Original Contributions
Determinants of Patient Satisfaction and Willingness to Return With Emergency Care,☆☆

Abstract presented at the Society for Academic Emergency Medicine annual meeting, Boston, MA, May 1999.
https://doi.org/10.1067/mem.2000.104195Get rights and content

Abstract

Study objective: To identify emergency department process of care measures that are significantly associated with satisfaction and willingness to return. Methods: Patient satisfaction and willingness to return at 5 urban, teaching hospital EDs were assessed. Baseline questionnaire, chart review, and 10-day follow-up telephone interviews were performed, and 38 process of care measures and 30 patient characteristic were collected for each respondent. Overall satisfaction was modeled with ordinal logistic regression. Willingness to return was modeled with logistic regression. Results: During a 1-month study period, 2,899 (84% of eligible) on-site questionnaires were completed. Telephone interviews were completed by 2,333 patients (80% of patients who completed a questionnaire). Patient-reported problems that were highly correlated with satisfaction included help not received when needed (odds ratio [OR] 0.345; 95% confidence interval [CI] 0.261 to 0.456), poor explanation of causes of problem (OR 0.434; 95% CI 0.345 to 0.546), not told about potential wait time (OR 0.479; 95% CI 0.399 to 0.577), not told when to resume normal activities (OR 0.691; 95% CI 0.531 to 0.901), poor explanation of test results (OR 0.647; 95% CI 0.495 to 0.845), and not told when to return to the ED (OR 0.656; 95% CI 0.494 to 0.871). Other process of care measures correlated with satisfaction include nonacute triage status (OR 0.701, 95% CI 0.578 to 0.851) and number of treatments in the ED (OR 1.164 per treatment; 95% CI 1.073 to 1.263). Patient characteristics that significantly predicted less satisfaction included younger age and black race. Determinants of willingness to return include poor explanation of causes of problem (OR 0.328; 95% CI 0.217 to 0.495), unable to leave a message for family (OR 0.391; 95% CI 0.226 to 0.677), not told about potential wait time (OR 0.561; 95% CI 0.381 to 0.825), poor explanation of test results (OR 0.541; 95% CI 0.347 to 0.846), and help not received when needed (OR 0.537; 95% CI 0.340 to 0.846). Patients with a chief complaint of hand laceration were less willing to return compared with a reference population of patients with abdominal pain. Willingness to return is strongly predicted by overall satisfaction (OR 2.601; 95% CI 2.292 to 2.951). Conclusion: These data identify specific process of care measures that are determinants of patient satisfaction and willingness to return. Efforts to increase patient satisfaction and willingness to return should focus on improving ED performance on these identified process measures. [Sun BC, Adams J, Orav EJ, Rucker DW, Brennan TA, Burstin HR. Determinants of patient satisfaction and willingness to return with emergency care. Ann Emerg Med. May 2000;35:426-434.]

Introduction

With the rise of medical consumerism, evaluation of patient satisfaction has become increasingly important for health care institutions. Satisfaction is one measure of health care quality and captures subjective dimensions of patients’ experiences. In addition, patient satisfaction in the ambulatory setting is correlated with other important outcomes, including higher medical compliance, decreased utilization of medical services, less malpractice litigation, and greater willingness to return.1, 2, 3, 4, 5 Faced with pressures to improve patient experiences and expand patient volume, health care institutions and administrators are developing instruments to study the determinants of patient satisfaction.6, 7, 8

A large body of research examines patient satisfaction in the inpatient and ambulatory settings.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14 Process of care measures that influence patient satisfaction include subjective and technical components of a medical interaction. Actual and perceived wait times,15, 16 ratings of nurse and physician empathy,6 and how perceptions of technical care15 affect patient satisfaction. Patient characteristics that influence satisfaction include demographic variables and health status. Elderly and high-income patients tend to have higher levels of satisfaction, whereas black, Hispanic, and non–English-speaking patients are reportedly less satisfied with their care.19 Furthermore, patients with good baseline health2, 11, 13 and regular access to medical care2 tend to be satisfied.

