CurrentConceptsReview MeasuringPatientSatisfaction

CurrentConceptsReview

Measuring Patient Satisfactionin Orthopaedic Surgery

Brent Graham, MD, FRCSC, Andrew Green, MD, Michelle James, MD, Jeffrey Katz, MD, and Marc Swiontkowski, MD

� In addition to their wish to understand the clinical results of orthopaedic interventions, clinicians, patients, andpayers are increasingly interested in patient satisfaction, both with the process of care and with outcomes.

� The construct of satisfaction is complex and depends on the context in which care takes place, including the natureof treatment, its setting, and most importantly the expectation of patients prior to treatment.

� The characteristics of scales that are effective measures of satisfaction are the same as those of all effectivemeasurement instruments—i.e., reliability, validity, and responsiveness.

� Measurement of patient satisfaction may be especially important in evaluations of established procedures andprocesses so that the value of those procedures and processes to patients can be more completely understood.

The goal of this review is to discuss aspects of the measurementof patient satisfaction, identify the characteristics of usefulmeasures of patient satisfaction, describe some existing mea-sures of patient satisfaction, and establish when it is importantto report patient satisfaction in clinical research studies.

What Is Patient Satisfaction?In the last twenty years, clinicians have begun to increasinglyacknowledge and understand the importance of patient-reportedoutcomes. The emphasis on outcomes that matter to patients hasled to the development of a wide range of measurement instru-ments to supplement objective measures and a move away fromobjective measures of impairment, such as range of motion orstrength, that are assessed by clinicians. Clearly, inmany instancesthe most informative reporting of clinical results includes ele-ments of both patient and clinician evaluations, and when theseappear to conflict—as they frequently do—an attempt to explainthe discrepancies.

Authors of clinical studies now often report on patientsatisfaction as well as functional outcomes. On the surface, thisseems to be a natural outgrowth of the desire to measure out-

comes that concern patients, and an important element ofmeasuring such outcomes is assessing their satisfaction with themanagement of their health. However, patient satisfaction iscomplex and does not necessarily have a clear link to eitherexisting patient-reported outcomes or outcomes measured byclinicians.

To begin with, it is important to understand the contrastbetween satisfaction as it relates to the outcome of care andsatisfaction with the process of care1. These are two related butseparate concepts. Situations arise in which the outcome oftreatment is considered to have been successful by both thepatient and the clinicians but the process of care is considered tobe unsatisfactory because of cost, inconvenience, or hardshiprelated to receiving that care. Conversely, treatment may beconsidered to have been unsuccessful, at least from the stand-point of having failed to achieve the desired outcome, but sat-isfaction with the process of care may still be high because it wasdelivered in a careful, empathetic manner. The relationshipamong patients, caregivers, treatment setting, and any of a va-riety of additional factors may influence the determination ofwhether a given patient is “satisfied” with the care.

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support ofany aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission ofthis work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Noauthor has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence whatis written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version ofthe article.

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Regardless of the methodology used to evaluate satisfac-tion, it must be acknowledged that the meaning of “satisfaction”may vary from patient to patient and between investigators. As isthe case for measurement of all clinical results, the complexity ofevaluating satisfaction dictates the need for instruments that arereliable, valid, and meaningful. This complexity is not capturedby a simple, one-item measure such as a visual analog scale.

Can Patient Satisfaction Be Measured?The measurement of patient satisfaction is elusive because it is amultidimensional construct that has not necessarily been welldefined for orthopaedic surgery. Many instruments designed tomeasure satisfaction are unvalidated or rudimentary2. Others,such as the Consumer Assessment of Healthcare Providers andSystems (CAHPS) surveys, are specifically designed to measuresatisfaction only with the process of care. Some of these instru-ments are reviewed below. A common problem of many scales isthe failure to differentiate patient satisfaction with outcomefrom their satisfaction with the quality of the health servicedelivered—in other words, satisfaction with the process of care3.

