Oncology-Radiotherapy Department, Besançon University Hospital, 3 boulevard Fleming, 25030 Besançon, Cedex, France
Radiotherapy Department, Montbéliard Hospital, 25200 Montbéliard, France
Clinical Research Department, EA 3181, Université de Franche Comté, 25030 Besançon, France
Nancy University, Paul Verlaine Metz University, Paris Descartes University, EA 4360 Apemac, Nancy, France - INSERM, CIC-EC CIE6, Nancy, France
Psycho-Oncolog Unit, Institut Curie, 75 231 Paris cedex, France
Health-Related Quality of Life in Oncology Platform, Nancy University, Cancéropole Grand Est, France
Abstract
Background
The aim of this study was to identify factors associated with satisfaction with care in cancer patients undergoing ambulatory treatment. We investigated associations between patients' baseline clinical and socio-demographic characteristics, as well as self-reported quality of life, and satisfaction with care.
Methods
Patients undergoing ambulatory chemotherapy or radiotherapy in 2 centres in France were invited, at the beginning of their treatment, to complete the OUT-PATSAT35, a 35 item and 13 scale questionnaire evaluating perception of doctors, nurses and aspects of care organisation. Additionally, for each patient, socio-demographic variables, clinical characteristics and self-reported quality of life using the EORTC QLQ-C30 questionnaire were recorded.
Results
Among 692 patients included between January 2005 and December 2006, only 6 were non-responders. By multivariate analysis, poor perceived global health strongly predicted dissatisfaction with care (
Conclusions
A number of clinical of socio-demographic factors were significantly associated with different scales of the satisfaction questionnaire. However, the main determinant was the patient's global health status, underlining the importance of measuring and adjusting for self-perceived health status when evaluating satisfaction. Further analyses are currently ongoing to determine the responsiveness of the OUT-PATSAT35 questionnaire to changes over time.
Background
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
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
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.
Methods
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).
Patients
Patients were enrolled in two centres (one university teaching hospital and one local (non-academic) hospital) in eastern France between January 2005 and December 2006. Inclusion criteria were: patients aged over 18 years, able to understand written and spoken French, able to provide written consent, able to complete the questionnaires, with a confirmed histological diagnosis of cancer, and due to undergo ambulatory treatment by chemo- or radiotherapy,
The subsequent cancers were included in 9 treatment groups: 2 prostate cancer groups (radiotherapy only or surgery followed by radiotherapy), 3 breast cancer groups (surgery plus radiotherapy, or surgery plus chemo and radiotherapy, or chemotherapy alone), 2 head and neck cancer groups (surgery plus radiotherapy or radiotherapy with or without concurrent chemotherapy), 1 rectum cancer group (radiochemotherapy plus surgery) and 1 lung cancer group (chemo and radiotherapy).
Study procedures and measures
Patients were invited to participate in the study at the end of the first week of radiotherapy or at the second cycle of chemotherapy. However, it was not technically possible to meet all patients on a systematic basis.. Once the patient agreed to participate and provided informed consent, the socio-demographic questionnaire was completed with the research technician. The EORTC QLQ-C30 and OUT-PATSAT35 questionnaires were given to the patient to complete at home and mail back using a pre-addressed, stamped envelope. Patients were reminded to return the questionnaires on their next visit, if they came back for radiotherapy treatment, or by phone after 2 weeks, where necessary.
The EORTC IN-PATSAT32 questionnaire was developed by the EORTC QOL group in order to assess patient satisfaction with care in oncology hospitals [Additional file
OUT-PATSAT35 contains 35 items covering 12 multi-item scales organized into three sections of four scales each: 2 sections evaluating doctors and nurses (for chemotherapy) or radiation therapists (for radiotherapy), as regards their technical skills (knowledge, experience, assessment of physical symptoms), interpersonal skills (interest, willingness to listen), provision of information (about the disease, medical tests and treatment), and availability (time devoted to patients); and a third section evaluating the organization of the department, the exchange of information between caregivers (coherence, identification of the reference doctor), the interpersonal skills and quality of information provided by other hospital staff, waiting times (for consultation, medical tests, or treatment), the physical environment (access, comfort, orientation), and lastly, a single-item, overall satisfaction scale.
