Jurnal Lari 2004

Health and Quality of Life Outcomes
BioMed Central
Editorial Open Access

Patients' needs, satisfaction, and health related quality of life:
Towards a comprehensive model
Mohsen Asadi-Lari*1, Marcello Tamburini2 and David Gray1
Address: 1Division of Cardiovascular Medicine, University Hospital, Nottingham, NG7 2UH, UK and 2Unit of Psychology, Istituto Nazionale
Tumori, Via Venezian 1, 20133 Milan, Italy
Email: Mohsen Asadi-Lari* - [email protected]; Marcello Tamburini - [email protected];
David Gray - [email protected]
* Corresponding author
Published: 29 June 2004 Received: 10 May 2004

Accepted: 29 June 2004
Health and Quality of Life Outcomes 2004, 2:32 doi:10.1186/1477-7525-2-32
This article is available from: http://www.hqlo.com/content/2/1/32
2004 Asadi-Lari et al; licensee BioMed Central Ltd. This is an Open Access article: verbatim copying and redistribution of this article are permitted in all
media for any purpose, provided this notice is preserved along with the article's original URL.
With the publication of its 100th paper, the new open health care intervention may differ significantly from a
access Journal Health and Quality of Life Outcomes patient perspective vis--vis the health care provider's per-
(HQLO), achieves a significant milestone. Launching a spective. When this occurs we may ask ourselves; Has a
journal in this field was not just a challenge with respect health need been met? Was the care process satisfactory?
to nomenclature, [1] but also provided a forum for dis- Has the burden of disease on the patient's quality of life
seminating research which emphasises the unique contri- been minimised?
butions as well as the inter-relationships among
determinants of health, provision of care, and outcomes. This traditional approach to patient assessment, using
So far, prominence (as measured by the number of scien- clinical and laboratory evaluation, is largely based on
tific manuscripts accepted for publication) has been given observer ratings by health professionals. In the 'medical
mainly to the unique contributions of health-related qual- model', there is an optimal level of functioning and every-
ity of life (HRQL). Other determinants like health needs body below this could be assumed to suffer ill health.
and satisfaction have sporadically been considered [2-7]. However if these cases are examined carefully, physically-
A few additional papers have focused on approaches to disabled individuals could be found with better quality of
detect ill health. In this editorial we would like to explore life than individuals with optimal functioning, as quality
the relationship between needs, satisfaction and quality of of life refers to a broader concept of health than has tradi-
life, identify gaps in the current knowledge base, and tionally been defined. Modern medicine is slowly begin-
encourage future research in these areas. ning to recognise the importance of the perspective of the
patient in health care and more investigations are needed
Clinical approach to understand the importance of the inter-relationships
The World Health Organisation (WHO) in 1948 defined among health needs, satisfaction, and quality of life.
health as a "a state of complete physical, mental, and
social well being not merely the absence of disease or 'Need': conceptually complex
infirmity" [8]. While this definition is comprehensive No consensus seems to be exist about the meaning and
(though rather utopian and ambitious) it clearly indicates concept of 'need' in health, sociology and political litera-
what should be the goal of health care intervention. Med- ture [11-13]. The ambiguity of the concept of 'needs' and
ical professionals however tend to focus more narrowly enormity of the task imposed upon practitioners has
on a medical model of health care -a history and examina- made the transition from service-led to needs-led much
tion- followed by investigation and treatment, and finally harder [14]; this vagueness is more apparent when a spe-
clinical measures of successful outcome. This approach cific need fails to fall neatly into 'health care' or 'social
has been criticised for producing a paternalistic doctor- care' domains, each of which is correlated with the other.
patient relationship [9,10]. The relative success of a given Patients with depreciated perception of health status have
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(page number not for citation purposes)
Health and Quality of Life Outcomes 2004, 2:32 http://www.hqlo.com/content/2/1/32
more social needs [4], thus meeting social needs may have isfied with services, and lead to better quality of life. At the
a direct impact on general health status, which eventually moment, there is no single definition of genuine health
falls into the health domain, perhaps indicating the 'holis- needs precisely within the context of public health policy,
tic nature' of needs [14]. For example, cancer patients may yet it makes sense to describe this inherently complex
have a need to better understand their diagnosis and the issue as 'what patients and the population as a whole-
specific prognosis. However, they may feel guilty about desire to receive from health care services to improve over-
interrupting a busy General Practitioner, and so their all health'. Even this definition may leave practitioners
needs are not met. This may raise the patient's level of anx- 'open to making judgement based on implicit knowledge,
iety, which in turn may worsen their emotional health sta- rooted in professional training and values, office culture
tus [6,15,16]. and assumptive world' [17].
Need has a broad spectrum, as the range of human expe- Patient satisfaction surveys
riences is quite large. The main focus in Wen and Gus- The modern approach to healthcare seeks to engage the
tafson's paper [6] was on emotional problems, which attention of both patients and the public in developing
despite its importance in perceived HRQL, consists of just healthcare services and equity of access, but this is not
one part of the whole concept- there are more subscales. easy to achieve, requiring time, commitment, political
Apparently, the physical scale has been ignored in their support and cultural change to overcome barriers to
models, as are other components of the physical and emo- change [18,19]. Improvement in selected aspects of health
tional domains such as quality of sleep, pain and discom- care delivery through quality assurance and outcome
fort, social contacts and overall perception of quality of assessment has been driven by political expediency. While
life perception. this is important, a 'bottom up' assessment of patient sat-
isfaction seems preferable if service improvement is to be
'Need' may have a direct effect on satisfaction with care translated into outcomes meaningful to patients, espe-
but the direction of the relationship is not clear. For exam- cially improved quality of life [20,21].
ple, patients may have a need for more or better informa-
tion on some aspect of health. If this need is unmet, it may Satisfaction can be defined as the extent of an individual's
result in dissatisfaction with services. Alternatively, the experience compared with his or her expectations [22].
better informed patient tends to have higher expectations Patients' satisfaction is related to the extent to which gen-
and so be dissatisfied with care [6]. Both of these scenarios eral health care needs and condition-specific needs are
directly influence quality of life [5]. met. Evaluating to what extent patients are satisfied with
health services is clinically relevant, as satisfied patients
A current definition of need that has been occasionally are more likely to comply with treatment [23], take an
published in the National Health Service (NHS) docu- active role in their own care [24], to continue using med-
ments indicates that need is the 'capacity to benefit from ical care services and stay within a health provider (where
health care services'. However this definition may be too there are some choices) and maintain with a specific sys-
restrictive as "legitimate" patient needs might be limited tem [25]. In addition, health professionals may benefit
to those that can be easily addressed within existing health from satisfaction surveys that identify potential areas for
services and that are considered 'medically necessary', service improvement and health expenditure may be opti-
maintaining the medical model which experience sug- mised through patient-guided planning and evaluation
gests has proven unsatisfactory in meeting patient needs. [19].
