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* From the Department of Health Administration, Faculty of Medicine, University of Toronto, Toronto, Ontario, Department of Anesthesia,
North Bay General Hospital, North Bay, Ontario, and the Centre for Research in Women's Health and the Department of Anesthesia,
University of Toronto, Canada.
Address correspondence to: Dr. Donald Fung, Department of Anesthesia, North Bay General Hospital, 750 Scollard St., North Bay, Ontario, P1B 5A4 Canada. E-mail: dfung{at}efni.com
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Methods: A 36 item mail-back questionnaire was administered post-operatively to 45 surgical outpatients and to 15 expert anesthesiologists. Respondents were asked to rank the three highest items from each of four lists of nine items representing pre-operative, intra-operative, pre-discharge and post-discharge outpatient anesthesia care.
Results: Complete responses were obtained from 30 outpatients and all anesthesiologists.
In each phase of their care (pre-operative, intra-operative, pre-discharge and post-discharge), outpatients ranked highest those elements representing information and communication. Physical conditions of care tend to be least valued. Although anesthesiologists were able to predict what patients valued in the pre and post-discharge phases of their anesthesia care (r = 0.85 and 0.91), they undervalued the importance to patients of communication and information in pre-operative and intra-operative care (r = -0.09 and .65).
Conclusions: Our results reinforce the value that patients place in adequate communication and provision of information in all phases of outpatient anesthesia care, a value that may be underappreciated by anesthesiologists.
OBTAINING patient feedback can provide valuable insight into the quality of clinical practice and hospital programs.1 Until recently, most large patient surveys designed to evaluate anesthesia programs or practices have utilized multi-item questionnaires developed without the direct input of patients. The survey questionnaires constructed by anesthesiologists tended to ask patients to report on what they perceived or felt but may not necessarily have reflected on what patients themselves wanted in their anesthesia experience.2 A more valid approach would be to discover first what patients value or prefer in their care and to then formulate a multi-item questionnaire to assess whether these preferences had been met.3,4
In an earlier investigation, as part of a master's thesis in health administration (available on request), we conducted in-depth interviews with same day surgery patients and carried out a Delphi process (a series of mail-back questionnaires) with a panel of anesthesiologists in order to obtain a comprehensive list of those features of outpatient anesthesia care that mattered most to patients. An analysis of the detailed descriptions patients gave of their anesthesia experience yielded items of patient satisfaction which could then be used to create a patient satisfaction questionnaire. Patients' responses to the interviews yielded items which fell naturally into the four phases of peri-operative care (i.e. pre-operative, intra-operative, pre-discharge and post-discharge phases). In each phase, there were between 10 and 20 items that were then grouped into four or five dimensions namely, physical structure, technical content, interpersonal relationship, efficiency of care, and outcomes of care.
In the present study, we asked a new group of surgical outpatients to rank items drawn from this list (nominal rankings5) as a means of identifying those elements and dimensions of anesthesia care of greatest priority to patients. At the same time, we asked members of an expert panel of anesthesiologists to predict the rankings that patients placed on different elements of their anesthesia care.
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Methods |
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A 36 item questionnaire was constructed from a comprehensive list of determinants of patient satisfaction that had emerged derived directly from detailed post-operative telephone interviews of surgical outpatients (Master's thesis, University of Toronto, 1997, available on request). The questionnaire contained four sets of nine items corresponding to the four temporal phases of outpatient anesthesia care (pre-operative, intra-operative, pre-discharge, and post discharge care) (Table II
). Each item in the questionnaire described an element of anesthesia care using, as far as possible, the wording found in verbatim transcripts of patient interviews.
