The Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 (together known as the Affordable Care Act) changed the way in which physicians and hospitals are evaluated and emphasized a trend in focusing on quality of care and patient satisfaction.1 With implementation of the Affordable Care Act, physicians and hospitals are evaluated based on the quality of care that they provide in addition to the number of patients they treat.2 Furthermore, the Centers for Medicare & Medicaid Services will link physician payment and hospital reimbursement to such quality measures.3
One measure of quality care that has been implemented through the Centers for Medicare & Medicaid Services is the Consumer Assessment of Healthcare Providers and Systems Survey (CAHPS). This survey assesses the quality of care based on patient satisfaction to understand the patient experience and employ accountability by increasing transparency of the health care system.4 Achieving high patient satisfaction scores promotes a patient-centered approach to health care, which has been linked to better health outcomes. These include increased adherence to treatment plans and a better outlook on the health care system as a whole.5–8 However, patient satisfaction is often not directly linked to patient outcomes, and reimbursement based on patient satisfaction presents the risk of incentives that do not align with optimal patient care.
Many studies have previously examined factors that effect patient satisfaction, such as wait time to see a physician, physician empathy, and patient expectations.9–11 Interestingly, there have been mixed results when examining the role of patient expectations on satisfaction.12–17 Although several studies have explored patient expectations in primary and urgent care settings, few have evaluated patient expectations in surgical specialty clinics. Hageman et al13 examined the role of patient expectations in an orthopedic clinic and concluded that met expectations correlated with satisfaction; however, they did not evaluate intervention expectations. In addition, when applied to specialty clinics, patient satisfaction has been linked to surgical outcomes rather than to the outcomes of individual referral appointments.18,19
Other studies have examined the vague definition of expectation itself in relation to what a patient realistically expects and what he or she ideally expects from the health care system.16 No studies have evaluated the role of patients' expectations for interventions in a surgical specialty clinic. The goal of this study was to examine the role that patients' expectations, and in particular their expectations of intervention, play in determining patients' satisfaction in orthopedic specialty clinics.
Materials and Methods
Institutional review board approval was obtained prior to initiation of this study. Patients were surveyed in 3 orthopedic specialty clinics between June 2015 and September 2015: 2 joint replacement clinics and 1 sports medicine clinic. Patients new to the provider who agreed to enroll in the study (N=126, age range, 18–87 years) were given 2 surveys during their appointment. Verbal consent was provided before patients participated. The inclusion criteria consisted of all patients older than 18 years, English-speaking, and nonincarcerated individuals who agreed to enroll. Surveys were considered complete with presence of a Likert scale for the provider, as well as preexpectation and post-intervention data provided. All patients completed this portion of the survey but some demographic data were not recorded and reported (Table 1).
Patient Demographics (N=126)
Patients were given a total of 2 surveys and were asked to complete them before and after their appointment. Patients were given a pre-visit questionnaire while they waited in an examination room for the physician. Patients were then given a post-visit questionnaire after their appointments to complete before leaving the clinic. Patients were instructed to complete the surveys anonymously.
Patients were asked to select common orthopedic interventions that they expected to receive during their appointments (advice and education, recommendation for surgery, prescription for narcotic medication, prescription for anti-inflammatory medication, joint or muscle injection, or prescription for physical therapy). Patients were also asked about their expectations of physician treatment (understanding, listening, respect) on a 3-point scale (1, “Yes, definitely”; 2, “Yes, somewhat”; and 3, “No”), based on the CAHPS survey. Patients were asked to answer based on realistic and ideal expectations. Answers of 1 an 2 were included together. Realistic expectations were used in the data analysis, and no significant differences were found between ideal and realistic expectations.
Patients reported the outcomes of their appointments and rated their physicians on Likert scales based on the CAHPS survey. Physician rating was used as a measurable marker for patient satisfaction. Patients were also asked about their education, mental and emotional health, tobacco use, marital status, and age on the post-visit questionnaire.
Data were recorded in REDCAP software (version 8; Vanderbilt University, Nashville, Tennessee). Calculations were performed using SPSS version 23 software (IBM Corp, Armonk, New York). Previous literature was used to determine the sample size needed. An a priori power analysis indicated that a sample of 77 patients would provide 80% statistical power, with alpha set at 0.05. An additional 49 patients were added to decrease the risk of a type II error given the ease of patient enrollment and limited invasiveness of the survey.