The pressure of political self-preservation obliges health Critics draw attention to the lack of a standard approach
decision makers to handle health issues with no further to measuring satisfaction and of comparative studies
increase in global health budget, thus they prefer to [26,27] and so the significance of the results of those sur-
manipulate and introduce rather strict and somewhat arti- veys that do exist in the literature is often ignored. There
ficial definitions to justify shortages in resources devoted is less controversy with respect to clinical outcome meas-
to the health sector. Unfortunately using a more restrictive ures, as health-related quality of life (HRQL) is not only
definition of 'need' masks the larger amount of genuine widely regarded as a robust measure of outcome assess-
health needs of the population. Satisfying all of these ment but also is extensively used in several clinical areas
desired health needs would, most certainly, require more [28,29].
monetary resources.
Patient satisfaction is considered by some to be of dubi-
The challenge therefore is to identify and target patients' ous benefit in facilitating the process of clinical care, as
genuine needs. Mobilising resources to meet these needs patients have no specific clinical expertise and are -per-
would certainly avoid further expenses, keep patients sat- haps- readily influenced by non-medical factors; in
Page 2 of 15
addition, there are few reports on the reliability of satisfac- gate, is an essential first step towards optimising the use of
tion surveys [19,30,31]. Nevertheless, satisfied patients allocated resources.
are more likely to comply with medical treatment and
therefore ought to have a better outcome [23]. The correlation between health needs and health-related
quality of life scores might have potential benefits in rou-
The role of health-related quality of life tine clinical investigation, too, where comprehensive care
Reliable (and increasing) evidence exists about the robust- is targeted. Administration of appropriate HRQL tools in
ness of the predictive value of patients' perception of their clinics, surgeries or health centres may detect areas of
own health status [32,33]. Some HRQL tools are able to health care needs worthy of health professionals' closer
assess post-MI patients' perceived health status and there scrutiny. For example, a patient with an impaired Short
is a significant correlation with conventional clinical Form Physical Component Score [33] or physical dimen-
assessments like the treadmill exercise test [34,35], or with sion (SAQ-Phys) may perhaps be distinguished not only
functional classification such as the New York Heart Asso- as being at high risk in terms of clinical end points [48],
ciation (NYHA) scale [36]; however reports are inconsist- but also as a vulnerable patient who might have difficulty
ent [37,38]. It is noteworthy that the correlation accessing health care services, for which extra care (such as
coefficient for treadmill-induced angina on tests one day after hours services or ambulance transport) may be
apart was 0.70 [39] and for patient-reported angina was required. Similarly where the satisfaction component in
0.83 when SAQ was applied three months apart [40]. The the SAQ yields a lower score, cardiac care teams must be
shift to the patients' viewpoint, however, is pessimistically aware of potential shortcomings in the delivery of care
asserted to be inevitable in chronically ill or dying patients and investigate reasons for any dissatisfaction; even provi-
as there is no option for further clinical assessment [41]. sion of information about the nature of cardiovascular
disease or its treatment may improve the satisfaction
There is growing evidence indicating that 'quality of life score.
assessment' can be considered as adjuvant to clinical and
physiological assessments in many chronic conditions, Health-related quality of life tools have the potential to
particularly cancers [42] and coronary artery diseases [43]. identify specific and general health needs. First, compo-
This approach is postulated to be the 'gold standard' in the nents of disease-specific HRQL tools are more likely to be
evaluation of healthcare services and outcome assess- associated with specific health care needs. Second, meas-
ment. The large variety of generic and disease specific uring HRQL provides outstanding insight towards
instruments can confuse researchers contemplating the approaches that may lead to improved quality of care
most appropriate tools for quality of life investigation. As [40]. Third, the administration of 'off-the-shelf' quality of
a general rule, however, the combination of generic and life tools affords a rapid screening test to identify both
disease-specific HRQL questionnaires provide comple- populations and individuals who warrant a more detailed
mentary information [3,44,45]. health needs assessment.
Relationship of satisfaction, quality of life and A common critique of quality of life tools in clinical
health needs research is that data are 'soft' and less reliable than tradi-
Wen and Gustafson [6] proposed an interesting model of tional clinical assessment or physiological measurement.
the relationship between health needs, satisfaction with Nevertheless, both generic and disease-specific tools can
care and quality of life in cancer patients. Their research detect subtle clinical changes quite precisely [40], espe-
makes a compelling case for us to reassess the concept of cially in cardiac disease [49]. Some are concerned that
needs assessment and better explore its relationship with HRQL tools may not precisely identify the most impor-
outcome measurements, like clinical endpoints, quality of tant problems yet, from an economic and existential point
life, and satisfaction with care. The association of health of view, it is conceded that patients' perception has equal
needs and health-related quality of life and also satisfac- validity and legitimacy to that of physicians [41]. English
tion with health services have been acknowledged in can- language-based quality of life tools have been tested in a
cer patients, oral health and cardiac patients in Health and wide range of diseases; overall in clinical practice and in
Quality of Life Outcomes [3-5,7], and a few in other jour- health service research, they have proven so useful that
nals [46]. both generic and disease-specific tools have been trans-
lated into a variety of other languages for wider
A comprehensive evaluation of health care should ascer- application.
tain a patient's expressed health needs [47]. Identification
of the needs of individuals (and of the local population), Basing health care needs on quality of life scores, however,
whether through formal needs assessment or some surro- necessarily incorporates several sources of uncertainty due
to factors such as age, sex, social class and individual
Page 3 of 15
patient's health status. In addition, quality of life tools 5. Have studies of patients' satisfaction been conducted
may fail to distinguish between health problems and the but not published because of negative results, poor valid-
desire to get professional attention [50]. ity and reliability and responsiveness of the instruments
developed (eg high levels of ceiling effect with high levels
Despite the documented relative merits of HRQL tools in of satisfaction due to patients' fear of giving negative eval-
various clinical and research settings, these tools may not uations)? Or studies which could not be published
detect individual health needs in depth. For example, because non-validated instruments were deployed, to
assume a coronary artery patient who has attended in a assess patient satisfaction, not only wasting scarce hospi-
cardiac rehabilitation session with an impaired emotional tal resources but also delaying changes in health service
score in the MacNew (Quality of Life after Myocardial Inf- delivery by local health authorities.
