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Use of the BATHE Method in the Preanesthetic Clinic Visit

DeMaria, Samuel Jr., MD*; DeMaria, Anthony P., MA; Silvay, George, MD*; Flynn, Brigid C., MD*

doi: 10.1213/ANE.0b013e318229497b
Ambulatory Anesthesiology: Research Reports
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BACKGROUND: In the primary care setting, use of the BATHE (Background, Affect, Trouble, Handling, and Empathy) method of interviewing has been shown to increase patient satisfaction. This technique is a brief psychotherapeutic method used to address patients' physical and psychosocial problems. The BATHE technique has not been evaluated in the perioperative setting as a way of improving patient satisfaction. In this study, we sought to determine whether satisfaction could be enhanced by use of the BATHE technique during the preoperative evaluation by anesthesiologists.

METHODS: Fifty cardiac and 50 general surgery patients were interviewed in the preanesthesia clinic (PAC) of an academic hospital. They were randomly enrolled in the BATHE group or the control group and asked to complete an anonymous satisfaction survey after their visit. This survey was modified from current studies and not validated elsewhere. The relative influence of the BATHE condition was examined as it pertained to interview duration, patient satisfaction, and patient report of the BATHE items being asked.

RESULTS: Ninety-two percent of patients approached by the study group voluntarily enrolled. Patients interviewed using the BATHE method reported being asked about all BATHE questions significantly more often than control patients: t(98) = 19.10, P = 0.001 (95% confidence interval [CI] = 2.59, 3.20). Patients in the BATHE group were more satisfied with their visit to the PAC than those in the control group: t(98) = 5.37, P = 0.001 (95% CI = 0.19, 0.41). The use of the BATHE method did not significantly increase the amount of time physicians spent evaluating patients: t(98) = 0.110, P = 0.912 (95% CI = −1.519, 1.359).

CONCLUSIONS: Use of the BATHE method in an academic medical center's cardiac and general PAC showed promising results in this preliminary study. A validated and fully developed survey instrument is needed before we can convincingly conclude that the BATHE method is an effective way of improving patient satisfaction.

Published ahead of print August 24, 2011

From the *Department of Anesthesiology, The Mount Sinai Medical Center, New York; and The New School for Social Research, New York, New York.

Supported solely by the Department of Anesthesiology, Mount Sinai Medical Center.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Samuel DeMaria, MD, Department of Anesthesiology, The Mount Sinai Medical Center, One Gustave Levy Place, Box 1010, New York, NY 10028. Address e-mail to samuel.demaria@mountsinai.org.

Accepted June 13, 2011

Published ahead of print August 24, 2011

The preoperative evaluation period has evolved from a time for gathering patient records and labs, to a time when patients can seek discussion, guidance, and the allaying of fears by clinicians. Anesthesiologist-led preanesthesia clinics (PACs) have been instrumental in streamlining the process and decreasing associated costs of preoperative evaluation.13 Patient satisfaction after preanesthetic visits is generally good, but often not optimal because of various logistical factors (e.g., wait times, interactions with staff).4 Evidence of patients' desires for supportive, efficient, and medically sound care comes from the growth of routine satisfaction surveys and from formal studies of patients' views regarding their care.5,6 This is important because patient satisfaction is increasingly used by consumers and insurers as a factor in the selection process of health care providers.79 In an era when patients are consumers in a competitive health care marketplace, it is also in the best interest of physicians and hospitals to ensure that patients are not only properly evaluated, but also satisfied with their visit.

Validated methods by which patient satisfaction can be improved are underresearched and nonuniformly implemented. Previous work has addressed complex and often costly ways in which patient satisfaction might be enhanced in the PAC setting.10 These measures may not be economically feasible for many, if not most institutions. However, inexpensive evaluation techniques designed to provide psychosocial support, such as “patient centeredness,” have had conflicting results regarding satisfaction improvement.6 A promising intervention that has been shown to improve satisfaction in the family medicine setting without increased time or financial burden is the BATHE method. This method of medical interviewing is a brief psychotherapeutic intervention designed to fit within the typical 15-minute outpatient medicine consultation. BATHE, which is an acronym for Background, Affect, Trouble, Handling, and Empathy, allows for rapid assessment of patients' psychological stress without adding to appointment duration.1113 The BATHE method requires that the interviewing physician incorporate key questions as well as direct empathic statements into his or her patient interview.

