Patient Satisfaction and Functional Status in Patients Who Received Inpatient Medical Rehabilitation

1
Patient Satisfaction and Functional Status in
Patients Who Received Inpatient Medical
Rehabilitation Services

• Pei-Fen J. Chang, MSG, OTR/L
• University of Texas Medical Branch
• Department of Preventive Medicine and Community
  Health
• Division of Rehabilitation Sciences

2
Outline

• Introduction
• Background and Significance
• Research Design and Methods
• Results
• Discussion and Conclusion

3
Introduction

• Concept of Satisfaction
• Satisfaction in the Healthcare System
• Quality of Care Model
• Rehabilitation and Functional Outcome
• Satisfaction and Functional Outcome

4
Background

• Theoretical Models Lawler (1973)
• Discrepancy Theory
• Satisfaction is the perceived difference between
  what an individual desires and what the
  individual experiences.
• Fulfillment Theory
• Satisfaction is simply the difference between
  what happened and what was expected.
• Equity Theory
• Satisfaction is the perceived balance between
  inputs and outputs.

5
Background

• Theoretical Models
• Cognitive Model by Hunt (Pascoe, 1983, p.187)
• Satisfaction is an evaluative reaction resulting
  from the interaction of the product/situation
  with the individuals expectation it is a
  cognitive response.
• Affective Model by Linder-Pelz (1982)
• Satisfaction is a positive attitude resulting
  from the favorable comparison of beliefs about
  care to actual care received.

6
Background

• Theoretical Models
• Normative Decision Theory by Brennan (1995)
• Satisfaction is an appraisal whether the care
  provided met the individuals expectations and/or
  preference.
• Pragmatic Model by Baker (1997)
• Satisfaction is an evaluative judgment to the
  care received. It is a continuous and
  multi-dimensional variable.

7
Background

• Theoretical Models
• Primary Provider Theory (PPT) by Argon (2003)
• Healthcare providers hold the power to meet
  patients expectations for treatment and/or
  medications. Satisfaction happens through the
  interaction of patient expectation and provider
  power.

8
Background

• Theoretical Models
• Keith (1998, p.1122)
• Satisfaction is defined as an attitude about
  service, service providers or patients health
  status. There are both affective and cognitive
  components the affective reflects positive or
  negative feelings and the cognitive is concerned
  with what is important and how it is evaluated.

9
Background

• Patient Satisfaction and Patients
  Characteristics
• Loker Dunt (1978)
• Older, white, male, married, and patients with
  higher social class tended to be more satisfied
• Fox Storms (1981)
• Older and female more satisfied
• Hall Dornan (1990)
• Female and less educated patients more satisfied
• Stein, Fleishman, Mor Dresser (1993)
• More educated, less satisfied other patients
  demographic variables not related to satisfaction

10
Background

• Satisfaction Studies in Medical Specialties
• Satisfaction studies in ER, nursing care,
  internal medicine, surgical procedures, and other
  medical interventions.
• Providers characteristics
• Type of physician (Roblin et al., 2004)
• Language one speaks (Bischoff et al., 2003)
• Personal choice of physician (Kalda, Polluste,
  Lember, 2003)
• Care provided for patients
• Relationship between care providers and patients
• Whether services are organized
• Teaching materials, time spent, how fast the care
  providers respond to a patients request

11
Background

• Inconsistent results of patient satisfaction
  studies are due to
• Different definitions of patient satisfaction
  structure, process, or outcome
• Difference between satisfaction measurements
• Variation of study samples

12
Background

• Model for Quality of Care by Donabedian (1988)
• Structure Attributes of the facilities where
  care is provided
• Process Activities happen between care
  providers and the patients who received care
• Outcome Ultimate health conditions resulting
  from services provided