arction) or sleep disorder in the Nottingham Health Pro-
file (NHP) questionnaire: can we distinguish the We have addressed these questions to a selected number
background reason for this impairment? Is it due to (at of researchers (most of them editorial board members of
worst) heart failure disturbing depth of sleep or simply the Journal or Authors of articles published in HQLO; see
because the patient has teen-aged grandchildren who Table 1). Their answers/comments are reported in the fol-
afford little time for rest? At this stage, an in-depth needs lowing sections and provide HQLO readers with interest-
assessment could reveal the background explanation, ing thoughts about the direction of future studies.
which may warrant changes in medical treatment or the
provision of social support. Any comprehensive model- The concept and approaches of needs assessment, satisfac-
ling must include both needs and outcome assessment to tion, and HRQL seems fundamental to 'good practice',
evaluate the whole process of care in individual and pop- 'quality care', and 'community participation' at a time of
ulation levels. The optimum approach, perhaps, could be greater patient empowerment. However, resource con-
a combination of needs and outcome assessment, prefer- straints on one hand and medical expectations on the
ably at individual levels [41]. other may jeopardise the impact of the patient's
perspective.
Comments/ Discussion
While a large body of literature exists and continues to It is our hope that drawing attention to the importance of
expand on generic and condition specific health-related the interaction of patients' health needs, satisfaction and
quality of life assessment theory and applications, and to health-related quality of life will stimulate further
a lesser degree patient satisfaction, the inter-relationship research to produce valid and reliable data and perhaps
between needs, satisfaction, and quality of life remains new investigational tools which take all these non-medi-
ambiguous; there is no consensus over the actual contri- cal factors into account.
bution of these measures in modelling a comprehensive
health care arrangement. Are the current research efforts in the evaluation of health
status, needs, satisfaction and quality of life appropriately
As we reflect on the current state of research in these areas, balanced?
a number of challenges confront us: My view is that the best, most accurate quality of life data
and conclusions should point to unmet needs and should
1. Are the current research efforts in the evaluation of be closely associated with satisfaction. Therefore, rather
health status, needs, satisfaction and quality of life appro- than seeing this as a competition for limited resources,
priately balanced? potentially spawning a short-term feeding frenzy on the
nature of these relationships, I view it as a call for better
2. Should research on health status and quality of life be appreciation for how existing quality of life evaluations
terminated or should the emphasis on traditional clinical point to appropriate treatment directions and patient sat-
outcomes (such as survival) be reduced? Which should isfaction with care. Recently, several researchers have
prevail? turned their focus to such application of existing tools.
David Cella
3. To what extent can quality of life be used as a proxy or
surrogate for satisfaction and/or the needs of patients? Why is 'balance' needed? And what is an appropriate bal-
Just as clinical indicators have been used as surrogates for ance? I find this sort of question a bit pointless, as
quality of life [51], are we in danger of similarly mistaking researchers will do what researchers do anyway. But the
health need as a surrogate? question lacks explicit criteria in terms of which to discuss
the matter. Anthony Culyer
4. What is the evidence for the psychometric properties of
the instruments used to evaluate satisfaction and needs?
Page 4 of 15
Table 1: Appendix. Authors of the comments Table 1: Appendix. Authors of the comments (Continued)
Mark J. Atkinson, PhD Brown Medical School

Senior Outcomes Research Scientist Providence, Rhode Island, USA
Worldwide Outcomes Research Luis Prieto, PhD
La Jolla Labs, Pfizer Inc. Health Outcomes Research Unit
San Diego, CA, USA Lilly, S.A., Madrid, Spain
Anne Brdart, PhD Ewa Roos, PT, PhD,
Unite de Psychiatrie et D'Onco-Psychologie Associate Professor
Institut Curie, Paris Cedex, France Dept of Orthopedics
Cinzia Brunelli, ScD Lund University Hospital
Unit of Psychology Lund, Sweden
Istituto Nazionale Tumori, Milan, Italy Rob Sanson-Fisher, PhD
David Cella, PhD Professor of Health Behaviour
Professor, Psychiatry and Behavioral Science Faculty of Health
Research Professor University of Newcastle, Australia
Institute for Health Services Research Richard Shikiar, PhD
and Policy Studies Senior Research Scientist and COO
Northwestern University MEDTAP International, Inc.
Director, Center on Outcomes, Seattle, WA, USA
Research and Education Davide Tassinari, MD
Evanston Northwestern Healthcare Department of Oncology, City Hospital
Evanston, IL, USA Rimini, Italy
Anthony Culyer, CBE, BA, Hon DEcon, FRSA, FMedSci Andrew Vickers, PhD
Professor and Chief Scientist Integrative Medicine Service
Institute for Work and Health Memorial Sloan-Kettering Cancer Center
Toronto, ON, Canada New York, USA
James T. Fitzgerald, PhD
Department of Medical Education
University of Michigan Medical School
Ann Arbor, MI, USA
Samuel C. "Chris" Haffer, PhD I don't think it is a good idea to dictate which areas of
Director, Medicare Health Outcomes research should be continued and discontinued. The best
Survey Program research stems from investigator initiation. Robert M.
Centers for Medicare & Medicaid Services Kaplan
Baltimore, Maryland, USA
Michael E. Hyland, PhD, CPsychol
Professor of Health Psychology We need to make our assumptions clear. We, as research-
School of Psychology ers and clinician, categorise the world so as to make sense
University of Plymouth, UK of the world. We divide it into manageable parcels. One of
Robert M. Kaplan, PhD these parcels is health related quality of life (HRQL);
Professor and Chair another is patient satisfaction; and yet another is patient
Department of Family need.
and Preventive Medicine
University of California
San Diego, La Jolla, CA, USA However, these are our interpretations, they are not neces-
Richard Kravitz, MD, MSPH sarily what goes on inside the patient. Consider the fol-
Professor and Director lowing truisms:
UC Davis Center for
Health Services Research 1. When patients respond to a questionnaire, they are
in Primary Care actually responding to the individual items of the ques-
Co-Vice Chair for Research
Department of Internal Medicine
tionnaire. The researcher then sums those items in one
Sacramento, CA, USA way or another.
Ruth McCorkle, RN, PhD, FAAN
Director of the Center for 2. The patient's response to individual items reflects (a)
Excellence in Chronic Illness Care what the researcher thinks the item is measuring and (b)
School of Nursing, Yale University many other things as well, some of which the research
New Haven, CT, USA
may be aware of but others are unknown.