Satisfaction with emergency care is critical because of the high volume of patients seen in emergency departments.3 ED satisfaction is complicated by queues, wide variations in patient complaints and baseline health, and complexities of acute care. Unfortunately, essential determinants of patient satisfaction with emergency care are incompletely understood. The majority of the relevant literature has focused on the effects of individual variables, such as complaints, patient education, waiting times, and perceptions of technical competence, on patient satisfaction.3, 15, 16, 17, 18, 19, 20 These studies fail to adjust for the effects of patient characteristics and process of care measures on satisfaction. One prior study identified various process of care ratings as potential determinants of emergency care satisfaction.17 These findings, however, are limited by a small sample size and modest response rate.

Furthermore, little research has studied the effects of patient-reported problems on satisfaction. Most of the satisfaction literature has focused on the relationship between satisfaction and ratings of various aspects of care. Ratings measure patients’ evaluations of a process of care, whereas patient reports reflect perceptions of what occurred during a medical encounter. Patient reports have the advantage of providing information about discrete elements of care, and this information is important for targeted quality improvement efforts.21 Reports can also measure patients’ perception of whether or not an action occurred. This is different from ratings because a patient can only indirectly indicate the lack of a desired event by assigning a low score.

Finally, the predictors of willingness to return and the relationship between patient satisfaction and willingness to return to the ED have not been previously studied. The association between these 2 variables is ambiguous for emergency care, since factors such as location, preexisting relationships with the hospital, severity of illness, constraints placed by health insurance, and hospital reputation may have equal or greater importance than satisfaction.

This study examines the effects of process of care measures and patient characteristics on satisfaction and willingness to return with emergency care. It also studies the relationship between satisfaction and willingness to return. The findings of this research are being used to develop quality improvement programs at participating emergency departments.

Section snippets

Materials and methods

This study was conducted at 5 urban teaching hospital EDs in the same metropolitan area.22, 23 All EDs were staffed by resident physicians with attending physician supervision. None of the EDs had an emergency medicine training program at the time of the study. The ED directors, or their designates, served on the research team. This investigation was approved by the human subjects committees at each institution.

Data were collected from February through June 1995. During a 1-month study period

Results

During study hours, 3,455 eligible patients presented to the EDs, and 2,899 patients completed baseline questionnaires (84% of eligible population). Patients who left against medical advice represented 27 of all 6,005 patients who presented during the study periods. These patients did not have a medical chart review or a telephone follow-up interview performed. They were not analyzed further because of the small sample size and the lack of data. There were no significant differences in age,

Discussion

We identified discrete process of care measures that significantly affect patient satisfaction and willingness to return with emergency care. This research differs from prior ED satisfaction studies because of the focus on specific problems with care, the large sample size, high response rate of the survey, and the use of appropriate statistical methodology for analyzing ratings of overall care and willingness to return. To our knowledge, we are also the first to study the determinants of

References (31)

  • EJ Thomas et al.

    Patient noncompliance with medical advice after the emergency department visit

    Ann Emerg Med

    (1996)
  • CM Sox et al.

    Hospital admissions through the emergency department: does insurance status matter?

    Am J Med

    (1998)
  • GL. Weiss

    Patient satisfaction with primary medical care

    Med Care.

    (1988)
  • JM. Vaccarino

    Malpractice: the problem in perspective

    JAMA

    (1977)
  • GB Hickson et al.

    Obstetricians’ prior malpractice experience and patients’ satisfaction with care

    JAMA

    (1994)
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    Funding for the 1995 Harvard Emergency Department Quality Survey provided by the Harvard Risk Management Foundation. Supported by an Emergency Medicine Foundation/Society for Academic Emergency Medicine Medical Student Grant (Benjamin C. Sun).

    ☆☆

    Address for reprints: Helen Burstin, MD, MPH, Agency for Primary Care Research, Agency for Healthcare Research and Quality, 6010 Executive Boulevard, Rockville, MD 20852; 301-594-4028, fax 301-594-3721; E-mail [email protected].

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