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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 5  |  Issue : 3  |  Page : 178-185

The Satisfaction Levels of Heart Transplant Recipients Seeking Posttransplant Medical Care at a Tertiary Care Government Hospital: A Questionnaire-Based Study


1 Department of Cardiothoracic and Vascular Surgery, Cardiothoracic Sciences Center, All India Institute of Medical Sciences, New Delhi, India
2 Department of Cardiology, Cardiothoracic Sciences Center, All India Institute of Medical Sciences, New Delhi, India

Date of Submission07-Aug-2019
Date of Acceptance24-Sep-2019
Date of Web Publication20-Dec-2019

Correspondence Address:
Dr. Sarvesh Pal Singh
Department of Cardiothoracic and Vascular Surgery, CN Center, All India Institute of Medical Sciences, Room No. 2, 8th Floor, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpcs.jpcs_50_19

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  Abstract 


Background: India is a country of approximately 1.35 billion people. Heart transplant surgery is resource intensive requiring extensive efforts both on the part of the patient and the treating physician. This study was designed to assess the satisfaction level of heart transplant recipients seeking post transplant medical care at our hospital. Methods: Twenty heart transplant recipients who are in our follow up participated in this study anonymously. The quality of medical care was evaluated by using Long Form Patient Satisfaction Questionnaire III (RAND Healthcare, CA). Results: All the grouped items - general satisfaction (82.4%), technical competence (82.4%), interpersonal aspects (79.1%), communication (84%), financial aspects (76.7%), time spent with the doctor (84%) and access to care (77.3%) had similar satisfaction levels. The aspects of “communication” and “time spent with the doctor” had maximum satisfaction levels at 84%. Conclusion: The average satisfaction level of heart transplant recipients for the medical care they receive at AIIMS, New Delhi (as evaluated by the help of long form patient satisfaction questionnaire III) was 80%.

Keywords: Care, heart, medical, satisfaction, transplant


How to cite this article:
Singh SP, Sahu MK, Seth S, Hote MP. The Satisfaction Levels of Heart Transplant Recipients Seeking Posttransplant Medical Care at a Tertiary Care Government Hospital: A Questionnaire-Based Study. J Pract Cardiovasc Sci 2019;5:178-85

How to cite this URL:
Singh SP, Sahu MK, Seth S, Hote MP. The Satisfaction Levels of Heart Transplant Recipients Seeking Posttransplant Medical Care at a Tertiary Care Government Hospital: A Questionnaire-Based Study. J Pract Cardiovasc Sci [serial online] 2019 [cited 2020 Jan 25];5:178-85. Available from: http://www.j-pcs.org/text.asp?2019/5/3/178/273742




  Introduction Top


India is a country of about 1.35 billion people. There is a private–public sector divide in healthcare in India.[1] Irrespective of the type of hospital the patient seeks healthcare in, there is a general discontent in most of the patients or their relatives. The number of patients visiting government hospitals is huge, and therefore, patients often struggle with long queues, delays in investigations and surgeries, repeated visits, less time per patient, and seldom impolite behavior.[2] The healthcare in private sector is convenient but costly often leading to inflated medical bills.[3] The technical expertise and communication between doctor and patient may vary among each hospital.

Heart transplant surgery is resource intensive requiring extensive efforts both on the part of the patient and the treating physician. The preoperative workup for heart transplant is quite comprehensive with multiple visits to clinics of different specialties and laboratories.[4] Similarly, in the postoperative period, these patients undergo follow-up checkups, initially, weekly, and then monthly in the 1st year. Furthermore, their first hospital stay (perioperative period) duration ranges from 10 to 14 days twice compared to nontransplant patients undergoing cardiac surgery.[5],[6] Therefore, in comparison to routine cardiac surgery patient, a heart transplant recipient stays longer and visits more often. They need good quality and readily accessible healthcare.