Stephen P McKenna, PhD
Director of Research
Galen Research, Manchester, UK 3. Measures of satisfaction reflect items measuring refer-
Brian Ott, MD ring specifically to some defined aspect treatment (the
Department of Clinical Neurosciences selection is made by the researchers). Measures of HRQL
Page 5 of 15
include a range of emotional and physical aspects (again uated cross-sectionally, for example, by comparing scores-
selected by the researcher) but typically without referring between patients with early and late stage disease. There is
to the actual treatment received. Both these kinds of item less researchlooking at the responsiveness of instruments
are highly correlated with trait negative affect (e.g., neu- to change following treatment; in particular, there is insuf-
roticism), which is itself often a component of HRQL ficient research on how to develop instruments that are
scales. There is often some overlap in the wording of items maximally sensitive to change. Andrew Vickers
from different kinds of scale, so not surprisingly satisfac-
tion, HRQL and personality scales inter-correlate quite I think one needs to have more research on assessing the
highly. contribution of general health and specific disease com-
ponents to quality of life, and how this contribution var-
4. Perception of need depends on trait negative affect, as ies between cultures, ethnic groups, genders, and age
well socially constrained expectations. If all of your neigh- groups. More research on health related quality of life as
bours have donkeys but not cars, then you don't 'need' a an outcome measure in clinical trials is needed. Pharma-
car. But if your neighbours all have two cars, then you may ceutical companies for example are still reluctant to use
be dissatisfied with one. The idea of 'genuine needs' quality of life as an outcome due to perceptions that the
referred to in the editorial is one of those fictions it available measures lack reliability and, to a lesser extent,
depends on who decides what is genuine. validity. There is also reluctance to use clinical indicators
as proxies for quality of life, which I think is justified,
5. Perceptions about need have an impact on satisfaction given our present state of knowledge. Brian Ott
and HRQL the more you need the less satisfied you are.
People with high self-expectations are more likely to be The issue is not so much balance as continuing to explore
depressed. Is it better to be happy and live in a gutter, or the connections between these concepts and to be explicit
unhappy and live in a palace? Are health professionals about their relationships to one another. Health status,
encouraging patients to be unhappy palace dwellers by needs, satisfaction, and quality of life are empirically
showing them how much better their health could be? related. Are they conceptually distinct? Not yet. As the edi-
torial points out, needs are subjective, satisfaction is
6. The above shows that outcome is conceptually far more related to "needs", and measures of quality of life should
complex than is often thought and from the patient's per- (but rarely do) incorporate the values of patients rather
spective, the distinction between satisfaction, HRQL and than investigators. As Sullivan points out [52], the out-
needs is by no means straightforward, and furthermore comes movement is changing the physician's job descrip-
assessment is associated with value judgements which are tion from a focus on patients' bodies to a focus on their
often not made explicit. lives. We better get it right. Richard Kravitz
7. Despite all these problems, my personal view is that the The editorial covers a number of different types of health
really is no alternative to questionnaire based assessment outcome that could be assessed; health status / health-
of patients satisfaction, HRQL and need. All health care related quality of life (HRQL), quality of life (QoL),
resource allocation is based on value judgements. We can- patient satisfaction and health needs. Each has a different
not avoid resource allocation, and we cannot avoid value purpose and these different outcomes are not dependent
judgements. Outcome assessment forces us to make these on each other though they may be correlated to a greater
assumptions a little more explicit. Perhaps if I am making or lesser extent [53]. Research into HRQL is more exten-
recommendations for the future, it is that we should make sive than that into the other outcomes but it is questiona-
the assumptions on which our scales are based far more ble whether it has reached a particularly high quality in
explicit than we do at the moment. Michael E. Hyland most cases. Further research is required to improve the
assessment of HRQL and into assessment of the other out-
My reflection on this question and above is: how encour- comes. There is no reason why, for example, development
age, help communicating, sharing viewpoints between work on the assessment of QoL should be sacrificed to
various specialists (e.g. clinicians, psychometricians,...). increase efforts to assess patient satisfaction. However, it
There are still barriers between them and this may cause seems likely that market forces will govern where research
unproductive research. Clinicians need to understand the efforts are directed.
relevance and usefulness of working on "soft" data
besides traditional medical endpoints. This is far to be As the different types of outcome are based on different
achieved. Anne Brdart measurement models and have dissimilar aims, one type
of outcome cannot (and should not) be seen as a surro-
One area where we do think there is imbalance is that gate for another. The science of patient-reported outcome
quality of life and health status instruments are often eval- measurement has been hindered by the practice of taking
Page 6 of 15
measures of one type of outcome and implying that they Each of the three broad areas addresses a potentially dif-
assess a different outcome. Instruments such as the Sick- ferent and important field. Many measures of quality-of-
ness Impact Profile [54], Nottingham Health Profile [55] life reflect the views and judgements of the experts. The
and SF-36 [56] were developed as health status instru- respondent is asked to indicate whether or not they can
ments for use in population surveys (as indicated by their perform or feel in a certain way. Dependent upon the
authors). Over the years they have become commonly answer a judgement is made usually on statistical basis
referred to as 'QoL' measures, as the need arose to assess that they have what do not have a high quality of life. In
this construct in clinical trials. As a consequence of their Needs analysis the respondent is often asked for their
widespread use in this context, relatively few 'true' QoL judgement about whether or not they have a need in a par-
instruments are now available, limiting our ability to ticular area. This allows the respondent themselves to
determine the true overall impact of disease and its treat- determine priorities and perceptions of what assistance
ment on the patient. they require. It is this area of research which currently
requires more effort on development of both the theoret-
Care must also be taken in using the terms 'health needs' ical and pragmatic aspects of measurement. Rob Sanson-
and 'needs' interchangeably. The issue is analogous to that Fisher
of equating HRQL with QoL. HRQL restricts considera-
tion to issues that are capable of influence by health More than balancing current research in the evaluation of
services [57] and, consequently, misses many important health status, needs, satisfaction and quality of life, the
aspects of a patient's QoL which may benefit from an integration of these scientific researches in the assistance
improvement in health status. As defined in the editorial, process is, in my opinion, the most important challenge
'health needs' are also restricted to ways in which 'health that is currently set to the health agents. Luis Prieto
services can improve overall health'. This could lead to the
conclusion that health needs have been satisfied while Since the mid-1990s there seems to have been an increase
neglecting the fact that this has been at the cost of other in research focusing on health status, satisfaction, and
needs. For example; economic needs may be increased as quality of life as independent concepts. Very little seems
a result of paying for treatment, emotional needs may be to have focused on needs. Even fewer (if any) efforts have
adversely affected by certain pharmaceutical treatments or attempted to study the inter-relationships between health
appearance needs may deteriorate following radical status, needs, satisfaction, and quality of life. Chris Haffer
surgery.
Should the research focus on health status and quality of
A more holistic approach to 'needs' can be taken, follow- life be reduced or should the research on traditional
ing from Hunt & McKenna's work on needs-based QoL. clinical outcomes (such as survival) be reduced?
