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Research project: Measurement of patients' expectations for health care continuation

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There is widespread recognition of the importance of evaluating services from consumer perspectives. What people expect from their health care, compared with their experiences, may influence their satisfaction with it. There is also some evidence that patients who receive the health care they expect may recover better than patients who do not. However, there are many definitions of what patients expect from health services, for example, relating to different types of expectations (e.g. desires, predictions) and of health care structures (e.g. buildings, equipment, staff), processes (e.g. waiting lists, the way staff and patients interact) and health outcomes (e.g. the effects of the health service on patients' health, including patients' assessments of their health), and different visit types/episodes. There is also no well-tested, multidimensional, questionnaire to measure these different expectations. Funder:  NIHR HTA

Objectives

We aimed to examine existing models and definitions of patient expectations in the literature; to explore expectations with patients; and to develop and test an expectations questionnaire, informed by both approaches.

The study aimed to address the multiple research questions, summarised below:

  • How do expectations for different health care settings compare?
  • What are the most common types of met and unmet expectations expressed by patients, and do these vary by health care setting?
  • Are expectations influenced by respondents' characteristics, behaviours and circumstances?
  • What are the psychometric properties of the developed expectations questionnaire (in different health care settings)?                                 
  • How does mode of questionnaire administration (face-to-face interview or self-administration) affect the expectations elicited?
  • How does pre-visit expectation type affect post-visit met expectations and patient satisfaction?


Methods

 

The narrative review
A comprehensive search was run on the following databases: AMED (Allied and Complementary Database), British Nursing Index (BNI), Cinahl (Cumulative Index to Nursing and Allied Health Literature), Embase, Medline, PsycInfo, Assia (Applied Social Sciences Index and Abstracts), the Cochrane Library, Intute Social Sciences, Sociological Abstracts, Web of Science as part of Web of Knowledge and the HTA (Health Technology Assessment) reports. We searched for any type of literature published or written between 2000 and 2009, and for reasons of practicality we only searched for publications in the English language. In the following databases, the term ‘patient expectation OR patient expectations' was searched: Assia, Cochrane Library databases, Intute (Social Sciences and Medicine), Sociological Abstracts, Web of Knowledge. In the remaining databases a number of terms, synonyms and subject headings for ‘patient expectations' and ‘healthcare' were used. The search strategies can be found in the appendices. The following databases were also searched to retrieve any unpublished or grey literature: Index to Theses, Dissertations and Theses, and Open SIGLE (System for Information on Grey Literature in Europe). The searches were limited to 2000-2009; a data extraction form was used. The approach was a narrative review.

A total of 213 papers were included in the review from a total of 20437 titles and 268 abstracts identified. Most research designs were weak with small or selected samples. A theoretical frame of reference was rarely stated. In terms of measurement, the origin of questions about expectations was often absent, questions were frequently untested, and those with reported reliability or validity data had generally mixed results. Little attempt was made to examine expectations in detail or present findings in terms of contribution to existing knowledge.

The studies of patients
We first conducted semi-structured interviews with 20 general practice (GP) patients and 20 cardiology clinic patients in Norwich to ascertain patterns in expectations. These results, together with the literature review, informed the development of an expectations questionnaire, which aimed to measure pre-visit ideal and realistic expectations, and post-visit experiences (met expectations). This was piloted on a small number of patients, refined, and then field tested on 833 people in Norwich, Essex and Greater London before and after their consultations in general practice and hospital out-patient departments. The data also provided information on whether expectations between GP and hospital out-patient populations varied, and whether pre-visit ideal and/or realistic expectations predicted post-visit experiences (met expectations) and patient satisfaction. Caution is needed as the samples of patients were not randomly sampled. This is acceptable for the psychometric testing, but the survey distributions may not be generalizable.                                                       

Conclusions

A fully integrated model of expectations needs to be dynamic, multidimensional and able to identify its determinants, including socio-cognitive components. Furthermore, it needs to be able to model potential causal pathways between expectations, attitudes, behaviours and patient-based health outcomes. Past research has generally failed to state such a model: it is hoped that the current research, particularly following the further development and utilization of the expectations instrument developed here, may aid in such model development. However, the initial results of the patient surveys found that there were relatively few independent predictor variables of Ideal, Realistic or Met expectations, indicating the complexity of the topic.

The descriptive findings revealed that most patients ideally expected, in particular, site cleanliness, information about where to go, convenient appointments, being seen on time, helpfulness of reception staff and of doctor, knowledge of doctor, a clear and easy to understand doctor, involvement in treatment decisions, and a reduction in symptoms/ problems. However, the expectations least likely to be met, particularly among the hospital sample, included being seen on time, and the two items requested by the ethics committee:  being given a choice of hospitals if referred and doctors to consult (not included in scaling as not applicable to all patients). Other items which had low met expectations were helpfulness of reception staff doctor being respectful and treating with dignity (hospital sample), doctor knowledgeable about condition (hospital), being given reassurance, advice about health/condition, cause of condition, how to manage it, information about benefits/ side effects of treatment, opportunity to discuss problems in life, and the three items on outcome expectancies. These all have implications for the quality of health services, and their improvement. Awareness of patients' expectations, and unmet expectations, among health service staff should enable staff to understand the patient's perspective and improve communication - and met expectations. This study examined the perspective of the patient only. As there were no observations of consultations in this study, or questioning of health service staff, it is not possible to examine the extent to which any expectations might have been unrealistic, or inappropriate, at that time in a dynamic process (e.g. being given a diagnosis or other procedures).

Further study and validation of the expectations instrument will also enhance the confidence with which it may be adopted by health service providers in order to benchmark service quality and indicate deficiencies and areas of improvement (be these down to improving communication to make expectations of health service users more appropriate, or to enhancing service provision by staff and the NHS more generally).

Associated research themes

Patients' expectations

Psychometric assessment

Related research groups

Complex Healthcare Processes
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