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Original Article |
1 Department of Social Medicine, University of Bristol, Canynge Hall, Whiteladies Road, Bristol, BS8 2PR, United Kingdom
2 Division of Surgery, Head and Neck, Bristol Royal Infirmary, Bristol, BS2 8HW, United Kingdom
3 Clinical Sciences at South Bristol, University of Bristol, Level 7, Bristol Royal Infirmary, Bristol, BS2 8HW, United Kingdom
Correspondence: Address correspondence and reprint requests to: Jane M. Blazeby, MD, FRCS; E-mail: j.m.blazeby{at}bristol.ac.uk.
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONPATIENTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Methods: Consecutive patients who had completed treatment in one unit were invited to participate in this study and complete the European Organization for Research and Treatment of Cancer QLQ-PATSAT32 and QLQ-C30 questionnaires within 2 months of discharge. Regression analyses examined relationships between satisfaction and surgical morbidity (major complications and type of treatment) and between satisfaction and QOL variables, adjusting for age and sex.
Results: During the study, 181 patients were treated, 162 were eligible, and 139 returned both questionnaires (response rate, 86%). Of the study sample, the treatment outcome was potential cure in 105 (67 esophagectomy and 38 D2 gastrectomy), and 34 received palliative treatment. Thirty-seven patients (27%) had major complications. Patients who received palliative treatment reported satisfaction and QOL scores similar to those of patients who received curative treatment. However, patients who experienced major morbidity reported significantly worse QOL than those without morbidity (P < .01). Satisfaction scores were the same in patients with or without complications. There were no associations between satisfaction and QOL scores (r < .34).
Conclusions: Patient satisfaction with hospital care is independent of morbidity, treatment type, and QOL outcomes. It may be used to feed back information to providers of health care to improve patients’ experiences of treatment.
Key Words: Gastrointestinal neoplasms • Outcome assessment • Patient satisfaction • Quality of life
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONPATIENTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Treatment for cancer of the esophagus or stomach can be difficult, and morbidity after surgery or palliative treatment is common.2,3 Recovery is often prolonged, and it may be masked by recurrent disease before the benefits of surgery have been realized. These factors contribute to the profound negative effect on QOL that patients can experience.4,5 Patients who experience treatment-related complications have a longer hospital stay and recovery period than those who do not experience morbidity, and, because of this, it was hypothesized that patients with surgical morbidity (major morbidity or undergoing palliative treatment) would be more dissatisfied with care than those with better outcomes. It was also hypothesized that, over and above the influence of surgical morbidity, poor QOL scores would be associated with dissatisfied patients. The aims of this study were therefore to investigate associations between patient satisfaction and major morbidity and type of treatment and between patient satisfaction and QOL outcomes after in-hospital treatment for esophageal and gastric cancer.
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PATIENTS AND METHODS |
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TOPABSTRACTINTRODUCTIONPATIENTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Before admission to the hospital, patients were selected for treatment by the upper gastrointestinal multidisciplinary cancer team with consideration of pathologic type, disease stage (chest and abdominal computed tomography, endoluminal ultrasound scanning, and laparoscopy), and information about comorbid health status. The planned treatment was discussed with each patient, and written information was made available with specialist nurse support if necessary. While in the hospital, patients were informed of early treatment outcomes and given the opportunity to discuss pathologic disease stage and prognosis. Clinical and sociodemographic data were recorded, including age, sex, marital status, cohabitation status, employment status, level of education, type and date of treatment, morbidity, and date of death. A major complication was defined as reoperation, readmission to the high-dependency or intensive care unit, readmission to the hospital within 30 days of operation, or death within 30 days of operation (or later if the patient did not leave the hospital).
Questionnaires and Data Collection
An independent nonclinical research nurse explained the study to patients and gained written informed consent before patients’ discharge from the hospital. After discharge, patients who had undergone surgery were sent study questionnaires by post. Home visits were arranged for those who had undergone palliative treatment because previous research shows that they require more support to complete the instruments.12 Returned completed questionnaires were included in the analyses if returned up to 12 weeks after treatment. Where patients had long hospital stays (> 6 weeks), questionnaires were included if returned within 6 weeks of discharge.
Completed questionnaires were checked for missing items, and patients either were prompted for the information or were telephoned. Satisfaction with care was assessed with the validated European Organization for Research and Treatment of Cancer (EORTC) satisfaction with hospital care questionnaire, EORTC QLQ-PATSAT32.8 This 32-item measure contains 7 scales that address various aspects of patients’ satisfaction with care and 1 general item that assesses overall satisfaction. Items are all rated on a five-level Likert scale with the category labels "poor," "fair," "good," "very good," and "excellent." QOL was assessed with the EORTC QLQ-C30, a valid and reliable instrument that has been extensively used in many patients with upper gastrointestinal cancer.13 It contains nine multi-item scales and six single items that address global QOL, functional aspects of QOL, and symptoms commonly reported by patients with cancer.
