Published online before print October 20, 2008, doi: 10.1161/CIRCULATIONAHA.108.792713
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(Circulation. 2008;118:1938-1945.)
© 2008 American Heart Association, Inc.
Health Services and Outcomes Research |
Patient Satisfaction and Its Relationship With Quality and Outcomes of Care After Acute Myocardial Infarction
From the Institute for Clinical Evaluative Sciences (D.S.L., J.V.T., A.C., D.A.A.), Division of Cardiology, University Health Network (D.S.L.), Division of Cardiology, Sunnybrook Health Sciences Centre (J.V.T.), and Division of Cardiology, St Michael’s Hospital (D.A.A.), University of Toronto, Toronto, Canada.
Reprint requests to David A. Alter, MD, PhD, Senior Scientist, Institute for Clinical Evaluative Sciences, Room G-106, 2075 Bayview Ave, Toronto, Ontario M4N 3M5, Canada. E-mail david.alter{at}ices.on.ca
Received May 16, 2008; accepted September 8, 2008.
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Abstract |
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Background— Patient satisfaction is a widely used measurement for the evaluation of medical care. We examined the extent to which quality of care received after acute myocardial infarction predicted subsequent patient satisfaction with care and whether patient satisfaction itself was associated with long-term survival after acute myocardial infarction.
Methods and Results— In a longitudinal cohort of acute myocardial infarction, we examined the associations of patient-reported satisfaction with care with clinical characteristics, physical and psychological function measures, quality indicators of myocardial infarction care, and outcomes. Among 1933 eligible patients (mean age 62.9±12.8 years, 70.5% men), 1866 survey respondents were analyzed. Of the study cohort, 1711 (91.7%) reported that they were satisfied with their overall care. Patients who reported satisfaction with care were older (mean age 63.1±12.7 versus 60.1±13.3 years, P=0.005), had improved physical function, and were less likely to be depressed. Better physical function, measured by the Specific Activity Scale, predicted higher satisfaction, with an OR of 1.75 (95% CI 1.17 to 2.68, P=0.008) for intermediate versus poor function and 2.96 (1.39 to 7.34, P=0.009) for high versus poor function, after adjustment for age, sex, income tertile, and ethnicity. Depression was the major predictor of dissatisfaction with overall care, with an OR of 0.44 (95% CI 0.29 to 0.67, P<0.001). Quality indicators for myocardial infarction care and clinical outcomes were not associated with patient satisfaction.
Conclusions— Satisfaction with care was more likely in patients who were older, in those without depression, and in those with better functional capacity, but it was not associated with the quality of myocardial infarction care or survival.
Key Words: myocardial infarction • patient satisfaction • health status • quality of health care • outcomes
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Introduction |
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Patient satisfaction is a complex multidimensional construct that likely involves comparing one’s healthcare experiences against one’s own subjective standards. Accordingly, one might hypothesize that care satisfaction is more influenced by patient-related sociocultural, psychosocial, and disease-related characteristics than by objective quality indicators of care.1 Nonetheless, patient satisfaction scales are being used with increasing frequency in the evaluation of medical care worldwide.2–4 Indeed, recent studies have used patient satisfaction surveys as the primary metric for assessing the quality of care in the hospital setting5 and in international comparisons.6 Although patient satisfaction is advocated widely to motivate changes in healthcare systems,7 there is a paucity of evidence associating patient satisfaction with objectively measured indicators of care quality or improved outcomes.
Clinical Perspective p 1945
The aim of the present study was to examine the extent to which patient satisfaction is associated with objective measures of quality and outcomes of care among survivors of acute myocardial infarction (AMI). AMI provides a useful test case to examine for 2 reasons: First, AMI has a well-characterized and delineated natural history, which allows for the incorporation of well-validated measures of prognosis and both psychosocial and sociocultural factors, all of which may influence satisfaction perceptions; second, quality indicators have been well established among the AMI population, thereby providing objective benchmarks by which patient satisfaction can be compared.