Many validated outcome instruments in orthopaedic sur-gery are not specifically designed to measure patient satisfaction,although they may include questions related to satisfaction4-6.Authors of orthopaedic studies often attempt to determine whichoutcomes or other components of the care pathway are associatedwith satisfaction. For example, the strongest predictor of dissat-isfaction with total knee arthroplasty appears to be a failure tomeet a patient’s preoperative expectations7. Similarly, patientswho attach higher importance to the results of spine surgery havebeen shown to have larger discrepancies between their preoper-ative expectations and the outcome8, and higher preoperativeexpectations are associated with decreased postoperative satis-faction9. Satisfaction with hand surgery has been correlated withpain relief, the ability to perform activities of daily living, ap-pearance, strength, range of motion, and fulfillment of expecta-tions10. Satisfaction with foot and ankle surgery is influenced byappearance, shoe wear, pain, and social interactions6. A study ofparents of children being treated in the hospital for an ortho-paedic condition showed that dissatisfaction was associated witha perceived need formore information, evenwhen they had beenprovided with the information they felt they lacked11. Patientexpectations have also been shown to have significant relation-ships with patient-reported outcomes of rotator cuff repair andshoulder arthroplasty12. In contrast, Godil et al.13 found thatpatient satisfaction is not a valid measure of overall quality oreffectiveness of surgical spine care. They studied correlationsbetween patient-reported satisfaction and outcome as well asbetween patient satisfaction with provider care and a number offunctional outcome scores related to the surgical treatment ofspine disorders and concluded that satisfaction metrics are im-portant patient-centered measures of health-care service butshould not be used as a proxy for overall quality, safety, or ef-fectiveness of surgical spine care.

The wide spectrum of findings regarding patient satisfac-tion with orthopaedic surgery care is a reflection of the complexnature of satisfaction and of the interaction between different

facets of the satisfaction construct. Some attempts have beenmade to reduce this confusion by developing and validating in-struments specifically designed to measure satisfaction withoutcomes. Mahomed et al. described a simple instrument de-signed to evaluate satisfaction with pain relief and function afterlower-extremity arthroplasty, and it was found to be internallyconsistent, valid, and reliable14. A scale to test patients’ expecta-tions of spine surgery was developed and found to be valid,reliable, and applicable to diverse diagnoses15.

A common theme in most studies of patient satisfactionwith orthopaedic surgery is the relationship between preoperativeexpectation and postoperative satisfaction. In a recent review ar-ticle, Shirley and Sanders3 noted that linking satisfaction toquality-of-care initiatives is important, in part because satisfactiondata may be used for accreditation and compensation formulas.However, they also found that surgeons are more interested in themeasurement of satisfaction with outcomes even if aspects of theprocess of care, often beyond the surgeon’s control, contributesubstantially to patients’ overall satisfaction. Effective communi-cation with patients and their families and appropriate expecta-tions are factors that may be under the control of surgeons.

Given the importance of assessing satisfaction, the currentstate of development of tools for measuring satisfaction with or-thopaedic care, and the imperative that orthopaedic surgeons focuson the measurement of factors on which they can have an impact,it appears that setting and communicating appropriate expecta-tions with patients is a key objective. Measuring whether theseexpectations have been met is an attainable and worthwhile goal.The Canadian Occupational Performance Measure (COPM)16, ageneric outcome measure, is an example of a tool that meets theseneeds. The COPM consists of a semi-structured interview thatmeasures problems with daily function that are identified by thepatient or caregiver and scores satisfaction with performance ofthese activities before and after interventions designed to improvethem. It has proven to be a valid, reliable, clinically useful, andresponsive tool that focuses on outcomes that are important to thepatient and that are within a range that the patient and caregiveragree is reasonable and achievable before the intervention17.

What Measures Are in Widespread Use in Health-CareSystems and Professional Organizations?American Academy of Orthopaedic Surgeons (AAOS)The AAOS was a leader among surgical specialty groups in en-tering the arena of the measurement of patient-oriented out-comes, including patient satisfaction. It has become clear that thedocumentation of patient satisfaction is critical to proving qualitycare to managed care organizations and third-party payers. Veryearly on, the AAOS developed a Patient SatisfactionQuestionnairethat helped orthopaedic surgeons to obtain these valuable data.The questionnaire was a validated nine-item instrument withinthe Musculoskeletal Outcomes Data Evaluation andManagementSystem (MODEMS) that focused on the process of care in anorthopaedist’s office. The patient satisfaction tool was widely usedto measure and improve office performance from the patientperspective. Unfortunately, the MODEMS initiative was aheadof its time and financial constraints resulted in discontinuation of

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THE JOURNAL OF BONE & JOINT SURGERY d J B J S .ORG

VOLUME 97-A d NUMBER 1 d JANUARY 7, 2015MEASURING PATIENT SAT I SFACT ION IN ORTHOPAEDIC SURGERY

program support. However, the instruments developed within theprogram remain in widespread use for clinical research.