Items are rated on a 5-level Likert scale as follows: "poor", "fair", "good", "very good", "excellent". All scores are linearly transformed to a 0-100 scale, with a higher score reflecting a higher level of satisfaction.
The EORTC QLQ-C30 (version 3.0) is a 30-item self-assessment of 15 scales of quality of life: 5 functional scales (physical, role, emotional, cognitive, social), 9 symptom scales (fatigue, nausea or vomiting, pain, dyspnoea, insomnia, constipation, diarrhoea, financial difficulties) and finally, a global health scale. All measures range from 0 to 100. High scores on the functional scales represent a healthier level of functioning, whereas high scores on the symptom scales represent a higher level of symptoms.
The following variables were collected by self-administered questionnaire and from medical records: gender, age (in years), marital status, level of education (primary, secondary, high school diploma or higher), number of children, occupation (employed versus unemployed/retired), monthly income (in Euro), distance from home to hospital (in kilometres (km)), means of transport (personal car versus other), leisure activities (yes/no), number of co morbidities (renal, cardiac, respiratory, hepatic, diabetes), primary cancer site (prostate, head and neck, breast, rectum, lung), treatment modality (chemotherapy and/or radiotherapy).
Statistical methods
The sample size of 520 patients was calculated according to Cohen's procedure based on multiple regression with a β risk of 20%, an α risk of 1%, a participation rate of 90% and a ΔR2 of 0.05
Patient characteristics were compared using Fisher's exact test, or Chi square for categorical data, and the Student t test for continuous data. Continuous data were subsequently coded into 2 or more classes categorical variables for the further analyses.
Bivariate analysis
The associations between EORTC QLQ-C30 and OUT-PATSAT35 scores were analysed by Pearson correlation and general linear regression. Then, we assessed the relationship between each categorical variable (clinical and socio-demographic data) and all OUT-PATSAT35 scores (considered as dependent variables) using analysis of variance (MANOVA model). We investigated collinear relationships between sex, chemo- or radiotherapy, and primary cancer localization.
Multivariate analysis
Significant categorical and continuous variables (QLQ-C30 scores) by bivariate analysis, were introduced into the multivariate models using analysis of variance (ANOVA) for each scale score of the OUT-PATSAT35 questionnaire.
The significance level for bivariate analysis was set at α = 0.05 and for multivariate analysis at α = 0.01 (to correct for multiple testing). All tests were two-sided.
For the interpretation of the scores, we considered the minimal difference defined as clinically meaningful by Osoba et al as a mean change of at least 5 points