13
Background

• Components of Model for Quality of Care

Structure / Facilities
Outcome / Patients
Process / Providers
14
Background

• Satisfaction and Model for Quality of Care
• Satisfaction is thought to reflect the quality of
  care
• Structure and process of care have been studied
  extensively in the past
• Very little attention has been devoted to health
  status or outcome
• In a meta-analysis by Hall (1988), only 6 of 221
  articles measured outcome

15
Background

• Measurement of Patient Satisfaction
• Two major aspects of patient satisfaction
  measurement (Hudak and Wright, 2000)
• Content Areas of measurement
• Method How the measurement is administered

16
Background

• Measurement of Patient Satisfaction

17
Background
Measurement of Patient Satisfaction

• Global Approach
• One or two questions for overall satisfaction
• Easy to administer and analyze
• Lack of variability
• Result in higher satisfaction rating (Krowinski
  Steiber, 1996)

• Multi-dimensional Approach
• Require additional time and effort
• Require to establish reliability and validity of
  the questions
• Provide comprehensive information on satisfaction
• Examine various components of patient
  satisfaction such as structural, technical and
  interpersonal aspects of care

18
Background

• Examples of Patient Satisfaction Measurement
  Instruments
• Ware and Colleagues (1977)
• Larson, Attkisson, Hargreaves, Nguyen (1979)
• Cherkin, Deyo, Berg (1991)

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Examples of Patient Satisfaction Measurement
Instruments

• Ware and colleagues (1977)
• Patient Satisfaction Questionnaire (PSQ)
• One of the first multi-dimensional instruments
• 8 dimensions

• Physical environment
• Availability of providers and facilities
• Continuity of care
• Efficacy and outcome

• Interpersonal manner
• Technical quality
• Accessibility / convenience
• Financial aspect

20
Background

• Measurement of Functional Status
• Functional Independence Measure (FIMTM)
  Instrument
• Developed by the Uniform Data System for Medical
  Rehabilitation (UDSMR) during 1980s
• Serve as interdisciplinary indicator of the
  severity of disability defined by the World
  Health Organization
• In 2002, FIMTM was incorporated in the inpatient
  rehabilitation perspective payment system by the
  Centers for Medicare and Medicaid Services (CMS)

21
Background

• Previous Studies of Patient Satisfaction
• Most studies were in the primary care area with
  the association between patient characteristics
  and patient satisfaction
• Some studies included health-related patient
  behavior and patient-provider interaction but not
  related to outcome
• Did not include patients with physical
  disabilities in the studies

22
Background

• Recent Satisfaction Studies Included Patients
  with Disabilities
• Higher scores in transfer, social-cognition and
  locomotion associated with better overall
  satisfaction (Ottenbacher et al., 2001)
• Motor and cognition improvements were
  significantly associated with overall
  satisfaction at follow-up (Tooth et al., 2003)
• Higher motor function at discharge was associated
  with better overall satisfaction at follow-up
  (Mancuso et al., 2003)

23
Background

• Limitations in Previous Studies of Patient
  Satisfaction
• Limited by sample size in the primary care
  studies
• Most studies were retrospective, only used
  cross-sectional data
• Most studies only measured satisfaction once at
  follow-up
• Most studies used one question to assess global
  satisfaction

24
Significance

• From This Study
• A prospective study
• Satisfaction is measured at discharge and at
  follow-up
• Using multiple questions
• Included patients with physical disabilities

25
Significance

• Satisfaction as a component of quality of care
  with focus on patient-centered care by the
  Institute of Medicine (IOM)
• Satisfaction as an outcome in healthcare by the
  Joint Commission on Accreditation of Healthcare
  Organization (JCAHO)
• Satisfaction as a quality indicator of program
  excellence by the Commission of Accreditation of
  Rehabilitation Facilities (CARF)

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Research Design and Methods

• Research Questions
• Specific Aims
• Research Design
• Cross-lagged Panel Design
• Data Source
• Measurements and Variable Definitions
• Measurement of Functional Status
• Measurement of Patient Satisfaction
• Data Analysis

27
Research Design and Methods

• Research Questions
• Does functional status and satisfaction change
  over time in patients with disabilities?
• Are patterns of change over time in functional
  status and satisfaction different between
  patients with the neurological and orthopedic
  impairments?
• Does functional status predict satisfaction
  response at a later time?
• Does satisfaction predict functional status at a
  later time?

