Patient satisfaction is becoming widely recognized as a key determinant of patient experience and quality of care.1 Metrics on patient satisfaction have growing implications for reimbursement, especially for patients insured through the Centers for Medicare & Medicaid Services (CMS).2 For example, the CMS considers “patient experience of care” 1 of 5 domains constituting excellent care in an accountable care organization.3,4 Increased patient satisfaction also has been linked to increased compliance with treatment plans, increased referrals, increased revenues, and decreased malpractice suits for physicians.2 Patient satisfaction is multifactorial, and although it remains an important aspect of patient care, few orthopedic studies have investigated patient satisfaction. A recent study among orthopedic patients with upper extremity symptoms showed that wait time, not time with the provider, was associated with patient satisfaction.5 Research in the primary care setting has suggested that both time with the provider and clinic wait time are key determinants of patient satisfaction.6–9
Although patient satisfaction is subjective, many tools are used to provide a quantitative measure of this consideration.10 The Consumer Assessment of Healthcare Providers and Systems survey (CAHPS) is a federally developed and validated survey that is commonly used to assess patient satisfaction.5,9 The CAHPS survey has been used to measure satisfaction among orthopedic patients in the clinical setting.5,10 In addition to satisfaction, a more traditional measure of quality in health care is functional outcome. The Patient Reported Outcomes Measurement Information System (PROMIS) Physical Function item bank is a 124-item questionnaire that provides valid, reliable, and comparable results to assess the functional status of orthopedic patients.11 In addition, PROMIS question banks for depression and pain are available to provide comparable results between patients for these outcome measures. Despite the attention paid to patient functional outcome by policymakers and the intuitive importance of this metric, few studies have explored the relationship between patient satisfaction and functional outcome.
Although recent literature showed an association between patient satisfaction and both clinic wait time and time with the provider in certain clinical settings, this relationship has not been fully explored among orthopedic patients.5,8,12 Research on this topic in the orthopedic literature has been limited to 1 study of patients with upper extremity symptoms.5 The primary goal of this study was to determine whether patient satisfaction is associated with clinic wait time and time with the provider among orthopedic patients with lower extremity symptoms. A secondary goal was to evaluate the relationship between patient satisfaction and patient functional outcome, as measured by the PROMIS scores for physical function, depression, and pain.
Materials and Methods
Institutional review board approval was obtained before implementation of this prospective cohort study. Patients were enrolled prospectively over the course of 8 weeks, from February 2015 to April 2015, at a foot and ankle clinic and 2 adult reconstruction clinics at the authors' tertiary academic medical center. All new and return patients were included in this study. Additional inclusion criteria were patient age older than 18 years and clinic visits to 1 of the 3 providers participating in the study (C.W.O., D.J.D., J.N.T.). Patients were excluded if they were being evaluated for an upper extremity symptom or if they could not read or speak English.
A total of 187 patients were eligible for the study. Five patients elected not to participate, citing a lack of interest. The remaining 182 patients participated and were included in the final analysis. A total of 89 patients were enrolled from the foot and ankle clinic, and 93 patients were enrolled from the adult reconstruction clinics. Patients were enrolled by a member of the research team after they were taken to an examination room. For each patient, the check-in time at the clinic front desk was noted in the electronic medical record. The time that each patient was taken to the examination room was documented manually by the researchers, as was the time that the patient was first seen in the clinic examination room by the attending physician. Subsequently, the time that the attending physician left the room was documented manually and used to calculate the total time with the surgeon. At the end of the visit, each patient completed the PROMIS and CAHPS surveys. The CAHPS questionnaire was completed on paper and included demographic information, including educational level and marital status. The PROMIS surveys were completed on a tablet computer through Assessment Center (Northwestern University, Evanston, Illinois), which allows for web-based data collection.
Patient satisfaction was measured with 7 items from the CAHPS survey. Five questions assessed the experience of care: (1) Did the provider listen carefully to you? (2) Did the provider spend enough time with you? (3) Did the provider show respect for what you had to say? (4) Did the provider explain things in a way that was easy to understand? (5) Would you recommend this provider to your friends and family? Answer choices included the following: yes, definitely; yes, somewhat; and no. To evaluate for any possible provider effect that may have influenced the overall results, top box scores were compared across each of the 3 providers for the following 3 questions: Did the provider listen carefully to you? Did the provider show respect for what you had to say? Did the provider explain things in a way that was easy to understand?