NRC PickerThe NRC (National Research Corporation) Picker patient sat-isfaction tool was based on extensive research conducted by thePicker Institute in collaboration with Harvard Medical School.In 2002, NRC Picker approached the Centers for Medicare &Medicaid Services (CMS), the Department of Health andHuman Services (HHS), and the Agency for Healthcare Re-search and Quality (AHRQ) and shared their experiences increating a standardized patient-experience public reportingprogram for the National Health Service in the U.K.

Centers for Medicare & Medicaid Services (CMS)In 2005, CMS launched Pay-for-Performance (P4P) initiativesin order to address quality deficiencies in all aspects of healthcare. At the present time, CMS and state Medicaid programs aswell as all health plans and prominent health-care-qualitygroups support this approach. These programs use variousquality measures such as clinical quality, utilization and costmanagement, patient-oriented outcomes, and patient satis-faction. As patient-centered approaches to care become dom-inant in P4P programs, patient satisfaction measures havebecome a critical point of focus for improving care by bothgovernmental agencies and professional organizations.

Consumer Assessment of Healthcare Providers andSystems (CAHPS)Included in the Patient Protection and Affordable Care Act is therequirement that CMS create a web site that features data on thecomparative performance of physicians. The site, called PhysicianCompare, went online in 2011. CMS plans to expand the website to include an area for patient ratings along with informationon clinical quality. The Physician Quality Reporting System(PQRS) will soon begin public reporting. Patient satisfaction isassessed with the measure developed by the AHRQ. Known asthe Clinician and Group Consumer Assessment of HealthcareProviders and Systems, or CGCAHPS, this instrument is similarto the CAHPS instruments, the survey tools that hospitals andhome-care agencies already use.

Press GaneyPress Ganey is the nation’s largest provider of tools for patientsatisfactionmeasurement and analysis. The survey simply knownas the “Press Ganey Survey” is the only survey approved by theNational Quality Forum (NQF), a private, multi-stakeholderorganization that evaluated the clinical quality metrics in thePQRS. CMS is legally required to use measures approved by thegroup. Many large physician groups already use this survey, inwhich the CGCAHPS questions are embedded, in anticipation ofthe coming requirement. For similar hospital quality programs(Hospital Consumer Assessment of Healthcare Providers andSystems, or HCAHPS), the first tool successfully developed tocreate a standard measure of patient-centered care for providersacross the U.S., reporting was voluntary at first. Later, hospitals

that did not report data lost 2% of their Medicare reimburse-ment. Measures now available are designed to evaluate homehealth care (HHCAHPS), physician practices/medical groups(CGCAHPS), and ambulatory surgery. It remains to be seenwhether there will eventually be a similar impact on physicianreimbursement based on compliance with these measurementtools, and whether the newer tools will make it easier to “drilldown” to patient satisfaction data for individual physicians.

Usefulness of Patient Satisfaction MeasuresGovernment programs that require reporting of quality and pa-tient satisfaction measures are not the only reason why ortho-paedic practice groups should survey their patients with one ofthese tools. The process of collecting patient satisfaction data in-forms physicians of their patients’ actual opinions. Smart practicestake the data and use them to inform process and flow im-provement in addition to helping individual physicians improvetheir patient communication skills. Using these data to improvecustomer service helps to retain patients as well. Physicians withthe lowest 20% ratings are nearly four times more likely to havepatients leave their practices compared with the top 20%18.