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Methods |
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Data Sources
The present study examined data collected in the Socio-Economic Status and Acute Myocardial Infarction (SESAMI) study, a prospective observational study of patients hospitalized for AMI in Ontario, Canada.8,9 The study cohort of 2848 patients participated in a telephone survey, administered by trained standardized interviewers within 30 days after the index myocardial infarction. All study participants had a baseline survey of cardiac risk factors and socioeconomic profile. The hospital chart during the index myocardial infarction was abstracted in detail for clinical information regarding patient characteristics, treatment, and contraindications to therapy. Clinical and survey data were linked to administrative databases by the patient’s unique, encrypted health card number. These included the Registered Persons Database, which contains vital status information, and the Canadian Institute of Health Information database for hospitalizations that occurred after the index myocardial infarction. With the primary diagnosis coded via the International Classification of Diseases, 9th and 10th editions (ICD-9 and ICD-10), subsequent readmissions for recurrent myocardial infarction (ICD-9 code 410 and ICD-10 codes I21–I23), angina (ICD-9 codes 411, 413, and 414 and ICD-10 codes I20, I24, and I25, excluding I25.5), and heart failure (ICD-9 codes 415, 425, and 428 and ICD-10 codes I25.5, I42, and I50) were identified.
Study Patients
The design of the SESAMI study has been described previously.8–10 Briefly, the study recruited English-speaking patients admitted with AMI in 53 large-volume hospitals (defined as admitting >100 patients with myocardial infarction per year) in Ontario from December 1999 to February 2003. Patients eligible for SESAMI were required to complete a self-administered baseline survey and questionnaires pertaining to functional status and psychosocial well-being (see below). Of 2848 eligible patients who participated in the initial surveys, 1933 consented to the study and to data linkage with administrative databases and had information from their index myocardial infarction hospitalizations abstracted from the chart. Patients who did not respond to the questions that pertained to patient satisfaction (n=67) were excluded, for a final study sample of 1866 patients. All patients participating in the present study gave informed consent, and the study received approval from the University of Toronto research ethics board.
Assessment of Satisfaction With Care, Functional Status, and Psychosocial Well-Being
Data collected from the SESAMI study included a 13-item presurvey questionnaire on risk factors for atherosclerosis and socioeconomic status. Satisfaction with care was determined by telephone-administered questionnaire within 30 days after the index myocardial infarction. The timing of the survey allowed the respondent to reflect on care received during the entire hospitalization episode and early after discharge. In this survey, patients were asked to rate their overall satisfaction with care numerically on an ordinal scale as 1 (very unsatisfied), 2 (unsatisfied), 3 (neutral), 4 (satisfied), or 5 (very satisfied). Patients were categorized as "not satisfied" if they submitted a response of 1, 2, or 3, or "satisfied" if they responded with a rating >3. The rating scale for patient satisfaction was structured to emulate global scores for satisfaction that are commonly used.11,12 Patients were also asked to rate on a 5-point scale their satisfaction with (1) ability to see a specialist, (2) ability to access emergency care, and (3) the skill, caring, and concern provided by their physician(s) in the past 4 weeks.
We assessed physical health and functional status using the Duke Activity Status Index (DASI) questionnaire,13 the Specific Activity Scale of Goldman et al,14 the Katz activities of daily living index,15 the Canadian Cardiovascular Society angina class, and the physical domain of the SF-12 health survey.16 Maximal oxygen consumption (
O) was calculated from the DASI score with a validated equation and was categorized on the basis of the percent predicted for age and sex as low (<60% predicted), fair (60% to 73% predicted), and average or good (
74% predicted), as described previously.17 Severity of the AMI episode was assessed with the Global Registry of Acute Coronary Events (GRACE) prognostic index.18 Psychosocial status was determined with questions obtained from the following validated instruments: (1) Brief Carroll Depression Rating Scale, a validated index for depression with sensitivity of 92% and specificity of 89%;19 (2) SF-12 mental component;16 and (3) Duke psychological well-being score.20
Quality Indicators of Myocardial Infarction Care
In-hospital care was assessed with 8 core quality indicators, which included 4 core pharmacological measures in ideal candidates and all patients: aspirin, β-adrenoceptor antagonist, angiotensin-converting enzyme inhibitor, and hydroxymethylglutaryl coenzyme A (HMG-CoA) reductase inhibitor prescriptions at hospital discharge. Ideal patients were those who were eligible for therapy and had no contraindications, as defined previously.21 The core measures also included 4 follow-up indicators: referral to cardiologist, referral to general internist, follow-up with family physician, and referral for cardiac rehabilitation. We also assessed use of invasive procedures (eg, cardiac catheterization, percutaneous coronary intervention, or coronary artery bypass surgery) and prescription of clopidogrel as additional quality indicators. All quality indicators temporally pertained to experiences received before the assessment of patient satisfaction.