The BATHE method has been shown to improve patient satisfaction in the nonperioperative setting, yet may be equally useful therein given its brief and easily usable nature. We hypothesized that applying the BATHE method to randomly selected cardiac and noncardiac patients scheduled for a visit to the PAC would improve patient satisfaction over patients interviewed by physicians not using the BATHE method. We chose presurgical patients because they are likely to experience anxiety about their upcoming procedures and might be more satisfied with their care if physicians systematically use measures intended to allay this anxiety. We also sought to measure whether the BATHE method added significantly to the amount of time participating physicians spent with their patients as a surrogate of increased physician burden in using the method.

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METHODS

After obtaining approval from the Mount Sinai School of Medicine IRB, preoperative patients at the Mount Sinai Medical Center were voluntarily enrolled in this study. Informed consent was obtained orally for all subjects because a waiver for written consent was granted. The BATHE method has been published elsewhere by Leiblum et al.11 Our assessment tool was modified to be more applicable to the perioperative setting using language modeled after that used and validated by Hepner et al.14 (Fig. 1).

Figure 1

Figure 1

We developed a 1-page, 20-item survey for this study consisting of 2 parts (Fig. 2). The first 5 questions assessed whether practitioners asked the items as instructed and the next 15 items were questions evaluating patient satisfaction. Patient age and gender were self-reported. Surgical risk variables (cardiac versus general, ASA physical status), and consultation variables (treating doctor, length of consultation) were also collected.

Figure 2

Figure 2

A passive enrollment scheme was used wherein all patients arriving for evaluation at the PAC were approached for participation in the study by a study group member (not an interviewing physician) in the registration area. Patients were asked if they wished to participate in a study concerning satisfaction with the preoperative visit. All patients aged 18 to 80 years scheduled for either cardiac or general surgery were eligible for enrollment. Within the general surgery population, only patients undergoing noncancer, nonthoracic procedures were included because these patients undergo a separate assessment. All cardiac surgery patients for whom cardiopulmonary bypass was planned (i.e., not presenting for cardiac catheterization) were included because nonbypass patients also undergo a separate assessment. Exclusion criteria included inability to understand the content of the survey or inability to provide consent for one's self. All patients had scheduled appointments in the PAC, and the entire sampling took place over an 8-week period.

Five senior anesthesia (CA3) residents were asked to voluntarily participate as patient interviewers in the study. All agreed to participate. Each interviewer was trained in the BATHE method used in this study. A study group member (APD) who has published work on the BATHE method and performed formalized training therein trained the interviewers in a brief 10-minute group session 2 weeks before initial patient enrollment. The training was deemed adequate if the participant could successfully perform a mock evaluation on one of the other trainees.

The first 3 patients of any given workday were not enrolled because they are least likely to experience significant delays based on institutional data and this might have falsely improved satisfaction scores. The subsequent 10 patients of a given work day were enrolled. To avoid interviewer fatigue and order effects, the BATHE method was used in varying orders, in blocks of 5 patients. Participating physicians were notified before the beginning of their shift whether to use the BATHE method on their patients or to interview them in their standard fashion. The physician interviewers were instructed to use the method after they gathered pertinent, routine preoperative historical information. Also, to decrease order effects, some interviewing physicians performed the BATHE method for their first 5 patients and did not perform the BATHE method for the subsequent 5 patients, whereas others did the opposite. Several cycles of BATHE application were used but not recorded, to ensure that physicians did not alter their behavior because they knew satisfaction surveys would be distributed (i.e., Hawthorne effect15). In this manner, interviewers performed several more interviews than would be recorded in the final data analysis and they were not sure which block of patients would be used. These cycles were determined using a random number generator and tabulated by a blinded study group member. Physicians who performed the interviews were not aware which patients were being enrolled and which were not.