Proponents of the needs-based approach postulate that Rather than reducing either, we should continue to strive
life gains its quality from the ability and capacity of the for combining them in meaningful ways that each "side"
individual to satisfy their needs (either inborn or learned understands and values. David Cella
during socialisation processes) [58]. Functions such as
employment, hobbies and socialising are important only Why these two alternatives? I would like to see more of
insofar as they provide the means by which these needs both, but especially more on discriminating between the
can be fulfilled. In this approach it is taken as axiomatic characteristics of the main Health Related QoL measures,
that QoL is high when most human needs (not just health their empirical significance, and their usefulness to organ-
needs) are fulfilled and low when few needs are being sat- isations such as NICE. (Any sensible answer to this ques-
isfied. Again, focusing only on those needs that can be tion has to begin by asking 'what the research is for?').
influenced by health services will give an incomplete pic- Anthony Culyer
ture of their value to patients.
I have read the editorial with interest but also with some
In order to evaluate the benefits of any service it is essen- confusion. After some thinking I find my confusion might
tial to have high quality instruments with good psycho- arise from the fact that in orthopaedics we deal with dis-
metric properties. For most diseases such instruments are eases that you do not die from (at least not primarily).
lacking for all types of outcomes listed above. Extensive This applies to your open question 2, research on QOL or
instrument development work is required in each of these survival. That is not applicable to my area, if we do not
outcome areas. Consequently, it is too soon to talk of take prosthesis survival into account. This is how ortho-
achieving a 'balance' or reducing efforts into any one par- paedic surgeons have assessed the success of total joint
ticular type of patient-reported outcome. Stephen P. replacement for years. Generally, assessing QOL in musc-
McKenna uloskeletal disease seem the most appropriate in clinical
studies since the correlation between the patients perspec-
Page 7 of 15
tive and impairments such as radiographic status is poor. larger set of disease-specific measures is extremely seduc-
Ewa Roos tive but ultimately misguided. The reason is that medical
care can extend lives and improve function but cannot,
Which area should "pay" for an increase in the number of ultimately, make people happy. Richard Kravitz
studies on needs and satisfaction assessment? In my opin-
ion, we have too many disease targeted QOL measures. It is difficult to make a judgement about this issue without
Although these measures are sometimes sensitive to clini- having a clearer idea about the clinical topic which is
cal change in specific populations, they do not clearly being addressed. For example in the area of cancer control
guide us toward overall better outcomes. Robert M. that has not been a clinically significant improvement in
Kaplan mortality for some types of cancer. Here the research focus
should continue to be on health status, perceived need,
The degree of focus on health status or Health Related and quality-of-life until the interventions exist which will
Quality of Life (HRQL) measures compared to more tra- substantively increase the length of life. When this occurs
ditional clinical outcomes depends on a number of fac- there will be a need to balance the length of life with the
tors. Typically, if the disease state and the outcomes of quality of that experience. Rob Sanson-Fisher
treatment can best be reported by the patient (e.g.,
migraine or depression/anxiety), there is a greater depend- The challenge, again, is in the integration of these two
ence on Patient-Reported Outcomes (PROs) than clini- ways of health assessment. Despite the quality-adjusted
cally defined endpoints. A second consideration is life year (QALY) continue to represent the paradigm of the
whether achieving a particular clinical endpoint is the pri- integration of the biomedical and the psychosocial mod-
mary objective of a medical treatment. In palliative care, els, this indicator has been criticised on technical and eth-
for example, patient comfort and well-being may be ical grounds. A salient problem relies on the numerical
favored over aggressive chemotherapies that might pro- nature of its constituent parts. The appropriateness of the
vide a limited extension of life. PROs may also be given QALY arithmetical operation is compromised by the
equal weight in situations where the costs of treatment are essence of the utility scale: while life-years are expressed in
considered against the degree to which such treatments a ratio scale with a true zero, the utility is an interval scale
provide some larger societal benefit. In Europe, for exam- where 0 is an arbitrary value for death. In order to be able
ple, QALYs are a routine part of formulary decisions and to obtain coherent results, both scales would have to be
patient access to competing treatments. In contrast, the expressed in the same units of measurement. The different
market access in the USA is less centrally determined and nature of these two factors jeopardises the current mean-
to some degree diverse market forces determine medica- ing and interpretation of QALYs. Further steps in the inte-
tion availability. Thus a variety of cultural and clinical fac- gration of different health dimensions, like quality of life
tors need to be considered when addressing this question and survival, are thus necessary. Luis Prieto
and advances in outcomes research are not by any means
uniform. Mark J. Atkinson Rather than viewing these research foci as being in compe-
tition, I believe it is more beneficial to view each as com-
I think there is no white/black answer. Perhaps the ques- plimentary. Both bring unique value to and are essential
tion would be: in which contexts (type, stage of disease, in providing effective patient care. In other words, they
treatment side effects), should health status and QoL stud- both measure different components of the same phenom-
ies be expanded? Anne Brdart enon and both are necessary to maximize positive patient
outcomes. James T. Fitzgerald
In our view this is not an either / or choice. Both can be
measured. Where more thought and research is required is Although there has been an increase in health related
how to combine results from different types of endpoint. quality of life studies over the last decade, there remain
For example, what if in a clinical trial one group experi- major gaps in the literature. Decisions about areas of pri-
ences improved survival, but worse quality of life? What if orities and the balance of studies must be driven by the
an intervention affects a clinical outcome, such as a pain research questions to be answered. There continue to be
score, but does not appear to have an important effect on too many isolated studies, with small samples; rather than
quality of life? Andrew Vickers multi-site investigations combining samples using stand-
ardized measures with established protocols. We also
This question begs a Solomonic response: both "subjec- need additional studies related to methods, such as deter-
tive" measures such as health status and quality of life and mining the best times to measure quality of life in relation
"objective" measures such as morbidity and mortality are to the critical events we are trying to capture. Evidence
critically informative, but in different ways. Creating a related to ethnically diverse populations is just beginning
parsimonious set of generic health measures absent a to emerge and as our world becomes smaller with the use
Page 8 of 15
of increased technology, these studies will only enrich our Important conceptual and practical distinctions exist
interventions. between HRQL and treatment satisfaction (and more
broadly, patient satisfaction). As the term suggests, Qual-
As our knowledge base grows, clarity will evolve about ity of Life is typically considered a quality or characteristic
how HRQL relates to other variables. It's important we of one's life and HRQL is an independently definable
design studies that help to clarify the mechanisms to effect quality or state of one's life (or health). Although such
predictors and outcomes. Clinically, standardized HRQL perceptions are subjectively influenced by disease proc-
measures can enhance screening patients for clinical prob- esses, they are thought to exist somewhat universally and
lems and monitoring them for changes; but overall this independently of particular life events and circumstances.
