AN INTEGRATIVE REVIEW ON PATIENT SATISFACTION MEASURING TOOL FOR PHYSIOTHERAPY CARE AMONG CLIENTS IN THE OUT-PATIENT DEPARTMENT

ABSTRACT

BACKGROUND AND AIMS

Patient satisfaction is acknowledged as the corner stone of quality management and it is the paramount of any quality management program in health care system. This study is aimed to conduct an up-to-date systematic review on different validated tools that provide quantification of patient satisfaction in out-patient physical therapy services.

LITERATURE SEARCH & DATA EXTRACTION

The process of data extraction was performed in accordance with PRISMA guidelines. An extensive literature search was performed using 3 electronic database systems (Google scholar, PubMed, and PEDro) for articles published between 2000 and 2020. Boolean operator AND was used in compilation with the exhaustive list of search terminologies. A total of 19 studies that investigated any patient satisfaction tool in outpatient physiotherapy settings were included.

RESULTS

Consensus based standards for the selection of health status measurement instruments (COSMIN) scoring quantified psychometric property of each study as excellent, good, and fair. 8 studies reflected fair scoring of Cronbach alpha, 3 studies showed excellent whereas, 2 appeared to be poor.

CONCLUSION

The COSMIN scoring quantified multiple patient satisfaction tools. However, no gold standard was found. Nevertheless, physiotherapists working in out-patient care can increase the efficiency of patient-centered treatment by identifying and maximizing these patient satisfaction tool determinants.

KEYWORDS

Satisfaction, Physical therapy, Satisfaction Tool, Psychometrics, Health care, Health Services

Joel Rey Acob

Faculty of Nursing

Visayas State University

Baybay City, Philippines

[Acob RJ. An Integrative Review on Patient Satisfaction measuring tool for Physiotherapy Care among Clients in the Out-patient department. Pak.j.rehabil. 2021;10(2):05-17] DOI: 10.36283/pjr.zu.10.2/003

 

This is an open-access article distributed under the terms of the Creative
Commons Attribution Licence (CC BY) 4.0 https://creativecommons.org/licenses/by/4.0/

 

INTRODUCTION

Patient satisfaction is narrated as an impressionistic assessment of the health services provided to the client1. It is one of the most significant sources of evaluation of the standard of care provided to the patient whereas, the patient’s knowledge of the explanation given by the health care provider is an essential predictor of patient’s adherence to return visits2. A patient who is satisfied with a specific hospital and the health care facilities provided by it may tend to regularly visit the institution and retain a positive interaction with the respective health care provider. Such patients are also anticipated to show compliance with their prescribed therapy plans and retain a beneficial interaction with the personnel assigned for their medical care in the facility3.

The keystone of any relationship between patients and healthcare provider is based on communication. This is generally referred to as the interaction between patient and therapist. Moreover, it is the patient and therapist’s sense of cooperation, warmth and support4. In addition to it, positive patient therapist interaction in physical therapy environments have been shown to be associated with decrease in pain, decrease in disability and in turn increase in satisfaction of the patient4.Communication and satisfaction goes hand in hand thus, a lack of good communication has shown to influence patient satisfaction5. However, a number of studies showed that effective training could help in overcoming this set back of communication skills, and ultimately it improves medical outcomes leading to increased patient satisfactory level and adherence to the health care provider 5, 6, 7.

On the other hand, opinions of patient have also been found to be of significant importance. Patients who are more involved in raising their opinions related to the services provided are shown to be more satisfied than the contrary8.

In order to quantify these satisfactory levels of a patient a tool is necessitated. Meanwhile, it is of equal importance to know the psychometric analysis of a developed tool, i.e. reliability, content, criterion, and construct validity9. Validity of a tool is defined as principles that concern the degree to which an instrument actually calculates what it is supposed to be measuring. Validity checking is an attempt to endorse the measurement claim, ensuring that the term under review is clearly defined by different objects on the measuring instrument. Reliability is consistency of the results when it is performed repeatedly whereas, the interclass coefficient, kappa statistics, and Pearson correlation coefficient are the ways to test the reliability10.