Statistical analysis was performed using Statistical Analysis Software (version 9.1, SAS Institute, Cary, NC).
Results
Patient characteristics
733 patients met the eligibility criteria and were invited to participate in the study: 41 patients (5.6%) declined. Thus, 692 patients were included. of whom 2 patients failed to answer both questionnaires OUT-PATSAT35 and QLQ-C30 and 4 patients for the OUT-PATSAT35 (0.9% of non respondents). The characteristics of the study population are shown in Table
Socio-demographic and clinical characteristics of the study population
Characteristics
Local hospital
Teaching hospital
p
309
383
Sex
male/female
157 (51)
198 (51.7)
0.88
Age
Median [min;max]
66 [29;88]
63 [31;84]
0.06
30-55
65 (21)
87 (22.7)
56-65
72 (23.3)
114 (29.8)
66-75
118 (38.2)
138 (36)
76-88
54 (17.5)
44 (11.5)
Marital status
Single or separated
55 (18.2)
81 (21.2)
0.34
Living with partner, or family
248 (81.8)
301 (78.8)
Education level
primary
149 (50.5)
169 (44.6)
0.01
secondary
80 (27.1)
87 (23)
high school diploma or higher
66 (22.4)
123 (32.4)
Employment status
Employed
64 (21.1)
111 (29.1)
0.02
Retired or unemployed
239 (78.9)
270 (70.9)
Children
No
28 (10.3)
47 (12.5)
0.52
Yes (not dependent)
193 (70.7)
268 (71.1)
Yes (still dependent)
52 (19)
62 (16.4)
Distance home-hospital
Number of km: Median [min;max]
15 [1;160]
35 [1;145]
< 0.0001
≤ 20
203 (65.7)
146(38.1)
< 0.0001
> 20
106 (34.3)
237(61.9)
Means of tranport
Personal car
135 (48.8)
120(31.3)
0.0007
Other (taxi, ambulance, bus)
173 (56.2)
263(68.7)
Monthly income
In Euro
0.03
MW or less
34 (13)
36 (9.8)
MW-1499
103 (39.3)
115(31.4)
1500-2999
96 (36.6)
152(41.5)
≥ 3000
29 (11.1)
63 (17.2)
Leisure activities
Yes/no
178 (59.3)
242 (64.2)
0.20
Localization treated
Prostate
76 (24.6)
52 (13.6)
< 0.0001*
RT
Surgery+RT
32 (10.4)
50 (13)
Head and neck
6 (1.9)
16 (4.2)
Surgery+RT
RT+/-CT
26 (8.4)
45 (11.8)
Breast
72 (23.3)
133 (34.8)
Surgery+RT
Surgery+CT+RT
66 (21.4)
35 (9.1)
CT
5 (1.6)
0
Rectum
5 (1.6)
18 (4.7)
RT+CT+surgery
Lung
21 (6.8)
34 (8.9)
CT+RT
Chemotherapy
Yes
111 (36)
111 (29)
0.048
Radiotherapy
Yes
236 (77.1)
347 (90.6)
< 0.0001
Number of comorbidities
0
94 (30.4)
107 (27.9)
0.24
1
132 (42.7)
142 (37.1)
2
63 (20.4)
97 (25.3)
≥ 3
20 (6.5)
37 (9.7)
RT = radiotherapy; CT = chemotherapy; MW = minimum wage.
*p for heterogeneity between primary localizations
EORTC QLQ-C30 and OUT-PATSAT35 scores
Mean scores for the OUT-PATSAT35 scales ranged from 61.7 to 71.3 for the evaluation of doctors, from 58.5 to 72.5 for nurses or radiation therapists, from 59.8 to 64.6 for the organization or physical environment, while the mean overall satisfaction score was 72.5. Mean scores for the EORTC QLQC30 functional scales ranged from 63.6 (global health) to 82.7 (cognitive functioning) and for symptom scales from 8.7 (financial difficulties) to 33.5 (fatigue) (Table