Participating patients were assessed per routine by a registered nurse before their interaction with an anesthesiologist. Immediately after the preanesthetic evaluation by the anesthesiologist, participants were instructed to complete the survey and to return it to a locked box before they left the clinic. All physician interviews were timed by the charge nurse at the PAC using a stopwatch at the nursing station, with the interview starting when participants entered the patient room and ending when they left the room. Average wait times were also recorded for each patient as part of standard PAC procedure at our institution (time to clinic check in to nurse escort to the examination room). Participating physicians were not informed that they were being timed. Participating patients were ensured that responses were anonymous and they were encouraged to share their opinions openly. Any necessary blood or imaging tests deemed necessary were performed after the return of this survey and all interactions occurred in one examination room throughout the visit.

A prior trial of the BATHE method showed differences in satisfaction ratings using a total sample size of <100 patients.11 Our survey was first trialed using 50 nonstudy patients as a performance improvement measure and to ensure ease of use and understandability. Rather than perform a formal power analysis, these data were used to determine the sample size needed for an approved study. In the initial trial, we were able to find statistically significant differences in overall satisfaction scores between groups: t(49) = 4.85, P < 0.05. Based on these data, we enrolled 100 patients to assess differences in patient satisfaction between BATHE conditions.

Independent samples t tests (2-tailed, equal variance assumed) and χ2 tests were used to identify potential differences in consultation duration, ASA rating, and patient satisfaction between BATHE and control conditions, as well as general and cardiac patients. χ2 analyses (1-tailed) were performed to verify that doctors in the BATHE condition significantly used more specific BATHE interventions than doctors asked to engage in the usual standard of care. To establish a main effect, Pearson correlation coefficients (2-tailed) were computed between the sum of specific BATHE items reported by patients as administered and overall patient satisfaction. BATHE items were summed using the first 5 questions of the survey. Each item was assigned a 1 if the item was reported as having been asked and a 0 if not. The 5 items were then summed to get a BATHE score of 0 through 5. The relationship of this BATHE score to patient satisfaction was then analyzed. A hierarchical regression analysis was conducted to assess the extent to which BATHE items related to outcome when controlling for patient variables (age, gender), surgical risk variables (cardiac versus general, ASA physical status), and consultation variables (treating doctor, length of consultation). To assess the effect of the relevant and appropriate covariates on patient satisfaction, an analysis of covariance was performed. Covariates that were conceptually meaningful did not violate the assumption of homoscedasticity (as measured by Levene's test),16 and homogeneity of regression slopes were used.

Because slight modifications were made to an existing survey, a factor analysis was conducted on the current sample to assess the measure's current factoral structure. A principal component analysis of the satisfaction measure suggested a 2-factor solution for the satisfaction survey. The first factor, which explained 27% of the measure's variance, comprised items 8 to 11, 13, 18, and 20. Factor 2, which explained 19.2% of the variance, comprised the remaining satisfaction survey items. Because Leiblum et al.11 did not report the factor structure of the original satisfaction measure, it cannot be known if the current study's modifications changed the original factor structure of the measure. However, because the 2 factors that emerged from the principal component analysis were not conceptually discrete and it was not of interest to differentiate between the possible components contributing to patient satisfaction, all items were retained. All analyses were performed using the statistical program STATA/IC 10.1.

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RESULTS

In total, 238 patients were approached for enrollment in this study, 220 patients agreed to enrollment (92%) and were interviewed by the physicians, but only 100 were actually used in the final data analysis. Figure 3 details the enrollment scheme. In the randomly enrolled group (n = 100), the return rate was 100%. Of the 100 surveyed patients randomized to be included in the final analysis, 50 were interviewed using the BATHE method and 50 were not. The patients' ages ranged from 18 to 75 years with a mean age of 48.6 years (SD = 17.6) with 52 male and 48 female participants (Table 1).

Figure 3

Figure 3

Table 1

Table 1

Patients answered questions assessing the administration of each of the 5 specific areas of the BATHE protocol (Table 2). Patients in the BATHE group reported being asked about their background, affect, trouble, and handling significantly more than in the control condition. No significant differences were found in the perception of the interviewing doctor as sympathetic. The BATHE scores (summed data for determining whether all BATHE questions were asked of patients) for the 2 groups were significantly different, with BATHE condition patients reporting being asked the BATHE questions significantly more often: t(98) = 19.01, P < 0 0.001.

