Satisfaction with Medical Care: A Review of the Field (1991)

J. Hughes


© 1991


The Importance of Patient Satisfaction

Satisfied patients are less likely to disenroll from health plans, more likely to return to a physician or hospital (Ware and Hays, 1988; Weiss and Senf, 1990; Steiber and Krowinski, 1990), and less likely to bring a malpractice suit. The kinds of medical care that patients find satisfying also tends to make them more compliant with their treatment regimes, and thereby produce better clinical outcomes (Greenfield, 1985; Kaplan et al., 1989; Hauck, 1990). Satisfied patients also tend to improve the quality of the work experience for providers, reducing staff turnover and burnout (cite).

Measuring and Managing Satisfaction

High Satisfaction, Little Variance

Most patients are satisfied with their personal physician and hospital care, even though Americans' satisfaction with their doctors and health care in general is the lowest in the industrialized world (Blendon 1989, 1990). The generally high satisfaction with personal experiences of care, however, has introduced some difficulty in interpreting surveys (Fitzpatrick and Hopkins, 1983; Steiber, 1988). For instance, if satisfaction with physician care is above 95% in a hospital, and recedes into the background as a constant, physician care may not appear to predict any of the overall satisfaction, while it would be the most important variable in a setting that had more variance in physician quality. The gradual accumulation of studies over the last two decades, however, has begun to provide adequate variance in the predictors of satisfaction.

Incompleteness of Most Surveys

Surveyors interested in the doctor-patient relationship have tended to find that the quality of doctor care was the most important predictor of patient satisfaction. Hospital managers, on the other hand, who had little control over doctors' behavior, and therefore focused less attention on the doctor-patient relationship, have found that nurse and staff behavior, food quality, and even cleanliness of the rooms were the important predictors. Surveys that were interested in segmented marketing tended to find sociodemographic variables predictive of satisfaction, while other surveyors have found that sociodemographic variables are insignificant when controlled for consumer attitudes and organizational characteristics. Again, it is only after decades of meta-analysis that the full picture of satisfaction variables is beginning to emerge.

Poor Operationalization of Surveys

Surveys that asked simply if patients were satisfied with care provided little useful feedback to providers. One trend in recent years has been toward increasing operationalization of patient satisfaction surveys, or at least those conducted by providers. One of the most successful initiatives in making survey results specific enough to inform and change staff behavior has been mounted by the Picker Commonwealth Fund. For several years the Picker group has been working with hospital marketing and quality assurance personnel to refine survey instruments to measure ten aspects of "patient-centered" care, reviewed below under "Interpersonal Aspects of Care." Most recently the Picker group fielded their survey to a sample of 6455 patients of 62 hospitals across the country, and in 1992 will be coordinating the use of a common satisfaction instrument by academic hospitals.

Predictors of Satisfaction

Patient Characteristics

Sociodemographic Variables

Sociodemographic variables are related both to the kinds of health care experiences that patients have, and to the way that they interpret them. For instance, better educated patients may participate in diagnosis and treatment decisions more than less educated patients, but remain less satisfied with their degree of participation because physicians are not meeting their higher expectations. Consequently it is often difficult to interpret findings of relationships between sociodemographics and satisfaction.

Secondly, most research is now finding that the sociodemographics contribute little to predicting satisfaction if one controls for the aspects of care, such as access to a regular source of care, or the attitudes, such as desire for participation, which the sociodemographics are correlated with.

Age Generally, older people are more satisfied with medical care (Ware et al., 1978; Pope, 1978; Gray, 1980; DiMatteo and Hays, 1980). This is probably due to their greater continuity of doctor-patient relationships, and their lower expectations about patient involvement in care.

Gender Most studies find that gender is not related to satisfaction (Doyle and Ware, 1977; Greenley and Schoenherr, 1981; Pope, 1978; Gray, 1980). Some report higher satisfaction among women however (Shortell et al., 1977; Lieberman et al., 1989).

Race Some studies find whites more satisfied, some blacks, and some find no difference.

Education Again, some studies find the better educated more satisfied, some less, and some find no difference.

Income Poor people have poorer health, get poorer health care, have less continuous relations with doctors, and have harder times getting appointments. They are also treated differently from privately insured patients to some degree. Consequently, they tend to be less satisfied (Patrick et al., 1983; Hulka et al., 1975; Chaska et al., 1985; Calnan, 1988).

Attitudes and Expectations

Health Status Evaluation The sicker people are, the less satisfied they tend to be with their health care (Tessler and Mechanic, 1975; Pope, 1978; Chaska et al., 1980; Lochman, 1983; Hall et al, 1990).

Life Satisfaction People who are generally happier with their life tend to be more satisfied with their health care, though the reverse is also true (Weiss, 1988).

Confidence in the Medical Community People who have a better opinion of American health care are more satisfied with their own care, though again the reverse is also true (Weiss, 1988).

Organization of Care

The most consistent finding of satisfaction research is that the provider and organizational characteristics which result in more "personal" care and better communication are associated with higher levels of satisfaction (Cleary and McNeil, 1988).