Number of patients, mean score and standard deviation for each scale of the OUT-PATSAT35 and QLQC30 questionnaires
OUT-PATSAT35
QLQC30
Scale
Number of patients
Mean score (SD)
Scale
Number of patients
Mean score (SD)
Overall satisfaction
Functional scales
SATGEN
669
72.5 (19.7)
Global health
679
63.6(19.8)
Evaluation of Doctors
Physical
685
82.6 (18.6)
SATDTS
661
71.3 (20.3)
Role
682
78.7 (27.6)
SATDIS
659
67 (24.1)
Emotional
684
75 (23.1)
SATDIP
668
65.1 (25)
Cognitive
684
82.7 (20.9)
SATDAV
671
61.7 (23.6)
Social
681
80.4 (25)
Evaluation of Nurses or radiation therapists
Symptom scales
SATNTS
679
72.5 (21.1)
Fatigue
680
33.5 (25.6)
SATNIS
676
71.6 (20.5)
Nausea
684
10 (20.7)
SATNIP
640
58.5 (26.4)
Pain
685
19.4 (24.7)
SATNAV
653
66.1 (23)
Dyspnoea
674
18.4 (27.9)
Organization, physical environment
Sleep
679
30 (31.7)
SATEXE
609
64.6 (23.1)
Appetite
671
16.5 (28)
SATOTH
634
63.7(21.9)
Constipation
678
17.6 (28.8)
SATWAI
625
60.6 (20.6)
Diarrhoea
670
9.50 (20.4)
SATPE
674
59.8 (20.1)
Financial difficulties
675
8.74 (20.9)
SATGEN = overall satisfaction; SATDTS doctors' technical skills; SATDIS = doctors' interpersonal skills; SATDIP = doctors' provision of information; SATDAV doctors' availability; SATNTS = nurses' or radiation therapists' technical skills; SATNIS = nurses' or radiation therapists' interpersonal skills; SATNIP = nurses' or radiation therapists' provision of information; SATNAV = nurses' or radiation therapists' availability; SATEXE = exchange of information between caregivers; SATOTH = other personnel's interpersonal skills and provision of information; SATWAI = waiting time; SATPE = physical environment. OUT-PATSAT35 scales: SATGEN = overall satisfaction, SATDTS doctors'technical skills, SATDIS = doctors'interpersonal skills, SATDIP = doctors' information provision, SATDAV doctors'availability, SATNTS = nurses' or technologists' technical skills, SATNIS = nurses' or technologists' interpersonal skills SATNIP = nurses' or technologists' information provision, SATNAV = nurses' or technologists' availability, SATEXE = exchange of information between caregivers, SATOTH = other personal interpersonal skills and information provision, SATWAI = waiting-time, SATPE = physical environment
Bivariate analysis
Correlation coefficients were significant between almost all OUT-PATSAT35 scales and the QLQ-C30 functional scales, fatigue, pain and sleep. The highest correlation coefficients (0.20 < r < 0.30,
We identified primary localization, type of treatment, age, sex, marital status, leisure activities, home-hospital distance and monthly income as variables significantly associated with at least one OUT-PATSAT35 scale (
Univariate analysis (Manova model) between each clinical and sociodemographic variable and all OUT-PATSAT35 scales
SATGEN