The effective use of patient satisfaction data also reducesthe likelihood of patient lawsuits19. Poor communication be-tween physicians and patients is more likely to result in a mal-practice suit than in a poor outcome. Physicians who ranked inthe bottom one-third of the Press Ganey database were 110%more likely to have suits brought against them. Less clear is therelationship between patient perceptions of individual physi-cians and the quality of clinical care. A study supported by theCommonwealth Fund has also identified a direct relationshipbetween hospital care quality and patient satisfaction ratings20.This is likely related to the quality of communication betweenphysicians and their patients, which is the basis for shareddecision-making; engaging patients in these decisions throughquality communication improves the results of care in additionto enhancing overall patient satisfaction.

Characteristics of an Effective Measure of SatisfactionAs withmeasures of any construct, measures of patient satisfactionshould be reliable and valid21. Reliability refers to whether a mea-sure is reproducible between and within individual raters. Validityaddresses whether the scale measures what it purports to measure.

Reliability encompasses three features. The first is intra-rater reliability, which addresses the question of whether themeasure provides the same satisfaction rating if the subject an-swers it on two separate occasions. It is tested by comparingsatisfaction scores on two different administrations, spacedsufficiently far apart in time to ensure that the subject is notsimply recalling from memory their prior responses. The ad-ministrations must also be close enough in time that the subject’sclinical status has not changed (as this could result in an actualchange in their satisfaction with the outcome or process of carebetween the times of the two administrations). There is no clearstandard, but one to two weeks is often used for test-reteststudies. Standard statistical tests are used to calculate the re-producibility. If the scale is continuous, the intraclass correlation

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coefficient and the Pearson correlation coefficient providecomplementary evidence of reproducibility. The Pearsoncoefficient—or its nonparametric analog, the Spearman correla-tion coefficient—measures correlation and not agreement. Thus,if satisfaction wanes over time and the result of the retest is uni-formly lower than the original result, the correlation may remainvery high. The intraclass correlation coefficient essentially com-pares the variance within individuals with that across individualsand thus accounts more directly for disagreement over time.

Interrater reliability is pertinent when the measure is ad-ministered by another person rather than by self-report. In thesecircumstances, the research team must ensure that two researchstaff members administering the measure to the same subjectobtain the same result. Here, too, it is important that the twoinstances be spaced far enough apart to ensure that the subject isnot simply reporting from memory but close enough that therehave been no meaningful changes.

Internal consistency, or scale reliability, is a third measure ofreliability germane tomulti-item scales that is used in an attempt toassess a unidimensional construct—for example, a six-item scale inwhich responses to the six items are added or averaged to assesssatisfaction. The items should have high correlation with one an-other and with the overall score. There are various ways of mea-suring whether the scale is internally consistent. The mostfrequently used are Cronbach alpha and the individual correlationsbetween the individual item score and the total score. Cronbachalpha provides a measure of the extent of intercorrelation of allitems in the scale. Most experts agree that a Cronbach alpha of 0.70or higher indicates that the scale has acceptable internal consistency.

There is frequently no gold standard against which tocompare ameasure for validity, so several approachesmay be taken.Content validity is assessed by clinical and other experts reviewingthe proposed scale to ensure that the items appear to make sensefrom a clinical standpoint. Discriminant validity addresses whetherthe scale effectively distinguishes groups hypothesized to have dif-ferent scores. For example, subjects who had repeat surgery in thefirst year would be expected to have lower satisfaction scores thansubjects who did not have repeat surgery. Convergent validity refersto the association between the proposed measure and measures ofrelated concepts hypothesized to be correlated. For example, onewould expect the measure of satisfaction following total joint re-placement surgery to be positively correlated with a measure ofimprovement in functional status or reduction in pain.

Reliability and validity are not fixed properties of mea-sures. They may differ across populations and interventions andmay be influenced by differences in literacy, culture, and clinicalcontext. Thus, the process of establishing reliability and validityis both iterative and ongoing, and investigators should endeavorto establish reliability and validity in their particular populationsand settings whenever possible.

How and When Should Patient Satisfaction Be Reported?Patient-reported outcomes, including satisfaction, are clearly acrucial aspect of determining the effectiveness of health-caredelivery and treatment. “Satisfaction” reflects the patient’s as-sessment of the process and outcome of treatment, and it may

differ from health status because, in part, patient satisfactiontakes into account the more subjective issues of expectationsand preferences22.

