Original Research

Patient Preferences in Office-Based Orthopedic Care: A Prospective Evaluation

Publish date: October 11, 2018

References

1. Kocher MS, Steadman JR, Briggs K, Zurakowski D, Sterett WI, Hawkins RJ. Determinants of patient satisfaction with outcome after anterior cruciate ligament reconstruction. J Bone Joint Surg Am. 2002;84–A(9):1560-1572.

2. Carr-Hill RA. The measurement of patient satisfaction. J Public Health Med. 1992;14(3):236-249.

3. Ross CK, Steward CA, Sinacore JM. A comparative study of seven measures of patient satisfaction. Med Care. 1995;33(4):392-406. doi:10.1097/00005650-199504000-00006.

4. Strasser S, Aharony L, Greenberger D. The patient satisfaction process: moving toward a comprehensive model. Med Care Rev. 1993;50(2):219-248. doi:10.1177/107755879305000205.

5. Bozic KJ. Orthopaedic healthcare worldwide: shared medical decision making in orthopaedics. Clin Orthop Relat Res. 2013;471(5):1412-1414. doi:10.1007/s11999-013-2838-5.

6. Youm J, Chenok KE, Belkora J, Chiu V, Bozic KJ. The emerging case for shared decision making in orthopaedics. Instr Course Lect. 2013;62:587-594. doi:10.2106/00004623-201210170-00011.

7. Blumenthal D, Abrams M, Nuzum R. The affordable CARE Act at 5 years. N Engl J Med. 2015;373(16):1580. doi:10.1056/NEJMc1510015.

8. Shirley ED, Sanders JO. Patient satisfaction: implications and predictors of success. J Bone Joint Surg Am. 2013;95(10):e69. doi:10.2106/JBJS.L.01048.

9. Morris BJ, Jahangir AA, Sethi MK. Patient satisfaction: an emerging health policy issue. AAOS Now Web site. http://www.aaos.org/AAOSNow/2013/Jun/advocacy/advocacy5/?ssopc=1. Published June 2013. Accessed November 19, 2016.

10. Donabedian A. The quality of care. How can it be assessed? JAMA. 1988;260(12):1743-1748. doi:10.1001/jama.260.12.1743.

11. Bozic KJ, Kaufman D, Chan VC, Caminiti S, Lewis C. Factors that influence provider selection for elective total joint arthroplasty. Clin Orthop Relat Res. 2013;471(6):1865-1872. doi:10.1007/s11999-012-2640-9.

12. Davies AR, Ware JE Jr. Involving consumers in quality of care assessment. Health Aff (Millwood). 1988;7(1):33-48.

13. Black N, Burke L, Forrest CB, et al. Patient-reported outcomes: pathways to better health, better services, and better societies. Qual Life Res. 2016;25(5):1103-1112. doi:10.1007/s11136-015-1168-3.

14. Gilbert A, Sebag-Montefiore D, Davidson S, Velikova G. Use of patient-reported outcomes to measure symptoms and health related quality of life in the clinic. Gynecol Oncol. 2015;136(3):429-439. doi:10.1016/j.ygyno.2014.11.071.

15. Van Der Wees PJ, Nijhuis-Van Der Sanden MW, Ayanian JZ, Black N, Westert GP, Schneider EC. Integrating the use of patient-reported outcomes for both clinical practice and performance measurement: views of experts from 3 countries. Milbank Q. 2014;92(4):754-775. doi:10.1111/1468-0009.12091.

16. Franklin PD, Lewallen D, Bozic K, Hallstrom B, Jiranek W, Ayers DC. Implementation of patient-reported outcome measures in U.S. Total joint replacement registries: rationale, status, and plans. J Bone Joint Surg Am. 2014;96(Suppl 1):104-109. doi:10.2106/JBJS.N.00328.

17. Williams B. Patient satisfaction: a valid concept? Soc Sci Med. 1994;38(4):509-516. doi:10.1016/0277-9536(94)90247-X.

