Arch Gynecol Obstet DOI 10.1007/s00404-014-3248-y

General Gynecology

Patient satisfaction and willingness to return to the provider among women undergoing gynecological surgery Tonio Schoenfelder · Tom Schaal · Jörg Klewer · Joachim Kugler 

Received: 19 September 2013 / Accepted: 2 April 2014 © Springer-Verlag Berlin Heidelberg 2014

Abstract  Purpose  To identify factors associated with ‘patient satisfaction’ and ‘willingness to return to the provider’ in gynecology and to assess similarities as well as differences between the two concepts. Methods  Study data were obtained from 968 randomly selected gynecology patients discharged from 22 hospitals who responded to a mailed survey. The validated instrument consisted of 37 items and assessed medical and service aspects of care, patient and visit characteristics. The dependent variables consisted of ratings of willingness to return to the provider and overall satisfaction. Bivariate and multivariate techniques were used to reveal relationships between indicators and both dependent variables. Results  The multivariate analyses identified individualized medical care, kindness of medical practitioners, treatment outcome and organization of discharge as the most consistent predictors of the patients’ likelihood to return and overall satisfaction. Differences between both concepts pertained to the significance of service variables

(cleanliness and quality of food) for patient satisfaction and visit-related characteristics (length of stay and occurrence of complications) for willingness to return. Conclusions  Study findings suggest that patient satisfaction and willingness to return to the provider do not reflect the same concepts. Although service aspects such as quality of food influence satisfaction ratings, they do not increase the likelihood that patients choose the same hospital in case of another treatment. Communication between patients and medical practitioners is highly important. Revealed predictors of both concepts are alterable by healthcare professionals and should be focused on to enhance patient satisfaction and to increase the probability patients return to their provider. Keywords  Gynecology · Health services research · Outcome assessments · Patient satisfaction · Quality indicators · Surgery

Background T. Schoenfelder (*) · T. Schaal · J. Kugler  Department of Public Health, Dresden Medical School, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany e-mail: [email protected] T. Schaal e-mail: [email protected] J. Kugler e-mail: [email protected]‑dresden.de J. Klewer  Department of Public Health and Health Care Management, University of Applied Sciences Zwickau, Dr.‑Friedrichs‑Ring 2A, 08056 Zwickau, Germany e-mail: joerg.klewer@fh‑zwickau.de

Patient satisfaction is an important element of the quality of medical care [1]. Prior studies indicate that patient assessments are related to compliance with various aspects of treatment [2, 3] and willingness to continue receiving care [4]. When patients evaluate health services, they provide unique information that is not available from any other source [5]. Their feedback may highlight areas for quality improvement that physicians and other healthcare professionals may not have considered before. Therefore, patient satisfaction is increasingly being seen as an important tool with which to examine the quality of care and to evaluate the performance of individual physicians, hospitals and health plans [4, 6].

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Factors affecting patient perceptions of received care are diverse. Studies found that demographic data and visit characteristics such as age, type of admission and length of stay are influential aspects [7, 8]. Findings, however, are inconsistent and ambiguous regarding the magnitude and direction of the factors. This can be partially attributed to health system differences and the limited number of studies involving patients from multiple institutions [6, 9]. Predictors of satisfaction also vary according to setting. For example, while a study analyzing a sample of women admitted for labor and delivery showed that associations between demographic characteristics and patient assessments were relatively small [6], other research demonstrated that patients’ age was the strongest determinant of satisfaction in a medical and surgical setting [8]. These inconsistencies imply that other study findings regarding patient satisfaction might not be fully generalizable to gynecology. However, understanding which aspects of the hospitalization contribute the most to increase satisfaction can be essential to improve the overall quality of care. Therefore, the current analysis was conducted to identify factors associated with satisfaction among gynecology patients and to indicate the intensity of this relationship. In a competitive market environment with many choices for patients, it is important for healthcare providers that patients return when they need care again. An association between satisfaction levels and patient loyalty appears to be logical and has been shown in other branches [10]. Although the healthcare market should be no exception, prior research implies that patient satisfaction and patient loyalty are different concepts that do not measure exactly the same [11, 12] and should be analyzed separately. Therefore, another study objective was to investigate patient satisfaction and willingness to return independently to compare similarities and differences.