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Pre-testing of the questionnaire in lay subjects (n=5), and in anesthesiologists (n=5) established its feasibility and comprehensibility. All pre-test questionnaires were easily completed with no missing or incomplete responses. The pre-test further evaluated two possible response formats: asking patients to rank the top three items (from 1 to 3) in each list or rating each individual item on a scale of ‘not important’ to ‘very important’. Based on pretest results, ranking the top three items on each list required respondents to consider carefully all items, demanded that respondents "commit themselves" to certain items, and was more likely to uncover which of the elements listed was most preferred in each respondent's care. Ratings of items produced scores with extreme positive skew and placed virtually all items in the very important category (data not shown).
The final version of the ranking questionnaire was administered in a single written mail-back form to 45 surgical outpatients. Patients were recruited from both a large tertiary metropolitan hospital (n=10) and a smaller community hospital (n=35). All respondents were adult outpatients 16 yr-of-age and older who had experienced a general anesthetic irrespective of surgical procedure. Recruitment of patients occurred immediately after admission to the outpatient ward. The questionnaire was taken home by the patient who was asked to complete it on or after the third day following surgery. A follow-up phone call between the 4th to the 7th day was made to all patients in order to optimize the questionnaire response rate.
The same questionnaire was also mailed to 15 anesthesiologists who were asked to choose the three items on each page that patients would rank highest. These anesthesiologists included noted researchers in anesthesia outcomes and outpatient anesthesia research, and representatives of academic and community practice. Eleven practiced in Canada, three in the US, and one in the United Kingdom.
Analysis of responses
Each returned ranking questionnaire (anesthesiologist or surgical outpatients) was analyzed as follows: The top three ranked items of each temporal phase were assigned numerical weights; rank 1 received a score of 3, rank 2 a score of 2 and rank 3 a score of 1. The items of each list were then summed over all completed responses (n=30 for patients, n=15 for anesthesiologists), yielding a ranked order of all nine items based on the pooled scores of each item.
The extent of concordance of the overall ranked order of the nine items of each temporal phase (based on pooled rankings) between patients and anesthesiologists was estimated using a Spearman correlation coefficient (P < 0.05 being considered statistically significant).
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). Among respondents, gynecological surgical procedures (53%) and women (84%) predominated. The next most frequent category of procedure was orthopedic (25%). The age of respondents ranged from 16-75 yr (median = 31; mean 34). Two questionnaires were not ranked as per instructions (6.25% rate of spoiled questionnaires). Thus data from 30 completed questionnaires were used to generate pooled rankings of items in the questionnaire.
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). The overall rank order for each temporal phase of care consistently placed items representing the technical content of care higher in priority than all other dimensions. The highest ranked items in all phases of care described aspects of care related to the provision of adequate information and effective communication (Table II). On the other hand, items describing the physical conditions or environment of care ranked last or next to last even though the item representing physical conditions had been presented first in all lists. The importance of other dimensions of care such as interpersonal dimension, efficiency of care, and outcomes of care depended on the temporal phase. Interpersonal care (confidence and trust in the anesthesiologist) was ranked second in the intra-operative phase; efficiency and outcome dimensions were highly ranked in the post-operative phase of care.
Prediction of patients' ranked ordering by anesthesiologists
Anesthesiologists were unable to predict what outpatients most preferred in their pre-operative phase of care (r = -0.09, Table II). Although both patients and anesthesiologists ranked as their top item "identifying and addressing adequately patient concerns and a desire for information", subsequent ranked items diverged between patients and anesthesiologists; outpatients want more detailed information about side effects and discussion about their care, anesthesiologists emphasized the importance of friendly and efficient care.
In the intra-operative phase of care, the correlations between the rank order of items obtained from anesthesiologists remained less than optimal (r = 0.65, P > 0.09, Table II). Anesthesiologists were unable to predict the item of greatest value to patients in this phase of care: being spoken to during the preparation for and induction of the anesthetic.
In the pre-discharge and post-discharge phases of care (Table II), the overall ranked order of items in each temporal phase obtained from anesthesiologists correlated well with the corresponding overall ranked order obtained from patients. Spearman correlations between patients and anesthesiologists were 0.85 (P =0.01) in the pre-discharge phase of care; 0.91 (P = 0.001) in the post-discharge phase of care.