Clinical Outcome Events
We examined mortality and the composite end point of recurrent myocardial infarction, angina, heart failure, or death that occurred after hospital discharge by searching for hospital admissions and vital status in the Canadian Institute for Health Information and Registered Persons Databases.
Sensitivity Analyses
We further explored specific facets of patient satisfaction: access to emergency care and specialist physicians and the perceived care provided by their physician. These sensitivity analyses were conducted with an approach similar to the main analyses of global patient satisfaction.
Statistical Analysis
A bivariate analysis was performed for potential covariate associations of patient satisfaction with sociodemographic status, physical health status, psychosocial distress, quality indicators, and outcomes. Age was examined continuously and categorically (
49, 50 to 64, 65 to 74, and 75 years), and household income was categorized into tertiles. Quality indicators were categorized as binary (eg, measure performed, yes/no) and ordinal (eg, number of quality indicators performed) variables. Continuous variables were compared with the Student t test and categorical variables with the 
2 statistic. A 2-sided probability value <0.05 was considered statistically significant.
The primary analyses examined satisfaction versus nonsatisfaction as the response variable. We examined predictors of patient satisfaction in sequential fashion using multiple logistic regression models, constructed hierarchically with the following covariates: (1) demographic characteristics (eg, age, gender, socioeconomic status, and ethnicity); (2) demographic characteristics and physical measures (eg, Specific Activity Scale, SF-12 physical component, and GRACE score); (3) demographics, physical measures, and psychosocial distress (eg, Duke psychological well-being score, SF-12 mental component); and (4) all variables listed above plus quality indicators of myocardial infarction care received before the assessment of patient satisfaction. For parsimony, only demographic variables and covariates with P<0.05 were retained. All logistic regression models were determined to have good model fit with the Hosmer-Lemeshow statistic. In secondary analyses, we examined whether patient satisfaction was a predictor of survival using Cox proportional hazards regression models, adjusting for age, sex, comorbidities, and GRACE score. The proportionality of hazards assumption was confirmed. All analyses were performed with SAS version 9.1.3 (Cary, NC).
The authors had full access to and take full responsibility for the integrity of the data. All authors have read and agree to the manuscript as written.
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Results |
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Patient Sample
Among 2848 patients initially approached in the SESAMI study, 310 (10.9%) refused to participate in the survey, 544 (19.1%) could not be contacted, and 61 (2.1%) died after myocardial infarction. Of the 1933 patients (67.9%) who agreed to survey participation, 1866 completed all surveys and consented to linkage with administrative databases. The mean age of participants was 63±13 years, and they were predominantly male (n=1317, 71%) and white (n=1569, 84%). Survey nonparticipants were older, of lower socioeconomic status, and had marginally more comorbid conditions than participants (Table 1).
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Association Between Demographic/Physical Characteristics and Satisfaction With Care
The demographic and clinical characteristics of participants are shown according to satisfaction status in Table 2. Patients who were satisfied with their care were older and less likely to be university or college educated. Those who were satisfied were also more likely to have better functional status than those not satisfied. Specifically, patients who were satisfied had higher DASI scores, higher maximal oxygen consumption, and better Canadian Cardiovascular Society functional class than those who were not satisfied with care (Table 2). In addition, patients with a Katz Index greater than the median value (eg, more independence in activities of daily living) were more frequently satisfied with the care they received (satisfied versus nonsatisfied, 51.5% versus 42.0%; P=0.03). Those with poor functional status on the Specific Activity Scale (eg, class 3; inability to perform activities requiring >4 metabolic equivalents) more frequently reported lack of satisfaction with care (67.7% versus 54.2%; P=0.001; Table 2).