In the field of healthcare, patient’s satisfactory level is generally evaluated through survey questionnaires. These tools are used to show the level of therapeutic care provided and the amount of satisfaction encountered by the patient in relation to it11.

In the light of literature it is observed that, patient satisfaction surveys are easily built without much consideration being paid to establishing their legitimacy and reliability. Thus, making it difficult to choose a suitable tool for a patient-related outcome measurement; it relies on the desired outcome use and may have an effect on results precision12.

The analysis of psychometric properties for validation of the instruments used for patient satisfaction in physiotherapy out-patient department has found to be lacking in previous literature. Therefore, a study is needed in order to gather the validity evidence regarding the different instruments being used.

 

Rationale

Patient satisfaction is considered as the cornerstone of any quality management program. Patients who are satisfied are more likely to adhere to therapy and have a greater quality of life related to health. Therefore, quality measurement requires significant validated tools. Unfortunately, in the health care system the selection of a tool is often times questioned subjected to the unmet standards of validity and reliability. Hence, a study is required to evaluate the present validity measures and ultimately standardize a tool that can be used for the assessment of patient satisfaction in out-patient physiotherapy care.

Objectives

To validate different tools that provides measurement of patient satisfaction in out-patient physical therapy services.

METHODOLOGY

Protocol

This systematic review was conducted in accordance with the principles of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Study Design and Data Sources

A systematic review was conducted on patient satisfaction that underwent physiotherapy services in any out-patient department. A literature search was taken from past two decades from 2000 to 2020 using electronic databases i.e. PEDro, Google Scholar, and PubMed. The quest strategy was based exclusively on validation studies of patient satisfaction instruments used in out-patient physiotherapy and thus no other words were included that may be applicable to the standard of care. Additionally, the exhaustive search terms in the database

 

were not only confined to validation study, we also explored via various different MESH terms like “Patient satisfaction questionnaire” AND “psychometric properties” OR “Physiotherapy” AND “Satisfaction questionnaire” OR “Out-patient physical therapy” AND “Satisfaction survey”.

Study selection

Articles were reviewed by three reviewers independently. The analysis included examination, based on the inclusion requirements. The articles were selected upon the criteria that, they must be written in English, the abstract or title had to suggest that an empirical (qualitative or quantitative) research was performed investigating the definition, measure or action of patient centered treatment and some form of outcome measure. Collection of full text article was retrieved and their list of references was also searched to gain additional articles. Further, the removal of duplicate articles was done and a final list was made for full text reading. The reviewers elected the articles for further selection according to the quality synthesis. All these discussions were done amongst reviewer via video call meetings and email.

Inclusion and Exclusion criteria

Data Extraction

The reviewers extracted the following  information from each qualifying paper i.e.  Author name, year, title, study design, hospital / health care setting, construct dimensions,sample size of practitioners or patients, instruments used, psychometric values and COSMIN scores. The data was extracted in between the year 2000 to 2020.

Evaluation of quality assessment

The methodological quality of the studies was analyzed using the Consensus based standards for the selection of health status measurement instruments (COSMIN) checklist that is one of the standard ways for measuring the instrument in various fields13. The COSMIN checklist consists of 10 items with different measuring psychometric property. These items were validity, conceptual validity, internal consistency, cross-cultural validity, precision, measurement error, criterion validity, hypotheses and responsiveness14. The checklist comprises of 10 boxes each containing an item to be measured in each study. The statements written in each box were rated according to a rating scale of excellent, good, fair, and poor. Then the methodological qualities were rated according to lowest rating of any statement. Further IRT and CRT and generalizability boxes were not utilized in this study as they don’t provide any score.