process will not take the place of asking patients what they
want and what helps to improve their health. With the On the surface, measures of patient satisfaction may
increased opportunities to do collaborative research appear to be just another type of HRQL or Health Status
across continents, it is a time to increase our efforts to do measure. Indeed, both HRQL and satisfaction constructs
HRQL research not to reduce them. However, our studies are both strongly influenced by the effects of illness and
must be theory driven, well designed, multi-site, and moderated by the effects of available treatments. Never-
build on our previous work. Ruth McCorkle theless, these classes of PROs differ in some profound
ways. A closer inspection reveals that satisfaction meas-
Neither should be reduced. Instead incentives should be ures are actually composed of questions asking patients to
provided which would encourage researchers to under- make judgments or appraisals about a specific set of treat-
take studies on the undeserved topics mentioned above. ment-related events and experiences. Treatment/patient
Incentives could be: financial (providing money to sup- satisfaction may be thought of as an interaction between
port the work), educational (encouraging students to a set of personal expectations and judgments and particu-
undertake dissertations and theses in the areas), or profes- lar experiences associated with current or past treatments.
sional (thematic journal issues dedicated only to publish- HRQL and Health Status, on the other hand, are apprais-
ing research on particular topics). Chris Haffer als of a quality or status of one's health, and thought to
exist somewhat independently of specific situational
To what extent can quality of life be used as proxy or events.
surrogate for satisfaction and/or the needs of patients? Is
there a danger of making the same mistakes as in the when Such a distinction between the two types of measures is
clinical indicators were used as surrogates for quality of more clearly appreciated when one realizes that HRQL
life? measures may be used prior to starting a treatment at
Yes, this kind of risk always emerges when one tries to use baseline but that the same cannot be said for treatment
a related concept to estimate another. David Cella satisfaction. Prior to the occurrence of a treatment event,
one cannot assess treatment satisfaction only the expecta-
I would say, not at all to the former and only to the extent tions or anticipations towards future treatment events.
that it correlated with a conceptually correct version might Moreover, such expectations have been shown to be rela-
the answer to the second be affirmative. Anthony Culyer tively weak predictors of patients' later satisfaction with
treatment [59]. Thus treatment satisfaction can be
In orthopedics, measures of satisfaction have been used to thought of as an experiential appraisal of the degree to
determine the outcome of total joint replacement. I am which a current treatment has been able to moderate the
however concerned about the single question that has impact of illness without being causing bothersome side
been used. From unpublished data I know that patients effects or be a great inconvenience. Such a distinction may
reporting to be satisfied with a total knee replacement explain why measures of treatment satisfaction do not
may have revision surgery within a year. This is bothering seem to be as strongly associated with patients' emotional
when considering validity of the satisfaction question. states as HRQL measures [60].
Ewa Roos
Thus satisfaction and HRQL/Health Status measures focus
I do not think that QOL measures can serve as surrogates on different, although interrelated, PRO constructs. Any
for satisfaction and needs. In fact, it is important to main- decision to use one as a proxy for another would be based
tain independence. For example, it would be valuable to on a fair number of assumptions that are not yet well
demonstrate that satisfaction goes up when outcomes understood. The use of HRQL/Health Status measures as
improve. However, evidence is necessary to demonstrate a proxy for evaluation of patient need may be more easily
this relationship. Robert M. Kaplan justified. A parallel can be drawn between 'patient need' as
defined by the authors of this author, namely, a state of
Page 9 of 15
discrepancy from a condition that most healthy persons When it became evident that an improve in overall sur-
would be expected to possess. Mark J. Atkinson vival could not be so easy to obtain with standard chem-
otherapy in a large part of solid tumours, the oncologists
Quality of life is only a moderate proxy of satisfaction reconsidered the problem of the symptoms burden,
with care as the latter, but not the former, is strongly hypothesising both a possible role of chemotherapy in the
dependent of the *process* of care, and not just it's out- treatment of cancer-related symptoms, and a direct rela-
come. Patients who experienced an important improve- tionship between response rate and symptoms improve.
ment in quality of life are likely to be more satisfied that Two approaches were followed:
those who do not; however, a patient who responds dra-
matically to a treatment my have poor satisfaction if, for The identification of arbitrary indices to define and
example, the clinician was rude, treatment overly expen- assess the clinical benefit in cancer-related symptoms with
sive or waiting times too long. Quality of life, satisfaction chemotherapy;
and needs are distinct concepts that should largely be
measured separately; that said, it is not always important The identification of a new field for clinical research, in
to measure all three. Andrew Vickers which quality of life (or better "health-related quality of
life") was defined as an outcome for a medical approach.
This question cannot be addressed without a clear concep-
tual model linking medical care to physiological and psy- Introducing health-related quality of life raised further
chological health to quality of life and satisfaction [61]. problems:
Quality of life is not a proxy for satisfaction unless meas-
ured using scales that incorporate patients' own utilities. What was the relationship between health-related qual-
Richard Kravitz ity of life and overall survival (if any)?
I really appreciate the discussion you approached in this What was the relationship between symptom relief and
paper. Several years ago, physicians tried to treat a disease, quality of life (if any)?
supposing that a reduction in the tumoural mass could
improve patients' health status. In this context, complete Did health-related quality of life represent an outcome
or partial responses by the tumour were classified as both in patient's and physician's points of view?
"response rate", and the response rate was considered as
the main outcome of a treatment. In this context this paper about patients' needs, satisfac-
tion and quality of life intervenes approaching some con-
Unfortunately, it was easy to demonstrate that response troversial aspects of the problem:
rate and overall survival were not always correlated;
response rate was classified as an index of activity and Are the researches in quality of life, patients' needs or
overall survival as an index of efficacy of a treatment, satisfaction adequately approached in clinical setting? In
using response rate as a surrogate index of efficacy in clin- my opinion the response is no, as we are still creating in
ical practice. our mind a surrogate index of the needs of patients that is
still too much "physician-related" but too-little "patient-
Likewise, after the first enthusiastic results of chemother- related".
apy against metastatic tumours, a plateau in the outcomes
was rapidly reached, and all oncologists met a sort of Can improvement in health-related quality of life be
stalemate in the results of their approaches, regardless the assumed as an index of satisfaction of the patient? In my
introductions of new molecules or new schedules. It was opinion the response is no, because it only represents the
the time when the oncologists became aware of the side "health-related" dimension of quality of life, that could be
effects of chemotherapy, and beyond side effects, the way strictly related to, but shall not be considered the same of
to overcome the resistance to chemotherapy and to out- patient satisfaction.
come improvement were considered.