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Association Between Psychosocial Characteristics and Satisfaction With Care
Patients who were unsatisfied had higher Carroll depression scores than those who were satisfied (3.1±2.3 versus 1.9±1.9) and more frequently scored in the depressed range (26.5% versus 11.3%, P<0.001). Patients who were not satisfied with care scored lower on the emotional and mood domains of the SF-12, with a mean score of 16.2±3.9 versus 18.0±3.6 (P<0.001). The mean Duke psychological well-being score was also higher among those who were satisfied with their care (30.5±6.2 versus 26.5±6.8, P<0.001); more patients who were not satisfied had Duke scores in the depressed range than those who were satisfied with their care (Table 2; P<0.001).
Association Between Quality Indicators and Satisfaction With Care
Compliance rates for quality indicators are shown in Table 3 for all study patients and for ideal candidates (eg, those who were eligible for treatment, with no contraindications). There were also no differences in the rates of other nonpharmacological indicators, including revascularization procedures and postdischarge management, between those who were and were not satisfied with the care received. Moreover, there were no significant differences in the composite quality indicators (eg, the total number of pharmacological and postdischarge quality indicators) of AMI care across satisfaction categories (Table 3).
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Association Between Satisfaction With Care and Outcomes
Survival curves according to satisfaction with care status are shown in Figure 1. Survival free of recurrent myocardial infarction, angina, and heart failure is shown in Figure 2. The unadjusted hazard ratio for mortality was 0.95 (95% CI 0.64 to 1.42), and for composite events, it was 0.95 (95% CI 0.75 to 1.20). There was no significant difference in the GRACE mortality prediction score among those who were (mean score 113±29) or were not (109±30) satisfied with care received (P=0.10). The hazard ratio for death after adjustment for age, sex, comorbidities, and GRACE score was 1.10 (95% CI 0.69 to 1.77), and the adjusted hazard ratio for the composite outcome was 1.03 (95% CI 0.79 to 1.34).
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Multivariable Predictors of Global Patient Satisfaction
Although patients 65 years of age were more likely to be satisfied with their care than those <50 years of age, other sociodemographic characteristics, including income tertile, sex, and ethnicity, were not associated with care satisfaction (Table 4). Notably, patients with high (Specific Activity Scale class 1) and intermediate (class 2) functional status were 3-fold and 1.7-fold more likely to be satisfied with their care, respectively, than those in the lowest category (class 3). A Carroll score in the depressed range (>4) correlated modestly with worse Specific Activity Scale functional class (Spearman r=0.23, P<0.001). Thus, in multivariable analysis, depressed-range Carroll score was a predictor of dissatisfaction with overall care (Table 4). The results were consistent when satisfaction scores were analyzed as continuous covariates.
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In contrast to patient characteristics, processes of care were not associated with satisfaction. The 8 core AMI quality indicators, which included prescription of aspirin, β-blockers, angiotensin-converting enzyme inhibitor, and HMG-CoA reductase inhibitor and referral to a cardiologist, general internist, family physician, or cardiac rehabilitation, were not associated with care satisfaction. An expanded list of quality indicators that included the 8 core and 4 additional measures (eg, clopidogrel prescription, cardiac catheterization, percutaneous coronary intervention, and CABG surgery) was also not associated with care satisfaction.
