Satisfaction with health care among dermatological inpatients

ARTICLE

Increasing attention to health care quality has led to a renewed interest in patients' satisfaction, regarded as one of the principal elements for obtaining patients' evaluation of the services they received [1-3].

Several authors underscored the importance of evaluating in different settings (e.g. primary care, inpatient and outpatient hospital care) the patient's opinion about the care received. Many physicians are reluctant to accept data generated from patients' satisfaction surveys or to have their patients participating in such surveys, discounting the importance of the patient perspective [4]. On the other hand, the results of satisfaction surveys clearly showed how this kind of research improves the physician patient interaction and the outcome of patients, especially those affected by chronic diseases [5] requiring long term treatment and regular follow-up.

The 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 programs [6, 7].

In order to improve perceived quality of health care, it is important to understand which are the main factors influencing patient satisfaction. These can include factors related to the health care provider such as infrastructures and access to care, interpersonal skills of personnel, and patient related factors such as socio-demographic characteristics of patients, disease severity and health related quality of life.

A recent study evaluating this topic in a dermatological setting among outpatients concluded that improving physician's interpersonal skills could increase patient satisfaction which was observed to have a positive effect on treatment adherence and health outcomes [8].

To the best of our knowledge, there are no published studies examining factors related to the satisfaction of dermatological inpatients. Even if improved outpatient care represents the core of dermatological treatment, inpatient care remains essential especially for those who have extensive skin disease, are physically frail, or have disabilities and lack of social support [9]. The elderly, in particular, may require inpatient care to ensure adequate treatment of their skin disorders.

Even more than in other specialties, dermatological inpatients need emotional support because the disfigurement caused by their diseases may often result in an attribution of negative or denigrating qualities by society and by the patient himself [10] and is also associated with increased psychiatric morbidity [11].

The specific aim of the present study was to evaluate the independent effect on patient satisfaction of patient characteristics and of specific aspects of health care (competence and efficiency of caregivers; information about the clinical status, progress and prognosis; physical comfort with pain management; emotional support, hospital success in involving patient's family and friends; information about treatment and follow-up), with the practical purpose to help the Hospital Management to intervene in the identified critical areas of care.

Materials and methods

We studied a sample of consecutive dermatological inpatients, recruited from October 1^st to November 30^th 2001, at the Istituto Dermopatico dell'Immacolata (IDI IRCCS) (Rome, Italy). IDI IRCCS is a large research hospital and a referral point for dermatological patients from Central and Southern Italy. In 2001, there were 170,000 outpatients, while there were 17,000 inpatients.

The patients' eligibility criteria for this study were: a) age ³ 18 years b) ability to read Italian c) no major cognitive deficits precluding questionnaire completion. The study protocol was approved by the Institutional Ethical Committee. A nurse invited participants to complete a self-administered questionnaire originally elaborated by Picker Institute and validated in the U.S.A. in multiple settings [12, 13]. Our version, already used on vascular patients [14], included 23 neutrally worded questions: 14 to be answered on a five point scale ranging from totally positive to totally negative opinions, 7 on a yes/no response, and 2 questions about patient "overall satisfaction" of care and "access" on a 0/10 points scale. It was possible to mark the response "not applicable" for each of the questions. All of the questions were part of 7 different dimensions of care: respect for patient preference, co-ordination of care; information and education, physical comfort and pain relief, emotional support, involvement of family and friends, continuity and transition out of the hospital (the questionnaire is available upon request). The non-anonymous questionnaire was completed by the patient on the last day of hospital stay, just before discharge.

Patients were categorized as satisfied or not satisfied with regards to each single dimension, considering as satisfied those who rated at the maximum level at least 75 % of the questions included in each dimension.

In order to identify the dimension most related to overall satisfaction and to assess if it was influenced by potential confounding factors, patients' demographic characteristics (age, sex, educational level, region of residence) and specific aspects of care known to be associated with satisfaction (length of stay, severity of disease, multiple hospital admissions) were analyzed and a regression analysis was performed.

Disease severity was defined by means of All Patient Refined Diagnosis-Related Group (APR DRG) [15-17] because by adding subgroups to the basic DRG it allows us to address differences in patients' severity of illness and risk of mortality. The APR DRG classifies the disease in four subgroups or classes: minor, moderate, major and extreme according to the extent of organ-system loss of function or physiologic decompensation.