The All India Institute of Medical Sciences (AIIMS), New Delhi, India is a 2400-bedded government hospital with an inflow of 10,000 patients per day.[7],[8] The number by itself is reflective of the workload in each department's outpatient clinic. In the early period of transplant program, it was a policy for the transplant recipients to visit the cardiology outpatient's clinic for their follow-up and other specialty consultations (endocrinology, orthopedic, neurology, etc.). Five years ago, when the number of heart transplants increased at AIIMS, we realized that the existing practice was highly inconvenient to the heart recipients and exposing them to vast number of sick patients in crowded places. Therefore, a new arrangement was established so that all the transplant recipients may report for their follow-up in a noncrowded place with least trouble. We came up with the concept of establishing transplant follow-up clinic in our cardiothoracic ward. The current policy at our cardiothoracic and vascular surgery (CTVS) department is that all the transplant recipients report to the transplant cubicle in our cardiothoracic ward. All the sampling for biochemical investigations, clinical checkups, radiological investigations, and specialty consultations are done in the ward only. When the patient reports to the heart transplant follow-up clinic on the scheduled day, he/she is first attended by a heart failure nurse who assesses the general well-being and takes blood samples. The trainee resident takes clinical history and performs a brief examination to rule out any problems. The transplant cardiologist or intensivist performs the routine echocardiogram, tailors immunosuppression, plans endomyocardial biopsies, and addresses any fresh complaints. The nutrition specialist and physiotherapist recommend about the diet and physical exercises, respectively. If required, patients are admitted to the ward from this follow-up clinic only. As an institute policy, poor and underprivileged patients receive immunosuppressive drugs and other medicines from the hospital free of cost. In times of emergency, the patient reports to the same follow-up clinic (in ward) and is evaluated first by the trainee resident and then the consultant Intensivist of CTVS department. The patient may then be admitted to the ward or shifted to the ICU depending on the emergency. This new policy has improved healthcare delivery and satisfaction levels in all the transplant recipients.

This study was designed to assess the satisfaction level of heart transplant recipients seeking posttransplant medical care at our hospital.


  Methods Top


This observational study was conducted at the AIIMS, New Delhi. Our hospital has 22 transplant recipients in regular follow-up from the date of their surgery till writing of this article. Recipients who were operated at our hospital and received early care with us but later went to their native cities were not included in this study. A long form patient satisfaction questionnaire (PSQ) III (RAND Healthcare, RAND Corp, CA) was used to obtain the responses from heart transplant recipients about their medical care at our hospital. This instrument has been validated in earlier studies multiple times.[9],[10] Of 22 patients, 1 patient was out of city for 3 months and one patient refused to fill the questionnaire. 20 patients completed the questionnaire. Out of these 20, one patient was omitted from the analysis, as the responses were same for all the questions (response 1). All the forms were completed anonymously; therefore no effort was made to identify this particular patient. For children the PSQ III instrument was filled by their mothers (parent who usually accompanies the children to the hospital).

The long form PSQ III has a set of 51 items (PSQ1-51) grouped into general satisfaction (6 items), technical competence (10 items), interpersonal aspects (7 items), communication (5 items), financial aspects (8 items), time spent with the doctor (2 items), and access to care (12 items). The form is detailed in [Annexure 1]. A Hindi translation was used to keep uniformity in the methodology. The Hindi version was verified by “Hindi Section” of AIIMS, New Delhi as an exact translation of the original form. All questions have five possible responses – 1 - strongly agree, 2 - agree, 3 - uncertain, 4 – disagree, and 5 - strongly disagree.



The direction of wording in the questions is either positive or negative. For e.g.,: Positive worded item is “I am very satisfied with the medical care I receive” and negative worded item is “I worry sometimes about having to pay large medical bills.” Item number 30 (PSQ 30) is the belief of the patient about healthcare in his/her own country and is not included in the analysis.

Scoring the individual answers is done by recoding the answers as follows. All the positive worded questions are recoded so that higher item scores indicate greater satisfaction.[11]

Following recoding higher the value better is the satisfaction levels of patients.



Analysis

A composite score was calculated by summing the average of all the parameters and individual item scores were calculated by summing the average score of all items in that group.