SATDTS
SATDIS
SATDIP
SATDAV
SATNTS
SATNIS
SATNIP
SATNAV
SATEX
SATOTH
SATWAI
SATPE
0.93
0.46
0.98
0.85
0.78
0.80
0.35
0.33
0.30
0.41
0.43
0.93
0.40
Teaching hospital
72.5 (19.8)
71.6 (20.7)
68.3 (23.9)
66.0 (24.4)
61.8 (23.9)
73.1 (20.9)
72.0 (19.9)
60.2 (25.0)
66.6 (22.1)
64.2 (22.5)
63.9 (21.4)
60.4 (20.7)
59.3 (21.1)
Local hospital
74.7 (19.7)
73.4 (19.7)
67.9 (24.0)
67.7 (24.7)
63.4 (24.3)
73.3 (21.2)
72.8 (21.1)
61.0 (26.6)
66.5 (23.6)
65.7 (23.6)
65.7 (22.5)
63.2 (20.8)
61.9 (20)
0.01
0.005
0.09
< 0.0001
0.002
0.14
0.12
0.004
0.09
0.03
0.40
0.61
< 0.0001
prostate
77.6 (18.6)
74.6 (19.6)
70.3 (23.9)
69.4 (24.6)
68.0 (22.9)
76.0 (19.9)
75.7 (20.0)
61.1 (26.3)
68.6 (22.6)
68.4 (23.7)
67.4 (22.6)
63.4 (20.8)
66.3 (20.0)
head neck
69.1 (21.6)
64.8 (22.1)
61.2 (26.3)
54.1 (29.4)
55.0 (25.4)
69.3 (22.2)
69.8 (20.7)
53.7 (27.6)
60.4 (22.9)
58.8 (23.1)
62.6 (22.1)
59.2 (21.6)
52.4 (18.9)
breast
72.1 (18.2)
73.9 (19.3)
68.9 (22.1)
70.4 (20.8)
61.6 (23.1)
73.0 (20.5)
71.4 (19.9)
64.1 (23.7)
67.8 (22.3)
65.1 (21.9)
63.5 (21.3)
60.8 (20.3)
58.9 (20)
rectum
75.0 (21.1)
72.2 (24.3)
71.1 (26.3)
61.7 (25.9)
60.0 (25.5)
75.0 (21.7)
68.9 (23.6)
51.1 (30.7)
62.5 (25.4)
65.8 (20.3)
62.2 (25.2)
62.8 (19.9)
57.8 (24.3)
lung
71.7 (25.3)
68.6 (20.4)
66.1 (27.4)
59.7 (26.5)
59.4 (26.5)
69.4 (24.5)
69.9 (21.7)
53.7 (25.3)
64.4 (23.8)
60.1 (24.6)
65.1 (20.6)
63.0 (22.9)
60.6 (22.2)
0.64
0.0004
0.009
< 0.0001
0.17
0.05
0.04
0.0002
0.02
0.03
0.23
0.003
0.63
No
74.4 (16.8)
79.4 (16.9)
74.2 (18.1)
76.6 (17.6)
65.7 (20.3)
77.1 (19.3)
76.5 (18.4)
69.8 (20.7)
71.6 (20.5)
69.6 (20.5)
67.3 (17.8)
67.6 (19.7)
59.6 (19.9)
yes
73.4 (20.3)
71.1 (20.6)
67 (24.8)
64.7 (25.4)
61.8 (24.7)
72.4 (21.3)
71.6 (20.6)
58.8 (26.2)
65.7 (23.1)
63.9 (23.4)
64.2 (22.6)
60.5 (20.9)
60.7 (20.8)
0.07
0.56
0.99
0.05
0.17
0.33
0.10
0.02
0.72
0.56
0.27
0.45
0.19
female
71.8 (19.1)
72.9 (20.1)
68.1 (23.2)
68.9 (22.5)
61.0 (23.2)
72.2 (21.2)
70.8 (20.4)
63.2 (24.8)
67.0 (23.1)
64.2 (22.7)
63.6 (21.4)
60.9 (20.3)
59.2 (20)
male
74.9 (20.2)
71.9 (20.5)
68.1 (24.6)
64.8 (26.2)
63.8 (24.7)
74.0 (20.9)
73.7 (20.3)
58.1 (26.3)
66.3 (22.6)
65.4 (23.3)
65.7 (22.3)
62.3 (21.2)
61.5 (21.1)
0.09
0.06
0.06
0.06
0.0002
0.04
0.03
0.07
0.01
0.20
0.07
0.21
0.001
[30;55]
70.4 (19.7)
72.0 (21.3)
64.7 (25.5)
64.4 (25.3)
54.0 (23.4)
74.3 (21.5)
71.9 (20.4)
60.9 (25.0)
65.5 (21.9)
63 (22.8)
61 (22.3)
59.1 (22)
55.7 (21.3)
[55;65]
75.7 (19.3)
75.5 (20.3)
71.5 (23.1)
71.3 (24.1)
64.9 (24.2)
75.7 (19.3)
75.0 (19.2)
64.4 (24.5)
70.0 (21.9)
68 (23.5)
67.5 (20.3)
63.5 (20.2)
59.5 (19.6)
[65;75]
72.8 (20.1)
69.6 (20.0)
66.7 (23.9)
64.9 (23.7)
65.0 (23.1)
69.7 (22.0)
69.3 (21.4)
56.9 (26.5)
63.0 (23.6)
63.2 (23)
63.9 (22.6)
60.8 (20.6)
61.6 (20.3)
[75;88]
76.1 (19.1)
74.1 (18.3)
70.9 (22.0)
66.1 (25.6)
65.1 (24.4)
75.2 (20.2)
75.5 (19.0)
61.5 (26.5)
70.8 (22.6)
65.9 (21.8)
67.3 (21.6)
