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* From the Department of Anaesthesiology, Cantonal Hospital, St. Gallen, Switzerland;
Empirical Consulting, Freiburg, Germany;
Department of Anaesthesiology and Intensive Care Medicine, Landeskrankenhaus Feldkirch, Austria;
Department of Anaesthesiology, University Hospital of Bern, Switzerland;
¶ Picker Institut, Zug, Switzerland.
Address correspondence to: Dr. Thomas Heidegger, Department of Anaesthesiology, Cantonal Hospital, St. Gallen, Rorschacherstrasse 95, 9007 St. Gallen, Switzerland. Phone: +41-71-494-1509; Fax: +41-71-494-2889; E-mail: thomas.heidegger{at}kssg.ch
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Abstract |
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Methods: In 2000, we carried out an assessment of patient satisfaction with anesthesia care. "Information/involvement in decision making" was identified as the worst problem area. The three hospitals involved in this study introduced strategies to improve this dimension of patient satisfaction by launching information campaigns, producing or improving information brochures (particularly in hospitals A and C), and by expanding the preanesthetic care unit (hospital B). In 2002, a second survey was carried out. Each of the hospitals sent questionnaires to 600 elective surgery patients after discharge. We compared the total problem scores (the percentage of patients who responded that a problem was present) and the problem scores for the dimension ‘information/involvement in decision making’ between 2000 and 2002.
Results: The total problem score (mean in %, 95% confidence interval) for all three hospitals together remained unchanged [19% (1)], as well as the problem scores for each hospital [hospital A 16% (1), hospital B 21% (1), hospital C 20% (1)]. The problem score for ‘information/involvement in decision making’ remained unchanged also: 31% (29–33) in 2000 compared to 28% (26–30) in 2002.
Conclusion: Information campaigns and the introduction of information leaflets alone do not improve patient satisfaction with anesthesia care.
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Introduction |
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The goal of the present study was to evaluate if concrete measures taken to improve ‘information/involvement in decision making’ undertaken after the survey in 2000 would lead to an improvement in this dimension and decrease the total problem score.
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Methods |
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lists the actual measures taken in each hospital. For practical reasons, these varied from one institution to the other. Each hospital adopted specific measures which had a good chance of realization in the institution.
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The psychometric qualities of the dimensions were verified again in 2002.
The items of the questionnaire which measured potential problems, for example ‘Did you feel that the anesthesiologist gave you enough of his time?’ were dichotomized (i.e., were assigned to one of two groups depending on whether a problem was mentioned or not). For the above mentioned question the following answers were possible: ‘yes - completely’ (not a problem response); ‘yes - to a certain extent,’ and ‘no’ (problem responses). Therefore the problem score of the question is the percentage of patients who responded that a problem was present (in this example ‘yes - to a certain extent’ or ‘no’). The problem score for a dimension (group of items) is the proportion of problems mentioned for all relevant questions in the dimension. The total problem score is the percentage of problems mentioned regarding all questions measuring the quality of the anesthetic (for further details see Heidegger et al.3).
We compared the total problem score for all three hospitals together and for each hospital between 2000 and 2002. We also compared the problem scores for the dimension ‘information/involvement in decision making’ obtained in 2000 and 2002 for each of the hospitals and for all hospitals together. We focused on single-item analysis only where specific interventions were implemented and change could be expected.
Data are presented as means in % [95% confidence interval (CI)] or median (range) were appropriate; P < 0.05 for the comparison of means (ANOVA, t test) was considered significant. All analyses were conducted using the SPSS 10 analysis package (SPSS Inc., Chicago, IL, USA).
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Results |
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The psychometric qualities of the dimensions were very similar to those found in the first survey in 2000. Table II shows the six dimensions together with the results of the reliability analysis and the analysis of the importance of the dimensions using the standardized beta coefficients8 of multiple linear regression on the total problem score as the criterion. The dimension ‘information/involvement in decision making’ again had the greatest influence.
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). The problem scores for ‘information/involvement in decision making’ at all hospitals remained unchanged [31% (2) in 2000 vs 28% (2) in 2002] (P = ns).
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shows the results of single-item analysis of the dimension ‘information/involvement in decision making.’ Although there was an improvement in some areas where concrete interventions were taken, for example ‘information before anesthesia’ in hospital B [problem score decreased from 45 (CI 40–50) to 32 (CI 27–37), P < 0.001] and ‘privacy during preanesthetic talk’ in hospital B [36 (CI 31–41) vs (21 (CI 16–25), P < 0.001] (Table III) the problem score of the whole dimension did not change significantly.
