Patient Satisfaction With Service Quality in an Oncology Setting

Implications for Prognosis in Non-small Cell Lung Cancer

Digant Gupta; Mark Rodeghier; Christopher G. Lis


Int J Qual Health Care. 2013;25(6):696-703. 

In This Article


We investigated association between patient satisfaction with service quality and survival in NSCLC patients treated in an acute care national oncology hospital network.

The univariate and multivariate findings of this study suggest that patients completely satisfied with their service quality experience better survival outcomes compared with those who are not. One possible explanation could be that more satisfied patients might experience positive emotions that may favorably influence biologically relevant factors (e.g. enhanced immune function, patient-focus on maintaining adequate nutrition). Another possible interpretation is that a third variable, such as the patient's general state of health which was not measured in the current study, may affect both patient satisfaction and survival, leading to a spurious association. Patients with a better state of general health may rate their satisfaction with service quality more highly than patients whose general health is not as good.

There were systematic differences across the three CTCA hospitals with regard to the baseline patient characteristics as reported in Table 4. CTCA Southwestern had a significantly smaller number of patients with advanced stage and recurrent disease, which could perhaps explain its better survival outcomes. It is also likely that the three CTCA hospitals differ from each other with regard to some unknown/unmeasured factors which could have confounded the results. As a result, the CTCA hospital variable, which could be considered a proxy for differences across hospitals, was controlled for in the multivariate analysis.

Patient satisfaction, which is often assessed by heath-care organizations, may be viewed as a useful, if imprecise, indicator of survival in NSCLC patients, whether that association be due to improved general health, more positive emotions or a combination of these. Although clinical indicators of prognosis are primary, these findings suggest that health-care providers pay close attention to those patients who are less than completely satisfied during treatment. Doing so and alleviating any readily remedied causes of dissatisfaction may improve commitment to treatment protocols and secondary factors such as adequate nutrition.

A recently published prospective cohort study by Fenton et al.[28] investigated the relationship between patient satisfaction and mortality in adult respondents. Patient satisfaction was assessed using five items from the Consumer Assessment of Health Plans Survey. It was found that respondents in the highest patient satisfaction quartile (relative to the lowest patient satisfaction quartile) had higher mortality (adjusted HR, 1.26; 95% CI, 1.05–1.53). Another prospective cohort study by Mold et al.[29] investigated whether the quality of the primary care measured using the Components of Primary Care Index (CPCI) was associated with subsequent changes in health-related quality of life and/or survival in older patients greater than 64 years of age. Neither total CPCI nor any CPCI subscale score was associated with quality of life change over time or survival. The authors argued that patient satisfaction scores should not be relied on as measures of clinical effectiveness, although they might still be regarded as subjective indicators of other aspects of quality. These results are in contrast to the results observed in our study, where better overall patient satisfaction was associated with greater survival. However, there are several differences between our study and those by Fenton and Mold et al. that are worth mentioning. The patient population in the Fenton study comprised a national sample of adults with a variety of underlying medical conditions excluding cancer, while the Mold study included only older patients. The Fenton study did not include psychosocial measures of patient satisfaction with the exception of the question on 'time spent with the physician'. The Mold study used the following eight subscales of CPCI: comprehensiveness, accumulated knowledge, coordination, preference for regular primary care physician, interpersonal communication, advocacy, family context and community context. The Fenton study did not adjust for the main underlying disease/medical condition, although the authors did control for a surrogate measure of underlying disease, the self-reported health. Similarly, the Mold study controlled for the severity of illness as well as baseline general health. Collectively, these observations suggest that the relationship between patient satisfaction and survival might well be a function of the underlying disease population being investigated. Clearly, future prospective studies among diverse patient populations are warranted to better elucidate the relationship between patient satisfaction and survival.

We acknowledge several limitations of this study. The patient cohort was limited to only those patients who spoke English and so this study sample is, therefore, not broadly representative of NSCLC patients in general. Further, our study, which is exploratory and hypothesis generating by nature, used a non-validated patient satisfaction questionnaire. As discussed above, it might be argued that patients with greater satisfaction with service quality might be the ones with better general health, leading to a confounded association between patient satisfaction and survival. However, we did control for the effects of tumor stage and prior treatment history in our analysis. These two variables can be considered proxies for self-rated health, given that patients with advanced stage disease who have been extensively treated are likely to have a worse general health compared with patients who are newly diagnosed with early stage disease. That said, it is imperative for future studies to control for self-reported health when analyzing the relationship between patient satisfaction and survival. We were not able to control for patient co-morbidities due to lack of relevant data. Given that co-morbidities are significantly associated with patient survival, lack of adjustment for them leaves room for residual confounding in our analysis. Finally, we could not perform a comparison of baseline characteristics between responders and non-responders since we did not have any information available on non-responders.

The strengths of our study include a prospective cohort study design, a large randomly selected sample size, a good response rate of 69%, the fact that we measured service quality as close to the time service was delivered as possible and the fact that we used patient survival (the most objective and most commonly used health outcome measure in oncology) as our dependent variable. To the best of our knowledge, this exploratory study is the first in the health-care literature to report on the association between patient satisfaction with service quality and survival in a large sample of NSCLC patients.

In conclusion, our study suggests the predictive significance of patient satisfaction with service quality as it relates to survival in NSCLC, an entirely new finding in the oncology literature to the best of our knowledge.