64.3 (20)
67.5 (20.5)
0.03
0.79
0.54
< 0.05
0.76
0.11
0.18
0.07
0.16
0.27
0.37
0.89
0.93
Living with partner/family
74.4 (19.4)
72.6 (20.2)
68.6 (24)
67.8 (24.0)
62.7 (24.4)
73.9 (20.4)
72.9 (20.0)
61.5 (24.9)
67.2 (22.2)
65.4 (22.6)
65.1 (21.5)
61.8 (20.5)
60.4 (20.4)
Single/separated
69.7 (20.9)
72.0 (20.4)
66.9 (23.5)
62.3 (28.5)
61.9 (22.2)
70.1 (23.6)
69.8 (22.2)
56.3 (28.8)
63.6 (25.0)
62.6 (24.5)
62.9 (23.4)
61.5 (22.1)
60.6 (21.9)
0.73
0.03
0.19
0.09
0.16
0.52
0.37
0.07
0.23
0.14
0.58
0.05
0.04
[1; 20]
73.7 (20.7)
74.2 (20.6)
69.4 (25.1)
68.5 (25.6)
63.9 (24.6)
73.7 (23.0)
73.1 (21.7)
62.4 (26.3)
67.7 (24.0)
66.3 (24.1)
65.2 (22.5)
63.3 (21)
58.7 (21.2)
[20; 145]
73.1 (18.7)
70.4 (19.7)
66.7 (22.5)
64.9 (23.3)
60.9 (23.3)
72.5 (18.7)
71.5 (18.8)
58.5 (25.0)
65.3 (21.4)
63.3 (21.6)
64.1 (21.2)
59.8 (20.5)
62.3 (19.8)
0.20
0.007
0.004
0.0001
0.006
0.01
0.09
0.14
0.04
0.009
0.22
0.82
0.25
no
71.9 (20.8)
69.3 (21)
64.2 |(24.9)
61.4 (26.3)
58.7 (24.8)
69.9 (22.0)
70.3 (20.8)
58.2 (26.1)
63.7 (22.7)
61.4 (24.3)
63.1 (22.6)
61.4 (21.7)
59.1 (21.4)
yes
74.2 (19.2)
74.3 (19.5)
70.4 (22.7)
69.8 (22.8)
64.7 (23.1)
74.8 (20.3)
73.4 (20.0)
61.7 (25.4)
68.1 (22.8)
66.8 (22)
65.5 (21.3)
61.8 (20.4)
61.3 (20.2)
Monthly income
0.32
0.06
0.60
0.10
0.64
0.05
0.37
0.15
0.33
0.16
0.65
0.94
0.37
MW or less
75.0 (21.8)
67.5 (23.2)
64.5 (28.2)
62.4 (29.3)
60.5 (24.9)
74.8 (20.6)
73.2 (21.4)
62.1 (25.0)
64.7 (24.6)
61.9 (26.8)
64.1 (26.6)
60.1 (24)
63.4 (21.6)
MW-1499
71.8 (19.3)
70.9 (19.6)
67.7 (21.7)
64.9 (23.8)
61.1 (24.8)
69.8 (21.4)
70.9 (19.8)
58.3 (26.0)
64.5 (21.9)
62.7 (21.3)
63.9 (21.1)
61.6 (21.9)
58.5 (21.2)
1500-2999
75.1 (19.0)
73.6 (20.5)
68.5 (23.9)
68.5 (23)
63.4 (23.0)
75.6 (20.8)
74.4 (20.5)
63.7 (26.0)
68.5 (22.7)
66 (22.7)
66.4 (21.5)
61.8 (19.2)
61.5 (18.7)
?3000
71.9 (18.6)
76.1 (18.6)
70.1 (25.2)
71.5 (25.8)
64.4 (24.1)
75.0 (20.3)
71.2 (20.9)
57.5 (25.7)
68.2 (22.9)
69 (23.6)
63.3 (21)
60.7 (20.1)
60.5 (22.9)
SATGEN = overall satisfaction; SATDTS doctors' technical skills; SATDIS = doctors' interpersonal skills; SATDIP = doctors' provision of information; SATDAV doctors' availability; SATNTS = nurses' or radiation therapists' technical skills; SATNIS = nurses' or radiation therapists' interpersonal skills; SATNIP = nurses' or radiation therapists' provision of information; SATNAV = nurses' or radiation therapists' availability; SATEXE = exchange of information between caregivers; SATOTH = other personnel's interpersonal skills and provision of information; SATWAI = waiting time; SATPE = physical environment. MW = minimum wage.
Multivariate analysis
The linear regression between the QLQC30 and the OUT-PATSAT35 scales selected the following significant scales for subsequent analyses: global health status, emotional and social functional scales, and sleep, pain and fatigue for symptom scales.
