The goal of this review is to discuss aspects of the measurement of patient satisfaction, identify the characteristics of useful measures of patient satisfaction, describe some existing measures of patient satisfaction, and establish when it is important to report patient satisfaction in clinical research studies.
What Is Patient Satisfaction?
In the last twenty years, clinicians have begun to increasingly acknowledge and understand the importance of patient-reported outcomes. The emphasis on outcomes that matter to patients has led to the development of a wide range of measurement instruments to supplement objective measures and a move away from objective measures of impairment, such as range of motion or strength, that are assessed by clinicians. Clearly, in many instances the most informative reporting of clinical results includes elements of both patient and clinician evaluations, and when these appear to conflict—as they frequently do—an attempt to explain the discrepancies.
Authors of clinical studies now often report on patient satisfaction as well as functional outcomes. On the surface, this seems to be a natural outgrowth of the desire to measure outcomes that concern patients, and an important element of measuring such outcomes is assessing their satisfaction with the management of their health. However, patient satisfaction is complex and does not necessarily have a clear link to either existing patient-reported outcomes or outcomes measured by clinicians.
To begin with, it is important to understand the contrast between satisfaction as it relates to the outcome of care and satisfaction with the process of care1. These are two related but separate concepts. Situations arise in which the outcome of treatment is considered to have been successful by both the patient and the clinicians but the process of care is considered to be unsatisfactory because of cost, inconvenience, or hardship related to receiving that care. Conversely, treatment may be considered to have been unsuccessful, at least from the standpoint of having failed to achieve the desired outcome, but satisfaction with the process of care may still be high because it was delivered in a careful, empathetic manner. The relationship among patients, caregivers, treatment setting, and any of a variety of additional factors may influence the determination of whether a given patient is “satisfied” with the care.
Regardless of the methodology used to evaluate satisfaction, it must be acknowledged that the meaning of “satisfaction” may vary from patient to patient and between investigators. As is the case for measurement of all clinical results, the complexity of evaluating satisfaction dictates the need for instruments that are reliable, valid, and meaningful. This complexity is not captured by a simple, one-item measure such as a visual analog scale.
Can Patient Satisfaction Be Measured?
The measurement of patient satisfaction is elusive because it is a multidimensional construct that has not necessarily been well defined for orthopaedic surgery. Many instruments designed to measure satisfaction are unvalidated or rudimentary2. Others, such as the Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys, are specifically designed to measure satisfaction only with the process of care. Some of these instruments are reviewed below. A common problem of many scales is the failure to differentiate patient satisfaction with outcome from their satisfaction with the quality of the health service delivered—in other words, satisfaction with the process of care3.
Many validated outcome instruments in orthopaedic surgery are not specifically designed to measure patient satisfaction, although they may include questions related to satisfaction4-6. Authors of orthopaedic studies often attempt to determine which outcomes or other components of the care pathway are associated with satisfaction. For example, the strongest predictor of dissatisfaction with total knee arthroplasty appears to be a failure to meet a patient’s preoperative expectations7. Similarly, patients who attach higher importance to the results of spine surgery have been shown to have larger discrepancies between their preoperative expectations and the outcome8, and higher preoperative expectations are associated with decreased postoperative satisfaction9. Satisfaction with hand surgery has been correlated with pain relief, the ability to perform activities of daily living, appearance, strength, range of motion, and fulfillment of expectations10. Satisfaction with foot and ankle surgery is influenced by appearance, shoe wear, pain, and social interactions6. A study of parents of children being treated in the hospital for an orthopaedic condition showed that dissatisfaction was associated with a perceived need for more information, even when they had been provided with the information they felt they lacked11. Patient expectations have also been shown to have significant relationships with patient-reported outcomes of rotator cuff repair and shoulder arthroplasty12. In contrast, Godil et al.13 found that patient satisfaction is not a valid measure of overall quality or effectiveness of surgical spine care. They studied correlations between patient-reported satisfaction and outcome as well as between patient satisfaction with provider care and a number of functional outcome scores related to the surgical treatment of spine disorders and concluded that satisfaction metrics are important patient-centered measures of health-care service but should not be used as a proxy for overall quality, safety, or effectiveness of surgical spine care.