The relative importance of all items
The rankings for each temporal phase of care exhibited a wide variability. Variability in rankings reflects a lack of complete agreement amongst respondents on which items were most important and is indicative of the relative importance of all items to patients. The inability of patients to agree consistently on the importance of any one item is more apparent when the actual score based on summed ranks is listed along with the number of times each item appeared as one of the top three and the number of times it was chosen as the most important item (Table III).
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). However, in all phases of care, the five topmost items possessed raw scores that often differed from their closest neighbour by no more than three units. The precise rank order of all topmost items depends on the response of a single patient.
In addition, virtually all items were ranked highly by at least one or two patients. All items except one were considered important enough to make the top three of at least one respondent (column 2, Table III). (The only item of the 36 that failed to make the top three of any respondent was item 5 in post-discharge care, "the hospital phones me in the first 72 hr to see how I'm doing".) Furthermore, in each temporal phases, at least five out of the nine items were considered a top item by at least one respondent (column 3, Table III).
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While both investigative groups provide important new evidence suggesting that patient preferences of post- operative adverse outcomes such as nausea and pain can be measured and should be factored into their care, they focused on only a select few post-operative outcomes chosen by the investigators and not patients themselves. No study in anesthesia has asked patients to prioritize what they most prefer in their care from a list of processes and outcomes that were also chosen first by patients themselves.
In this study, we asked patients and anesthesiologists to rank a list of elements of anesthesia care drawn from a comprehensive bank of items that were culled directly from detailed interviews with surgical outpatients. All items ranked were known to have been features or aspects of the anesthesia experience that were associated with positive or negative connotations in patients' accounts of their anesthesia experience. We administered a simple nominal ranking questionnaire comprised of 36 items representing all four temporal phases of anesthesia care to 30 surgical outpatients and an expert panel of 15 anesthesiologists. Although our sample size of patients and anesthesiologist sample was small, the results of nominal rankings of these items offer a number of preliminary insights into what patients value most in each temporal phase of their anesthesia care and the ability of anesthesiologists to predict it.
We found that, in agreement with numerous studies in peri-operative and medical care 1,8–13 patients undergoing anesthesia care value highly those elements of care that pertain directly to communication and information. In pre-operative care, patients placed the most weight on whether their concerns were identified and addressed. In the operative phase of care, patients prefer being spoken and attended to; and in both post-operative phases of care, they valued most being adequately provided with information about complications of surgery and anesthesia (if any) and post-discharge care. In all phases of anesthesia care conducted in hospital, patients placed the least weight on the physical environment of their care.
Anesthesiologists were unable to predict the priority that patients placed on different aspects of their pre- operative and intra-operative care primarily because they underestimated the value placed on information and communication by patients. In pre-operative care, patients and anesthesiologists both agreed on the importance of identifying and responding to concerns and questions. Patients, however, preferred greater interaction with the anesthesiologist (discussion of possible minor side effects and involvement in decisions about the anesthesia care itself) over the smooth and efficient pre-operative course that anesthesiologists predicted patients would value more. In intra-operative care, anesthesiologists were unable to anticipate the greater value to the patient of "the anesthesiologists or nurse talk(ing) to me as they ready me for the anesthestic" (patients rank 1; anesthesiogists rank 6) over "going to sleep quickly and smoothly" (patients rank 5; anesthesiologists rank 1). It is noteworthy that, in both phases of care, anesthesiologists over-estimated the value that patients placed on care that was smooth and trouble free.
Anesthesiologists demonstrated an excellent ability to predict the rank order of the items in the pre-discharge and post-discharge phases of care. The fact that both patients and anesthesiologists agree on the importance of minimizing and explaining outcomes or consequences of their care (relief of pain, prevention of nausea, smooth trouble-free discharge) supports the ongoing emphasis of outpatient anesthesia research on minimizing the frequency and severity of post-operative adverse events.14 Interestingly, however, the preparation, explanation and support given to post-operative outcomes appears as vital to patients as their frequency and severity.