Demographic data were obtained (Table 1). Means were calculated from responses in each category and subgroup. Likert scores were compared with Wilcoxon–Mann–Whitney tests and 2-tailed t tests were performed to determine significance at P<.05. Spearman correlations were used to test for a correlation between continuous variables. Analysis of variance was used to test for differences in physician satisfaction with multiple groups.
All patients entered their visit with at least 1 expectation, with most patients expecting advice/education (Figure 1). Forty-five percent of patients who expected a common orthopedic intervention had an unmet expectation (Table 2). For the individual interventions, unmet expectations ranged from 14% of patients expecting education and advice to 83% of patients expecting physical therapy (Figure 2). When comparing the number of unmet expectations, 25% of all patients had 1 unmet expectation, with 20% having 2 or more unmet expectations (Table 2).
Patients who reported expectations for common orthopedic interventions. Abbreviation: NSAIDS, nonsteroidal anti-inflammatory drugs.
Physician Rating for Patients With Met Versus Unmet Expectations
Patients who reported unmet expectations for common orthopedic interventions. Abbreviation: NSAIDS, nonsteroidal anti-inflammatory drugs.
Patients ranked their provider on a scale from 0 (worst provider possible) to 10 (best provider possible), as a measure of their satisfaction for their overall appointments. Mean satisfaction scores were compared among patients expecting to receive common orthopedic interventions (Table 3), as well as with the number of unmet expectations (Table 2). Overall, patients who had any unmet expectation had a statistically significantly lower physician rating than patients with all expectations met. No statistically significant correlation was found between physician rating and increasing numbers of unmet expectations.
Physician Rating for Patients Expecting Interventions
When evaluating individual interventions, patients who expected to receive a recommendation for surgery but did not receive it had a statistically significant lower physician rating than patients who did receive a recommendation for surgery (Table 3). No other statistically significant difference was found when evaluating individual interventions. No statistical evaluation was performed in physician perception factors (physician listening, understanding, and explaining) because all patients who responded listed their physician as receiving the highest score for each factor. No statistically significant difference was found in physician rating between the 3 providers when comparing individual providers or when comparing wait time (P>.05).
This study evaluated the role that patient expectation plays in determining patient satisfaction in 2 orthopedic specialty clinics. Patients with unmet expectations regarding a surgical recommendation, as well as patients with any unmet expectation, rated their physician lower on the Likert scale compared to those who had expectations met. No association was found between wait time or physician factors that have previously been evaluated in orthopedic clinics.10,13 The results of this study and of previous literature demonstrate the difficulty in using patient satisfaction to measure patient care because other factors can influence patient satisfaction scores.
This finding is important in a setting where physician and hospital reimbursement is tied to patient satisfaction. The physician rating scale is a component of the CAHPS and has been used to evaluate physician and hospital performance. There are concerns that physicians will be incentivized to cater their decision making to “improve” patient satisfaction scores as opposed to providing the best patient care. In a surgical clinic, if patients provide higher satisfaction scores when their surgical expectations are met, it may incentivize providers to provide surgery when they otherwise would not.
However, the lack of significant difference in other interventions does not support that all patient expectations affect satisfaction. The difference between a surgical decision and the other interventions that did not reach statistical significance could be explained by the their exclusivity to a surgical clinic. Surgical decisions are unique in that they can only be obtained through a surgical clinic. The other interventions included in this study could be performed at a primary care office and patients may not feel as dependent on the surgical clinic for these interventions, which decreases their impact on satisfaction and ultimately their surgeon's rating. It is also possible that a patient whose condition has already failed multiple interventions provided elsewhere, such as a steroid injection and prescription pain relievers, or who has been given surgical expectations by another patient or provider may have a higher expectation for surgical management of his or her condition, regardless of alternatives offered by the surgeon.
Although this study illustrates that patients who left their appointments with unmet expectations were more likely to provide lower satisfaction scores, it is important to consider that most patients still provided high satisfaction scores. Given that all patients in the current study indicated that their conditions were explained to them and that their physicians listened to them and respected them, there could be a greater role of patient communication than meeting expectations. It is possible that these factors are more important to patient satisfaction than interventions are because they have previously been shown to influence satisfaction.13 Educating patients about their condition is associated with less patient anxiety and may contribute to their physician rating and satisfaction.20–24 A patient's lack of education about his or her disease process can influence expectations before and after their appointment, and providers should be prepared to understand and address these expectations to provide best patient care and satisfaction.