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Discussion |
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In the present study we focused on items of the dimension ‘information’ where changes were expected, for example by improving privacy by providing single rooms in the preanesthetic care unit (intervention in hospital B). In this limited area there was an improvement.
Assessment of patient satisfaction with anesthesia care or interventions must use reliable and valid instruments.4–7 We found very similar psychometric qualities of the questionnaire between 2000 and 2002,3 demonstrating a high degree of stability of the instrument and its scales.
There are several potential reasons why we could not demonstrate an improvement of the total problem score. First, our strategies focused only on one dimension (‘information and involvement in decision making’) and not on other areas with a high problem score (‘continuity of personal care by anesthesiologist’) or a high importance (‘respect and confidence’).3 This resulted from an agreement of the participating hospitals which decided to focus primarily on the dimension with both a high problem score and a high importance. Second, we used a practical approach instead of a detailed breakdown of the interventions, as recommended by Hulscher et al.9 This means that each hospital took measures with a good chance of realization within their own department. The pragmatic nature of our design may have affected the results but it represents the real clinical impact of introducing leaflets and information campaigns. As Hulscher et al.9 further point out, it is also important to determine unsuccessful interventions, as in our case.
Another limitation is that we did not use evidence-based leaflets. Therefore the effectiveness of our leaflets in providing information is questionable. However, as O’Cathain et al.10 showed, even the use of evidence-based leaflets was not effective in promoting informed choice in women using maternity services.
A further limitation of the study is that we did not investigate the potential influence of improvement strategies directed towards ‘information and involvement in decision making’ on other dimensions, mainly ‘continuity of care.’ From an organizational point of view the preanesthetic visit is conducted more and more in preanesthetic care units (as in hospital B). As a result, the subsequent anesthetic is seldom administered by the same anesthesiologist.11 This probably has an influence on the patient’s perception of continuity of care and would therefore result in a dilemma, not only for the patient but also for the anesthesiologist and the process management of the hospitals, as recently pointed out by Simini et al.12 We focused only on inpatients because outpatients were not visited systematically postoperatively by an anesthesiologist and, therefore, this would render comparisons difficult.
In conclusion, information campaigns and introduction or improvement of information leaflets alone do not improve patient satisfaction with anesthesia care. We believe that measures destined to improve patient satisfaction with anesthesia care should be accompanied by other measures, such as improvement in communication skills. Further studies will determine the most effective strategies to improve patient satisfaction.
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Footnotes |
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Declaration of interest: Y. Husemann is the director of the Picker Institut in Switzerland, which partly funded this study.
Accepted for publication February 4, 2004. Revision accepted May 14, 2004.
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References |
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2 Myles PS, Williams DL, Hendrata M, Anderson H, Weeks AM. Patient satisfaction after anaesthesia and surgery: results of a prospective survey of 10 811 patients. Br J Anaesth 2000; 84: 6–10.
3 Heidegger T, Huseman Y, Nuebling M, et al. Patient satisfaction with anaesthesia care: development of a psychometric questionnaire and benchmarking among six hospitals in Switzerland and Austria. Br J Anaesth 2002; 89: 863–72.
4 Le May S, Hardy JF, Taillefer MC, Dupuis G. Patient satisfaction with anesthesia services. Can J Anesth 2001; 48: 153–61.
5 Fung D, Cohen MM. Measuring patient satisfaction with anesthesia care: a review of current methodology. Anesth Analg 1998; 87: 1089–98.
6 Sitzia J. How valid and reliable are patient satisfaction data? An analysis of 195 studies. Int J Qual Health Care 1999; 11: 319–28.
7 Wu CL, Naqibuddin M, Fleisher LA. Measurement of patient satisfaction as an outcome of regional anesthesia and analgesia: a systematic review. Reg Anesth Pain Med 2001; 26: 196–208.[Medline]
8 Streiner DL, Norman GR. Health Measurement Scales. A Practical Guide to their Development and Use, 2nd ed. Oxford: Oxford University Press; 1995.
9 Hulscher ME, Laurant MG, Grol RP. Process evaluation on quality improvement interventions. Qual Saf Health Care 2003; 12: 40–6.
10 O’Cathain A, Walters SJ, Nicholl JP, Thomas KJ, Kirkham M. Use of evidence based leaflets to promote informed choice in maternity care: randomised controlled trial in everyday practice. BMJ 2002; 324: 643–6.
11 Roizen ME. More preoperative assessment by physicians and less by laboratory tests (Editorial). N Engl J Med 2000; 342: 204–5.
12 Simini B, Bertolini G. Should same anaesthetist do pre-operative anaesthetic visit and give subsequent anaesthetic? Questionnaire survey of anaesthetists. BMJ 2003; 327: 79–80.
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