Patients were also asked whether they were seen within 15 minutes of their appointment time, with possible responses of yes and no. Finally, patients were asked to rate their provider on an 11-point ordinal scale from 0 to 10, with the highest score denoting the best possible provider. To score the CAHPS survey, the authors followed the top box scoring system, as developed and reported by the CMS, which refers to the percentage of patients who selected only the most positive response to a given question.13 With the top box scoring system, an answer of “yes, always” is awarded 1 point and an answer of “yes, sometimes” or “no” is awarded 0 points. On the 11-point provider scale, scores of 9 and 10 are awarded 1 point, whereas any answer from 0 to 8 is awarded 0 points. The CAHPS survey does not provide a composite patient satisfaction score, so the authors used the 0-to-10 provider rating as a surrogate for overall patient satisfaction.
This study used computerized adaptive testing instruments for the PROMIS questionnaires. These instruments allow the patient to use a tablet computer to answer a series of questions in a progressive manner, with each question determined by the answer to the previous question. Each PROMIS question is formatted with 5 answer choices on a 5-point Likert scale, and each answer choice contributes to the final composite score. The PROMIS scores are reported on a scale of 0 to 100 points, with a score of 50 representing the average score for the general public. Each PROMIS survey used in this study was validated previously to measure how much each patient's pain, physical function, and depression interfere with the patient's daily activities.11,14,15
The authors used previously published literature to determine the sample size needed for this study. Teunis et al5 found a correlation coefficient of −0.3 between clinic wait time and patient satisfaction. An a priori power analysis indicated that a total of 84 patients would provide 80% statistical power, with α=0.05, given a correlation coefficient of −0.3 between clinic wait time and patient satisfaction, with an average wait time of 30 minutes. The authors increased the estimated sample size of 84 patients to a total of 182 patients to decrease the probability of a type II error.
Patients were compared on the basis of clinic type to evaluate the population and on the basis of top box (9–10) vs low box (0–8) provider rating. Statistical analyses were conducted with SPSS version 21 software (IBM Corp, Armonk, New York). Dichotomous variables were compared with chi-square tests except in cases with small expected values, which violate the assumptions of chi-square testing. In these cases, 2-tailed Fisher's exact tests were used. Continuous variables were tested for normality with Kolmogorv-Smirnov tests. Parametric variables were compared with Student's t tests and reported as mean±SD. Nonparametric variables were compared with Mann-Whitney U tests and reported as median (interquartile range). Statistical significance was determined with α=0.05.
The study population included a total of 182 patients, including 89 patients seen at a foot and ankle clinic and 93 patients seen at adult reconstruction clinics. These 2 groups resembled each other in composition, with similar levels of education and self-reported mental health, a similar proportion of new patients, a similar rate of tobacco use, and a nearly identical ratio of male to female patients. The reconstruction group was older on average (P<.001), was less likely to be single (P<.001), was more likely to be widowed (P<.001), and was more likely to report favorable mental health (P=.004) (Table 1). No significant difference was found in the proportion of top box scores for providers in terms of ability to show respect for patients (P=.335), ability to listen carefully to patients (P=.237), or ability to explain things to patients in a way that was easy to understand (P=.101).
Time spent waiting to see the orthopedic surgeon was not associated with patient satisfaction (P=.625). A significant correlation was found between time spent with the surgeon and overall patient satisfaction (P=.037). A correlation between older age and increased satisfaction was also identified (P=.024). No correlation was found between satisfaction and PROMIS score for physical function (P=.790), pain (P=.769), or depression (P=.242). Additionally, satisfaction was not correlated with education level, sex, marital status, evaluation by a resident physician before seeing the attending surgeon, self-reported mental health, self-reported tobacco use, or the type of clinic visit (Table 2). Perceived wait time was subject to a high level of error among orthopedic patients, and most patients did not report accurately whether they had been waiting longer than 15 minutes to see a provider until they had waited for more than 60 minutes (P=.007) (Figure).
Correlations With Provider Rating
Perceived vs actual wait time. P values compare individual adjacent columns.
Time with the provider was associated with increased patient satisfaction among orthopedic patients with lower extremity symptoms, but clinic wait time was not. Age was also identified as a key determinant of patient satisfaction in this study. Perceived wait time was subject to a high level of error in the study population, with most patients unable to report accurately whether they had waited longer than 15 minutes to see the orthopedic surgeon until they had waited more than 1 hour.