It is important to note some of the limitations of this study. The sample population only included 126 patients and 3 physicians (2 in the joint specialty clinic [C.W.O., D.J.D.], and 1 in the sports medicine clinic [G.V.K.]) at a tertiary referral center. The study population may not be applicable to all practices. As a state institution, a large number of patients at this center are referred by other orthopedists or primary care providers and, therefore, may have higher expectations for intervention or have more complicated issues. The sample size was powered appropriately to measure all met vs unmet expectations but was not powered to identify statistical differences between individual interventions and may be susceptible to a type II error. Finally, participants were asked to agree to enter in the study, leading to possible selection bias because patients who had particularly good or poor care may more readily report their satisfaction.
To the authors' knowledge, this is the only study that reports on the association between pre-visit intervention expectations and their effect on physician rating in an orthopedic clinic. Patient expectations for intervention affected physician ratings and patient satisfaction, particularly with an expectation for surgery. Reimbursement structures involving patient satisfaction should take into account the possibility that expectations may alter patient satisfaction.
- Rangel C.H.R. 3590: 111th Congress (2009–2010): Patient Protection and Affordable Care Act. https://www.congress.gov/bill/111th-congress/house-bill/3590. Accessed May 14, 2016.
- HCAHPS Hospital Survey. http://www.hcahpsonline.org/facts.aspx. Accessed May 14, 2016.
- QualityNet: scoring. http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier3&cid=1228772237147. Accessed May 14, 2016.
- HCAHPS: Patients' Perspectives of Care Survey. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-instruments/HospitalQualityInits/HospitalHCAHPS.html. Accessed May 14, 2016.
- Kane RL, Maciejewski M, Finch M. The relationship of patient satisfaction with care and clinical outcomes. Med Care. 1997;35(7):714–730. doi:10.1097/00005650-199707000-00005 [CrossRef] PMID:9219498
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Patient Demographics (N=126)
|Sex, No. (%)|
| Male||64 (51)|
| Female||62 (49)|
|Age, mean (range), y||56.79 (18–81)|
|Education, No. (%)|
| 8th grade or less||4 (3)|
| Some high school||6 (5)|
| High school degree||22 (17)|
| Some college||39 (31)|
| 4-year college degree||18 (14)|
| More than 4 years of college||26 (21)|
| No response||11 (9)|
|Mental health perception, No. (%)|
| Poor||3 (2)|
| Fair||3 (2)|
| Good||28 (23)|
| Very good||47 (37)|
| Excellent||36 (29)|
| No response||9 (7)|
|Tobacco use, No. (%)|
| Yes||19 (15)|
| No||99 (79)|
| No response||8 (6)|
|Marital status, No. (%)|
| Single||23 (18)|
| Married/partner||69 (55)|
| Separated/divorced||13 (10)|
| Widowed||8 (7)|
| Other/no response||13 (10)|
|Physician, No. (%)|
| Surgeon 1||47 (37)|
| Surgeon 2||49 (39)|
| Surgeon 3||30 (24)|
|Wait time <15 min, No. (%)|
| Yes||85 (67)|
| No||36 (29)|
| No response||5 (4)|
Physician Rating for Patients With Met Versus Unmet Expectationsa
|No. of Expected Interventions Unmet||No. of Patients (% of Total No.)||Mean (±SD) Physician Rating Expected and Met|
|Any no. of unmet expectations||57 (45)||9.0 (±1.4)|
|0||69 (55)||9.5 (±0.8)b|
|1||32 (25)||8.9 (±1.6)|
|2||16 (13)||8.8 (±1.4)|
|3||5 (4)||9.6 (±0.6)|
|4||0 (0)||Not applicable|
Physician Rating for Patients Expecting Interventionsa
|Intervention||Mean±SD No. of Factors||P|
|Expected and Met||Expected and Unmet|
|Nonsteroidal anti-inflammatory drugs||7.4±2.5||9.3±6.8||.161|