Myles et al.15 reported similar findings when they examined in detail what patients valued in their post-anesthetic care during the psychometric development of a nine item post-anesthetic "quality of recovery" questionnaire. To guide item construction, these investigators asked patients, their relatives, doctors and nurses to rate in terms of importance a list of 61 potential items (developed by the investigators from a review of the literature). Doctors tended to underestimate the importance of all items to patients. For patients, virtually all items (57/61) had median scores of important or very important compared with less than half (30/61) for doctors. However, doctors and patients agreed on the three highest rated items (able to breathe easily, no severe pain, and able to understand). As in our study, post-operative aspects of care that scored highest in importance to patients were those pertaining to communication and support as well as the minimizing of adverse events such as pain and nausea.
The variability exhibited by the raw scores of nominal rankings indicates that the rank order must be interpreted with caution. The differences in the scores of topmost items were small and, in all temporal phases of care, actual topmost rank hinged on the response of a single patient. Furthermore, five of the nine items in any temporal phase were considered to be the most important by at least one patient and eight of nine were ranked in the top three by at least one patient. Eliminating even the lower ranked items in any specific temporal phase may discard items that represent issues of considerable importance to a significant number of patients. Therefore, using the ranked order of items does not allow us to decide which of the top ranked items are most reflective of quality or patient satisfaction with their anesthesia care. The relative priority of all items may be best confirmed through the use of psychometric techniques during pilot testing of a multi-item questionnaire.2
This study contains other important limitations. We surveyed a small convenience sample of Canadian outpatients from a community hospital and a tertiary care institution and compared it to the consensus opinion of a more diverse international panel of expert anesthesiologists. Further investigations will be necessary to determine whether similar rankings would be found in larger or different groups of patients or how patient rankings to a set of items would compare with the rankings made by their own anesthesiologists.
In conclusion, nominal rankings of items representing each of four temporal phases of anesthesia care suggest that patients value a number of elements of care in all four phases (rather than only one or two) and they tend to rank highest those elements representing information and communication. Physical conditions of care tend to be least valued. Anesthesiologists were better able to predict what patients valued in the post-operative phases of their care but undervalued the importance to patients of communication and information in pre-operative and intra-operative phases of care. While this small study cannot provide definitive answers, it suggests where improvements can be made that will lead to high quality of anesthesia care from the perspective of patients.
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Acknowledgments |
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Dr. D. Bevan, Dr. M. Bogetz, Dr. F. Chung, Dr. D. Craig, Dr. A. Davies, Dr. J. Davies, Dr. P. Duncan, Dr. C. Eagle, Dr. F. King, Dr., J. Lunn, Dr. F. Orkin, Dr. D.K. Rose, Dr. M. Sullivan, Dr. R. Twersky, and Dr. D. Yee.
Accepted for publication September 22, 2000.
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2
Fung D, Cohen MM. Measuring patient satisfaction with anesthesia care: a review of current methodology. Anesth Analg 1998; 87: 1089–98.
3 Ware JE, Snyder MK, Wright WR, Davies AR. Defining and measuring patient satisfaction with medical care. Evaluation and Program Planning 1983; 6: 247–63.[Medline]
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11 Meredith P. Patient satisfaction with communication in general surgery: problems of measurement and improvement. Soc Sci Med 1993; 5: 591–602.
12 Greenhow D, Howitt AJ, Kinnersley P. Patient satisfaction with referral to hospital: relationship to expectations, involvement, information-giving in the consultation. Br J Gen Pract 1998; 48: 911–2.[Medline]
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Myles PS, Hunt JO, Nightingale CE, et al. Development and psychometric testing of a quality of recovery score after general anesthesia and surgery in adults. Anesth Analg 1999; 88: 83–90.
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