Family Practice Vol. 19, No. 4, 333-338
© Oxford University Press 2002
Health Services Research |
Meeting patient expectations of care: the major determinant of satisfaction with out-of-hours primary medical care?
Department of General Practice and Primary Health Care, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK.
RK McKinley; E-mail: rkm{at}le.ac.uk
McKinley RK, Stevenson K, Adams S and Manku-Scott TK. Meeting patient expectations of care: the major determinant of satisfaction with out-of-hours primary medical care? Family Practice 2002; 19: 333–338.
Received 9 May 2001; Revised 17 October 2001; Accepted 11 March 2002.
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Abstract |
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Background. Client or consumer expectation is considered to influence their satisfaction with the service provided, but its importance has not been quantified in health care.
Objective. The aim of this study was to determine the effect of ‘patient expectations of care’ on satisfaction with care provided by out-of-hours services.
Methods. We surveyed 3457 patients who requested out-of-hours care from five practices, two general practice out-of-hours co-operatives and a deputizing service in an English health authority during late 1997. The independent variables were: the service providing the care (service type), where out-of-hours care was given (location of care) and whether the care met the patient's expectations. The independent variable was overall patient satisfaction with out-of-hours care.
Results. Patients who received the care they hoped for (their idealized expectation was met) were more satisfied than those who did not. Patients who attended centres were more satisfied with the care received than those who had had home visits. Patients were more satisfied if they received care from the co-operative which did not employ assistants than from the deputizing service. Idealized expectation (care which was hoped for) match, location of care and service type explained 34, 2 and 4% of the variance, respectively. Age, sex, ethnicity, access to a car, normative/comparative expectation (care which was expected) and whether patients expected and received telephone advice, a home visit or domiciliary care, and the delay between request for care and care provision were not independently associated with satisfaction.
Conclusions. Meeting or failing to meet the care patients hoped for is an important predictor of patient satisfaction with out-of-hours care. Purchasers and providers of out-of-hours care should consider whether and how patient expectation of service can be managed. This may reduce patient dissatisfaction with the service they provide. These findings also have important implications for the design of studies which use patient satisfaction as an outcome variable.
Keywords. Care, idealized expectation, out-of-hours, patient satisfaction.
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Introduction |
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Patients' satisfaction with the health care they receive is an important health outcome1 which has been given particular emphasis in the current review of the National Health Service. Nevertheless, the relationship between satisfaction and the quality of care received is complex and affected by patient, doctor and service factors.2 Recent commentators have speculated that patient expectation of care they will receive has an important impact on satisfaction:3,4 patients with inappropriately high expectations may be dissatisfied with optimal care, and those with inappropriately low expectations may be satisfied with deficient care. Furthermore, observed differences in satisfaction between people from different social classes, age, sex and cultural group or between different services and types of care2,5–13 may be confounded by match or mismatch between expectation and the service received. Based on the work of Prakash, we have conceptualized patient expectation of care as having two aspects; what patients expect as a result of their own or others' experiences (normative/comparative expectation) and the care they would like and/or hope for (idealized expectation).14
We have surveyed patient satisfaction with out-of-hours primary medical care by different providers in varying locations and also collected data on whether the care received matched patients' expectations. We now present a multivariate analysis of the relationship between these variables.
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Methods |
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Participating services and patients
We invited providers of out-of-hours primary medical care in a large English health authority to participate in the survey. These were the practices providing their own out-of-hours care, GP out-of-hours co-operatives and the deputizing service. The characteristics of the ‘participating services' are summarized in Table 1
; three practices and one co-operative declined to take part. All ‘services' offered out-of-hours domiciliary care, centre attendance or telephone advice.
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Everyone who requested care after their practice had closed on weekday evenings and weekends for the 10 weeks between 29 September 1997 and 6 December 1997 were considered for inclusion. Patients were excluded if the doctor had been called to certify death, was known to have died subsequently or were between 12 and 16 years old (in case they wished to keep their consultation confidential from their parent or guardian). All services except the deputizing service faxed a list of eligible patients to the research team on the working day after the request for care from which the study sample was drawn at random (see below). The deputizing service's contact rate made faxing all contacts impractical so its staff were trained to draw the sample which was then faxed.
Every patient or parent or guardian of children younger than 12 years was sent the appropriate questionnaire with a covering letter agreed with each service or practice, with a stamped addressed envelope for return. All non-responders were sent a second questionnaire within 2 weeks of the request for care and we attempted to telephone all those who did not return a questionnaire within 4 weeks of their request. The study was approved by the local research ethics committee.
Questionnaires
The study questionnaire was based on Salisbury's modification of the Patient Satisfaction with Out-of hours Care questionnaire (PSOC).15,16 This is a questionnaire with previously established reliability and validity.15 Nevertheless, PSOC was developed when out-of-hours centre attendance was unusual and the choice of place of care was not an issue. We considered it necessary to develop and include a ‘choice of care scale’ (three items, Cronbach's alpha = 0.79). Two further questions were included to examine patients' expectation of the service they received, "Was the care what you hoped for?" (idealized expectation) and "Was the care what you expected?" (normative/comparative expectation) to which respondents could reply ‘Yes' or ‘No’.