Doctors, Nurses, Staff

Satisfaction with ambulatory care has largely to do with satisfaction with one's physician, while satisfaction with the inpatient experience has more to do with the quality of the staff (Hall and Dornan, 1988). With the physician, satisfaction breaks down into two aspects, (a) satisfaction with perceived technical competence and (b) satisfaction with interpersonal skills. In evaluating nurses and other staff, however, patients place much more emphasis of the interpersonal aspects than on perceptions of technical competence.

Continuity of Care

People like to stay with "their" doctors once they find one they like, and having a continuous doctor-patient relationship is a strong predictor of overall satisfaction (Linn, 1975, 1985; Hulka et al, 1975; Weinberger et al., 1981; Lochman, 1983; Weiss and Ramsey, 1989). Prior doctor-patient relationships are the major predictors of enrollment in managed care, and the disruption of provider relationships is a major cause of disenrollment (Mechanic et al. 1983, 1990).

Waiting

People don't like to wait for an appointment, and they don't like to wait in the waiting room when they show up for an appointment (Dolinsky and Caputo, 1990).

Convenience

Patients like to be able to park close to the facility, walk in through a safe neighborhood, and then find the appropriate room easily (Lochman, 1983).

Billing

People dislike out-of-pocket costs, co-payments and deductibles, particularly if they have to pay at the site of care (Dolinsky and Caputo, 1990). When they have questions, they like to have someone available to explain procedures to them until they understand. In factor analysis, satisfaction with insurance provider tends to be a very independent dimension from satisfaction with providers, contributing little to overall satisfaction (Singh, 1990).

Inpatient Aspects

Visitation Policies Patients generally like to have their relatives and friends have easy access to them, and to be communicated with by physicians and staff about the care of the patient. Food Service, Cleanliness, and Room Appearance Patients like good food and clean, attractive rooms without many other annoying patients in them. Admissions, Discharge and Billing Staff Patients like to be treated courteously and promptly at admission, discharge and when they have questions about billing. They like physicians, nurses and staff to wear clean, "gender-appropriate" clothing. If they have to wait for a room they like to know why, and how long it will take. When they are being discharged they like their doctor or other staff to explain what they should do to facilitate their recovery, and to assist them in overcoming home care difficulties. In the emergency room, they like being promptly attended to, and having staff frequently explain how long they still need to wait.

Interpersonal Aspects of Care

People like to have doctors talk to them in an egalitarian way, listen, ask a lot of questions, answer a lot of questions, explain things in a simple way that the patient can understand, and allow patients to make decisions about their care (Lochman, 1983; DiMatteo, 1980; Hall et al., 1988; Roter et al. 1987, 1988, 1989; Bertakis et al., 1991). Lengthening consultation time is the easiest and most direct variable shown to improve the interpersonal communication of providers and patients.

With nurses and staff, promptness and friendliness are the main determinants of patient satisfaction (Abramowitz, 1987).

The Picker Commonwealth surveys of patient satisfaction are probably the most specific about the subcomponents of quality interpersonal care:

1) patient involvement in decision-making;

2) patient education about condition and treatment;

3) support for and involvement of family members;

4) communication between patients and health professionals;

5) emotional support for patients;

6) timely attention to physical needs, such as going to the bathroom;

7) prompt, appropriate pain relief;

8) adequate financial information and counseling;

9) information regarding surgical procedures, pre- and post-operative;

10) preparation for discharge and post-discharge care.

Technical Quality of Care

To some extent there is a trade-off, among physicians and between physicians and paraprofessionals, between technical quality and interpersonal "humanism." General practitioners tend to score more highly than specialists on interpersonal aspects of care, while supposedly being less technically competent (though there are few studies of the clinical consequences of greater or lesser use of specialists).

Similarly, nurses, midwives and physician assistants tend to score highly on interaction with patients, though they are perceived to be less skilled. Interestingly almost all studies of using physician assistants for diagnosis and patient education in place of physicians show that they perform just as well as, or better than, physicians, in diagnostic accuracy and patient satisfaction (US OTA, 1986; Hall et al, 1990).

Of course, patients' perceptions of actual competence is only weakly related to actual competence. Patients are less satisfied if doctors display any uncertainty (Johnson et al, 1988) and presumably even the most competent doctors are occasionally uncertain. Patient satisfaction is also strongly predicted by ability or inability to see a specialists when consumers feel they need to see specialists (Dolinsky and Caputo, 1990).

Appendix

The following tables are based on a sample of 1600 outpatients and 700 inpatients of the University of Chicago, drawn from those who passed through the hospital in January 1991. According to the Picker Commonwealth sample of 1990, the University of Chicago has one of the highest rates of patient satisfaction in the country, so the findings are subject to the cautions about small variance noted above.

These two models of inpatient and outpatient satisfaction are suggestive of the variables that are generally found to predict overall satisfaction and the decision to return. The questions below were found to be the most predictive of four or five times as many questions in the surveys.


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