Sensitivity Analyses
When we examined specific aspects of care received, findings were concordant with the adjusted multivariable models for overall care satisfaction. The major predictor of dissatisfaction with emergency department access and care was a low Duke psychological well-being score. The OR for satisfaction with emergency department care among depressed patients was 0.47 (95% CI 0.29 to 0.76; P=0.002) compared with nondepressed patients. Compared with younger patients (<50 years), older patients were more likely to be satisfied with emergency department care, with ORs of 1.91 (95% CI 1.09 to 3.34, P=0.02), 1.66 (95% CI 0.92 to 3.02, P=0.09), and 2.05 (95% CI 1.03 to 4.19, P=0.04) in patients 50 to 64, 65 to 74, and 75 years old, respectively. Those at increased mortality risk with higher GRACE scores (>113) were more satisfied with their access to specialists, with an OR of 1.62 (95% CI 1.12 to 2.37, P=0.01). In contrast, a depressed-range Carroll score predicted reduced satisfaction with specialist access, with an OR of 0.55 (95% CI 0.37 to 0.81, P=0.002). Depressed patients were also less likely to be satisfied with the skill, caring, and concern demonstrated by physicians, with an OR of 0.38 (95% CI 0.25 to 0.60, P<0.001). However, older patients were more satisfied with physician care than those <50 years of age, with ORs of 1.85 (95% CI 1.13 to 3.05, P=0.02) and 1.87 (95% CI 1.08 to 3.30, P=0.03) for those 65 to 74 years old and 75 years old, respectively. Provision of care concordant with quality indicators (eg, number of myocardial infarction quality indicators and provision of any quality indicator) was not significantly associated with any of the above aspects of patient satisfaction.
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Discussion |
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Among survivors of AMI, we determined that patient satisfaction was associated with neither quality of care nor survival. In contrast, intrinsic characteristics, such as age, higher functional capacity, and psychosocial well-being, were predictive of greater patient satisfaction after AMI. Thus, the present study suggests that patients without depression and with better physical function are more likely to report being satisfied with their care.
Satisfaction with health care is being used with increasing frequency as a metric in medical care. Indeed, a recent search of the peer-reviewed literature demonstrated an 86-fold proliferation of articles with the coexisting key words "satisfaction" and "health care." The growth in publications of healthcare satisfaction was 23-fold higher than the proliferation of all published articles identified solely by the key word "health care" alone.
Consistent findings demonstrating no association between patient satisfaction and care quality have been reported. In such studies, satisfaction ratings were associated with better physician-patient communication22 but not the technical quality of care provided.23 Similarly, others have determined that process delays, poor disease awareness, reduced functional status, and depression were associated with reduced patient satisfaction.24,25
Contrasting studies support the assertion that patient satisfaction provides unique insights into consumer preferences that may be important for third-party payer-providers in the selection and marketability of health plans.26 Moreover, dissatisfaction with care has been found to be associated with patient complaints and malpractice litigation,27 as well as reduced willingness to return to the institution for care.28
Some may criticize the present study results on the basis that the satisfaction ratings for most participants were high, because a normalized distribution of responses could yield potential comparisons between the extremes. However, the present findings are consistent with most satisfaction studies, in which the distribution of scores is often heavily skewed toward the "higher ends of the satisfaction ratings scale."12 Indeed, the majority of satisfaction studies have demonstrated prevalence rates exceeding 80% for those who acknowledge being "satisfied" or "highly satisfied" with the care that they received.
Unlike other studies that have evaluated few dimensions of multiple conditions simultaneously, the present study was a detailed analysis of a single disease-specific cohort whose prognosis and clinical characteristics were well delineated. Moreover, the present study captured detailed functional status, prognostic, and psychosocial factors, which are all potential determinants of both patient satisfaction and outcomes. We also compared care satisfaction with well-established quality indicators that served as objective benchmarks. Finally, although studies have undertaken ecological analyses that have correlated institutional satisfaction ratings with severity-adjusted hospital mortality rates,29 the present study is the first to explore the relationship between patient satisfaction and downstream patient-level outcomes, incorporating detailed clinical and psychosocial factors by use of rigorous and widely validated risk-adjustment methodology.
The reasons for the lack of a relationship between care quality and patient satisfaction observed in the present study are likely multifactorial but may be attributable to differences in treatment expectations between patients and healthcare providers.30 A large study of Medicare beneficiaries found that patients in regions with higher levels of health spending for conditions including AMI did not report greater satisfaction with care.31 Physicians may expect that higher quality of care and better outcomes would be associated with greater patient satisfaction, but patients report higher satisfaction with care if functional capability is preserved relative to their expectations based on age and premorbid level of function. Enhanced physician-patient communication may be associated with improved patient satisfaction by reducing the disconnect between physician and patient expectations for care. Similarly, the correlation between age and satisfaction may relate to sociocultural differences in psychosocial well-being or patient expectations, which may vary systematically between the young and old.32
The present study has important implications for health services researchers, healthcare providers, senior administrators, and policy makers alike. Our findings suggest that patient satisfaction ratings after AMI may fallaciously be considered to be a reflection of higher quality of care. The absence of a relationship between care-satisfaction ratings and quality underscores the limitations in actionability and accountability associated with satisfaction measures. Despite their increasing use, physicians have found satisfaction ratings to be of limited value in improving patient care or management practices.33 Future evaluations that examine patient satisfaction ratings as an outcome event of interest should be undertaken with caution and will need to account for patients’ physical and psychological characteristics.