The assessment of satisfaction is especially important in acontext of value-based health care because there may be differ-ences between satisfaction associated with the process of careand satisfaction with the outcome of treatment. While mostclinical research emphasizes the outcome of care, the relation-ship among patient satisfaction, outcome, and effectiveness ofcare is not always well understood.

Patient satisfaction with the process of treatment can beevaluated when there is interest in measuring the quality of health-care providers, facilities, or organizations. Satisfaction with theprocess of care is in itself complex and dependent onmany factors,including lifestyle, past experiences, future expectations, and in-dividual and societal values, any or all of which may or may not bedirectly related to the disorder being treated23. As noted in thesection on measuring satisfaction, the concept of satisfaction im-plies one of expectation as well. In this regard, satisfaction mayactually represent the fulfillment of an expectation rather than asimpler idea of satisfaction with outcome. When the goal of aresearch investigation is to determine whether patients are satisfiedwith treatment, their treatment expectations should be evaluatedbeforehand rather than simply asking, at the end of treatment, ifpatients were satisfied. All too often the latter approach is the onetaken in clinical research studies in orthopaedic surgery.

Is greater satisfaction a measure of higher-quality care?Not necessarily. However, it seems clear that greater satisfactionmay improve patient engagement, which in itself might im-prove outcomes, and this could influence changes in health-care delivery. Nevertheless, the relevance of satisfaction to theeffectiveness of treatment is controversial and depends on theway in which satisfaction and treatment outcome are measured.

Is it always necessary and appropriate to measure and re-port on patient satisfaction with either outcome or process? Theanswer to this question depends on the nature of the investigation.For example, when a new or innovative procedure is being re-ported, whether patients are satisfied with treatment may be lessimportant than understanding whether the treatment is effective.For treatments and processes that have been established aseffective—for example, rotator cuff surgery—it may be moreimportant to fully understand satisfaction. For these investigations,it is important to evaluate satisfactionwith the process of care soonafter the experience in order to reduce the effect of recall bias.

The reporting of patient satisfaction is relevant to the as-sessment of both the process and the outcome of the treatmentfor many clinical disorders in orthopaedic surgery. Because ofthe inherent subjective nature of satisfaction assessment and thepossibility that satisfaction may not necessarily correlate withconventional evaluations of treatment effectiveness, satisfactionshould be reported with use of validated, responsive, and reliablemeasures.

Areas for Future ResearchIn general, the right measure of outcome varies with the natureof the research question. This may prove to be true of measures

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of patient satisfaction as well. Distinguishing between satis-faction with the process of care and satisfaction with theoutcome of care is a key dichotomy that future research inthis area should address. Patient expectation clearly has animpact on the perception of outcome as successful or not,and this is likely to be true for evaluations of satisfaction aswell. This is only one example of the many issues that mayconfront researchers seeking to develop measures of patientsatisfaction that are meaningful and useful in orthopaedicsurgery. The same methodological framework used in the de-velopment of outcome measures now in common use in or-thopaedic surgery—item generation, item reduction, reliabilitytesting, and validation—should be used to create measures ofpatient satisfaction. In the meantime, pending the develop-ment of scales that specifically measure aspects of the satis-faction construct in orthopaedic surgery, investigators shouldclearly define which aspect of the satisfaction construct they areevaluating and use established measures of satisfaction ratherthan ad hoc or poorly defined scales, which may lead to aninaccurate or misleading evaluation. n

Brent Graham, MD, FRCSCDepartment of Surgery,

University Health Network/University of Toronto,399 Bathurst Street, Toronto,ON M5T 2S8, Canada.E-mail address: [email protected]

Andrew Green, MDDepartment of Orthopaedic Surgery,Rhode Island Hospital,2 Dudley Street, Suite 200,Providence, RI 02905

Michelle James, MDDepartment of Orthopaedic Surgery,Shriners Hospital for Children Northern California,2425 Stockton Boulevard,Sacramento, CA 95817

Jeffrey Katz, MDDivision of Rheumatology,Immunology and Allergy,Brigham and Women’s Hospital,75 Francis Street,Boston, MA 02115

Marc Swiontkowski, MDDepartment of Orthopaedic Surgery,University of Minnesota,2450 Riverside Avenue,Minneapolis, MN 55454

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CurrentConceptsReview MeasuringPatientSatisfaction