Table 2

Table 2

The mean overall patient satisfaction in the BATHE group was 4.5 (SD = 0 0.23) and the non-BATHE group mean was 4.1 (SD = 0.3), with BATHE group patients reporting significantly higher satisfaction ratings: t(98) = 5.37, P = 0.001 (95% confidence interval [CI] = 0.19, 0.41). Average wait times for cardiac, noncardiac and BATHE versus non-BATHE patients were not significantly different. Also, no differences in the incidences of ASA ratings were found between the BATHE and control groups. ASA ratings, however, were significantly higher in the cardiac group than general populations: χ2 (4) = 47.6, P = 0.001. Significant differences in duration of consultation between cardiac and general populations were noted (mean = 20.3 minutes, SD = 2.3 vs mean = 15.8 minutes, SD = 2.1 for cardiac versus general, respectively), with cardiac patients having longer consultation durations measured in minutes: t(98) = 10.23, P = 0.001 (95% CI = 4.16, 6.16). There was no significant difference in duration of consultation between BATHE and control groups (Table 3) as measured in minutes. Also, an independent sample's t test (2-tailed) showed no significant difference in patient satisfaction between general and cardiac patients.

Table 3

Table 3

The relationship between the BATHE method and patient satisfaction was explored more thoroughly by correlating the sum of BATHE items and patient satisfaction. Use of the BATHE method was significantly related to satisfaction scores: r(98) = 0.40, P = 0.001 (95% CI = 0.188, 0.409). The extent to which BATHE items related to satisfaction when controlling for (1) patient variables (age, gender), (2) risk variables (cardiac versus general, ASA status), and (3) consultation variables (interviewing physician, length of consultation) as measured by a hierarchical regression analysis is shown in Table 4. Patient variables (step 1), risk variables (step 2), and consultation variables (step 3) did not significantly explain the variance in satisfaction scores. The BATHE score (step 4), however, significantly accounted for 24% of the variance in scores: r2 = 0.239, P = 0.001 (95% CI = 0.189, 0.408).

Table 4

Table 4

To further test the relationship between relevant covariates on patient satisfaction, an analysis of covariance was conducted. After assessing for homoscedasticity, independence of observations and homogeneity of regression slopes, duration of consultation was retained as a covariate. Results indicate that the duration of consultation was significantly related to patient satisfaction: F(1,97) = 4.82, P = 0.001, partial η2 = 0.047. The BATHE method also significantly related to satisfaction scores, with BATHE condition patients showing significantly higher patient satisfaction: F(1,97) = 29.71, P = 0.001, partial η2 = 0.234. When this covariate was added to the effect of condition, 25% of the variance was explained by the BATHE method and duration of consultation, with no interaction effects. Observed power of this test, computed using α of 0.05, was 0.584.

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DISCUSSION

Patients scheduled to undergo surgical procedures experience physical, emotional, social, and economic stresses that may negatively affect their perception of the care they ultimately receive. In this study of 100 PAC patients scheduled for either cardiac or general surgery, we were able to show similarly improved patient satisfaction measures as in the family practice setting11 for those patients who were randomized to the BATHE method. The amount of time spent with patients was similar between experimental groups, implying that no increased burden was placed on participating physicians using this method in terms of time spent interviewing their patients. No logistical changes in the PAC (e.g., streamlining waiting times, staff changes) were necessary to achieve these improvements.

The overall effect of the BATHE intervention on patient satisfaction in the PAC setting as measured by a survey instrument seems to have been positive. As patient satisfaction becomes an increasingly important part of outcome measurements, it is important to address it in various settings, such as the PAC, and through various strategies. The present results are in line with past studies which highlight that improved physician communication and information provision positively influenced patient satisfaction.17,18 Providing information regarding the planned anesthetic has been shown to bolster patient satisfaction in an oral surgery preoperative visit setting.10 Improving workflow and decreasing patient waiting times as well as ensuring education of PAC staff have also been shown to improve patient satisfaction in PACs.19 We have shown that a brief psychosocial therapeutic intervention such as BATHE might also increase patient satisfaction without imparting an undue burden on the preoperative evaluator or the health care facility in terms of actual interview duration or additional training.