18. Hickson GB, Clayton EW, Entman SS, et al. Obstetricians' prior malpractice experience and patients' satisfaction with care. JAMA. 1994;272(20):1583-1587. doi:10.1001/jama.1994.03520200039032.

19. Larsson BW, Larsson G, Chantereau MW, von Holstein KS. International comparisons of patients' views on quality of care. Int J Health Care Qual Assur Inc Leadersh Health Serv. 2005;18(1):62-73. doi:10.1108/09526860510576974.

20. McLafferty RB, Williams RG, Lambert AD, Dunnington GL. Surgeon communication behaviors that lead patients to not recommend the surgeon to family members or friends: analysis and impact. Surgery. 2006;140(4):616-624. doi:https://doi.org/10.1016/j.surg.2006.06.021.

21. Mira JJ, Tomás O, Virtudes-Pérez M, Nebot C, Rodríguez-Marín J. Predictors of patient satisfaction in surgery. Surgery. 2009;145(5):536-541. doi:10.1016/j.surg.2009.01.012.

22. Patterson BM, Eskildsen SM, Clement RC, et al. Patient satisfaction is associated with time with provider but not clinic wait time among orthopedic patients. Orthopedics. 2017;40(1):43-48. doi:10.3928/01477447-20161013-05.

23. Teunis T, Thornton ER, Jayakumar P, Ring D. Time seeing a hand surgeon is not associated With patient satisfaction. Clin Orthop Relat Res. 2015;473(7):2362-2368. doi:10.1007/s11999-014-4090-z.

24. Burkle CM, Keegan MT. Popularity of internet physician rating sites and their apparent influence on patients' choices of physicians. BMC Health Serv Res. 2015;15:416. doi:10.1186/s12913-015-1099-2.

25. Mohney S, Lee DJ, Elfar JC. The effect of orthopedic advertising and self-promotion on a naive population. Am J Orthop. 2016;45(4):E227-E232.

26. Halawi MJ, Barsoum WK. Direct-to-consumer marketing: implications for patient care and orthopedic education. Am J Orthop. 2016;45(6):E335-E336.

27. Mostaghimi A, Crotty BH, Landon BE. The availability and nature of physician information on the internet. J Gen Intern Med. 2010;25(11):1152-1156. doi:10.1007/s11606-010-1425-7.

DISCUSSION

The results of this study demonstrate that patients have several expectations and preferences with regards to the care they receive from physicians in the office. Patients prefer to wait <30 minutes before seeing their provider and desire only 10 to 20 minutes with their doctor. Patients do not have specific preferences with regards to the gender or ethnicity of their physician but would prefer a physician in the middle of their career, aged 45 to 55 years. Ultimately, patients do believe that seeing a physician at a postoperative visit is important, as just under half of patients thought that seeing a physician extender alone at a postoperative visit resulted in a lower quality of care.

While these results were obtained in a population specifically seeking the care of an orthopedic adult reconstruction surgeon, the results demonstrate that patients do not necessarily desire an unreasonable amount of time with their doctor. Patients simply want to be seen in a timely fashion and receive the full undivided attention of their doctor for approximately 20 minutes. Similarly, Patterson and colleagues²² found, in their series of 182 patients who presented to an orthopedic surgeon, that there was a significant correlation between time spent with the surgeon and overall patient satisfaction. Interestingly, the authors reported that patient satisfaction was not correlated with education level, sex, marital status, whether the patients were evaluated by a resident physician before seeing the attending surgeon, self-reported mental status, tobacco usage, the type of clinic visit, or the waiting time to see the surgeon (average, about 40 minutes for this cohort).²² Similarly, Teunis and colleagues²³ reported an average 32-minute wait time in 81 patients presenting for care at an orthopedic hand clinic and demonstrated that a longer wait time was associated with decreased patient satisfaction. These results corroborate the findings of this study that a short wait time is important to patients when evaluating the process of care. Additionally, patients do not have unreasonable expectations with regards to the amount of time they would like to spend with the physician. A physician who has a clinic for 9 hours a day would thus be able to see 54 patients and still spend at least 10 minutes with each patient. The quality of the physician-patient interaction is likely more important than the actual amount of time spent; however, based on this study, patients do have certain expectations about how much time physicians should spend with them.

There were no significant sex, age, or ethnicity preferences in our specific patient cohort. However, a sizable percentage of respondents, 41.8%, believed that they were receiving inferior care if they only saw a physician extender at a routine follow-up visit. Many orthopedic surgeons rely on the care provided by physician extenders to enable them to see additional patients. Physician extenders are well trained to provide high-quality care, including at routine postoperative visits. The results of this study, that many patients believe physician extenders provide lower-quality care, may be a result of inadequate patient education regarding the extensive training and education physician extenders undergo. Physician extenders are qualified, licensed healthcare professionals who are playing increasingly important roles within orthopedics and medicine as a whole. As the demand for orthopedic surgeons to see more patients increases, so does the role of physician extenders. Future research is warranted into educating the public regarding the importance of these healthcare providers and the adequacy of their training.

While many practices now routinely obtain patient satisfaction scores, another modality through which patients can express their satisfaction and experiences with healthcare providers is through online internet physician rating sites (IPRS). These sites have exploded in number and popularity in recent years and, according to some studies, have a very real effect on provider selection.²⁴ Interestingly, a low percentage of patients in this study utilized IPRS reviews to find their doctors. In a recent prospective survey study of 1000 consecutive patients presenting for care at the Mayo Clinic, Burkle and Keegan²⁴ reported that 27% of patients would choose not to see a physician based on a negative IPRS review. Interestingly, only 1.0% of patients reported finding their doctor through advertising. Numerous authors have recently addressed advertising in orthopedic surgery, specifically direct-to-consumer marking, including the influence of physician self-promotion on patients.^25,26 Specifically, Halawi and Barsoum²⁶ discussed how direct-to-consumer marketing is commonly disseminated to the public through television and print advertisements, which are modalities more commonly utilized by older generations. However, many advertising agencies are moving toward internet-based advertising, especially through orthopedic group and individual surgeon websites for self-promoting advertisement, as approximately 75% of Americans use the internet for health-related information.^25,27 The fact that many patients in this study did not utilize IPRS reviews or advertising (much of which is electronic) may be a result of the older, less internet-centric demographic that is often seen in an adult reconstruction clinic. Future research is warranted to determine what demographic of patients value IPRS reviews and how those reviews influence physician selection and the patient experience.

There are several limitations to this study. First, the majority of the surveyed population was Caucasian, and our results may not be equally reflective of diverse ethnic backgrounds. Second, the cohort size, while based on previous studies conducted in a similar fashion, may be underpowered to detect significant differences for 1 or more of these questions. In addition, having a question regarding the patient’s medical background or experiences may have provided further insight as to why patients selected the answers that they did. Furthermore, questions regarding the patient’s education level, religious background, and income brackets may have provided further context in which to evaluate their responses. These questions were omitted in an effort to keep the questionnaire at a length that would maximize enrollment and prevent survey fatigue. Future research is warranted to determine what patient-specific, injury/symptom-specific, and treatment-specific variables influence the subjective patient experience.

CONCLUSION

The vast majority of patients desire only 10 to 20 minutes with their doctor and are highly satisfied with the amount of time their surgeon spends with them. Patients reported no significant gender- or ethnicity-based preferences for their doctor. The majority of patients believe that a wait time exceeding 30 minutes is too long. A greater effort needs to be made to educate patients and the public about the significant and effective roles nurse practitioners and physician assistants can play within the healthcare system. While this cohort did not report notable utilization of IPRS reviews, it remains essential to understand what factors influence patients’ subjective experiences with their providers to ensure that patients achieve their desired outcomes, and report as such on these websites as they continue to gain popularity. Diminishing clinic wait times and understanding patient preferences may lead to a greater percentage of “satisfied” patients. While the majority of focus has been and will likely continue to be on improving patients’ satisfaction with their outcomes, more work needs to be done focusing specifically on the process through which outcomes are achieved.