Background
Research on patient satisfaction with medical care can be tracked to the late 1960s [1]. Initially, researchers focused on patient satisfaction as an intermediate condition in order to reach desirable clinical outcomes such as patient compliance with recommended treatment [2]. Gradually, patient satisfaction was shifted to a final outcome for evaluating and improving health and care services [3].
Different instruments have been used to measure satisfaction [4–12]. Studies dealing with patient satisfaction are not homogenous and more studies are needed to ascertain the best technique for measuring quality of health care services and the importance of various predictors on overall satisfaction. In addition, little information is available on patient satisfaction in Iran. The overall satisfaction in four social security hospitals in Tehran, in 3017 inpatients in hospitals in Kerman and patient satisfaction among women attending the Iranian Centre for Breast Cancer were around 60%, 50% and 82% respectively [13–15]. The two former studies were performed in general hospitals and the latter in a subspecialty hospital which might justify the difference observed. The present study is unique in that it attempted to assess patient satisfaction with eye care services in Iran and to examine the impact of different dimensions on overall satisfaction.
Method
The research was conducted during summer 2008 at a main academic hospital (Labbafinejad Medical Center), in Tehran. This hospital has a high turnover of inpatient/outpatient clients, with nearly 16,000 ophthalmologic surgeries, 90,000 outpatient visits, 23,000 patients visiting the emergency department (ED) and 4,000 patients being admitted to hospital wards in the corresponding year.
The study was approved by the ethics Committee of Shahid Beheshti University of Medical Sciences, and oral informed consent was obtained from all participants. Patients of various ethnicities and ages who attended different inpatient/outpatient ophthalmic services were eligible to be assessed, except those who could not mentally or physically communicate. Sixty patients were selected from each section, except from the operation room where 120 patients were selected to cover all operation types properly. Patients were selected from the admission list through systemic random sampling. In order to avoid any selection bias, all patients had an equal chance to enter the study at anytime during their attendance, even those who did not continue their treatment, Using n = [Z2×P× (1-P)/d2)] formula, where d = 0.05 and type I error of 0.05 and considering at least 50% of overall satisfaction based on previous studies in Iran [14, 15] and nearly 10% non-response rate, the sample size was calculated at least 410 persons.
The data collection tool was a three- part questionnaire; the first part consisted of demographic questions, patient's evaluation about his/her eye health and insurance status. The second part was based on the standard PSQ-18 questionnaire [5] and the third part consisted of complementary questions regarding physical setting of the hospital. PSQ-18 evaluates such dimensions as technical quality, interpersonal manner, communication (doctor-patient), financial aspects, time spent for patient, convenience, accessibility and overall satisfaction. The questionnaire was completed by a trained interviewer at the time of discharge. The validity of the original PSQ-18 was already verified [5, 12]. In this study it was translated to Persian and its content validity was evaluated using Delphi method and a multidisciplinary approach that involved ophthalmologists, social workers, medical staff members of the hospital and patients. The reliability was also checked by a pilot study in a group of 20 patients using a test-re-test assessment; the statistical measure of agreement (Kappa) between individuals' paired responses was more than 0.92.
In addition, 40 patients were asked to answer the questions in order to find the difficulties in performing the investigation and the clarity of the questions. The results of the pilot phase results were not used for final analysis.
Statistical analysis
Variables were described using mean ± standard deviation (SD) or percentage where appropriate. All the questions that assess satisfaction level were scored on a five-point Likert scale. Cronbach's alpha was used to assess internal consistency of questions in the physical setting dimension. After scoring, items within the same subscale were averaged together to create subscale scores. Univariate and multivariate statistical tests were used to assess and compare the effect of different variables on overall patient satisfaction. In all analyses α < 0.05 was considered as statistically significant. In a regression model, the contribution of individual domains including technical quality, interpersonal manner, communication, financial aspects, time spent for patient, convenience, accessibility (assessed by PSQ-18) and physical setting of the hospital (assessed by complementary questions in our study) to overall satisfaction, as the outcome variable, was addressed. All statistical analyses were done using SPSS-17.