Arch Gynecol Obstet

The data set was obtained through a self-administered, post-visit questionnaire. Surveys were accompanied by a cover letter informing the participants about the purpose, voluntary nature, and anonymity of the study and their consent to participation when sending back the questionnaire. This study has been performed in accordance with the ethical standards laid down in the Declaration of Helsinki. The overall survey response rate was 25.3 % with 979 of 3,865 patients responding. Subjects were excluded if they failed to answer more than 25 % of all items and did not answer the question concerning overall satisfaction. In total, data of 968 respondents were analyzed. Patient satisfaction and visit characteristics were assessed using a survey comprising of 37 items that covers domains which have been shown to be important components of satisfaction in prior research [13]. The instrument’s reliability was determined in 8,428 patients discharged from 39 hospitals [14]. Patient satisfaction ratings were assessed using 15 items on a six-point qualitative response classification ranging from ‘excellent’ to ‘very poor.’ Internal consistency of the scales in the study sample was acceptable. Cronbach’s alpha values for the dimensions ‘medical care’ and ‘performance of services’ were 0.91 and 0.72, respectively. The patients were also asked to rate their overall satisfaction with the hospital stay using the same six response categories. One question concerned the patients’ intention to return to the same hospital (‘yes,’ ‘no’ and ‘do not know’). Additional data collected included patients’ age (grouped in eight categories: 15–20, 21–30, 31–40, 41– 50, 51–60, 61–70, 71–80, 80+), perceived length of stay (LOS), source of admission, number of prior hospital stays and complications after discharge (in terms of pain, physical complaints or infections) (Table 1). Statistical analysis

Methods Setting, population and data collection The study population consisted of randomly selected women who underwent a gynecological operation (uterus, fallopian tube and ovary) aged 15 years and older who were discharged in 2010 from 22 hospitals of a metropolitan area in Germany with a total population of approximately 1.65 million (2010). Survey participants were policy holders of statutory health insurances that cover about 85 % of the area’s total population. To ensure that all participants receive an identical questionnaire and to avoid a selection of, for example, extremely critical patients, health insurances were used as source of contact instead of hospitals, which rendered the services.

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The level of significance was set at P  ≤ 0.05 throughout the study. For data analyses, the highest ratings were coded with ‘6’ and the lowest with ‘1’. Descriptive statistics and frequencies were computed. Bivariate and multivariate techniques were used to reveal relationships between assessed variables. SPSS 20.0 for Windows was used for all calculations. Bivariate analyses The distribution of the satisfaction scores was skewed toward higher satisfaction, which is why nonparametric tests were performed. Mann–Whitney U tests were used for all variables measuring patient assessments of received services. For that purpose, variables were dichotomized: ratings of ‘excellent’ and ‘good’ were considered satisfied,

Arch Gynecol Obstet Table 1  Sample baseline characteristics (n = 968)

Multivariate analyses

Age

N (%)

15–20 21–30 31–40 41–50 51–60 61–70 71–80 80+ Missing

6 (0.6) 55 (5.7) 88 (9.1) 205 (21.2) 167 (17.3) 197 (20.4) 189 (19.5) 59 (6.1) 2 (0.2)

Quantity of hospitalizations within the prior 5 years

N (%)

0 1–2 3–5 >5 Missing

23 (2.4) 602 (62.2) 284 (29.3) 54 (5.6) 5 (0.5)

Source of admission

N (%)

Specialist General practitioner Emergency Self-admission Transfer from another clinic Missing

785 (81.1) 109 (11.3) 26 (2.7) 11 (1.1) 3 (0.3) 34 (3.5)

Length of stay

N (%)

Too short Appropriate

109 (11.3) 726 (75.0)

Too long Do not know Missing

31 (3.2) 87 (9.0) 15 (1.5)

