European Journal of Vascular & Endovascular Surgery
Volume 25, Issue 1 , Pages 48-52, January 2003

Satisfaction with care in vascular surgery inpatient units

1Lab. Health Services Research and 2Lab. Epidemiology, Istituto Dermopatico dell'Immacolata–Istituto di Ricovero e Cura a Carattere Scientifico, Roma (IDI-IRCCS)

Accepted 17 September 2002.

*Please address all correspondence to: S. Tabolli, Lab. Health Services Research, Via Monti di Creta 104, 00167 Roma.

Article Outline

Abstract 

Objective: to identify and solve problems concerning satisfaction of inpatients in three different vascular surgery units. Materials and Methods: a self-administered non anonymous questionnaire was submitted. Four dimensions of patients' satisfaction and a measure of overall satisfaction were evaluated. For each of them a logistic regression model was elaborated. Results: one hundred and fifty-six eligible patients agreed to participate. For the “overall satisfaction” 56% rated the care received as excellent; patients completely satisfied for “treatment and related information” were 76%; for the “availability of staff” 96%, for “helpfulness and communication by staff” 56% and for “management of patient's complaint by medical staff” 86%. Logistic regression analysis showed, after adjustment for relevant background factors, a statistically significant difference among units of care for the overall satisfaction. Conclusions: the study highlighted the importance of considering in vascular units the patients' satisfaction as an essential component of quality of care independently of the severity of cases. The hospital management recognised the low level of communication by the staff as one of the hospital bottle-necks and tried to solve a logistic problem identified as responsible for a low score in the overall satisfaction in one unit.

Eur J Vasc Endovasc Surg 25, 48–52 (2003)

Keywords:  questionnaire, vascular surgery, quality, patient satisfaction, consumer survey

 

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Introduction 

During the last decades more and more interest has been devoted to patients' preferences and needs. At the same time increasing emphasis has been placed not only on the technical excellence of the care provided, but also to the characteristics of the interactions between providers and patients.1, 2, 3 These characteristics include the quality of communication and the ability of medical and nurse staff to deal with patients with concern, empathy, honesty, tact, and sensitivity. Thus, patient perceived quality of care or patient satisfaction is considered a legitimate measure of health care quality and should be included, together with other measures, in quality improvement programmes.4 Evaluating and improving patients' satisfaction is important, as it may lead to better compliance with treatment and consequently to better health outcomes.5 Moreover, the use of patient satisfaction surveys to improve consumer responsiveness has several useful outcomes, as it provides information to hospitals about areas where improvement is needed, and it informs policy and service development.6 At the hospital level, focused internal feedback or benchmarking with hospital satisfaction surveys can prompt action to improve services. Surveys repeated in different time periods may enable policy makers to assess the effectiveness of implemented policies and programmes and to investigate where these need adapting to the changing patients' need.7, 8

In this article we report the results of a study designed to asses the level of satisfaction with care in a sample of vascular inpatients at IDI-IRCCS in Rome where a programme of quality improvement is actually implemented also in three vascular units. Moreover, the article intends to investigate which factors may be associated with patient satisfaction.

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Materials and methods 

We studied a systematic sample of vascular patients recruited from October 1st to November 30th 2001 at the inpatient clinics of the Istituto Dermopatico dell'Immacolata (IDI-IRCCS) (Rome, Italy). IDI-IRCCS has vascular units that see approximately 2500 inpatients per year. In each vascular unit, over the study period the first two patients admitted each Monday, and the first patient admitted Tuesday to Saturday, were invited to participate. The patients' eligibility criteria for this study were: (a) age≥18 years, (b) ability to read Italian, (c) no major cognitive deficits precluding the questionnaire completion. The study protocol was approved by the Institutional Ethical Committee. Patients who agreed to participate were invited by the nurse staff, after signing an informed consent model, to complete a selfadministered questionnaire developed by the Picker Institute9 and validated in the U.S.A.10 (Appendix)

The non-anonymous questionnaire was filled by the patient on the last day of that hospital stay. The questionnaire included 23 neutrally worded questions: 15 to be answered on a five-point scale ranging from totally positive to totally negative opinions, 7 demanding a yes/no response, and one question about patient “overall satisfaction” of care on a 0/10-point scale. It was possible to mark the response “not applicable” for each of the questions.