The current findings are in contrast to a previously published report of patient satisfaction among orthopedic patients with upper extremity symptoms. Teunis et al5 found that increased patient satisfaction was associated with decreased clinic wait time and that time with the provider was not. A potential explanation for these conflicting results is that the current patient population was slightly older than the patient population in the study by Teunis et al.5 In the current study, average patient age was 55 years compared with 49 years in the study of Teunis et al.5 The current study found higher satisfaction scores among older patients. It is well documented that older patients tend to report increased overall satisfaction scores compared with younger patients.6,16 In addition, older patients are more likely than younger patients to give providers higher satisfaction scores, despite equally long wait times.17 There are likely inherent differences between younger and older patients with regard to how these patients value wait time. In the context of these reports, the current findings suggest that various patient subpopulations value clinic wait time differently. Therefore, focusing solely on clinic wait time may not yield consistently higher patient satisfaction scores.
The finding that increased time with the provider is correlated with increased patient satisfaction is consistent with the primary care literature.6,8 However, some communication experts have emphasized the quality of the visit over the amount of time spent with the provider.18 Given these earlier findings and the current findings, efforts to improve patient satisfaction may be most successful by targeting both the duration and the quality of time spent with the provider.6–8
No correlation was found in the current study between patient satisfaction and depression, pain, or physical function, as measured by PROMIS scores. This result is in conflict with a previous study of patients with lower extremity trauma.19 However, the current findings are consistent with those of Teunis et al.5 These authors also did not show a correlation between patient satisfaction and pain, depression, and physical function, as measured by PROMIS scores. This discordance in the literature may be attributable to differences between patients with trauma and those with more chronic conditions. Patients with chronic conditions constitute the majority of the population of the current study. Patients with trauma may be more sensitive to recent changes in levels of pain, depression, and physical function than patients with chronic conditions, who have had more time to acclimate to gradual changes in these categories.
The relationship between perceived wait time and actual wait time is not well understood, but previous research in other areas of medicine showed that patients often underestimate the amount of time they spend waiting for appointments or waiting to see a physician.20,21 The current findings are similar to previous reports because the current patients were likely to underestimate how long they had to wait before seeing the provider.
This study had several limitations. First, although including patients treated by 3 different providers increased the generalizability of the data, it increased the effect of different provider characteristics and practice patterns. The authors attempted to enroll an equal number of patients from both the foot and ankle clinic and the adult reconstruction clinics to mitigate this possible effect. The analysis also evaluated for possible provider effect to determine whether this effect was present. The study found no patient-reported differences in top box scores for the 3 providers included in this study in terms of overall communication skills. Second, the generalizability of the findings may be limited because the study setting was in a more rural environment than previous orthopedic studies of clinic wait time and patient satisfaction. Patients in an urban environment may be more sensitive to longer waiting times, given the inherent time constraints associated with daily life in a larger urban setting. Third, although the CAHPS survey is the most widely accepted tool for measuring patient satisfaction, it does not provide an aggregate patient satisfaction score. Therefore, in the current study, provider rating was used as a surrogate for patient satisfaction. The authors believe that this metric best encompasses the overall patient experience and is most relevant to CMS policies. Fourth, although the use of top box scoring reduces variability in patient responses, this scoring method has been adopted by CMS and will likely be the way that the CAHPS survey is used to compare physicians and group practices in the future.22
The study findings suggest that time spent with the surgeon was associated with patient satisfaction. In contrast, clinic wait time was not. Further, the study found that perceived wait time was subject to a high level of error, with many patients underestimating the amount of time they spent waiting to see the surgeon. Based on the study findings, a potential strategy for improving patient satisfaction may be for surgeons to spend more time with each patient, even at the expense of increased wait time. The study also found that age is a key determinant of patient satisfaction, suggesting that CMS should use this variable for risk adjustment of reimbursement policies that incorporate satisfaction scores.
- Morris BJ, Jahangir AA, Sethi MK. Patient satisfaction: an emerging health policy issue. AAOS Now. 2013. http://www.aaos.org/news/aaosnow/jun13/advocacy5.asp. Accessed August 23, 2015.
- Shirley ED, Sanders JO. Patient satisfaction: implications and predictors of success. J Bone Joint Surg Am. 2013; 95(10):e69. doi:10.2106/JBJS.L.01048 [CrossRef]
- Rogers F, Horst M, To T, et al. Factors associated with patient satisfaction scores for physician care in trauma patients. J Trauma Acute Care Surg. 2013; 75(1):110–114. doi:10.1097/TA.0b013e318298484f [CrossRef]
- Centers for Medicare & Medicaid Services. Accountable Care Organization 2013: Program Analysis. Quality Performance Standards: Narrative Measure Specifications. https://www.cms.gov/medicare/medicare-fee-for-service-payment/sharedsavingspro-gram/downloads/aco-narrativemeasures-specs.pdf. Accessed March 26, 2015.
- Teunis T, Thornton ER, Jayakumar P, Ring D. Time seeing a hand surgeon is not associated with patient satisfaction. Clin Orthop Relat Res. 2015; 473(7):2362–2368. doi:10.1007/s11999-014-4090-z [CrossRef]
- Gross DA, Zyzanski SJ, Borawski EA, Cebul RD, Stange KC. Patient satisfaction with time spent with their physician. J Fam Pract. 1998; 47(2):133–137.
- Lin CT, Albertson GA, Schilling LM, et al. Is patients' perception of time spent with the physician a determinant of ambulatory patient satisfaction?Arch Intern Med. 2001; 161(11):1437–1442. doi:10.1001/archinte.161.11.1437 [CrossRef]
- Anderson RT, Camacho FT, Balkrishnan R. Willing to wait? The influence of patient wait time on satisfaction with primary care. BMC Health Serv Res. 2007; 7:31. doi:10.1186/1472-6963-7-31 [CrossRef]
- Bleustein C, Rothschild DB, Valen A, Valatis E, Schweitzer L, Jones R. Wait times, patient satisfaction scores, and the perception of care. Am J Manag Care. 2014; 20(5):393–400.
- Graham B, Green A, James M, Katz J, Swiontkowski M. Measuring patient satisfaction in orthopaedic surgery. J Bone Joint Surg Am. 2015; 97(1):80–84. doi:10.2106/JBJS.N.00811 [CrossRef]
- Hung M, Clegg DO, Greene T, Saltzman CL. Evaluation of the PROMIS physical function item bank in orthopaedic patients. J Orthop Res. 2011; 29(6):947–953. doi:10.1002/jor.21308 [CrossRef]
- McMullen M, Netland PA. Wait time as a driver of overall patient satisfaction in an ophthalmology clinic. Clin Ophthalmol. 2013; 7:1655–1660.
- American Institutes of Research. How to Report Results of the CAHPS Clinician & Group Survey. https://www.facs.org/∼/media/files/advocacy/cahps/how%20to%20report%20results.ashx. Accessed August 23, 2015.
- Amtmann D, Cook KF, Jensen MP, et al. Development of a PROMIS item bank to measure pain interference. Pain. 2010; 150(1):173–182. doi:10.1016/j.pain.2010.04.025 [CrossRef]
- Pilkonis PA, Choi SW, Reise SP, et al. Item banks for measuring emotional distress from the Patient-Reported Outcomes Measurement Information System (PROMIS): depression, anxiety, and anger. Assessment. 2011; 18(3):263–283. doi:10.1177/1073191111411667 [CrossRef]
- Jackson JL, Chamberlin J, Kroenke K. Predictors of patient satisfaction. Soc Sci Med. 2001; 52(4):609–620. doi:10.1016/S0277-9536(00)00164-7 [CrossRef]
- Kong MC, Camacho FT, Feldman SR, Anderson RT, Balkrishnan R. Correlates of patient satisfaction with physician visit: differences between elderly and non-elderly survey respondents. Health Qual Life Outcomes. 2007; 5:62. doi:10.1186/1477-7525-5-62 [CrossRef]
- American Academy of Orthopaedic Surgeons.Patient-physician communication, information statement 1017. AAOS Now. 2011; 4:1–10. http://www.aaos.org/uploadedFiles/PreProduction/About/Opinion_Statements/advistmt/1017%20Patient-Physician%20Communication.pdf. Accessed August 23, 2015.
- O'Toole RV, Castillo RC, Pollak AN, MacKenzie EJ, Bosse MJLEAP Study Group. Determinants of patient satisfaction after severe lower-extremity injuries. J Bone Joint Surg Am. 2008; 90(6):1206–1211. doi:10.2106/JBJS.G.00492 [CrossRef]
- De Man S, Vlerick P, Gemmel P, De Bondt P, Matthys D, Dierckx RA. Impact of waiting on the perception of service quality in nuclear medicine. Nucl Med Commun. 2005; 26(6):541–547. doi:10.1097/00006231-200506000-00010 [CrossRef]
- Becker F, Douglass S. The ecology of the patient visit: physical attractiveness, waiting times, and perceived quality of care. J Ambul Care Manage. 2008; 31(2):128–141. doi:10.1097/01.JAC.0000314703.34795.44 [CrossRef]
- Centers for Medicare & Medicaid Services. Medicare program: hospital inpatient value-based purchasing program. Fed Regist. 2011; 76(88):26490–26547.
|Demographic||Total||Foot and Ankle||Adult Reconstruction||P|
|Patients, No.||182 (100%)||89 (49%)||93 (51%)||.675|
|Age, mean (range), y||58 (42–68)||44 (30–58)||67 (59–76)||<.001|
|Education level, No.|
| Did not complete high school/GED||16 (9%)||9 (10%)||7 (8%)||.538|
| Completed high school/GED||96 (53%)||49 (55%)||47 (51%)||.542|
| Completed college or more||70 (38%)||31 (35%)||39 (42%)||.325|
| Female||115 (63%)||56 (63%)||59 (63%)|
| Male||67 (37%)||33 (37%)||34 (37%)|
|Marital status, No.|
| Single||36 (20%)||30 (34%)||6 (6%)||<.001|
| Married||93 (51%)||40 (45%)||53 (57%)||.104|
| Divorced||25 (14%)||14 (16%)||11 (12%)||.445|
| Widowed||28 (15%)||5 (6%)||23 (25%)||<.001|
|Seen by resident before attending, No.||.661|
| Yes||93 (51%)||44 (49%)||49 (53%)|
| No||89 (49%)||45 (51%)||44 (47%)|
|Self-reported mental health, No.||.004|
| Fair or poor||17 (9%)||14 (16%)||3 (3%)|
| Good, very good, or excellent||165 (91%)||75 (84%)||90 (97%)|
|Tobacco use, No.||.899|
| Yes||28 (15%)||14 (16%)||14 (15%)|
| No||154 (85%)||75 (84%)||79 (85%)|
|Visit type, No.|
| New||56 (31%)||30 (34%)||26 (28%)||.401|
| Return||81 (45%)||35 (39%)||46 (49%)||.169|
| Postoperative||45 (25%)||24 (27%)||21 (23%)||.493|
Correlations With Provider Ratinga
|Low Box (n=21)||Top Box (n=161)|
|Age, mean (range), y||50 (31–61)||59 (43–70)||.024|
|Education level, No.|
| Did not complete high school/GED||2 (13%)||14 (88%)||.904|
| Completed high school or GED||11 (11%)||85 (89%)||.995|
| Completed college or more||8 (11%)||62 (89%)||Ref.|
| Female||15 (13%)||100 (87%)|
| Male||6 (9%)||61 (91%)|
|Marital status, No.|
| Single||7 (19%)||29 (81%)||.140|
| Married||9 (10%)||84 (90%)||.422|
| Divorced||2 (8%)||23 (92%)||.743|
| Widowed||3 (11%)||25 (89%)||1.000|
|PROMIS depression, mean±SD||53±8||51±10||.242|
|PROMIS pain, mean (range)||60 (54–69)||62 (56–67)||.769|
|PROMIS physical function, mean (range)||35 (30–46)||37 (32–43)||.790|
|Seen by resident before attending, No.||.292|
| Yes||13 (14%)||80 (86%)|
| No||8 (9%)||81 (91%)|
|Self-reported mental health, No.||.226|
| Fair or poor||0 (0%)||17 (100%)|
| Good, very good, or excellent||21 (13%)||144 (87%)|
|Time waiting, mean (range), min||41 (19–69)||42 (27–62)||.625|
|Time with surgeon, mean (range), min||8 (5–11)||10 (6–15)||.037|
|Tobacco use, No.||.538|
| Yes||17 (11%)||137 (89%)|
| No||4 (14%)||24 (86%)|
|Visit type, No.|
| New||9 (16%)||47 (84%)||.202|
| Return||9 (11%)||72 (89%)||.872|
| Postoperative||3 (7%)||42 (93%)||.238|