Questionnaire Scoring and Interpretation
The EORTC questionnaires were scored according to the developers’ instructions.8,13 Scores for all domains and single-item measures ranged from 0 to 100. High scores for the functional and overall QOL scales in the QLQ-C30 indicate a higher/healthier level, but high scores for the symptom scales represent a higher level of symptoms/problems. High scores in the satisfaction questionnaire indicate higher levels of satisfaction. Missing items in the EORTC QLQ-PATSAT32 and EORTC QLQ-C30 were imputed according to EORTC Quality of Life Group guidelines.14
Data Analysis and Statistical Methods
Linear regression models were used to investigate the associations between satisfaction with care and surgical morbidity by examining the effect of major morbidity (yes/no) and treatment type (curative/palliative) on each satisfaction and QOL score. All regression models controlled for the possible confounding effects of sex and age. Examining the association between QOL and satisfaction scores indicated that controlling for confounding by sex and age made no difference to the results obtained. Hence, for simplicity, unadjusted correlation coefficients are presented for these analyses. Core aspects of QOL and satisfaction scales were selected a priori and included in the analyses. Core QOL domains were physical, role, social, cognitive, and emotional function and the global QOL scale. Satisfaction domains included that were related to hospital personnel were satisfaction with doctors, satisfaction with nurses, and satisfaction with exchange of information between caregivers, as well as the overall satisfaction scale. Analyses were conducted with the Stata statistical software package version 8.2 for Windows (Stata Corporation, College Station, TX). A significance level of 1% was used to allow for multiple significance testing. Because of the nonnormal distribution of the satisfaction scores, P values were calculated by using traditional and robust methods. Because the two resulting sets of P values were in agreement, those calculated with traditional methods are presented here.
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RESULTS |
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Analyses of satisfaction scores and surgical morbidity indicated that age, sex, tumor site (esophagus or stomach), the presence of major postoperative complications, and treatment group (curative/palliative) were not related to patient satisfaction (Table 2). Analyses of QOL and surgical morbidity, however, indicated that physical, role and social function, fatigue, nausea, and global QOL were all significantly related to postoperative complications and that role function, fatigue, and nausea were significantly related to tumor site (P < .01). Patients who had undergone treatment for esophageal cancer reported worse scores than those who had gastric cancer.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONPATIENTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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There is some evidence in the literature of a relationship between symptom improvement and satisfaction with care. For example, Jackson et al.15 found that patient-doctor communication (receiving an explanation of the symptom cause and likely duration and a lack of unmet expectations) was a powerful predictor of immediate postvisit satisfaction in patients attending a general medicine walk-in clinic, whereas 2-week and 3-month satisfaction reflected aspects of symptom outcome. A study by Kane et al.16 indicated that, although cholecystectomy patients’ satisfaction with quality of care, hospital care, and physician time was significantly related to general functioning and specific symptoms, this relationship was limited. These studies have included large numbers of patients with benign disease, and, despite finding some relationships between self-reported health and satisfaction with care, they concluded that more goes into satisfaction with care than just surgical morbidity. The findings from this study support these views because patients with major morbidity can still be satisfied with the process of care despite having experienced major complications.
In this study, major morbidity after upper gastrointestinal surgery was not associated with patient satisfaction. Others have examined predictors of satisfaction with care, and it seems that aspects of care related to staff, doctors, or nurses are among those that most influence cancer patients’ overall appraisals of their health-care experience.11,17 This suggests that by modifying staff behavior, it may be possible to improve patient satisfaction. There is currently no evidence to support this, although it is an area that warrants future research.18
Satisfaction ratings combine personal preferences of patients with their expectations and the realities of the care received.19 In this study, selected scales from the EORTC QLQ-PATSAT32 were used to address patient satisfaction with staff and overall satisfaction. The lowest satisfaction score was reported for "exchange of information between hospital personnel," thus highlighting areas for improvement that may be critical to good team working. Good communication between team members is clearly important and essential to ensure high-quality care.20 This approach to evaluating outcomes of treatment with patient-based measures can provide feedback to improve patients’ satisfaction and, indeed, team function.
The QOL outcomes after inpatient treatment for upper gastrointestinal cancer were significantly related to several clinical factors, especially if patients had experienced complications. In this study, 27% of patients had major morbidity, and this rate is similar to those in other published series.21 Although efforts to reduce morbidity after upper gastrointestinal surgery have been made over the past decade, the operation remains one of the highest-risk and most morbid elective surgical procedures. There has been a reduction in postoperative mortality rates because of improved anesthetic and surgical techniques,21 but whether it is possible to further reduce morbidity is unknown. It is possible that the advent of minimal access surgery will reduce postoperative complications, improve recovery, and enhance QOL.22
Surgical or palliative treatment for cancer of the esophagus and stomach is associated with significant morbidity, and many patients are discharged with poor QOL. This study has shown that these clinical parameters, however, do not relate to patient satisfaction, which is independent of the type of treatment, presence of complications, and poor postoperative QOL. The purpose of measuring patient satisfaction in surgical oncology is, therefore, to provide health care providers with details of the patient’s perspective of the process of care and to inform changes aimed at improving patient experiences.
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ACKNOWLEDGMENTS |
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Received for publication August 12, 2005. Accepted for publication November 18, 2005.
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REFERENCES |
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This article has been cited by other articles:
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  M. Rutegard and P. Lagergren No Influence of Surgical Volume on Patients' Health-Related Quality of Life After Esophageal Cancer Resection Ann. Surg. Oncol., September 1, 2008; 15(9): 2380 - 2387. [Abstract] [Full Text] [PDF]
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