Are we sure that we have all the instruments to assess the
Unfortunately, neither the CSF, nor the other cytopro- needs and satisfaction of our patients? I do not know, but
tectans favoured a significant improve in the outcomes of I fear for two potential risks that we will be contented with
treatment of the most part of solid tumours, although it the easiest solution of some surrogate composite indices
was evident that chemotherapy could be better tolerated of satisfaction (as occurred with clinical benefit and qual-
with the use of appropriate supportive approaches. ity of life in clinical oncology) avoiding to define better
instruments to assess needs and satisfaction, or, worse,
that the needs and satisfaction assessment (or their surro-
Page 10 of 15
gate indices) will be used as an instrument for a political whereas satisfaction is evaluative in nature. Therefore, I do
or administrative consent, that is so far from- (but unfor- not think that HRQL can be used as a proxy for satisfac-
tunately even so near to-) the real dimension of patients. tion. Richard Shikiar
Davide Tassinari
These are testable hypotheses on which research should
The use of the word proxy is in my opinion inappropriate: be encouraged. However, as we anxiously await the results
Quality of life, (Qol) Health Care Needs (HCN) and Sat- of the research we should never forget the words of the
isfaction (Sat) are all distinct concepts and Qol cannot be philosopher George Santayana, "Those who do not learn
assessed "in the place of" the other two. An attempt to from history are doomed to repeat it". Chris Haffer
prove this replaceability was made by measuring the cor-
relation between them [3] the absence of such correlation What is the evidence for psychometric properties of the
would be surprising!! instruments used to evaluate satisfaction and needs?
Regarding satisfaction, the single biggest problem across
A sound proof would have been to demonstrate that the virtually all of them is a ceiling effect. We can at least take
contents of the three concepts are equivalent, but, unfor- heart in knowing that most people report being very satis-
tunately, this is not true also when speaking of different fied with their care. Regarding needs, this area has seldom
instruments for quality of life evaluation and is very likely moved beyond the qualitative level, reporting propor-
to be false for the three concepts in examination. Identify- tions of people having the studied range of needs. One
ing quality of life score cut-offs able to detect high levels example of a needs-based (or, more accurately, rehabilita-
of HCNs or low levels of Sat at an appreciable degree of tion-based) instrument in oncology, is the Cancer Reha-
sensitivity and specificity would be useful but would not bilitation Evaluation System (CARES). David Cella
solve the problem to have valid and reliable instruments
for HCNs and Sat assessment. Cinzia Brunelli Well, for the latter, it's there in the literature from Rosser
and watts on, through Torrance and the army of QALY,
Views will vary. However if we assume the needs of HYE etc. measurers. As for satisfaction, there's a huge eco-
patients represent their judgement about whether or not nomic and psychological literature but there's a lot of
they wish to receive assistance with a particular area, mystery as to what 'satisfaction' means. Many take it
reflected an item on questionnaire, then quality-of-life wrongly as a synonym for 'utility' though not, I think,
should not be used as a proxy. For example patients suf- most utilitarians. Anthony Culyer
fering from chronic condition may experience a substan-
tive pain, not be able to take care of themselves and lack I can not give you a conclusion regarding the psychomet-
of mobility. For most quality-of-life scales this would be rics of satisfaction outcomes in orthopaedics. However,
reflected in a low score. A poor quality-of-life. This maybe psychometric data on satisfaction measures in total joint
an accurate representation of the respondents experience. replacement have been reported [63]. Ewa Roos
However, perceived needs may reflect what the respond-
ent may wish to have improved. That is, they may indicate Standards with which to judge the psychometric proper-
while that they are experiencing considerable pain is not ties of various types of PRO measurement tools have been
that that they wish assistance with but how to deal more clearly established for several decades [64] and continue
effectively with the medical system or get help for their to be refined [65,66]. All PROs should be held to the same
partner. Given this scenario it is clear that quality-of-life high standards of both classical and modern measure-
should not be used as a surrogate measure for perceived ment theory, and be shown to possess adequate reliabil-
needs. Rob Sanson-Fisher ity, validity, and responsiveness to the phenomenon in
question.
This is a question that must be responded with empirical
evidence. In my opinion, there is a likely relationship What is needed in our field is to sharpen the ways in
between the concepts, but the direction and strength of which we conceive of our PRO constructs [67] and to elu-
this association must be ascertained in practice. Luis cidate the inter-relationships between direct and medi-
Prieto ated causal pathways between such constructs and illness
or treatment conditions [2,68]. Too often conceptual dis-
In my recent article [62] I distinguish between satisfaction tinctness between outcome measures is blurred. This is
with medication, treatment satisfaction, and satisfaction clearly evident when instrument content (e.g., appraisals
with health delivery. In the article cited above, I point out of medication effectiveness or ratings of disease severity)
that HRQL needs to be distinguished from satisfaction are indiscriminately mixed together with temporally dis-
with medication; the former basically represents the status tinct constructs in the causal pathway (e.g., the behavioral
of a patient on dimensions assumed to of importance, ramifications of the appraisal). For example, mixing treat-
Page 11 of 15
ment experience questions with one addressing the "will- up against a "wall of cognitive dissonance" that creates a
ingness to recommend to a friend" or, in the case of theoretical limit to the value of satisfaction ratings.