RESULTS

A total of 1200 search articles were approached. After the exclusion of duplicates, 1162 articles were obtained. However, only 34 articles remained after the implementation of inclusion and exclusion criteria. Each of these 34 studies was retrieved for reading, and further 15 studies were omitted. At the end only 19 articles were included in the review. (Figure 1)

General data

The findings showed that satisfaction measuring instruments have been used all over the world (Pennsylvania, New York, Italy, USA, Brazil, Republic of Korea, Saudi Arabia, Spain, Norway, United Kingdom, Iran, Switzerland, Philippines, Ireland and Hong Kong). The sample distribution revealed a large variance in screened trials. The inclusive number of citizens ranged from 40 to 1449. The health care setting where studies were conducted had variations from public to private setup, 5 studies were conducted in private outpatient departments15,16,17 whereas other studies were conducted in general hospitals18,19,20,21,22,23,24,25,26,27,28,29.

There are several tools used in these studies that intent to measure patient satisfaction in physical therapy setups. Among these 19 studies, 15 different measuring instruments were identified few of them were used in more than one study as MEDRISK were used in 3 of them18,25,29.

 

 

 

 

Patient Satisfaction Survey Physical Therapy (PTOPS) – was used twice30,31 and Participants experience with physical therapy-tool was used twice as well24,28 remaining all of the others were used once including Survey instrument: Compendium, Self-generated assessment instrument, newly design questionnaire (outpatient satisfaction questionnaire), SERVQUAL, rehabilitation patient experience questionnaire, 20 version MRPS Spanish version, survey instrument developed by authors, patient satisfaction questionnaire in germen (PSQ-G), 14 items self-design questionnaire, Treatment Outcome Satisfaction Questionnaire (TOSQ), Concise outpatient department user satisfaction scale and Filipino version).

 

Methodological quality of individual studies Out of the selected 19 studies, 8 were translated and cross cultural adapted validation study in other languages such as Italian, Portuguese, Persian, Swedish, Germen, Spanish15,16,19,25,26,29,30 and rest of the 11 studies were based on instrument validation. The Reliability, structural validity and internal consistency were the principal properties which were evaluated in these studies. Other properties such as content validity, face validity, reliability (test-retest), interclass correlation coefficient, criterion validity were analyzed in few of studies. The overall studies showed Cronbach alpha ranging from 0.63 to 0.96.

Analysis of Cosmin scoring showed most of the studies attained excellent to medium score whereas Cronbach alphas value showed variation. Upon analysis of psychometric properties, 8 studies reflected fair scoring of Cronbach alpha,20,23,24,26,27,28,30,31, 3 studies showed excellent22,32 3 studies showed good17,30 and 2 appeared to be poor16,25. Out of 15 different instruments only three of them (PSQ-G Patient satisfaction questionnaire in German, MedRisk  Brazilian version and 14 item Self design) attained excellent scoring in each of the psychometric properties defined (Table 1).

Table 1: Psychometric properties of studies
S.no Study year n Health

Care setting

Study design Instrument used Construct

Dimensions

Measurement

properties

Psychometric values Cosmin

score

1 Beattie

et al.

(2005)

1449 Hospital

Based

outpatient

department

Validation MedRisk Bidimensional 1-Reliability

 

r = 0.87 to 0.90 1-Poor

 

2 Vanti

et al.

(2013)

354 Hospital

based

Outpatient

clinic

Translated and

Cross-cultural

adaptation

(Italian)

Physical Therapy Out patient satisfaction

(PTOPS)

Multidimensional (4) 1-Reliability

2-Internal

consistency

 

α =0.758 to 0.88

intra class of correlation between

scale

r = 0.26 to 0.37

1-Good

2-Good

 

3 Goldstein

et al.

(2000)

289 Hospital

based OPD

and clinic

Validation Survey instrument: Compendium Multidimensional (5) 1-Reliability

2-Content

validity

3-Internal

consistency

α =0.99

item total

correlation

r=0.58 to 0.97

1-Fair

2-Good

3-Good

4 Diogenes

et al.

(2009)

221 Hospital

based OPD

and clinic

Validation Self-generated

Assessment

Instrument

measuring patient

satisfaction

Multidimensional (23) 1-Reliability

2-Internal

consistency

α=0.943 1-fair

2-good

5 Lee et al.

(2016)

40 Hospital

Based

Outpatient

clinic

Validation

 

Newly

Design

questionnaire

(Outpatient

Satisfaction

Questionnaire)

 

Multidimensional (7) 1-Validity

2-Reliability

3-Internal

consistency

α=0.87

Correlation with

another instrument,

r= 0.69 to 0.81

inter subscale

r=0.73 to 0.88

1excellent

2-fair

3-good

6 Carla Vanti

et al.

(2013)

315 Hospital

Based

Outpatient

Department

Translated and

cross cultural

adaptation

(Italian)

Physical Therapy

Patient Satisfaction

Questionnaire

Multidimensional (12) 1-Reliability

2-Internal

consistency

3-Structure

Validity

 

α=0.905

correlated

r=0.33

 

1-fair

2-excellent

3-excellent

7 Al Fraihi

et al.

(2016)

306 Hospital

Based

Outpatient

department

Validation SERVQUAL

questionnaire

Multidimensional (5) 1.Reliability

 

α=0.89 to 0.95

 

1-Fair

 

8 Medina-

Mirapeix

et al.

(2015)

465 hospital Validation Participants

experience with

Physical Therapy

questionnaire

(PEPAP-Q)

Multidimensional (7) 1-Reliability

2-Internal consistency

3-Structural validity

 

α =0.70 to 0.87,

item scale

correlation

r=0.70 to 0.93,

intraclass

correlation

coefficient

r=0.57 to 0.80

1-Fair

2-Good

3-Fair

9 Oliveira et

al.

(2014)

303 Hospital

Based

Outpatient

department

Translated and

Cross cultural

Adaptation

(Brazilian

Portuguese)

MedRisk instrument Multidimensional (3) 1-Reliability

2 Internal consistency

 

α =0.63 to 0.77

intraclass

correlation

coefficient

r=0.64 to 0.79,

SEM=0.86 to 1.75

1-Poor

2-Fair

 

10 Margeth

et al.

(2009)

412 Hospital

Based

Rehabilitation

center

Validation Rehabilitation

patient experience

questionnaire

(Re-PEQ )

 

Multidimensional (4) 1-Reliability

2-Internal

consistency

 

α =>0.7 item total

r = 0.77 to 0.87

1-Poor

2-Good

 

11 Beattie et

al.

(2007)

203 Health care

Setting

Outpatient

departments

Validation and

Transcultural

adaptation

(into

Spanish version)

20 version MRPS

Spanish version

Bidimensional 1-Reliablility

2-Internal consistency

3-Criterion referenced validity

 

α=0.90 for internal

factor

α=0.82 for external

factor

and correlation with

sub factors

r=0.59 to 0.82

1-Fair

2-Excellent

3-Fair

12 Beattie et

al.

(2002)

191 Hospital

Based

outpatient

department

Validation Survey instrument developed by authors Multidimensional (5) 1-Reliability

2-Internal consistency

3-Content validity

 

α=0.90

Item correlation

r = 0.095 to 0.722

 

1-Fair

2-Excellent

3-Excellent

 

13 Mosallanezhad et al.(2019) 297 Hospital

Based

outpatient

department

Translated and Transcultural adaptation

(Persian version)

Participants

experience with

Physical Therapy

(PEPAP-Q)

Multidimensional (4) 1-Reliabilty

2-Internal consistency

3-Structural validity

4-Face validity

α=0.95

ICC=0.88

1-Fair

2-Good

3-Poor

4-Excellent

 

14 Scascighini et al.

(2007)

123 Outpatient physical therapy department Validation and Transcultural adaptation (germen) PSQ-G

Patient satisfaction questionnaire in German

Multidimensional (13) 1.Face validity

2-Internal consistency

3-Content validity

α=0.85 to 0.96

r=0.53 to 0.83

1-Excellent

2-Excellent

3-Excellent

15 Almeida et al.

(2019)

326 hospital Translated and transcultural (Brazilian ) MedRisk (Brazilian version) Multidimensional (16) 1-Structure validity

 

Correlation between factors

r =0.05 to 0.44

RMSEA=0.10

CFA=0.84

1-Excelent
16 Monnin et al.

(2002)

528 Outpatient and inpatient department Validation 14 item Self design questionnaire (French)

 

Multidimensional (4) 1-Internal consistency α=0.77 to 0.90

r=0.96 to 0.98

 

1-Excellent
17 Martire et al.