Statistical methods
From a previous study of patient satisfaction with out-of-hours care,8 we estimated that 800 patients should be surveyed from each service to detect a difference of 4.5 scale points in overall satisfaction (half the observed difference between deputizing service and practice doctors8) between any two services with 80% power and 95% confidence assuming an eventual 60% response rate and ignoring the clustering effects which are known to be small.8 The initial sampling fraction was calculated from the known or estimated contact rates for each service and constantly revised to ensure recruitment remained on target for the 10 weeks of the study. The sample was drawn using random number tables.
Satisfaction scales were calculated according to the methods previously described15 and amended by Salisbury.16 Scales were calculated for all respondents who completed at least half of the items for each scale. SPSS 8.0 for Windows was used for analysis. The overall satisfaction scores were not distributed normally and were transformed to the power of 1.8 to normalize them. Variables [chosen on the basis of previous published work8,13 (Table 2)] were investigated for significant partial correlation with the response variable. When they were controlled for in descending order of size of correlation coefficient, five (age, sex, care expectation match, car, ethnicity and normative/comparative expectation) did not show a significant partial correlation with overall satisfaction and were not entered into the linear model. The remaining variables were entered into a GLM factorial model as co-variates, while care, service and idealized expectation were entered as fixed factors together with an interaction term between care and service.
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Results |
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A total of 3457 questionnaires were posted, of which 2263 (65.5%) were returned. Of these, 263 were not completed because 145 of the respondents did not reside at the address given, 38 refused by post, 67 refused at telephone interview and 13 had died since the request for care. Fifty-five per cent of respondents were female, 45% younger than 12 years and 17% older than 65 years. There were no differences in the age and sex distribution of those who returned questionnaires and those who did not, but there were significant differences in response rate between services (56.5–74.4%, chi-square = 60.9, df = 3, P < 0.001) and the type of care provided (domicilary care 72.0%, centre attendance 62.5%, telephone advice 62.7%; chi-square = 27.7, df = 2, P < 0.001). Overall, 81.7% of patients received the care they hoped for (idealized expectation match) but this varied between 67% with telephone advice from the hybrid co-operative to 91% with domiciliary care from the practices. (Table 3
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Table 4
shows the change in transformed satisfaction scores from the ‘reference’ for each level of each fixed factor. Patients whose care was what they hoped for were significantly more satisfied than those whose care was not. Similarly, patients who received care from the co-operative were significantly more satisfied than those who received care from the deputizing service and, when expectation and service are included in the model, patients are more satisfied with centre attendance than home visits. This model explains 70% of the variance. We used univariate analyses of variance for each fixed factor and transformed overall satisfaction using between-subjects models to estimate the relative magnitude of the contribution of each fixed factor. The models for idealized expectation (i.e. care was what was hoped for), service and care provided explained 34, 4 and 2% of the variance, respectively.
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Discussion |
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Match or mismatch between the service the patients hope for and the service they receive appears to be strongly related to levels of satisfaction with out-of-hours primary medical care. When this variable was included in the analysis, many of the previously described relationships (with age, sex, ethnicity, practice or deputizing service providing care, desire for a domiciliary visit) were not significant. This seems to suggest that many of the previously reported differences between groups and services in satisfaction could be explained by idealized expectation mismatch. We see no compelling reason to suppose that this effect is confined to out-of-hours primary medical care.
Although this was a large study of a large population (~700 000 people), it is of only one deputizing service, two co-operatives and five practices providing care in a single English health authority and should be generalized with caution. Similarly, the response rate was moderate (although broadly comparable with previous studies of satisfaction with out-of-hours care8,16,17) and could have introduced unknown biases. Although these providers serve very different populations, the demographic variables used did not contribute to the analysis, but the findings could be confounded by other unknown variables. Nevertheless, the findings are striking.
These data have important implications for providers of services and those researching satisfaction with service provision. More out-of-hours care is now provided in out-of-hours centres than 10 years ago (42% of episodes in this survey and 30% nationally by co-operatives18 compared with 22 and 2% in two studies between 1993 and 199519,20). Against a background of escalating demand for out-of-hours primary medical care,21 it is likely that the proportion of care provided in out-of-hours centres and by telephone advice is likely to increase. If this change in service provision continues against a background of patient expectation for domiciliary care, patient satisfaction with the service received is likely to decrease, and illustrates the need, where possible, to manage expectation.
The design of trials of service provision may also influence levels of satisfaction reported by patients. This study was an observational study of stable services to which most patients had become accustomed and few were likely to have had an opportunity to develop expectations based on their personal experiences of services. Conversely, a randomized trial of service provision could place patients in situations where they receive care from a provider different from the one to which they have become accustomed. Such comparisons may be flattering or unflattering to a particular provider and their comparative expectations could well influence satisfaction levels. We would therefore urge researchers to consider the influence of expectations in any study of satisfaction with service provision.
This study suggests that meeting or failing to meet idealized expectation of care is an important determinant of patient satisfaction. We believe commissioners and providers of care must consider whether and how patient expectations of their service can be managed. We would expect that dissatisfaction will be reduced if users know what they can expect and then receive it. Methods for managing patient expectation need to be researched. We suggest that investigation of patient expectations of service should be a priority for policy makers, commissioners and providers.
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Acknowledgments |
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We would like to thank the Consumers' Association who funded this study, practices and out-of-hours services who agreed to participate and their patients who completed and returned the questionnaires.
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References |
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