The dimensions with the strongest association to the outcome of interest were in turn considered as dependent variables, and the distribution of satisfied patients for each of them studied in respect to the principal diagnosis of hospital admission (according to the ICD9 CM classification system). For this purpose, the sample recruited for the study was divided in three main categories: patients with acute skin diseases, patients with chronic skin diseases, and patients with tumors. A fourth category was added and defined as "others" (i.e., when the dermatological diagnosis was the second or the third diagnosis in the hospital discharge reports).

The statistical analysis was performed using the STATA 7 statistical package (College Stata,TX, USA: Stata Corporation 1999).

Results

Six hundred and seventy two consecutive inpatients were recruited and completed the questionnaire. Of these, 16 were excluded because younger than 18 years. Eight were excluded because they completed less than 70 % of the items. The mean age of the 648 eligible patients was 49.9 years (sd ± 17.6); 266 (41.1 %) were males and 382 (58.9 %) females. In order to verify whether our sample was comparable with the total population of IDI patients, we used the hospital administrative data to assess the sex and age distribution of all patients who attended the dermatological units the year 2001 and matched our inclusion criteria. The mean age of all dermatological patients was 50.7 year (sd ± 16.3); 42.9 % were males and 57.1 % were females.

Twenty-two percent of the patients were affected by a tumor, 17.9 % by an acute dermatological disease, 47.9 % by a chronic skin condition, the remaining 11.7 % had a non-dermatological principal diagnosis.

According to the ICD9-CM international classification system of diseases the most frequent acute disease was dermatitis (61 cases), the most common chronic skin disease was urticaria (78 cases), while 57 patients were admitted with a diagnosis of tumor.

The APR-DRG classification attributed 482 patients to class I - minor - (74.4 %), 158 (24.4 %) to class II - moderate - and 8 (1.2 %) to class III - major -. Class II and III here were grouped and classified as "moderate" (25.6 %).

Figure 1 shows the "overall satisfaction" data. A total of 60.2 % of patients rated the care received as excellent.
This group was considered for the further analysis as "satisfied" whith the others as "not satisfied". We decided to be conservative, because the non-anonymous nature of the questionnaire could have induced patients to attribute particularly high scores.

Table I shows the prevalence of "overall satisfaction" according to patients characteristics (age, sex, educational level, region of residence), specific aspects of care (length of stay, multiple access, disease severity) and type of disease.

The oldest and less educated patients as well as those with an intermediate duration of hospital stay are more frequently "overall satisfied". As for the class of disease, patients with a tumor were more satisfied, whereas those with an acute disease were less satisfied.

Figure 2 shows the proportion of satisfied patients with regards to each dimension studied, except overall satisfaction. The dimension with the highest prevalence of satisfaction refers to "physical comfort" (89.6 %) while the lowest prevalence of satisfaction refers to "emotional support" (47.8 %) and "family involvement" (54.6 %).

To ascertain the dimension most closely related to the "overall satisfaction" a strategy suggested by Gunby et al. was performed [18]. It consists of repeated multiple logistic regression models where the single dimension is in turn removed if it reaches the higher X value. In our study "information and education" and "co-ordination of care" were the dimensions most closely related to overall satisfaction (data not shown). In order to see if these dimensions were affected by potential confounding factors, patients' demographic and clinical characteristics were added in the analysis individually and in combination. There was no evidence to suggest that the final choice of criteria was confounded. The selected dimensions were then further explored: Table II shows that patients with an intermediate length of stay (LOS) are the least satisfied regarding both dimensions while individuals aged ³ 65 years are more satisfied compared to younger regarding the "coordination of care". Residents in the same region as IDI and at their first admission are instead more satisfied with the information received during their stay. Patients with tumors compared to those affected by other diseases seem to be more satisfied for the two dimensions under study. Patients with chronic diseases show the lowest prevalence of satisfaction with coordination of care.

Furthermore, logistic regression analyses were performed with information and subsequently coordination of care as outcomes. The disease was included as independent variable and the results adjusted for the patient's characteris
tics. The results represented as O.R. and 95 % CI are displayed in Figure 3. Patients with tumors are more likely to be satisfied with the information received than those with acute diseases.