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Research Design and Methods

• Specific Aim 1 Examine whether functional
  status measured by the Functional Independence
  Measure (FIM) changes from discharge to follow-up
  following medical rehabilitation.
• Specific Aim 2 Examine whether patient
  satisfaction changes from discharge to follow-up
  following medical rehabilitation.
• Specific Aim 3 Examine the relationship between
  functional status measured by the Functional
  Independence Measure (FIM) at discharge and
  patient satisfaction at follow-up from medical
  rehabilitation.
• Specific Aim 4 Examine the relationship between
  patient satisfaction at discharge and functional
  status measured by the Functional Independence
  Measure (FIM) at follow-up from medical
  rehabilitation.

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Research Design

• Cross-lagged Panel Design

Functional Status at follow-up
Functional Status at discharge
Satisfaction at discharge
Satisfaction at follow-up
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Research Design

• Data Source
• Five hospitals provided comprehensive inpatient
  rehabilitation services located in Connecticut,
  Michigan, Georgia, and Tennessee
• Discharge data were collected between February
  and October, 2004, and follow-up data were
  collected between June 2004 and January 2005.

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Research Design

• Data Source
• All facilities that contribute information to the
  UDSMR have to follow a protocol
• Information on functional status (FIM scores) is
  collected within 72 hours of admission to
  inpatient rehabilitation, and within 72 hours of
  discharge from the program
• All assessments are performed by professional
  staff such as rehabilitation nurses, physical
  therapists, occupational therapists and/or speech
  therapists

32
Research Design

• Data Source
• Follow-up data were collected by IT HealthTrack
• Interviewers are nurses trained to administer and
  interpret the FIM instrument through phone
  interview with patient or proxy
• Patients are contacted at 80 to 180 days after
  discharge by telephone
• No proxy interviews were included in this study

33
Research Design and Methods

• Measurements and Variable Definitions
• Measurement of Functional Status
• Measurement of Patient Satisfaction

34
Research Design and Methods

• Measurement of Functional Status
• FIMTM Instrument
• 18 items, six subscales, two domains
• Each item ranges from minimum score 1 (total
  assistance) to maximum score 7 (total
  independence)
• Total scores range from 18 to 126 with higher
  scores indicating better functional performance

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Research Design and Methods

• Measurement of Functional Status
• Reliability of FIMTM Instrument
• Intra-class correlation coefficients (ICC) for
  rater agreement (Hamilton, Laughlin, Fiedler,
  Granger, 1994)
• .94 for self-care, .90 for sphincter, .92 for
  transfer, .90 for locomotion, .91 for
  communication, and .89 for social-cognition
• Inter-rater, test-retest and equivalence
  reliability (Ottenbacher, Hsu, Granger,
  Fiedler, 1996)
• .95 for inter-rater reliability, .95 for
  test-retest reliability, and .92 for equivalence
  reliability

37
Research Design and Methods

• Measurement of Patient Satisfaction
• Five satisfaction questions were selected
• Questions were developed by the IT HealthTrack
• From a pool of questions submitted by more than
  300 facilities between 1996 to 2001
• Recurrent themes
• Consistency with Commission on Accreditation of
  Rehabilitation Facility (CARF) requirements for
  patient participation
• Ease of administration and understanding when
  administered by telephone interview

38
Research Design and Methods

• Patient Satisfaction Questions
• What is your level of satisfaction with
  improvement in your ability to care for yourself
  following rehabilitation?
• What is your level of satisfaction with
  involvement in decision making (or goal setting)
  during your rehabilitation program?
  
  
• What is your level of satisfaction with achieving
  your goals in rehabilitation?
• What is your level of satisfaction with your
  quality of life?
• What is your level of overall satisfaction with
  the rehabilitation program?

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Research Design and Methods

• Patient Satisfaction as Process (and overall) and
  Outcome
• What is your level of satisfaction with
  improvement in your ability to care for yourself
  following rehabilitation?
• What is your level of satisfaction with
  involvement in decision making (or goal setting)
  during your rehabilitation program?
  
  
• What is your level of satisfaction with achieving
  your goals in rehabilitation?
• What is your level of satisfaction with your
  quality of life?
• What is your level of overall satisfaction with
  the rehabilitation program?

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Research Design and Methods

• Measurement of Patient Satisfaction
• Reliability of Patient Satisfaction Measurement
• Satisfaction responses were collected twice
  within a period of five days from 17 patients (6
  males, 11 females 7 with stroke, 10 with hip
  fracture) in an outpatient rehabilitation
  facility in Chicago.
• Test-retest reliability
• .76 for question 1
• .78 for question 2
• .81 for question 3
• .82 for question 4
• .81 for question 5

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Research Methods

• Data Analysis
• Two dependent variables
• Patient satisfaction from 5 questions
• Functional status (FIM scores)
• Motor Domain score
• Cognition Domain score
• Total FIM score

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Research Methods

• Data Analysis
• Patient satisfaction
• Dichotomized responses to very satisfied (score
  4) or less than very satisfied (score 1, 2, and
  3)
• A proportional satisfaction score on the 0-1
  scale was generated
• Number of very satisfied responses divided by
  the total responses and coded as 1
• Counting remaining responses (score 1, 2, and 3)
  divided the total responses and then coded as 0
• The ratio between very satisfied and less than
  very satisfied became the proportional
  satisfaction score

44
Research Methods

• Data Analysis
• Descriptive information percentage, mean,
  median, SD
• Repeated measures analysis of variance (ANOVA)
• Paired-proportion tests
• Chi-square tests
• Correlation analysis
• Logistic regression analysis
• Linear regression analysis

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Results

• Characteristics of the Study Sample
• All patients admitted to the five facilities were
  eligible for the study
• Age over 50
• Patients with speech difficulties, aphasia, or
  severe cognitive impairment were excluded from
  the study
• 185 patients had complete FIM scores at discharge
  ?143 patients (81) completed interviews at
  follow-up ? 120 patients 50 years and older

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Results

• Characteristics of the Study Sample
• Patients were divided into three impairment
  groups based on the Rehabilitation Impairment
  Categories (RICs)
• Neurological Impairment Group including stroke,
  brain dysfunction, spinal cord injury, and other
  neurological deficits
• Orthopedic Impairment Group including amputation
  of extremities, fractures or joint replacement
• Other category including cardiovascular
  dysfunction, pain or multiple disabilities

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Results
48
Results
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Results Aim 1

• Aim 1 Examine whether functional status
  measured by the Functional Independence Measure
  (FIM) changes from discharge to follow-up
  following medical rehabilitation.
• Analysis Repeated measures ANOVA (2x2) with one
  between subject factor (neurological and
  orthopedic group) and one repeated factor
  (discharge versus follow-up) to examine
  functional status change over time.

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Results Aim 1

• Functional Status Change Over Time in the Overall
  Sample

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Results Aim 1

• Functional Status Change Over Time between Two
  Impairment Groups

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Results Aim 1

• Functional Status Change from Discharge to
  Follow-up

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Results Aim 1

• Functional Status Change Over Time between Two
  Impairment Groups

54
Results Aim 1

• Functional Status Change from Discharge to
  Follow-up

55
Results Aim 1

• Functional Status Change Over Time between Two
  Impairment Groups

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Results Aim 1

• Functional Status Change from Discharge to
  Follow-up

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Results Aim 2

• Aim 2 Examine whether patient satisfaction
  changes from discharge to follow-up following
  medical rehabilitation.
• Analysis Paired-proportion testing along with
  chi-square tests to examine patient satisfaction
  change over time and difference between two
  impairment groups.