The wide spectrum of findings regarding patient satisfaction with orthopaedic surgery care is a reflection of the complex nature of satisfaction and of the interaction between different facets of the satisfaction construct. Some attempts have been made to reduce this confusion by developing and validating instruments specifically designed to measure satisfaction with outcomes. Mahomed et al. described a simple instrument designed to evaluate satisfaction with pain relief and function after lower-extremity arthroplasty, and it was found to be internally consistent, valid, and reliable14. A scale to test patients’ expectations of spine surgery was developed and found to be valid, reliable, and applicable to diverse diagnoses15.
A common theme in most studies of patient satisfaction with orthopaedic surgery is the relationship between preoperative expectation and postoperative satisfaction. In a recent review article, Shirley and Sanders3 noted that linking satisfaction to quality-of-care initiatives is important, in part because satisfaction data may be used for accreditation and compensation formulas. However, they also found that surgeons are more interested in the measurement of satisfaction with outcomes even if aspects of the process of care, often beyond the surgeon’s control, contribute substantially to patients’ overall satisfaction. Effective communication with patients and their families and appropriate expectations are factors that may be under the control of surgeons.
Given the importance of assessing satisfaction, the current state of development of tools for measuring satisfaction with orthopaedic care, and the imperative that orthopaedic surgeons focus on the measurement of factors on which they can have an impact, it appears that setting and communicating appropriate expectations with patients is a key objective. Measuring whether these expectations have been met is an attainable and worthwhile goal. The Canadian Occupational Performance Measure (COPM)16, a generic outcome measure, is an example of a tool that meets these needs. The COPM consists of a semi-structured interview that measures problems with daily function that are identified by the patient or caregiver and scores satisfaction with performance of these activities before and after interventions designed to improve them. It has proven to be a valid, reliable, clinically useful, and responsive tool that focuses on outcomes that are important to the patient and that are within a range that the patient and caregiver agree is reasonable and achievable before the intervention17.
What Measures Are in Widespread Use in Health-Care Systems and Professional Organizations?
American Academy of Orthopaedic Surgeons (AAOS)
The AAOS was a leader among surgical specialty groups in entering the arena of the measurement of patient-oriented outcomes, including patient satisfaction. It has become clear that the documentation of patient satisfaction is critical to proving quality care to managed care organizations and third-party payers. Very early on, the AAOS developed a Patient Satisfaction Questionnaire that helped orthopaedic surgeons to obtain these valuable data. The questionnaire was a validated nine-item instrument within the Musculoskeletal Outcomes Data Evaluation and Management System (MODEMS) that focused on the process of care in an orthopaedist’s office. The patient satisfaction tool was widely used to measure and improve office performance from the patient perspective. Unfortunately, the MODEMS initiative was ahead of its time and financial constraints resulted in discontinuation of program support. However, the instruments developed within the program remain in widespread use for clinical research.
The NRC (National Research Corporation) Picker patient satisfaction tool was based on extensive research conducted by the Picker Institute in collaboration with Harvard Medical School. In 2002, NRC Picker approached the Centers for Medicare & Medicaid Services (CMS), the Department of Health and Human Services (HHS), and the Agency for Healthcare Research and Quality (AHRQ) and shared their experiences in creating a standardized patient-experience public reporting program for the National Health Service in the U.K.
Centers for Medicare & Medicaid Services (CMS)
In 2005, CMS launched Pay-for-Performance (P4P) initiatives in order to address quality deficiencies in all aspects of health care. At the present time, CMS and state Medicaid programs as well as all health plans and prominent health-care-quality groups support this approach. These programs use various quality measures such as clinical quality, utilization and cost management, patient-oriented outcomes, and patient satisfaction. As patient-centered approaches to care become dominant in P4P programs, patient satisfaction measures have become a critical point of focus for improving care by both governmental agencies and professional organizations.
Consumer Assessment of Healthcare Providers and Systems (CAHPS)
Included in the Patient Protection and Affordable Care Act is the requirement that CMS create a web site that features data on the comparative performance of physicians. The site, called Physician Compare, went online in 2011. CMS plans to expand the web site to include an area for patient ratings along with information on clinical quality. The Physician Quality Reporting System (PQRS) will soon begin public reporting. Patient satisfaction is assessed with the measure developed by the AHRQ. Known as the Clinician and Group Consumer Assessment of Healthcare Providers and Systems, or CGCAHPS, this instrument is similar to the CAHPS instruments, the survey tools that hospitals and home-care agencies already use.