Patients classified as "others" were significantly more likely to be satisfied than those with chronic dermatological diseases where no significant difference was found between different diseases.

Discussion

The objective of the study was to examine the perceived quality of health care among dermatological inpatients to identify bottle necks in the quality perceived areas and to suggest positive solutions to the Hospital Management.

Increasing interest in patient perceived quality of care or patient satisfaction can be accounted for by numerous developments, including concerns over health care costs, informed consumerism and heightened awareness of the influence of psychosocial factors in the process and outcome of medical care [19]. A growing body of research has also shown that patient dissatisfaction with health care is related to patient non compliance with medical treatment, discontinuation of care and frequent changing of health care providers [20-23].

The majority of studies have focused exclusively on the role of health status and demographic variables when identifying predictors of patient satisfaction with health care. Others reported inconsistent findings regarding the influence of demographic variables such age, income, education, race and sex on patient satisfaction [21, 24].

Among the socio-demographic variables examined in this study, educational level was associated with overall patient satisfaction, confirming what was reported in a non dermatological meta analysis [24]. In particular, patients with less education were more satisfied with the general aspect of medical care. A possible explanation for the relationship between education and satisfaction with care is that less educated patients are not as knowledgeable about various aspects of medical care and thus apply less stringent criteria when judging health care compared with more educated patients.

Also the length of stay was related to overall satisfaction particularly for patients who have a short or a long stay. Out-patient care is considered the best approach for treating dermatological diseases but in settings where this is not possible a reduction of hospital stay is appreciated by the patients. Almost 40 % of IDI patients are from regions other than Lazio, with evident logistic problems. Patients with longer hospital stay were the most satisfied, and this perhaps reflected the peculiarity of some dermatological diseases. Serious diseases or disorders involving the entire body can be perceived as a stigma and the patient might prefer to be cured in a hospital environment [9].

Reports have demonstrated that there is a highly significant association between patient satisfaction and the amount of information given. In a previous study [25] on dermatological patients, those with chronic diseases asked for more information from care givers than those with tumors (63 % versus 37 %). Younger patients requested more information than older ones. In our study patients with tumors were more satisfied than those affected by acute or chronic diseases or by non-dermatological diseases. The likelihood of overall satisfaction increased with increased disease severity also in outpatients [8]. Patients with tumors usually receive special attention in order to facilitate their access and treatment and are better followed in time (scheduled visits for therapy or surgery, follow-up etc.). On the other hand, patients with chronic dermatological diseases often know almost everything about their disease and particularly with recurrent access to the hospital they have very low expectations and show a low overall satisfaction.

Among the seven dimensions of satisfaction, emotional support has the lowest percentage of maximum satisfaction (less than 50 %). The Hospital Management has recognized this as a critical area and promoted training in improving communication skills [26-28].

Actions are expected with staff dedicating greater attention to patients' fears and anxiety associated to the skin diseases, such as patients' worries about the impact of the illness on their ability to care for themselves or about the effects on interpersonal relationships. Patient satisfaction will be monitored over time and the impact of the interventions will be evaluated.

The performed analyses preserve details and reduce the amount of data presented offering composite scores. Each score represents a critical component of quality of care as defined by the patients. The Picker Institute developed this paradigm for synthesizing the information provided by patients in order to categorize the aspect of care they found especially critic. This allows each patient to suggest how the hospital might address his needs and preferences.
This level of detail contrasts sharply with other patient survey reports, which rely principally on global satisfaction.

In our Institute "coordination of care", "information and education" appeared to be strongly associated with overall satisfaction. In order to achieve satisfaction with the coordination of care, patients would expect to be able to identify a specific doctor in charge of their care, to receive from doctors and nurses consistent information, to perceive the admission process as good. In order to be satisfied with the education and information, patients expect doctors and nurses to answer their questions about the disease, the treatments, the diagnostic exams.

A modified "patient chart", new information sheets for the admission and round table discussions between health personnel are among the initiatives implemented by the Health Management following this survey.

Article accepted on 18/12/2002

CONCLUSION

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