In multivariate models, localization of the primary cancer (breast, prostate, head and neck, rectum, or lung) and type of treatment received (radiotherapy and/or chemotherapy) were included in two separate models because a collinear relationship was observed between these two variables. In the first model (Table
OUT-PATSAT35 scales' mean score, mean difference and p values for clinical, socio-demographic factors and QLQC30 scales by multivariate analysis: model with primary localization *$
Monthly income (euros)
0.17
0.43
0.59
0.44
0.17
0.02
0.1
0.008
0.45
0.56
0.28
0.92
0.07
MW or lessa
MW-1499
-4.8
0.1
-4.5
-5.3
-5.3
-8.1
-4.7
-6.9
-3.4
-0.9
-3.5
-0.2
-7.6
1500-2999
-2.2
2.4
-3.4
-3.3
-1.1
-3.3
-1.2
-2.7
0
2
-1.4
1
-5.4
? 3000
-5.4
3.9
-2.3
-3.6
-1.3
-5
-5.6
-12.5
-1.3
2.8
-6
1.5
-4.5
Age
0.33
0.19
0.05
0.02
0.001
0.11
0.14
0.02
0.11
0.42
0.14
0.44
0.03
30-55 a
56-65
4.1
3.3
7.5
6.5
9.2
0.4
2.1
3.95
3.3
3
5.7
4
3.7
66-75
2.9
-1
4.3
0
10
-4.6
-2.7
-4.6
-2.4
-0.9
2.5
1.8
4.6
76-88
2.3
0.9
3.8
-1.5
8.8
-2.3
-1.7
-2.8
1.6
1.8
4.1
2.5
8.9
Marital status
0.04
0.96
0.28
0.003
0.36
0.20
0.37
0.01
0.11
0.29
0.23
0.94
0.89
Living with partner or familya
Single or separated
-4.2
-0.2
-2.7
-7.3
-2.2
-2.8
-1.9
-6.9
-3.8
-2.6
-2.8
0.2
-0.3
Localization
Prostatea
Head and neck
0.03
0.03
0.13
0.002
0.02
0.04
0.11
0.02
0.09
0.04
0.47
0.46
0.002
-6
-6.3
-5.1
-10.4
-7.9
-6
-4.5
-9.1
-5.6
-6.9
-2.3
-2.3
-9.2
Breast
0.06
0.54
0.82
0.37
0.1
0.02
0.02
0.53
0.67
0.43
0.61
0.51
0.01
-3.7
-1.2
0.6
2.2
-4
-4.9
-4.8
1.8
-1.1
-1.9
-1.2
-1.5
-5.1
Rectum
0.23
0.19
0.67
0.11
0.04
0.43
0.03
0.04
0.23
0.69
0.34
0.67
0.22
-5.7
-6.3
-2.4
-9.1
-11.1
-4
-10.7
-13.8
-6.9
-2.2
-5.1
-2.3
-5.9
Lung
0.20
0.44
0.98
0.24
0.23
0.26
0.52
0.26
0.59
0.61
0.50
0.998
0.11
-4.5
-2.7
0.1
-4.9
-5
-4.2
-2.3
-5.55
-2.2
-2.1
2.7
0
-5.7
QLQC30 scales
Global health status
< 0.0001
< 0.0001
< 0.0001
< 0.0001
0.004
0.0004
< 0.0001
< 0.0001
< 0.0001
< 0.0001
0.0001
0.001
0.003
*adjusted for center, leisure activities, distance from home to hospital and QLQC30 scales (emotional, social, sleep, pain, fatigue). $numbers in bold correspond to p values, numbers in italic correspond to mean scores, otherwise numbers correspond to mean difference compared to the reference class. a: reference class. SATGEN = overall satisfaction; SATDTS doctors' technical skills; SATDIS = doctors' interpersonal skills; SATDIP = doctors' provision of information; SATDAV doctors' availability; SATNTS = nurses' or radiation therapists' technical skills; SATNIS = nurses' or radiation therapists' interpersonal skills; SATNIP = nurses' or radiation therapists' provision of information; SATNAV = nurses' or radiation therapists' availability; SATEXE = exchange of information between caregivers; SATOTH = other personnel's interpersonal skills and provision of information; SATWAI = waiting time; SATPE = physical environment. MW = minimum wage.