Press Ganey is the nation’s largest provider of tools for patient satisfaction measurement and analysis. The survey simply known as the “Press Ganey Survey” is the only survey approved by the National Quality Forum (NQF), a private, multi-stakeholder organization that evaluated the clinical quality metrics in the PQRS. CMS is legally required to use measures approved by the group. Many large physician groups already use this survey, in which the CGCAHPS questions are embedded, in anticipation of the coming requirement. For similar hospital quality programs (Hospital Consumer Assessment of Healthcare Providers and Systems, or HCAHPS), the first tool successfully developed to create a standard measure of patient-centered care for providers across the U.S., reporting was voluntary at first. Later, hospitals that did not report data lost 2% of their Medicare reimbursement. Measures now available are designed to evaluate home health care (HHCAHPS), physician practices/medical groups (CGCAHPS), and ambulatory surgery. It remains to be seen whether there will eventually be a similar impact on physician reimbursement based on compliance with these measurement tools, and whether the newer tools will make it easier to “drill down” to patient satisfaction data for individual physicians.
Usefulness of Patient Satisfaction Measures
Government programs that require reporting of quality and patient satisfaction measures are not the only reason why orthopaedic practice groups should survey their patients with one of these tools. The process of collecting patient satisfaction data informs physicians of their patients’ actual opinions. Smart practices take the data and use them to inform process and flow improvement in addition to helping individual physicians improve their patient communication skills. Using these data to improve customer service helps to retain patients as well. Physicians with the lowest 20% ratings are nearly four times more likely to have patients leave their practices compared with the top 20%18.
The effective use of patient satisfaction data also reduces the likelihood of patient lawsuits19. Poor communication between physicians and patients is more likely to result in a malpractice suit than in a poor outcome. Physicians who ranked in the bottom one-third of the Press Ganey database were 110% more likely to have suits brought against them. Less clear is the relationship between patient perceptions of individual physicians and the quality of clinical care. A study supported by the Commonwealth Fund has also identified a direct relationship between hospital care quality and patient satisfaction ratings20. This is likely related to the quality of communication between physicians and their patients, which is the basis for shared decision-making; engaging patients in these decisions through quality communication improves the results of care in addition to enhancing overall patient satisfaction.
Characteristics of an Effective Measure of Satisfaction
As with measures of any construct, measures of patient satisfaction should be reliable and valid21. Reliability refers to whether a measure is reproducible between and within individual raters. Validity addresses whether the scale measures what it purports to measure.
Reliability encompasses three features. The first is intrarater reliability, which addresses the question of whether the measure provides the same satisfaction rating if the subject answers it on two separate occasions. It is tested by comparing satisfaction scores on two different administrations, spaced sufficiently far apart in time to ensure that the subject is not simply recalling from memory their prior responses. The administrations must also be close enough in time that the subject’s clinical status has not changed (as this could result in an actual change in their satisfaction with the outcome or process of care between the times of the two administrations). There is no clear standard, but one to two weeks is often used for test-retest studies. Standard statistical tests are used to calculate the reproducibility. If the scale is continuous, the intraclass correlation coefficient and the Pearson correlation coefficient provide complementary evidence of reproducibility. The Pearson coefficient—or its nonparametric analog, the Spearman correlation coefficient—measures correlation and not agreement. Thus, if satisfaction wanes over time and the result of the retest is uniformly lower than the original result, the correlation may remain very high. The intraclass correlation coefficient essentially compares the variance within individuals with that across individuals and thus accounts more directly for disagreement over time.
Interrater reliability is pertinent when the measure is administered by another person rather than by self-report. In these circumstances, the research team must ensure that two research staff members administering the measure to the same subject obtain the same result. Here, too, it is important that the two instances be spaced far enough apart to ensure that the subject is not simply reporting from memory but close enough that there have been no meaningful changes.
Internal consistency, or scale reliability, is a third measure of reliability germane to multi-item scales that is used in an attempt to assess a unidimensional construct—for example, a six-item scale in which responses to the six items are added or averaged to assess satisfaction. The items should have high correlation with one another and with the overall score. There are various ways of measuring whether the scale is internally consistent. The most frequently used are Cronbach alpha and the individual correlations between the individual item score and the total score. Cronbach alpha provides a measure of the extent of intercorrelation of all items in the scale. Most experts agree that a Cronbach alpha of 0.70 or higher indicates that the scale has acceptable internal consistency.
There is frequently no gold standard against which to compare a measure for validity, so several approaches may be taken. Content validity is assessed by clinical and other experts reviewing the proposed scale to ensure that the items appear to make sense from a clinical standpoint. Discriminant validity addresses whether the scale effectively distinguishes groups hypothesized to have different scores. For example, subjects who had repeat surgery in the first year would be expected to have lower satisfaction scores than subjects who did not have repeat surgery. Convergent validity refers to the association between the proposed measure and measures of related concepts hypothesized to be correlated. For example, one would expect the measure of satisfaction following total joint replacement surgery to be positively correlated with a measure of improvement in functional status or reduction in pain.
Reliability and validity are not fixed properties of measures. They may differ across populations and interventions and may be influenced by differences in literacy, culture, and clinical context. Thus, the process of establishing reliability and validity is both iterative and ongoing, and investigators should endeavor to establish reliability and validity in their particular populations and settings whenever possible.
How and When Should Patient Satisfaction Be Reported?
Patient-reported outcomes, including satisfaction, are clearly a crucial aspect of determining the effectiveness of health-care delivery and treatment. “Satisfaction” reflects the patient’s assessment of the process and outcome of treatment, and it may differ from health status because, in part, patient satisfaction takes into account the more subjective issues of expectations and preferences22.
The assessment of satisfaction is especially important in a context of value-based health care because there may be differences between satisfaction associated with the process of care and satisfaction with the outcome of treatment. While most clinical research emphasizes the outcome of care, the relationship among patient satisfaction, outcome, and effectiveness of care is not always well understood.
Patient satisfaction with the process of treatment can be evaluated when there is interest in measuring the quality of health-care providers, facilities, or organizations. Satisfaction with the process of care is in itself complex and dependent on many factors, including lifestyle, past experiences, future expectations, and individual and societal values, any or all of which may or may not be directly related to the disorder being treated23. As noted in the section on measuring satisfaction, the concept of satisfaction implies one of expectation as well. In this regard, satisfaction may actually represent the fulfillment of an expectation rather than a simpler idea of satisfaction with outcome. When the goal of a research investigation is to determine whether patients are satisfied with treatment, their treatment expectations should be evaluated beforehand rather than simply asking, at the end of treatment, if patients were satisfied. All too often the latter approach is the one taken in clinical research studies in orthopaedic surgery.
Is greater satisfaction a measure of higher-quality care? Not necessarily. However, it seems clear that greater satisfaction may improve patient engagement, which in itself might improve outcomes, and this could influence changes in health-care delivery. Nevertheless, the relevance of satisfaction to the effectiveness of treatment is controversial and depends on the way in which satisfaction and treatment outcome are measured.
Is it always necessary and appropriate to measure and report on patient satisfaction with either outcome or process? The answer to this question depends on the nature of the investigation. For example, when a new or innovative procedure is being reported, whether patients are satisfied with treatment may be less important than understanding whether the treatment is effective. For treatments and processes that have been established as effective—for example, rotator cuff surgery—it may be more important to fully understand satisfaction. For these investigations, it is important to evaluate satisfaction with the process of care soon after the experience in order to reduce the effect of recall bias.
The reporting of patient satisfaction is relevant to the assessment of both the process and the outcome of the treatment for many clinical disorders in orthopaedic surgery. Because of the inherent subjective nature of satisfaction assessment and the possibility that satisfaction may not necessarily correlate with conventional evaluations of treatment effectiveness, satisfaction should be reported with use of validated, responsive, and reliable measures.
Areas for Future Research
In general, the right measure of outcome varies with the nature of the research question. This may prove to be true of measures of patient satisfaction as well. Distinguishing between satisfaction with the process of care and satisfaction with the outcome of care is a key dichotomy that future research in this area should address. Patient expectation clearly has an impact on the perception of outcome as successful or not, and this is likely to be true for evaluations of satisfaction as well. This is only one example of the many issues that may confront researchers seeking to develop measures of patient satisfaction that are meaningful and useful in orthopaedic surgery. The same methodological framework used in the development of outcome measures now in common use in orthopaedic surgery—item generation, item reduction, reliability testing, and validation—should be used to create measures of patient satisfaction. In the meantime, pending the development of scales that specifically measure aspects of the satisfaction construct in orthopaedic surgery, investigators should clearly define which aspect of the satisfaction construct they are evaluating and use established measures of satisfaction rather than ad hoc or poorly defined scales, which may lead to an inaccurate or misleading evaluation.
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