Principal component analysis was used to identify items covering similar aspects of care.11 The dimensions identified were: treatment and information, availability of staff, helpfulness and communication of staff, management of patients' complaints by medical staff. Principal components analysis has the aim of ascertaining whether the interrelations between a set of observed variables can be explained by a small number of factors. It looks for a few linear combinations of the original variables that can be used to summarise the data. In particular, it examines the variables having high correlation assessing what these variables have in common and then attributing a sensible denomination to the component. This analysis was performed using SPSS version 8.0 for Windows.12

Four different models concerning the four dimensions and one model for the overall satisfaction were performed using multiple logistic regression analysis to assess the independent role of the variables of interest. Patients' demographic characteristics (age, sex, educational level, origin) and specific aspects of care already known to be related with satisfaction (length of stay, severity of disease defined accordingly to the All Patient Refined-Diagnosis Related Groups (APRDRGs)13, 14, 15 classification system, multiple admissions) were selected and analysed as independent variables, as well as the “unit of care”. The model building strategy suggested by Hosmer and Lemeshow was used.16

In univariate analysis, statistically significance was assessed using X2 test. Adjusted odds ratio (OR) and 95% confidence intervals (CI) were calculated in the multivariate models. These analyses were performed using the Stata Statistical Software, release 7.0 (College Station, TX, U.S.A.: Stata Corporation, 1999).

All Patient Refined DRGs were selected because adding subgroups to the basic DRG addressed patient differences relating to severity of illness and risk of mortality. In the APR-DRGs severity of illness is defined as extent of organ system loss of function or physiologic decompensation, while risk of mortality is the likelihood of dying. The four severity of illness subgroups and the four risk of mortality subgroups represent minor, moderate, major or extreme severity of illness or risk of mortality.

For this analysis patients who answered at the maximum level to 75% of the questions included in each dimension were classified as completely satisfied; the others were classified as not completely satisfied.

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Results 

A total of 183 consecutive inpatients were contacted and 170 (93%) agreed to participate in the study. However, of these, ten did not meet the inclusion criteria, and four were excluded because they completed less than 50% of the items, leaving a total sample of 156 patients.

The median age was 53 years (interquartile range 40–66), 60 patients (38%) were males and 96 (62%) were females. In order to verify whether our sample was representative of the total population of our vascular patients, we used the administrative data to assess the sex and age distribution of all patients who attended the vascular units during October and November 2001 and matched our inclusion criteria. The mean age of all vascular patients was found to be 50 (interquartile range 40–63) with 58% for female.

According to the ICD9-CM international classification system of disease the most frequent diagnostic categories in the sample were varicose vein of leg (NOS) (77 cases, 50%); scrotal varices (8 cases, 5%) and intermittent claudication (8 cases, 5%). The APR-DRG classification for the observed cases reported n=118 for class I (76%), n=36 for class II and 2 for class III. Classes II and III here were joined and considered “moderate”. Table 1 shows satisfaction with care according to patients characteristics, and specific aspect of care.

Table 1. Percentage of maximum satisfaction.
Number of PatientsTreatment and information %Availability of staff %Helpfulness and communication of staff %Management of patient's complaint by medical staff %Overall satisfaction %
Age **
18–35258096508040
36–65897695638654
>65427397578871
Sex ** *
F966896548358
M609097689053
Education Level **
<13457598588776
13457195658749
>13668095568548
Residence
Rome1127495578454
Other448297659160
Lenght of stay ** ** **
<71257396598752
≥7319097618172
Multiple admission *
Yes917196558354
No658397658959
APR-DRG classes * **
11187396578651
>1388797678471
Unit of care **
I507496518269
II578196588244
III497396709457
Total1567696568656
*p<0.1. **p<0.05.

Results of X2 test for comparison of proportion.

For the overall satisfaction, 56% of the sample rated the care received as excellent. Patients completely satisfied for treatment and related information were 76%, for the availability of the staff were 96%, for helpfulness and communication by the staff were 56%, and for management of patients' complaints by medical staff were 86%. Maximum satisfaction with treatment and information was more frequently reported by males and patients with length of stay ≥7 days. Males were also more satisfied with helpfulness and communication of staff. Subjects with educational level <13, age >65, length of stay ≥7 and severity of disease >1 were significantly more satisfied overall. Finally no significant difference was found between patients' characteristics and availability of staff and management of patients' complaint by medical staff.

Multiple regression analysis shows that, after multiple adjustment for relevant background factors, the only statistical significant difference noted among units of care was seen in one unit for overall satisfaction (Fig. 1).

In addition to the unit of care, only a few variables were associated with satisfaction in the five models. In particular, for treatment and information, males were more satisfied than females (OR 4.0, 95% CI 1.4–11.1); also for helpfulness and communication males were more satisfied than females (OR 1.9, 95% CI 0.89–4.2). For overall satisfaction less educated subjects were more satisfied than subjects with intermediate education (OR 3.1, 95% CI 1.1–9.3) and in respect to high qualified (OR 2.3, 95% CI 0.9–6.2).