disease severity ratings, the functional effects of symptom
severity on daily activities. The lack of conceptually coher- Another important and unresolved issue is whether to
ent measures precludes elaboration of conceptual frame- adjust for patient characteristics when comparing satisfac-
works with which to understand our empirical tion ratings among providers. It is well known that age,
observations. ethnicity, and health status (among other characteristics)
influence patients' ratings of satisfaction. Some organiza-
As acknowledged in the preceding article, while Quality of tions have decided to use raw (unadjusted) comparisons
Life is broadly conceptualized, it is most often more nar- based on the argument that health care organizations and
rowly operationalized by disease-specific HRQL meas- practitioners need to adapt to their own patient popula-
ures. Similarly, patient satisfaction can be broadly tions and provide whatever is needed to generate satisfac-
thought to refer to all relevant experiences and processes tion in the groups they serve. But this may be a little
associated with a healthcare delivery, while treatment sat- unfair. In our own primary care clinic at UC Davis, Rus-
isfaction typically focuses on events related to a particular sian-speaking patients almost never choose the (properly
medication or surgical treatment. When designing new translated) "excellent" column when rating their care,
PRO tools, the referential scope of our measures is an while Spanish-speaking patients use it liberally. Physi-
important consideration. General and specific measures cians who see many Russian-speaking patients (or other
yield different sorts of information and perform in groups with systematically higher thresholds for satisfac-
differing ways. Narrowly specified PROs tend to be more tion) have a right to be concerned. Richard Kravitz
useful when the objective is to gain context specific under-
standing within a particular disease state. Moreover, such Traditionally the determination what constitutes an ade-
measures also tend to be more responsive to changes in quate measure has been grounded in the psychometric lit-
the underlying cause(s) over time (e.g., disease severity or erature. There is some reason to continue the utilisation of
treatment effects). On the other hand, more broadly concepts such as test retest reliability, face and content
defined PROs are generally phrased and, because of this validity. Con current validity has appeal when similar
they allow for greater diversity in how respondents inter- measures exist but is heavily dependent on the concept
pret their meaning. Such instruments allow for compari- that the existing measures accurately betray the issue
sons of diverse patient populations but provide more under consideration. To compare a new measure against
limited insight into the underlying reasons for observed an existing inappropriate or an accurate measure is obvi-
differences. Mark J. Atkinson ously foolhardy and inappropriate. The use of confirma-
tory factor analysis appears dubious as strategy for
There has been progress. In the recent past, satisfaction examining the potential usefulness of the scale. The fact
surveys were performed without any information on the that the items may be statistically related and then delete
psychometric properties of questionnaires. At present, other items may mean that the most predictive items are
information on the validity of these questionnaires is col- discarded. More importantly it is whether the scale can
lected. The criterion validity (degree to which the ques- predict future behaviour, use of resources or outcomes
tionnaire measures the true situation) and responsiveness such as mortality or morbidity. It is unusual for the devel-
of these questionnaires is hard to assess. In many research opment of new scale to be asked to demonstrate its predic-
on patient satisfaction in the oncology field, it appears tive validity and more difficult to achieve this important
that patients are less satisfied with the information pro- goal. It may be timely for those involved in the construc-
vided compared to other aspects of care. This should lead tion of questionnaires to consider some of the dimen-
to prioritise initiatives to improve information provision sions used by epidemiologists when discussing the
at the expense of other care aspects improvement. I think robustness of a new testing procedure. Rob Sanson-
that further research need to be performed to understand Fisher
the meaning of these results. Anne Brdart
A simple search of the literature shows that there is an
Developers of instruments designed to measure patient emerging emphasis in assessing the psychometric proper-
satisfaction face a paradox. On the one hand, mean scores ties of this type of instruments. In any case, I would like to
are invariably high (i.e., there is a ceiling effect). On the challenge the audience of this editorial with more open
other hand, huge numbers of patients every year switch questions: Is the 'need' attribute really quantitative? Does
doctors and health plans, do not comply with recom- it deserve the application of psychometric methods
mended therapy, sue their doctors (or at least think about directed to assign a number to the amount of 'need' that a
it), and complain to their children about their medical given patient has? Or the 'need' is it just a dichotomous
care. We may need to acknowledge that we are bumping variable (i.e. need present/need absent) that should not
Page 12 of 15
be defined by the patient itself but by professional health faction studies are one-off, and not adopted as a routine
care agents? Luis Prieto assessment of clinical care. Also impeding substantive
advancements are a host of poorly designed and inade-
Through its leadership is standardizing satisfaction instru- quately tested measures, which are often applied using
ments and publicly reporting the results, the U.S. Agency very weak study designs. These factors make it very diffi-
for Healthcare Research and Quality, and the U.S. Centers cult to increase the credibility of such evaluation activities
for Medicare and Medicaid Services has sponsored through publication in reputable peer-reviewed journals.
research on many aspects of measuring satisfaction Mark J. Atkinson
including psychometric properties of the instruments. A
good place to begin a review of the relevant literature is: Our measures of patient outcomes and satisfaction are
http://www.cahps-sun.org/References/Refer variegated and deeply flawed. Nevertheless, one of the
ences.asp#sart.Chris Haffer most promising trends in health care today is the collec-
tion and sharing of information about patient outcomes
Have studies of patients' satisfaction been conducted but and satisfaction at the hospital and medical group level.
not published because of negative results, poor validity, Unlike the uncoordinated efforts of the past, these initia-
reliability and responsiveness of the instruments developed tives seem to have roused health care executives from a
(i.e. a high levels of ceiling effect towards high level of deep slumber. Large measurement collaborations should
satisfaction due to patients fear of giving negative be encouraged at the same time that we support more
evaluations)? Or studies which could not be published basic work on instrumentation. Richard Kravitz
because non-validated instruments were deployed, to
assess patient satisfaction, not only wasting scarce There will always be cases where studies of patient satis-
hospital resources but also delaying changes in health faction and other measures are not published because of
service delivery by local health authorities their perceived lack of psychometric vigour. It is also the
It's not clear to me that there has been such a publication case that when one is attempting to change the health-care
bias with regard to satisfaction studies. But to the extent system by presenting findings which suggested adequate
this is true, I don't have the impression it is any more a care is being provided to the patient group the profession-
problem with satisfaction studies as opposed to others, als who are being asked to change will often resist using
except for the ceiling effect issue. The problem people what ever strategies they can. One of the methods is to
tend to face with satisfaction studies or outcomes, is that criticise the nature of the research or the research instru-
because most patients already have a high degree of satis- ment. Consequently, it is reasonable that the instrument
faction, it may be difficult to improve it further when it such as a patient satisfaction measure is credible. How-
comes to treatments that affect patient quality of life. Hos- ever, as suggested in my response to question for this may
pitals in the US can tend to focus on patient conveniences not necessarily mean the usual criteria that are used by
and impressions such as parking, lobby feel, way-finding psychometricians. Rob Sanson-Fisher
and personal services to improve satisfaction ratings, leav-
ing actual care delivery in the hands of the providers. In the U.S. a number of studies on patients' satisfaction
David Cella have been conducted and reported in the peer-reviewed
literature. As noted above a good place to begin is: http://
Isn't the premise of this question false? Anthony Culyer www.cahps-sun.org/References/References.asp#sart.
Chris Haffer
Various problems face those wishing to further our under-
standing of patient satisfaction. The most important Acknowledgements
seems to be a lack of good psychosocial science in the The authors are very grateful in particular to Neil Oldridge for reviewing
field, which may in-part be due to a resource-strained the manuscript and providing constructive comments and also thankful to
healthcare system. At the risk sounding somewhat repeti- James T. Fitzgerald, Chris Haffer and Rosemarie Kobau for their invaluable
suggestions.
tive; conceptually, Patient Satisfaction, Satisfaction with
Care, and Treatment Satisfaction should be clearly distin-
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