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Results Aim 2

• Proportional Satisfaction Scores Change Over Time
  in the Overall Sample

59
Results Aim 2

• Satisfaction Change Over Time in the Overall
  Sample

60
Results Aim 2

• Proportional Satisfaction Scores Change Over Time
  in the Neurological Impairment Group

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Results Aim 2

• Satisfaction Change Over Time in the Neurological
  Impairment Group

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Results Aim 2

• Proportional Satisfaction Scores Change Over Time
  in the Orthopedic Impairment Group

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Results Aim 2

• Satisfaction Change Over Time in the Orthopedic
  Impairment Group

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Results Aim 2

• Proportional Satisfaction Scores Change Over Time
  between two Impairment Groups
• Chi-Square test results ranged from 0.002 to 1.72
  with p values ranging between 0.19 to 0.96
  indicating that there was no statistical
  difference between the two impairment groups in
  all five questions

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Results Aim 3

• Aim 3 Examine the relationship between
  functional status measured by the Functional
  Independence Measure (FIM) at discharge and
  patient satisfaction at follow-up from medical
  rehabilitation.
• Analysis Logistic regression analysis to
  estimate the effect of the functional status at
  discharge on patient satisfaction at follow-up
  when controlling for satisfaction response at
  discharge.
• Satisfaction at follow-up Functional status at
  discharge satisfaction at discharge

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Results Aim 3

• Logistic Regression Analysis in the Neurological
  Group

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Results Aim 3

• Logistic Regression Analysis in the Orthopedic
  Group

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Results Aim 4

• Aim 4 Examine the relationship between patient
  satisfaction at discharge and functional status
  measured by the Functional Independence Measure
  (FIM) at follow-up from medical rehabilitation.
• Analysis Linear regression analysis to estimate
  the effect of patient satisfaction at discharge
  on functional status at follow-up when
  controlling for functional status at discharge.
• Functional status at follow-up Satisfaction at
  discharge Functional status at discharge

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Results Aim 4

• Linear Regression Analysis in the Neurological
  Group

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Results Aim 4

• Linear Regression Analysis in the Orthopedic
  Group

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Discussion Aim 1

• Aim 1 Examine whether functional status
  measured by the Functional Independence Measure
  (FIM) changes from discharge to follow-up
  following medical rehabilitation.

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Discussion Aim 1

• The motor, cognition and total FIM scores
  improved significantly from discharge to
  follow-up.
• The orthopedic group demonstrated significant
  improvement in the motor function and total FIM
  scores the neurological group had obvious
  increase in cognitive function.
• The trend of change in cognitive function in the
  neurological group from discharge to follow-up
  was different from the orthopedic group.

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Discussion Aim 2

• Aim 2 Examine whether patient satisfaction
  changes from discharge to follow-up following
  medical rehabilitation.

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Discussion Aim 2

• The Neurological Group
• Satisfaction declined in Q1 (83 to 56), Q2 (83
  to 72), Q3 (81 to 59) Q4 (from 60 to 56)
• Satisfaction increased in Q5 (85 to 87)

• The Orthopedic Group
• Satisfaction slightly decreased in Q1 (88 to
  79) and Q3 (81 to 80)
• Satisfaction increased in Q2 (78 to 85), Q4
  (62 to 80), Q5 (88 to 91)

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Discussion Aim 2

• Satisfaction responses declined in questions 1
  and 3 (outcome-related) in the neurological group
• In the orthopedic group, satisfaction responses
  increased (from 62 to 80) in question 4
  (health-related quality of life) when in the
  neurological group the responses decreased from
  60 to 56

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Discussion Aim 3 4

• Aim 3 Examine the relationship between
  functional status measured by the Functional
  Independence Measure (FIM) at discharge and
  patient satisfaction at follow-up from medical
  rehabilitation.
• Aim 4 Examine the relationship between patient
  satisfaction at discharge and functional status
  measured by the Functional Independence Measure
  (FIM) at follow-up from medical rehabilitation.