The other dimensions of satisfaction are characterised by a substantial uniformity of the data, especially for the availability of the staff and management of patients' complaints where the high prevalence of satisfied patients makes it difficult to obtain meaningful comparisons.

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Discussion 

About 2500 inpatients are annually treated in three vascular units at IDI-IRCCS. The majority 70% are in the class I of APR-DRG classification (minor diseases) and almost 30% are in class II.

The patients' perspective, especially in terms of quality of life, as outcome after major vascular surgery is reported in scientific literature,17, 18, 19 but to the best of our knowledge this is the first study in Europe which tries to evaluate satisfaction in vascular patients and the interest for such analysis in a programme of quality improvement appeared relevant, also if the case-mix is limited to lower classes of APR-DRG.

Reflecting an Italian national problem, the component of satisfaction: “communication of staff” has a lower percentage of patients satisfied.20 This is a common problem between the units of care at IDI-IRCCS, but seems to be the only relevant one, because the other components of satisfaction received very high scores. The hospital management will focus on the short-coming through further training of medical and nursing staff.

After the survey, a briefing was held involving the hospital management and the staff of each unit. In one unit, the fact that they treated a higher proportion of children was identified as a possible explanation of the low score. Children are usually in the hospital with their parents or relatives and this often means having more people around, a disturbing factor for other patients. A logistical problem could be the reason of such results even if the three units are close to each other and utilise the same premises. It has to be considered that the overall satisfaction is inclusive of many other determinants such as privacy, accommodation etc. These findings show that the Picker questionnaire is a helpful instrument to identify problems between units in the same hospital. However, dominant background factors should be controlled, to make comparisons reliable.

This study deals with diseases of moderate severity: however, it should be considered that the perceived quality reflects personal expectations, which could be great even in respect to minor diseases. The actual hospital policy, oriented toward “day care” activities, with a reduction of beds for minor–moderate pathologies, will permit the assessment in future of perceived quality in more complex cases. Until now attention of vascular surgeons was devoted to evaluating performance indicators and measures of quality of life. This study highlighted the importance of considering patient satisfaction as an essential component of quality of care. It also gives the hospital management useful information for improving hospital care delivery (low level of satisfaction for emotional support; logistic problems related to relatives and parents, access in a unit). Patients were fully involved in the study process and were quite interested in participating. The information obtained will be published in the “patient's chart”, promoted by the Institute, an important information document for transparency between patient and hospital.

The results of our survey now forms a “baseline” observation, and will be repeated in time. The hospital management intends to monitor the quality perceived by patients, assessing any impact of intervention applied and, moreover, evaluating progress between the units. We hope, finally, that more and more attention will be placed not only on technical excellence of care provided, but also on the characteristic of interaction between provider and patient.

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Appendix: Patient satisfaction questionnaire 

Patient Preferences

1. Did you have enough say about your treatment?

2. Were you treated with respect?

3. Did doctors talk in front of you as if you weren't there? Did nurses?

Coordination of care

4. Was there one particular doctor in charge of your care in the hospital?

5. Did one doctor or nurse say one thing and another say something quite different?

6. How well organized was the admission process?

Information and Education

7. When you had important questions to ask your doctor, did you get answer you could understand?

8. Did a doctor or nurse explain the results of texts in a way that you could understand?

9. Did you receive enough information about your medical condition and treatment?

Physical condition

10. Do you think the hospital staff did everything they could to help control your pain?

11. Overall did you get right amount of pain medicine?

12. How many minutes after you used the call button did it usually take before you got the help you needed?

Emotional support

13. If you had any anxieties or fears about your condition or treatment, did a doctor discuss them with you? Did a nurse?

14. Did you have confidence and trust in doctors treating you? In the nurses treating you?

15. Was it easy to find someone on the hospital staff to talk to about your concerns?

Involvement of family and friends

16. Did your family or someone close to you have enough opportunity to talk to your doctor?

17. Was enough information about your condition or treatment given to your family or someone

18. Did the doctors and nurses give to your family all the information they needed to help your recover?

Continuity and transition

19. Did someone tell you what danger signals to watch out for after you went home?

20. Were you told when you could resume normal activities (like going bach to work or driving a car)?

21. Did someone explain the purpose of and potencial side effects of any medicines you were to take at home in a way you could understand?

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References 

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PII: S1078-5884(03)70185-3

doi:10.1053/ejvs.2002.1788

European Journal of Vascular & Endovascular Surgery
Volume 25, Issue 1 , Pages 48-52, January 2003

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