Determinants of patient satisfaction in ambulatory oncology: a cross sectional study based on the OUT-PATSAT35 questionnaire

Patient satisfaction is recognised as a key performance indicator in assessing quality of care, increasingly required by accreditation agencies in the monitoring of quality of hospital care in order to identify care areas in need of improvement. Furthermore, satisfaction with care may influence a patient's adherence to medical treatment and consequently, impact on outcome.

Cancer treatments are often long, are associated with frequent interactions and increased dependency on multidisciplinary healthcare services. In this context, patient satisfaction with their experience of continuity of care, as well as their relationships and communication with caregivers, need to be evaluated with a view to determining whether the patients' expectations are being fulfilled.

Determining predictors of patient satisfaction has several objectives. Firstly, identifying patient characteristics (socio-demographic or clinical factors, baseline quality of life (QOL)), should aid in interpreting questionnaire results, by adjusting for these factors, particularly for benchmarking when comparing health care services [1‐3]. Furthermore, patient satisfaction surveys can help to identify patient groups who need additional attention or even targeted interventions, and bring to light areas of the care process (e.g. organisation, providers' communication skills) where there is room for improvement [4, 5]. Socio-demographic characteristics and health status are the most widely studied predictors of satisfaction, with older age, low education and a good state of health commonly reported to be associated with greater satisfaction [6‐11]. However, conflicting results have been observed in this regard and especially the relationship between these two concepts, self-perceived quality of life and satisfaction with care, remains debated.

In the setting of oncology, there has been an increase in the use of ambulatory treatments, which represent a completely different context to hospitalization. While interpersonal (i.e. communication) or technical (i.e. drug administration) aspects of care, and multidisciplinary teamwork are components common to patient satisfaction in both in- and out-patients, other factors, such as hospital accessibility and treatment environment (i.e. location, appointment waiting lists, waiting times, parking facilities) are concerns that are more specific to the ambulatory setting [12]. A number of studies evaluating patient satisfaction questionnaire responses in an ambulatory oncology setting have been published [12‐21] focusing mainly on organisational aspects of care and the quality of patient-caregiver relationships. However, none of these studies attempted to identify patient groups who may be more "at risk" of dissatisfaction with care.

The aim of the present study was, on the one hand, to identify patients' clinical and socio-demographic characteristics as potential determinants of satisfaction with care in cancer patients undergoing ambulatory chemo- or radiotherapy. On the other hand, we investigated the influence of self-reported quality of life on satisfaction with care, as measured by multi-dimensional questionnaires.

We conducted a multicenter, prospective cohort study of cancer outpatients from the beginning to 3 months after the end of their treatment. The present analyses were performed only on data collected at the beginning of the treatment

The protocol was approved by the ethics committee of the University Hospital of Besançon (Doubs, France), the National French Data Protection Agency, and supported by a regional grant (Programme Hospitalier de Recherche Clinique).

Using the OUT-PATSAT35 questionnaire, we identified clinical (global health status, primary cancer, treatment modalities) and socio-demographic factors (marital status, age) significantly associated with different domains of satisfaction with care among cancer outpatients at the beginning of their ambulatory treatment.

None of the OUT-PATSAT35 scales correlated highly with the EORTC QLQ-C30 (all r < 0.30; p < 0.0001). The same findings were observed in the French and Spanish [22, 23] validation studies of the OUT-PATSAT35 questionnaire, underlining the fact that these two questionnaires probably assess complementary concepts.

Using the EORTC IN-PATSAT32 and QLQ-C30 questionnaires, Avery et al investigated associations between patient satisfaction with care and surgical morbidity among inpatients undergoing surgery for oesophageal or gastric cancer [26]. Among the 181 patients included, results showed that patient satisfaction scores remained high and were not associated with the presence of major postoperative complications. These latter were, however, related to worse quality of life. Unfortunately, the authors did not directly assess relationships between QOL and satisfaction scores.