There are several notable limitations of the present study. The surveys were administered in English and thus may have excluded patients who were disadvantaged by a language barrier. Additionally, there were differences in those who did or did not participate in the study, with more elderly patients of lower socioeconomic status among the nonparticipants. However, socioeconomic measures were not significant predictors of care satisfaction in multivariable analysis, and the study did include a broad age range of patients. The primary outcome evaluated in the present study was the broad entity of global satisfaction with care; however, we found that specific subdimensions of the overall measure were consistent in the disassociation with quality indicators in sensitivity analyses. The present study examined satisfaction early after a myocardial infarction and not chronic coronary disease, in which resurgence of anginal symptoms may have more of an impact on the proclivity to worsening satisfaction with treatment.34 Finally, the present study was limited to patients with myocardial infarction, and similar analyses should be considered for other chronic diseases.
In conclusion, patient satisfaction with care was not associated with objective assessments of quality of care or clinical outcome events among patients with AMI. In contrast, intrinsic patient characteristics, such as higher functional status, increasing age, and the absence of depression, were strongly and positively associated with patient-care satisfaction. Although patient-reported satisfaction may shed light on consumer perceptions, the present study demonstrates that inferences between patient satisfaction and quality of care may give way to misleading conclusions and should be discouraged.
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Acknowledgments |
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Sources of Funding
This study was funded by grants from the Heart and Stroke Foundation and the Canadian Institutes of Health Research, as well as a Canadian Institutes of Health Research Team Grant in Cardiovascular Outcomes Research. Dr Lee is a clinician-scientist of the Canadian Institutes of Health Research. Dr Tu is a Canada Research Chair in Health Services Research and a career investigator of the Heart and Stroke Foundation of Ontario. Dr Alter is a career investigator of the Heart and Stroke Foundation of Ontario.
Disclosures
Dr Alter serves as a consultant/advisory board member to INTERxVENT Canada (PrevCan). The remaining authors report no conflicts. The Institute for Clinical Evaluative Sciences (ICES) is supported in part by a grant from the Ontario Ministry of Health and Long Term Care. The opinions, results, and conclusions are those of the authors, and no endorsement by the Ministry of Health and Long-Term Care or the Institute for Clinical Evaluative Sciences is intended or should be inferred.
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Related Article:
CLINICAL PERSPECTIVE
Satisfaction with care has been widely used as a metric of the quality of care experienced by patients; however, the factors that predict satisfaction with care are largely unknown. Specifically, it is unknown whether higher quality of care is associated with patient satisfaction or whether satisfaction with care portends improved survival. We examined correlates of satisfaction with care reported by patients after an acute myocardial infarction. Patient satisfaction was higher among those individuals who had better functional capacity and fewer depressive symptoms after acute myocardial infarction, after adjustment for all other baseline factors. Older patients were also more likely to report satisfaction with care than younger counterparts; however, patient satisfaction was not associated with better quality of acute myocardial infarction care, as measured with standard performance indicators (ie, the use of evidence-based pharmacological therapy, the receipt of interventions, and the timeliness to postdischarge follow-up primary and specialty care). Furthermore, satisfaction with care was not associated with improved overall or event-free survival. The present results were consistent for satisfaction with specific aspects of care, including emergency department care, physician care, and access to care. In conclusion, although patient satisfaction surveys may provide insight into consumer perceptions, such scales neither appropriately reflect the quality of care received during acute myocardial infarction nor the long-term outcomes afterward.
Circulation 2008 118: 1911-1912.
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