The results of this study must be tempered by its limitations. The major limitation of this study is the survey instrument used because it was adapted from instruments used in existing studies and not validated elsewhere. Therefore, it is unclear how this measure of patient satisfaction correlates with other published measurement tools. Also, we enrolled a relatively small sample group at only 1 institution with 5 participating physicians interviewing all participants. Selection bias is a concern with voluntary and passive enrollment schema, but because 92% of approached patients agreed to participate, this seems less likely. Satisfaction surveys are prone to errors, including the effects of various statistical tests on results and the present study is no different. Because this study was performed at an academic medical center, the results cannot necessarily be generalized to other hospitals. Although order effects and the Hawthorne effect were acknowledged and attempts were made to limit their relative influences (e.g., randomizing the order of BATHE use, multiple interviews that were not actually part of the study), these confounding factors could not be extinguished completely. Obtaining informed consent itself may have introduced potential bias in this study because patients were told their satisfaction scores were being analyzed. This may have led to their heightened awareness of what their interviewing physician was asking or to the reporting of falsely high or low satisfaction scores.

The current study design does not preclude the possibility that because both groups were taught the BATHE method, interviewers may have been less empathic on purpose to further the study's goals. This seems unlikely, however, because the empathy item was the 1 item in the BATHE score that did not differ between groups. We did not perform a formal power analysis; however, our pilot data informed our sample size and led to our choice of 100 participants as sufficient. Overall satisfaction was significantly higher for the BATHE patients than for controls, but because satisfaction was relatively high for both groups, these results are also possibly misleading. Given the fact that our power was 0.58, somewhat low, future studies should use a priori power analysis and larger sample sizes.

We did not follow these patients' satisfaction scores longitudinally in the postoperative period because we did not want to confound the effects of the BATHE method with the various influences of perioperative medical treatment and complications or poor outcomes. However, examining the long-term benefits of the BATHE method in improving patient satisfaction beyond the initial encounter in the perioperative setting is an area for future research. Future studies should also examine whether the BATHE method similarly improves other postoperative outcomes such as pain control and psychological impairment (e.g., depression, anxiety). In this study, implementation was found to be very easily accomplished with a 10-minute teaching session and this could likely be made into an online tutorial to further limit resource expenditure in training physicians for future endeavors.

Evidence of patients' desire for supportive and medically sound care comes from the use of routine satisfaction surveys and from investigations regarding patients' views of their care.5,6 Patient satisfaction is increasingly used by consumers and insurers as a factor when analyzing health care delivery,7,8,20 in lieu of more devastating medical outcomes (e.g., death, major worsening of disease), which are often difficult to study.21 In an era of consumer-based medicine, highly satisfactory care is not only desirable, but necessary to physicians and hospitals. A dissatisfied patient is more likely to obtain future care elsewhere22 and potentially more likely to pursue litigation should a complication occur.2325 As medical care providers, we seek high levels of satisfaction when serving patients and also seek to evaluate our performance in doing so. This preliminary work shows convincing evidence that the BATHE method is useful, but more research of satisfaction with this technique using validated measurement tools is needed.

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DISCLOSURES

Name: Samuel DeMaria, Jr., MD.

Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript.

Attestation: Samuel DeMaria has seen the original study data, reviewed the analysis of the data, approved the final manuscript, and is the author responsible for archiving the study files.

Name: Anthony P. DeMaria, MA.

Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript.

Attestation: Anthony DeMaria has seen the original study data, reviewed the analysis of the data, approved the final manuscript, and is the author responsible for archiving the study files.

Name: George Silvay, MD.

Contribution: This author helped design the study and write the manuscript.

Attestation: George Silvay has seen the original study data, reviewed the analysis of the data, approved the final manuscript, and is the author responsible for archiving the study files.

Name: Brigid C. Flynn, MD.

Contribution: This author helped design the study and write the manuscript.

Attestation: Brigid Flynn has seen the original study data, reviewed the analysis of the data, approved the final manuscript, and is the author responsible for archiving the study files.

This manuscript was handled by: Peter S. A. Glass, MB, ChB.

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