In the second model (Table
OUT-PATSAT35 scales’ mean score. mean difference and p values for clinical. socio-demographic factors and QLQC30 scales by multivariate analysis: model with treatment*$
Monthly income
0.22
0.28
0.49
0.28
0.13
0.02
0.16
0.01
0.40
0.40
0.30
0.89
0.08
MW or less a
MW-1499
-4.6
0.2
-4.6
-5.9
-5.4
-7.7
-4.5
-7
-3.4
-0.7
-3.8
-0.1
-7.3
1500-2999
-1.9
2.7
-3.1
-2.9
-0.9
-2.9
-1.5
-2.5
0.1
2.5
-1.9
1
-4.8
? 3000
-4.8
4.7
-1.5
-2.5
-0.6
-4.2
-5.2
-11.4
-0.8
3.8
-6
2
-3.5
Age
0.11
0.23
0.02
0.08
< 0.0001
0.41
0.31
0.1
0.15
0.43
0.07
0.22
0.001
30-55 a
56-65
4.9
4.1
8.3
6.3
10.2
1.7
3.5
4
4
3.7
6.5
4.9
4.8
66-75
4.9
1
6.2
1.7
12.8
-1.8
0.1
-2.8
-0.5
1.2
4
3.7
7.1
76-88
4.4
3.3
6.1
0.7
11.8
0.9
1.6
-0.1
4
4.3
5.8
4.8
11.3
Marital status
0.03
0.84
0.22
0.004
0.26
0.12
0.21
0.01
0.07
0.24
0.16
0.89
0.74
Living with partner or family a
Single or separated
-4.5
-0.4
-3
-7.2
-2.7
-3.4
-2.6
-6.9
-4.2
-3
-3.2
-0.3
-0.8
Radio-therapy
0.25
0.003
0.003
0.0001
0.03
0.06
0.03
< 0.0001
0.01
0.03
0.20
0.007
0.44
no a
yes
-2.7
-7.1
-8.4
-11
-6
-4.6
-5.2
-12.4
-7
-6
-3.4
-6.9
-1.8
QLQC30 scales
Global health status
< 0.0001
< 0.0001
< 0.0001
< 0.0001
0.002
0.0002
< 0.0001
< 0.0001
< 0.0001
< 0.0001
0.0002
0.001
0.0009
*adjusted for center. leisure activities. distance from home to hospital. and QLQC30 scales (emotional. social. sleep. fatigue. pain) $numbers in bold correspond to p values, numbers in italic correspond to mean scores, otherwise numbers correspond to mean difference compared to the reference class. a: reference class SATGEN = overall satisfaction; SATDTS doctors' technical skills; SATDIS = doctors' interpersonal skills; SATDIP = doctors' provision of information; SATDAV doctors' availability; SATNTS = nurses' or radiation therapists' technical skills; SATNIS = nurses' or radiation therapists' interpersonal skills; SATNIP = nurses' or radiation therapists' provision of information; SATNAV = nurses' or radiation therapists' availability; SATEXE = exchange of information between caregivers; SATOTH = other personnel's interpersonal skills and provision of information; SATWAI = waiting time; SATPE = physical environment. MW = minimum wage.
Socio-demographic determinants significantly linked to dissatisfaction with care, in both models, were marital status (living alone) associated with doctors' information provision, and young age (< 55 years) with doctors' availability. A monthly income > 3000 Euro was associated with less satisfaction with nurses' or radiation therapists' information provision, but this was only significant in the model with primary cancer (Tables
The centre was not found to be a significant determinant of patient satisfaction.
Poorer perceived global health status, in both models, was significantly associated with lower levels on OUT-PATSAT35 scales: regression coefficient ranged from 0.17 to 0.34 (
Discussion
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;
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
Indeed, the relationship between QOL and satisfaction with care remains unclear
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
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
Level of education was not associated with satisfaction scores, in our study. Poinsot et al observed similar findings to ours
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.
Conclusions
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.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
TVFN participated to the coordination of the study, performed the statistical analysis, the interpretation of data and drafted the manuscript. JFB and AM participated in the conception and design of the study. JF and VP contributed to the acquisition of data. CB and AB revised the manuscript critically for important intellectual content. MM participated in the conception and coordination of the study, and helped to the statistical analysis and the interpretation of data. All authors read and approved the final manuscript.
Appendix A. EORTC IN-PATSAT32.
Click here for file
Appendix B. OUT-PATSAT35.
Click here for file
Acknowledgements
The authors are grateful to Fiona ECARNOT and Marc PUYRAVEAU.
This publication was supported by Programme Hospitalier de Recherche Clinique (PHRC 2004 - France).
Part of this work was presented in poster presentation of ESMO in Berlin, september 2009: Nguyen TV, Bosset JF, Monnier A, Perrin V, Fournier J. Determinants of patient satisfaction in ambulatory oncology: a prospective study based on the EORTC OUT-PATSAT 35 questionnaire. Eur J Cancer Suppl 2009;7:241; in oral presentation of 10th Biennal ESTRO in Maastricht, September 2009: Nguyen TV, Bosset JF, Monnier A, Mercier M. Determinants of satisfaction with care in cancer outpatients: a prospective study based on the EORTC OUT-PATSAT35 questionnaire.
Pre-publication history
The pre-publication history for this paper can be accessed here: