Evaluation of the satisfaction of physical therapy patients in outpatient care

ABSTRACT

Satisfaction is determined by the patient’s reaction to the service received, acting as a sensitive indicator of quality in medical care. The goal of this study was to compare the satisfaction of patients receiving outpatient physical therapy treatment in public clinics (PC), private healthcare clinics (PHC) and school clinics (SC). A total of 382 patients aged over 18 years old who had been to at least five appointments were divided into three groups. A questionnaire containing questions about sociodemographic data and overall satisfaction as well as satisfaction with the patient-therapist relationship, access to and support offered by the team, convenience and the environment was used. The majority of the patients was female (68.6%), their mean age being 52.0 years old. In the comparison of the services, the school clinic showed greater satisfaction rates than the public clinics in relation to the support team, convenience and physical environment; and greater satisfaction rates than the private healthcare clinics in relation the therapist-patient relationship and overall satisfaction. The private healthcare clinics were better evaluated than the public clinics in relation to convenience and physical environment. The correlation analysis between overall satisfaction and each variable showed good and moderate values for the therapist-patient relationship variable and the lowest values for the convenience variable. The questionnaire had good internal consistency and coherence for the three services (α≥0.94). These results represent an important indicator of the patients’ perception about the services investigated, allowing the proper implementation of public, private and academic policies aimed at the improvement of the quality of physical therapy care.

Keywords |
Patient Satisfaction; Physiotherapy; Inquiries and Questionnaires; Public Sector; Private Sector

RESUMO

A satisfação é determinada pela reação do paciente ao serviço recebido, sendo, portanto, um indicador sensível da qualidade do atendimento. O objetivo deste estudo foi comparar a satisfação dos usuários que realizam tratamento fisioterapêutico ambulatorial em clínicas públicas (CP), em clínicas privadas de convênio (CC) e em clínica-escola (CE). Foram avaliados 382 pacientes, com idade mínima de 18 anos, que haviam sido submetidos a, no mínimo, cinco atendimentos. Os pacientes foram divididos em três grupos e utilizou-se um questionário com perguntas sobre dados sociodemográficos e satisfação nos domínios interação paciente-terapeuta, acesso e atendimento da recepção, conveniência, ambiente e satisfação geral. A maior parte dos pacientes eram do sexo feminino (68,60%), com média de 51,96 anos de idade. Na comparação entre os serviços, a CE apresentou maior satisfação que a CP em equipe de apoio, conveniência e ambiente físico, e a CC em relação terapeuta-paciente e satisfação geral. A CC foi mais bem avaliada que a CP em conveniência e ambiente físico. A análise de correlação entre a satisfação geral e cada um dos domínios mostrou valores de bom a moderado para relação terapeuta-paciente, e os menores valores para o domínio conveniência. O questionário mostrou boa consistência interna e coerência nos três serviços (α≥0,94). Esses resultados representam um importante indicador da impressão dos usuários nos serviços investigados, permitindo melhor direcionamento na implementação de políticas públicas, privadas e acadêmicas, visando a melhora da qualidade dos atendimentos de fisioterapia.

Descritores |
Satisfação do Paciente; Fisioterapia; Inquéritos e Questionários; Setor Público; Setor Privado

RESUMEN

Determinada por la reacción al servicio recibido, la satisfacción del paciente es un indicador sensible de la calidad de la atención. El objetivo de este estudio fue comparar la satisfacción de los usuarios que realizan tratamiento fisioterapéutico ambulatorio en clínicas públicas (CP), en clínicas privadas de convenio (CC) y en clínica-escuela (CE). Se evaluaron 382 pacientes, con edad mínima de 18 años, sometidos a por lo menos cinco atendimientos. Los pacientes fueron divididos en tres grupos y se utilizó un cuestionario con preguntas sobre datos sociodemográficos y satisfacción en los dominios interacción paciente-terapeuta, acceso y atención de la recepción, conveniencia, ambiente y satisfacción general. La mayoría de los pacientes eran mujeres (68,60%), con edad media de 51,96 años. En la comparación entre los servicios, la CE presentó mayor satisfacción que la CP en equipo de apoyo, conveniencia y ambiente físico, y la CC en la relación terapeuta-paciente y satisfacción general. La CC fue mejor evaluada que la CP en conveniencia y ambiente físico. El análisis de correlación entre la satisfacción general y cada uno de los dominios mostró valores de bueno a moderado para relación terapeuta-paciente, y los menores valores para el dominio conveniencia. El cuestionario mostró buena consistencia interna y coherencia en los tres servicios (α≥0,94). Estos resultados representan un importante indicador de la impresión de los usuarios en los servicios investigados, permitiendo un mejor direccionamiento en la implementación de políticas públicas, privadas y académicas, buscando la mejora de la calidad de las atenciones de fisioterapia.

Palablas clave |
Satisfacción del Paciente; Fisioterapia; Encuestas y Cuestionarios; Sector Público; Sector Privado

INTRODUCTION

Planning occupies a prominent position in the agenda of the management of health systems in all spheres. For managers to fulfill their planning responsibility, information is needed to help them find solutions to the issues raised by society¹.

A review of the studies published between 1988 and 2014 on the type of scientific production in health policies in Brazil highlights the participation of research as a health management tool².

Satisfaction, in sociopsychological theory, is the expression of an attitude. In health, it is determined by the reactions of patients to the service received, and can be modified when their expectations or comparative patterns change, even if the service remains constant³.

The frequent changes in health services and in the level of expectation of patients make the evaluation and follow-up of care essential to measure and control patient satisfaction.

In the world literature, there are questionnaires available to evaluate the patients’ satisfaction with the care offered by health insurances and other medical resources, but these instruments are not adequate to measure their satisfaction with physical therapy, because this is a service with different characteristics, involving physical contact and the patient’s active participation^{4), (5}_.

The development and validation of a research instrument to evaluate the patients’ satisfaction with physical therapy represents an important area of research in health, but the instruments should be tested in different situations, research centers and with varied populations. Brazilian researchers translated, culturally adapted and validated a questionnaire that evaluated 11 domains. After the research, the final version contained 23 questions assessing the therapist-patient relationship, access to and support provided by the team, convenience, physical environment and overall satisfaction⁶.

More than 90% of the Brazilian population are, in some way, users of the Brazilian Unified Health System (SUS), according to a survey carried out in 2003 by the Ministry of Health⁷. The authors describe the poor quality of the services offered and the lack of follow-up, control and evaluation mechanisms. In this context, evaluating the patients’ satisfaction with care is paramount to improve the work done⁸.

The private health system and its care plans have always been related to the growth of cities, the country’s industrialization, formal employment and income⁹. Brazilian physical therapy in the private sector is represented by 60% of registered physical therapists¹⁰.

The notorious growth of the private health care system requires more and more attention from patients and regulatory agencies. Therefore, the better understanding of these patients’ satisfaction seems to be an important source for standardization and growth in this sector.

Another alternative source of physical therapy care that has been growing a lot in recent years are the consultations performed by scholars of higher education institutions¹¹. Most of the care provided by this new health care model happens in the school clinics (SC) of physical therapy courses.

In this type of service, the management model is different from the ones mentioned above, since the main source of income is the students’ monthly payments or transfers made by the state or federal government, so it must reconcile the demands of patients to the pedagogical needs and curricular guidelines of undergraduate courses.

Given the above, the objective of this study was to compare the satisfaction of outpatients undergoing physical therapy treatment in public clinics (PC), private healthcare clinics (PHC), and school clinics.

METHODOLOGY

This is an observational, cross-sectional, analytical study with a representative sample of the patients of the physical therapy services of five neighboring municipalities in the state of São Paulo’s northwest region. In total, five private healthcare clinic, five public clinics and one school clinic were evaluated.

Considering 50% prevalence of satisfaction with the physical therapy services (unknown prevalence), 95% reliability and 5% error margin, the minimum sample size should have been 384 individuals, divided into three groups: SC, PC and PHC patients.

Patients of both sexes, aged over 18 years old, undergoing outpatient physical therapy treatment, were included in the study. A total of 390 patients who had undergone at least five sessions and who were able to read and understand the satisfaction assessment questionnaire were contacted. The Mini-Mental State Questionnaire (MMSE) was applied to evaluate the subjects’ cognitive function¹². To be included in the sample, the participants needed to obtain scores equal to or higher than the minimum required according to their education level.

This research project was approved by CEP via Plataforma Brasil and all subjects signed the informed consent form.

To evaluate these patients’ satisfaction with the physical therapy service, a questionnaire⁶ validated and translated into Portuguese was applied, containing 12 descriptive sociodemographic questions and 23 questions (Q) about the patients’ satisfaction with the physical therapy services received, divided into the following domains: therapist-patient relationship, access to and supported offered by the team, convenience, physical environment and overall satisfaction.

In the data collection step, the patients were approached in the waiting room of each of the studied sites immediately after their appointments, between the months of September 2014 and August 2015. Subsequently, the research’s objectives were explained and the guidelines for filling in the questionnaires were offered. All evaluation sheets were given and collected in a sealed, unidentified envelope.

For the statistical analysis, the answers were scored on a scale from 1 to 5, including sociodemographic data which were tabulated in ascending order, according to the order of presentation in the questionnaire. The questionnaire’s minimum and maximum scores were respectively: 23 and 115 for the total and, for each domain, the values varied according to the number of questions. The higher the score, the greater the patient’s satisfaction.

The sociodemographic data were analyzed based on descriptive measures of mean and standard deviation (quantitative variables) and relative frequency (qualitative variables).

To compare the satisfaction between SC, PHC and PC, an analysis of variance was performed, followed by the Tukey test, because it is a continuous variable. Subsequently, Spearman’s correlation was used to verify the impact of each of the four domains on overall satisfaction, in each of the services evaluated. Correlations were considered moderate when r≥0.5, and optimal when r≥0.7.

To evaluate the questionnaire’s internal consistency, Cronbach’s α coefficient was estimated, and α values ≥ 0.7 were considered satisfactory. The 5% significance level or corresponding p-value was applied in every test.

RESULTS

Of the 390 patients studied, eight did not want to participate in the study, and none of the interviewees failed the MMSE; thus, 382 patients were interviewed, 126 of them in SC, 126 in PHC, and 130 in PC.

The overall mean age in the three services was 51.93±13.66 years old, and it was noted that patients seen in PHC have higher income and education level than those seen in the other services. In all three groups, SC, PHC and PC, most of the patients had previously undergone physical therapy treatment and were referred to the service by their physician, according to Table 1.

Table 1
Distribution of the patients’ sociodemographic data according to service, 2016

Variable		SC	PHC	PC	Total	p
M Age (SD)		50.02 (12.67)b	56.91 (16.41)a	48.96 (9.91)b	51.96 (13.7)	<0.0001*
Sex % (n)	Male	28.57 (36)	32.54 (41)	33.08 (43)	31.40 (120)	0.69
	Female	71.43(90)	67.46 (85)	66.92 (87)	68.60 (262)
Education level % (n)	Incomplete primary education	30.16 (38)	26.19 (33)	50.77 (66)	35.71 (137)	<0.0001*
	Complete primary education	14.28 (18)	19.04 (24)	18.45 (24)	17.26 (66)
	Incomplete secondary education	12.70 (16)	3.97 (5)	14.62 (19)	10.43 (40)
	Complete secondary education	26.19 (33)	23.02 (29)	13.08 (17)	20.76 (79)
	Higher education	16.67 (21)	27.78 (35)	3.08 (4)	15.84 (60)
Household income in minimum wages % (n)	1 to 3	72.22 (91)	64.29 (81)	82.31 (107)	72.94 (279)	0.025*
	4 to 6	19.85 (25)	22.22 (28)	14.61 (19)	18.89 (72)
	7 to 10	7.14 (9)	10.32 (13)	2.31 (3)	6.59 (25)
	More than 10	0.79 (1)	3.17 (4)	0.77 (1)	1.58 (6)
Referred to the clinic by % (n)	Physician	53.17 (67)	38.10 (48)	63.85 (83)	51.71 (198)	0.0005*
	Health insurance	7.15 (9)	13.49 (17)	8.45 (11)	9.70 (37)
	Friend	22.22 (28)	33.33 (42)	11.54 (15)	22.36 (85)
	Former patient	11.90 (15)	7.14 (9)	11.54 (15)	10.19 (39)
	Other	5.56 (7)	7.94 (10)	4.62 (6)	6.04 (23)
First experience with physical therapy? % (n)	Yes	38.10 (48)	37.30 (47)	33.85 (44)	36.42 (139)	0.753
	No	61.90 (78)	62.70 (79)	66.15 (86)	64.03 (243)
First experience at this clinic? % (n)	Yes	61.90 (78)	50.79 (64)	50.00 (65)	54.23 (207)	0.010*
	No	38.10 (48)	49.21 (62)	50.00 (65)	45.77 (175)

• *Statistically significant values.

Cronbach’s α coefficient showed values greater than 0.7 in the assessment of the total number of patients in all sectors. In the evaluation by domain, values slightly lower than 0.7 were found for the convenience and overall satisfaction items in PC, and for convenience in SC.

The satisfaction level of the patients in the evaluated services were compared based on the means of each domain, according to Table 2. Statistically significant differences were observed in SC, in relation to PC in some domains, and in relation to PHC in others. PC showed the lowest mean overall satisfaction values in the comparison between the three services.

Table 2
Comparison of the overall and each domain’s service satisfaction scores between SC, PHC and PC, 2016

Variables	SC	PHC	PC	p
Total	100.3b	97.4	95.0	0.0032*
1. Therapist-patient relationship	35.6a	33.9	34.5	0.0153*
2. Support team	25.7b	25.3	24.4	0.0142*
3. Convenience	8.0b	8.3c	7.5	<0.0001*
4. Physical environment	17.1b	16.7c	15.2	<0.0001*
5. Overall Satisfaction	13.9a	13.3	13.5	0.0052*

• ^a: statistically significant values between SC and PHC; ^b: statistically significant values between SC and PC; ^c: statistically significant values between PHC and PC; *statistically significant values by Tukey’s multiple comparison test.

The analyses of correlation between the therapist-patient relationship (1), support team (2), convenience (3), and physical environment (4) domains and the questions about overall satisfaction are highlighted in Table 3. Moderate correlation was observed between domains 1 to 4 and question 21 in the three services, but the highest R values were reached in domain 1. Domain 3 had the lowest values of correlation with the questions about overall satisfaction in the three groups.

Table 3
Spearman’s correlation between the questions about satisfaction and the domains of the questionnaire for each service, 2016

	Domains	Q21 (Overall Satisfaction)	Q22 (Would return)	Q23 (Would recommend)
SC	1. Therapist-patient relationship	R=0.67 / p<0.0001*	R=0.47 / p<0.0001	R=0.56 / p<0.0001*
	2. Support team	R=0.57 / p<0.0001*	R=0.47 / p<0.0001	R=0.54 / p<0.0001*
	3. Convenience	R=0.52 / p<0.0001*	R=0.41 / p<0.0001	R=0.55 / p<0.0001*
	4. Physical environment	R=0.60 / p<0.0001*	R=0.58 / p<0.0001*	R=0.58 / p<0.0001*
PHC	1. Therapist-patient relationship	R=0.69 /p<0.0001*	R=0.52 / p<0.0001*	R=0.50 /p<0.0001*
	2. Support team	R=0.66 /p<0.0001*	R=0.45 /p<0.0001	R=0.42 /p<0.0001
	3. Convenience	R=0.68 /p<0.0001*	R=0.36 /p<0.0001	R=0.42 /p<0.0001
	4. Physical environment	R=0.68 /p<0.0001*	R=0.42 /p<0.0001	R=0.47 / p<0.0001
PC	1. Therapist-patient relationship	R=0.78 / p<0.0001*	R=0.43 /p<0.0001	R=0.40 /p<0.0001
	2. Support team	R=0.66 /p<0.0001*	R=0.33 /p=0.0001	R=0.39 /p<0.0001
	3. Convenience	R=0.45 /p<0.0001	R=0.22 / p=0.0122	R=0.25 / p=0.0041
	4. Physical environment	R=0.57 / p<0.0001*	R=0.36 / p<0.001	R=0.30 / p<0.0004

• *r values ≥0.5 and p values <0.05.

DISCUSSION

It is a consensus that satisfaction reflects the patient’s perception about the quality of the service received; however, this theme is broad and influenced by sociocultural values and the services’ environmental conditions¹³.

In a study¹⁴ conducted with 1,944 patients to assess their satisfaction with the treatment received, it was concluded that the patient’s satisfaction does not depend on the clinical outcome. These discrepancies justify the discussion about the importance of evaluating the effectiveness of a service in all its aspects.

Knowing the patient’s profile allows the creation of solutions adapted to the local reality. Studies show that the socioeconomic profile of a population influences health independently of individual characteristics¹⁵.

The mean age of the patients evaluated was approximately 51.96 years old, and the oldest patients were found in PHC, with mean age equal to 56.91 years old and statistical difference in relation to the others. The older Brazilian population has been growing, contributing to the increase in the indicators of chronic diseases that may require permanent care¹⁶. The physical limitation degree justifies the age profile of the patients in this study, and in most of the studies about satisfaction in physical therapy.

In the three groups evaluated, there was a majority of females. The prevalence of women in physical therapy care is highlighted by most publications in this field^{17)- (19}. Authors attribute this to the fact that many women, in addition to domestic tasks, perform professional activities, favoring musculoskeletal complications¹⁷.

The results of the study of the questionnaire’s reliability and validity indicated satisfactory psychometric properties for its use in this population. The reliability estimated by Cronbach’s α coefficient (α=0.94 in SC, 0.97 in PHC and 0.94 in PC) exceeded the values proposed as a criterion for exploratory studies²⁰. When the domains were evaluated individually, only convenience (SC and PC) and overall satisfaction (PC) did not obtain satisfactory scores, a fact that was also observed in another study in the field⁶.

In general, we may note that all the services evaluated showed good satisfaction rates, the highest having been found in SC, and the worst, in PC.

We may also note that SC had higher therapist-patient relationship and overall satisfaction values than PHC, as well as higher values of overall satisfaction and in relation to the support offered by the team, the environment and convenience than those of PC. PHC’s values were higher than PC’s in relation to the environment and convenience.

Considering the high levels of satisfaction observed in SC, this service’s management system and actions could be studied for the creation of new alternatives of administration for other outpatient physical therapy services.

A study carried out in a school clinic in the city of Santo André (SP) showed that the patients evaluated the competence of the work performed by the clinic’s team positively¹⁸.

PC had the lowest satisfaction means of the evaluated services, a fact that should also be highlighted, since the promotion of the citizenship of a significant portion of health users depends on the public sector’s efficiency.

Measuring and evaluating the actions undertaken and outcomes achieved is as important as planning them. Evaluations are important contributions of research institutions, which interact with segments of society for their continuous improvement²¹.

The analysis of the relationship between the questions about the patients’ overall satisfaction with each of the domains showed good correlation levels with question 21 in the three groups. It is important to note that the therapist-patient relationship domain had the highest correlation values.

Several authors point to this domain as one of those that most influence patient satisfaction^{4), (6), (8), (22), (23}. The way the physical therapist behaves during the session influences overall satisfaction more than the other domains of care.

SC had the best correlations with the domains evaluated in the three questions about overall satisfaction. In this service, the individuality of care is highlighted, since each student sees one patient per session. Another important factor is that a supervising trainee professor should be present for each group of six students, as established by the Federal Physical Therapy Committee²⁴ (Coffito) in 2013. In other physical therapy services, one professional may see up to six patients during office hours, depending on the nature of the pathology²⁵.

In a study about the access to and support received in health units, the professional’s performance and the bond established between the patient and the service were important factors highlighted by the patients²⁶. These results also corroborate those of the present study.

The public power’s lack of financial resources is considered one of the challenges that hinder the humanization of care, since it has an important impact on the physical and material structure of services²⁷.

In this study, the convenience domain had the lowest values of correlation with overall satisfaction. These results differ between publications in the area, as they are corroborated by some authors and refuted by others^{8), (19}.

It is important to emphasize that the evaluated municipalities are small, with less than 50 thousand inhabitants, which may favor the smaller impact of the evaluated items.

The lack of standardization of evaluation instruments reduces the possibility of comparing the results²⁸. In Brazil, the first questionnaire that was psychometrically validated and translated into Portuguese was developed in 2007 and, so far, about ten articles with the use of this instrument have been published.

The therapist-patient relationship may hinder the patient’s assessment, according to the researchers²⁹, as when patients have high levels of involvement with a service, they tend to attribute positive values to it. This type of bias is difficult to eliminate in physical therapy studies because of the services’ nature. Standardized questionnaires do not provide complete information about the research object, therefore, the inclusion of open questions could enrich the understanding about the needs of the service evaluated⁴.

Despite the high satisfaction rates found in this study, we cannot affirm that the therapeutic behaviors were the most appropriate, since the questionnaire evaluates the satisfaction of the patient with the care received, not with the procedures and the outcome achieved. It should also be noted that the individual tends to become more critical over time³⁰. Therefore, the process of evaluating the patient’s expectations in relation to health services should be a permanent concern.

CONCLUSION

Regarding the results of this research, it was possible to verify that, when comparing the physical therapy services, SC patients showed higher satisfaction than PC patients in relation to the support team, convenience and physical environment, and than PHC patients in relation to the therapist-patient relationship and overall satisfaction. PHC was better evaluated than PC in relation to convenience and physical environment. Of all domains investigated, the therapist-patient relationship had the highest correlation with overall satisfaction, and convenience, the lowest. A positive correlation was observed between overall satisfaction and age, female sex and income in PHC.

These results represent an important indicator of the patients’ perceptions about the services investigated in this study, describing the profile, values and differences in the patients’ satisfaction beliefs. These data allow the proper implementation of public, private and academic policies aimed at the improvement of the quality of physical therapy care.

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• Finance source: Nothing to declare
• Approved by the Research Ethics Committee of Faculdade de Ciências Campus de Bauru/Unesp - Júlio de Mesquita under protocol No. 709,324.

Publication Dates

• Publication in this collection
  16 Sept 2019
• Date of issue
  Jul-Sep 2019

History

• Received
  11 Dec 2018
• Accepted
  12 June 2019