outlined two methodologic influence on our sample patient satisfaction. This can be aspects: the reminders needed before a patient answered due, in our case, to the fact that there was little variability Page 7 of 9 (page number not for citation purposes) BMC Health Services Research 2006, 6:102 http://www.biomedcentral.com/1472-6963/6/102 since most male respondents had retired and most Patient satisfaction can be measured in different ways. women were working at home. We did not evaluate if the Among them, the use of surveys has been a common way type of insurance had any influence since 100% of our of conducting patient satisfaction studies. The forms of patients were covered by the public National Health Sys- administration of the survey, that is, self-administration, tem. personnel interview, or a phone interview, have been eval- uated in different studies[6,20]. However, the effect of The longer the length of stay of the index admission stud- who completed the questionnaire has been studied less ied, the lower the satisfaction on specific domains such as often. We showed in the current study that who com- comfort, visiting, and cleanliness, which seemed logical, pleted the questionnaire has an important effect on the as in other studies [14]. However, studies of mental health results, in that a more negative satisfaction level was services have found the opposite to be true [17], and those recorded on those surveys answered by someone other seem to be areas more likely conditioned by a long stay. than the patient. In addition, we found that patients who already had had a previous hospital admission tended to be more The limitations of this study include the type of design demanding or critical and have lower satisfaction levels chosen (descriptive) and the inevitable non-responders. on relevant areas such as information or human care, As in previous studies [21,22], the R values were low, comfort, visiting, or cleanliness. indicating room for improving the prediction of patient satisfaction with other variables not included here. In Two main aspects of the logistics of a self-administered addition, the range of possible explicative variables patient questionnaire were studied here: the effect of the included in this study, although large, was not as exhaus- time when the patient responded to our mailings, with tive as we would have wished. Several other variables have those who responded to a second or third reminder hav- been evaluated previously that also showed a relationship ing lower levels of satisfaction; and who complete the with patient satisfaction, as the previous health status or questionnaire, the patient or someone else. The latter had hospital characteristics[22]. However, we would theoreti- the worse scores on all domains of the satisfaction ques- cally expect most explanation to be given by the differ- tionnaire, except for the visiting domain. These logistic ences in health care experiences, rather than the aspects also have been studied previously[6,8] not finding characteristics of the patients and their method of the later differences among delay on response and responding to a survey. patients' satisfaction, but this could be due to the small sample size included in that study compared to ours Conclusion (between 78 to 254 patients depending on the time when We concluded that, as in previous studies, there is evi- the patient responded to their mailings), little lower dence that patient sociodemographic characteristics affect response rate, the design of the study, and the use of dif- patient satisfaction levels. In addition, it is logical that pre- ferent satisfaction questions, though they found a ten- vious admissions and the length of the current admission dency similar to ours in the decline in their satisfaction also affect the patient response. Also, depending on the levels. But so many determinants of the satisfaction of manner in which the survey was administered, the mail hospitalized patients have not been studied globally interview method may obtain high response rates when together in multivariate models. The current study pro- using reminders, but those reminders affect the patient vides valuable information on the effect of all variables on responses. Finally, we must consider who completed the the different domains that constitute our patient satisfac- questionnaire, the patient or someone else. Therefore, tion tool. Therefore, we provide a more complete picture when conducting a patient satisfaction survey we must be of the determinants of the satisfaction of the various aware of the effect of many variables on the patient domains. responses and make the appropriate adjustments to pro- vide valid results. The different studies that have evaluated the effect of the previous sociodemographic variables [13], previous Competing interests admission experience [18], the length of hospitalization The author(s) declare that they have no competing inter- [14], and survey logistics showed, in some cases, contra- ests. dictory results. Authors' contributions Studies of the impact of reminders on the results of JMQ and NG conceived of the study, coordinated and par- patient satisfaction surveys are contradictory: some have ticipated in the design of the study, and drafted the man- shown that reminders affect the patients' responses [19], uscript. AE, FA, CE, JASS, ES and AT participated in the as in our study, while others did not show that effect [8]. design and helped to draft the manuscript. AB, AT per- Page 8 of 9 (page number not for citation purposes) BMC Health Services Research 2006, 6:102 http://www.biomedcentral.com/1472-6963/6/102 15. Crow R, Gage H, Hampson S, Hart J, Kimber A, Storey L, Thomas H: formed the statistical analyses and drafted the manuscript. The measurement of satisfaction with healthcare: implica- All authors read and approved the final manuscript. tions for practice from a systematic review of the literature. Health Technol Assess 2002, 6:1-244. 16. Beck EJ, Griffith R, Fitzpatrick R, Mandalia S, Carrier, Conlon C, Man- Additional material del B, Ong E, Pozniak A, Tang A, Tomlinson D, Williams: Patient satisfaction with HIV service provision in NPMS hospitals: the development of a standard satisfaction questionnaire. Additional file 1 NPMS Steering Group. AIDS Care 1999, 11:331-343. 17. Rosenheck R, Wilson NJ, Meterko M, Rosenheck R, Wilson NJ, Summary of the questions included in the patient satisfaction question- Meterko M: Influence of patient and hospital factors on con- naire. Short description of the data: questions included in the question- sumer satisfaction with inpatient mental health treatment. naire, for each of the six domains that were obtained in the validation Psychiatr Serv 1997, 48:1553-1561. study; these questions have been summarized and listed in the file. 18. John J: Patient satisfaction: the impact of past experience. J Click here for file Health Care Mark 1992, 12:56-64. 19. Wensing M, Mainz J, Kramme O, Jung HP, Ribacke M: Effect of [http://www.biomedcentral.com/content/supplementary/1472- mailed reminders on the response rate in surveys among 6963-6-102-S1.doc] patients in general practice. J Clin Epidemiol 1999, 52:585-587. 20. Ford RC, Bach SA, Fottler MD: Methods of measuring patient satisfaction in health care organizations. [Review] [41 refs]. Health Care Manage Rev 1997, 22:74-89. 21. Kane RL, Maciejewski M, Finch M: The relationship of patient sat- Acknowledgements isfaction with care and clinical outcomes. Med Care 1997, This study was supported by a grant from the Fondo de Investigación San- 35:714-730. 22. Finkelstein BS, Singh J, Silvers JB, Neuhauser D, Rosenthal GE: itaria (FIS 00/0129), of the thematic networks (FIS G03/202) and the Patient and hospital characteristics associated with patient Research Committee of the Galdakao hospital. The authors of this article assessments of hospital obstetrical care. Med Care 1998, wish to thank all personnel at the data-gathering units of the four hospitals. 36:AS68-AS78. References Pre-publication history 1. Rubin HR: Patient evaluations of hospital care. A review of the The pre-publication history for this paper can be accessed literature. [Review] [56 refs]. Med Care 1990, 28:S3-S9. here: 2. van Campen C, Sixma H, Friele RD, Kerssens JJ, Peters L: Quality of care and patient satisfaction: a review of measuring instru- ments. [Review] [66 refs]. Med Care Res Rev 1995, 52:109-133. http://www.biomedcentral.com/1472-6963/6/102/pre 3. 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