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Discussion Aim 3 4

• Results from Logistic Regression
• Motor function at discharge was a significant
  predictor of satisfaction at follow-up in the
  orthopedic group for question 1.
• This finding supported an earlier study by
  Mancuso et al. (2003) that better motor status at
  discharge was associated with higher patient
  satisfaction at follow-up in a sample of patients
  with orthopedic impairments.

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Discussion Aim 3 4

• Results from Linear Regression
• Satisfaction responses at discharge were not
  significant predictors of functional status at
  follow-up.
• This finding was consistent with an earlier study
  by Hall, Milburm, Epstein (1993) that there was
  no evidence for satisfaction predicting
  self-perceived health status at a later time.

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Clinical Implications

• Patients with neurological impairments such as
  stroke, brain dysfunction, spinal cord injury
  satisfaction responses were lower at follow-up
• For clinicians
• Setting realistic treatment goals
• Better discharge planning for follow-up therapy
• Counseling and family support

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Clinical Implications

• Hospital environment versus home settings
• For clinicians
• Provide more opportunities for patients to
  experience a real home environment or a
  transitional environment while patients are
  still in hospital
• Realistic expectations regarding post-discharge
  environment

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Clinical Implications

• The decline of satisfaction responses from
  discharge to follow-up suggested that not only
  did the functional status change, patients
  psychological state also changed.
• For clinicians
• Psychological assessment and consultation should
  be offered as a part of outpatient rehabilitation
  services or home health services

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Strengths of the Study

• Satisfaction is measured using a
  multi-dimensional approach
• Process-related satisfaction
• Outcome-related satisfaction
• Emphasis on satisfaction as an outcome
• Important quality indicator of care
• Prospective and longitudinal design
• Satisfaction is measured at discharge and at
  follow-up

87
Limitations of the Study

• The study sample is not randomly selected and may
  not be representative of all patients who
  received inpatient medical rehabilitation
  services.
• In the study, 67 patients with neurological
  impairments, and 44 patients with orthopedic
  impairments
• Limited statistical power
• Response variability to the satisfaction questions

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Future Directions for Study

• Satisfaction measurement with different response
  format
• Different satisfaction questions for the patient
  population with different physical dysfunctions
• More studies in satisfaction change over time in
  specific impairment diagnoses/groups

89
Conclusion

• Functional status (motor and cognitive function
  and total FIM scores) improved significantly from
  discharge to follow-up.
• Satisfaction question 1 (related to functional
  improvement) demonstrated significant differences
  from discharge to follow-up in the neurological
  impairment group.
• Motor function at discharge was a significant
  predictor of satisfaction at follow-up in the
  orthopedic group for question 1.
• Satisfaction responses at discharge were not
  predictors of functional status at follow-up.

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Conclusion

• Patients with orthopedic impairments demonstrated
  greatest improvement in motor function patients
  with neurological impairments have more increase
  in cognitive function.
• The decline of satisfaction response over time
  was unique, and reduction in satisfaction was
  observed in the questions related to outcome.

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Acknowledgement

• Sincere appreciation to the committee members
• Dr. Kenneth J. Ottenbacher
• Dr. Judith C. Drew
• Dr. Steven V. Owen
• Dr. Malcolm P. Cutchin
• Dr. Glenn V. Ostir
• And to other mentors and friends
• Dr. Janida Rice, Dr. Gayle Weaver, Mrs. Emily
  Chen, Dr. Reginald Tsang, Dr. Bey-Dih Chang, all
  my schoolmates, and many friends.
• This research was sponsored by the American Heart
  Association

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? Thank you! ?

• Any Questions?