Indeed, the relationship between QOL and satisfaction with care remains unclear [10, 27]. Previous studies have reported contradictory results, depending on whether functional or symptom scales were considered (global health, physical functioning or pain), underlining the complexity of patient satisfaction interpretation. Despite the multidimensional concept of QOL, in our study, poor global health status was the main determinant of low levels of satisfaction with care. Similar findings were observed by Bredart et al among cancer inpatients [6, 28]. Our methodology suggests that health status may influence patient satisfaction, and not the other way around. Different explanations have been proposed for this relationship; for example, poorer health may negatively influence one's attitude towards medical care, or caregivers may respond less positively to patients with poor health, thus resulting in lower satisfaction levels [18]. In any case, this effect has not been confirmed in longitudinal studies with repeated measures of global health, in order to assess whether higher levels of satisfaction can result from interventions aimed at improving quality of life.

Patients treated for a head and neck cancer reported less satisfaction with the level of information provided by doctors. Patients who start radiotherapy for head and neck cancer are those who experience the most symptoms associated with their illness (such as pain, dysphagia, dysphonia), or may have complications linked to previous treatment (such as mutilating surgery). This can lead to aesthetic or functional problems and consequently, difficulties in patient-doctor communication. Moreover, because this type of cancer is usually related to an addiction to tobacco and alcohol, it may be hypothesised that this negatively influences care providers' attitude toward these patients compared to those treated for other cancer sites.

Radiotherapy, as compared to chemotherapy, was significantly linked to lower satisfaction scores in most scales. These results should be interpreted with caution because the few patients receiving chemotherapy were those treated for breast cancer and these two variables (namely treatment modality and cancer localization), were not entered into the same model. The first questionnaire was completed during the first week of radiotherapy treatment, when most patients had experienced very few side effects, and thus, treatment related toxicity cannot be the reason behind their dissatisfaction. Radiation therapists, as opposed to nurses in ambulatory chemotherapy, spend less time with patients during each radiation session, and the care pathway in a radiotherapy department is complex, requiring several appointments for preparation, and the time to the definitive start of treatment may be long. Moreover, radiation treatment is stressful in itself: patients have reported fears about the size and possible fall of the machine, the delivery of correct radiation doses, their ability to stay unmoved in uncomfortable positions and being shut up alone during the radiation session. Thus, the dissatisfaction with care observed among radiotherapy patients could be explained by a discrepancy between care expectations and the perception of care received, highlighting the importance of delivering adequate information [29].

Patients living alone seem to be less satisfied with doctors' information provision. Cancer patients' understanding is often affected by anxiety or denial then the presence of relatives, able to repeat and to discuss the information given during the consultation, should facilitate the doctor-patient communication.

Age was a minor determinant of satisfaction, with patients < 55 years old less satisfied with doctors' availability. Other studies using similar questionnaires did not find any relationship between age and satisfaction scores [6, 23, 26]. Poinsot et al suggest a cultural evolution in French cancer patients towards increased knowledge of the medical aspects of their disease, and thus, a greater homogeneity in their care expectation [23].

Level of education was not associated with satisfaction scores, in our study. Poinsot et al observed similar findings to ours [23], although other reports have shown that a higher level of education was associated with higher expectations as regards quality of care [6, 14].

It is likely that our study is not representative of all patients seen in oncology practice, since we did not include some common primary localizations such as uterine or upper gastrointestinal tract cancer, and metastatic patients.

Nevertheless, our results confirm the acceptability of the OUT-PATSAT35 questionnaire in a large outpatient sample. A number of clinical (primary site, radiotherapy) and socio-demographic factors (marital status, age) were significantly associated with different scales of the satisfaction questionnaire. However, the major determinant of satisfaction was patients' global health status, suggesting that self-reported quality of life is a key element in understanding cancer patient satisfaction.

Our findings brought to light a number of patient characteristics that are associated with dissatisfaction with care, as well as concerns about specific aspects of care. Healthcare providers should use such results to target these patient groups, who are at risk of experiencing less satisfaction with their pathway of care (in particular, head and neck cancer patients, patients treated by radiotherapy). Our observations also highlight some aspects of health professionals' behaviour that may leave room for improvement (e.g. providing adequate information to patients).

Lastly, our results underscore the importance of measuring and adjusting for self-perceived health status when comparing patient satisfaction with care between hospitals or assessing variations in patient satisfaction over time.

Further analyses are currently ongoing to determine the responsiveness of this questionnaire to changes over time, and to evaluate whether improvements in patients' quality of life could lead to improved satisfaction with care. Indeed, if this relationship is confirmed, initiatives targeting patients with poorer health status should generate greater returns in patient satisfaction.