Only variables significant in bivariate analyses were used for multivariate analyses. The bivariate screening was performed due to the limited sample size. Two separate stepwise backward logistic regressions were performed to identify factors that predict higher overall satisfaction and the patient’s willingness to return for care. Patients’ overall satisfaction ratings were dichotomized into ‘excellent/ good’ versus ‘fair/acceptable/poor/very poor’, and willingness to return was dichotomized into ‘yes’ versus ‘no/ do not know’. For the purpose of the logistic regression, missing data of the satisfaction variables were substituted with the average rating of the respective item in the questionnaire in order to have the largest possible set of data. Subjects were excluded from the analysis if they did not provide data regarding overall satisfaction and willingness to return.

Results Characteristics of the sample Most of the patients were aged 41–50; individuals aged 15–30 and 80+ comprised the smallest groups of the study sample (Table 1). Approximately 62.2 % of all patients reported 1–2 hospitalizations, about 29.3 % were hospitalized 3–5 times, and 5.6 % more than 5 times. About 81 % of all women were admitted by specialists, approximately 11.3 % were sent to the hospital by their general practitioner, and 2.7 % because of emergency. The majority of the sample (75 %) assessed length of stay to be appropriate, about 11.3 % assessed their hospital stay to be too short, 3.2 % to be too long, and approximately 9.0 % could not judge. A minority of 12.0 % reported post-discharge complications.

Complications after discharge

N (%)

Yes No Missing

116 (12.0) 837 (86.5) 15 (1.5)

Intention to return to the hospital

N (%)

Satisfaction ratings

Yes No Do not know

839 (86.7) 36 (3.7) 85 (8.8)

About 86.7 % of all patients would use the facility again in case of another hospitalization, 3.7 % would prefer another provider, and 8.8 % could not decide (Table 1). Approximately 88 % of the study population rated their hospital stay related to all performed services either ‘excellent’ or ‘good’, resulting in a satisfaction score of 5.27 (grouped median). The lowest scores related to discharge procedures and instructions (5.05) and quality of food (5.08). Patients were most satisfied with kindness of nurses and medical practitioners (5.56), as well as received information about the undergoing operation (5.54) and anesthesia (5.51).

Missing

8 (0.8)

whereas ratings of ‘fair’ to ‘very poor’ were considered dissatisfied. General associations between overall satisfaction/ patients’ willingness to return and visit and patient characteristics were investigated with χ2 tests, Fisher’s exact test, in case cell counts were small, and Kruskal–Wallis tests.

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Arch Gynecol Obstet

Table 2  Relationship between performance of care measures and patients’ overall satisfaction and willingness to return (grouped median) Item*

Overall satisfaction

Willingness to return

Satisfied patientsa

Dissatisfied patientsb

Likely

Unlikelyc

Organization of admitting procedure Medical practitioner’s knowledge of patient anamnesis and pathogenesis Clear reply of inquiries by medical practitioners Individualized medical care Clear information about undergoing operations Clear information about anesthesia Clear information about medication Organization of procedures and operations Discharge procedures and instructions Treatment outcome Kindness of the nurses Kindness of the medical practitioners Accommodation Cleanliness

5.48 5.36 5.46 5.38 5.62 5.57 5.25 5.28 5.16 5.49 5.63 5.65 5.34 5.48

4.71 4.52 4.47 3.92 4.67 4.92 4.37 4.22 3.55 4.17 4.91 4.73 4.74 4.85

5.47 5.36 5.46 5.47 5.61 5.56 5.24 5.27 5.14 5.49 5.61 5.64 5.34 5.47

4.86 4.63 4.59 4.24 4.80 4.80 4.37 4.39 3.95 4.38 5.09 4.89 4.82 5.04

Quality of food

5.17

4.32

5.14

4.57

* All differences between satisfied/dissatisfied patients and patients likely/not likely to return to their provider were significant. P 

Patient satisfaction and willingness to return to the provider among women undergoing gynecological surgery.

To identify factors associated with 'patient satisfaction' and 'willingness to return to the provider' in gynecology and to assess similarities as wel...
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