(2017)

131 Outpatient department Translated and transcultural adaptation (Swedish) Treatment Outcome Satisfaction Questionnaire (TOSQ) Uni dimensional 1-Test–retest reliability

 

ICC=0.79 1-Fair

 

18 Tso et al.

(2006)

344 Outpatient department Validation

 

Concise Outpatient Department User Satisfaction Scale Multidimensional (9)

 

1-Internal consistency

2-Criterion validity

 

α=0.90

r=0.38 to 0.85

1-Good

2-Poor

19 Palad et al.

(2014)

125 Outpatient department clinic settings Validation Filipino version of the Parent Satisfaction Scale (F-PSS) Multidimensional (11) 1-Internal consistency

 

α=0.96

k=0.56 to 0.72

total item correlation

r=0.79 to 0.82

1-Good

 

DISCUSSION

The patient or client satisfaction centered care in physiotherapy has been proposed all around the world to improve the treatment quality services. Creation or adaptation of surveys about satisfaction has found to be the most common tool for assessing patient satisfaction in outpatient. A number of instruments have been used in different studies for assessing or measuring patient satisfaction around the globe for quality assurance.

In our study we evaluated the quality of different questionnaires of patient satisfaction that focused on the assessement of the psychometric properties broadly; validity, reliability, and internal consistency. Moreover, each of them were evaluated on cosmin checklist scoring. Nonetheless,  other properties proposed by comsin checklist such as hypothesis testing, criterion and content validity, measurement error and cross cultural validity were not assessed in given studies. Besides, we also included studies that have had used cross culturally adapted questionnaire12,15,16,19,25,27,28 and have had assessed the psychometric properties of each translated versionas well30-35. Surprisingly, we concluded that there are some limitations in cross culturally adapted questionnaire that are used to check the level of satisfaction in outpatient physiotherapy department.

Few studies have found to be excellent at their each psychometric property12,15,32 but the choice of instrument usage and application were different among all. The study conducted by Scascighini et al study used an instrument Patient satisfaction questionnaire in German language (PSQ-G), that was multidimensional and further it assessed face validity, internal consistency and content validity of the tool15. Another Study conducted by Almeida et al used MedRisk instrument, a multidimensional questionnaire in Brazilian version and they assessed only the structural validity of their tool12. Further, another study proposed by Monninet et al used 14 Item Self Design Questionnaire, and analyzed only the internal consistency of their tool.

Adding more to it, the MedRisk instrument was used as a tool in another three of the studies. One of them conducted by Beattie et al assessed its reliability only. However, two of the studies proposed by balmeida et al and Oliveria et al  cross culturally adapted this questionnaire into Portuguese version and it showed a good cosmin scoring on the checklist25.However, Vanti et al used the instrument Physical Therapy Out-Patient Satisfaction and they evaluated reliability, internal consistency that appear to be good on Cosmin scoring30. Similarly Tso et al used Concise Outpatient Department User Satisfaction Scale and the psychometric properties and internal consistency were scored as good for them on cosmin.

Unfortunately, we do not have much systematic review available on this concern, so comparison with different studies was not possible36-39. Besides, most of the instruments appeared to be average in term of quantification of patient satisfaction on cosmin scoring. Further, this review highlighted the concern that there is no particular gold standard tool for assessing patient’s satisfaction that can be applied in out-patient physiotherapy services40-43. Moreover, our study recommends the construction of such questionnaires that covers all the aspects which a patient considers as an essential component of service, as patient satisfaction is significantly based on patient centered approach.

 

 

CONCLUSION

This review analyzed that most of the studies appeared to be good on COSMIN scoring, however no gold standard tool was found. In the considered studies some of the tools were analyzed on the basis of a single psychometric property that does not provide sufficient validation. However, others showed inclusion of multiple psychometric measures and thus, provides better construct on patient satisfaction tool. Concluding, physiotherapists can increase the efficiency of patient-centered treatment by identifying and maximizing these patient satisfaction tool determinants.

 

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