  • General satisfaction = PSQ (1 + 2 + 3 + 4 + 5 + 6)
  • Technical competence = PSQ (7 + 8 + 9 + 10 + 11 + 12 + 13 + 14 + 15 + 16)
  • Interpersonal aspects = PSQ (17 + 18 + 19 + 20 + 21 + 22 + 23)
  • Communication = PSQ (24 + 25 + 26 + 27 + 28)
  • Financial aspects = PSQ (29 + 30 + 31 + 32 + 33 + 34 + 35 + 36)
  • Time spent with the doctor = PSQ (37 + 38)
  • Access to care = PSQ (39 + 40 + 41 + 42 + 43 + 44 + 45 + 46 + 47 + 48 + 49 + 50).


The overall satisfaction percentage and for grouped items was calculated by dividing the obtained score with maximum possible score.


  Results Top


[Table 1] shows the mean scores on individual PSQ items with PSQ 44 (Where I get medical care people have to wait too long for emergency treatment) having the least mean score of 1.47 ± 0.5.
Table 1: Mean scores for individual items in the long form patient satisfaction questionnaire III instrument

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[Table 2] shows the minimum and maximum scores of grouped items with mean and standard deviation (SD).
Table 2: Mean scores of satisfaction according to the grouped items in patient satisfaction questionnaire III

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[Table 3] reveals the overall patient satisfaction levels and as per individual groups. It is evident from these results that there was no skewness in the observations and the patient satisfaction was on an average 80%.
Table 3: Percentage level of satisfaction according to various grouped items

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  Discussion Top


Heart transplant is a resource intensive procedure and recipients are kept on a close follow-up for the rest of their lives. Contrary to routine cardiac surgery patients, transplant recipients are followed more often, need multiple medications, frequent advice, routine endomyocardial biopsies, and lifelong immunosuppression (thus protection from opportunistic infections). This places a significant financial, mental, and physical burden on the transplant recipients. It is expected that these patients when receiving follow-up care in a government hospital will have much dissatisfaction.

The first PSQ about healthcare perceptions was developed by Ware et al. in 1976.[12] This original instrument had 80 items (PSQ). Later on, the number of items were reduced to 51 (PSQ III), and in 1994, the number was further decreased to 18 items (PSQ 18).[13] The latest format of PSQ 18 can be filled in 3–4 min, but the number of items is also reduced to about one-third of PSQ III.

To establish the degree of satisfaction in our heart transplant recipients, for the healthcare they receive, we used the long form PSQ III (RAND Healthcare, RAND Corporation, California, USA). The average satisfaction level was 80%. The items in the PSQ III instrument are grouped according to different aspects of medical care, and the level of satisfaction in all the aspects was not <76% [Table 2]. This is an extremely encouraging number especially in a government setup where 10,000 patients report to the hospital every day. The aspects of “communication” and “time spent with the doctor” had greatest satisfaction levels at 84%.

We further analyzed the response to all items individually. One item PSQ 44 had an exceptional low score with a mean (±SD) of 1.47 ± 0.5. The item PSQ III reads as “Where I get medical care people have to wait too long for emergency treatment.” It does not specify whether the person taking the survey himself had to wait too long for emergency treatment. It is possible that the participants erroneously commented on the time taken for routine patients (nonheart transplant) to receive emergency treatment at AIIMS, New Delhi. Moreover, the patients mean score to the PSQ item 41 which reads as “it is easy for me to get medical care in an emergency” was 4.57 ± 0.6. Because there was no way to confirm this hypothesis we included this result as such and analyzed it with other items.

Garg et al. performed a survey of 384 patients visiting our institute in January and February 2013 for various treatments.[14] They reported that 88% of respondents in their survey labeled overall satisfaction as excellent or good. However, they used an indigenous questionnaire and not a PSQ instrument. The questionnaire consisted questions on various services like Linen, food, billing, etc., and staff like nurses, doctors, and paramedics. In their study, 95% respondents labeled the care given by doctors as excellent or good and 85% accepted that the doctors were respectful towards patients. Although our survey used a 51 item instrument the satisfaction levels for technical quality, interpersonal aspects and communication was 82.4%, 79.1%, and 84%, respectively.

A study on 751 patients visiting a tertiary care government hospital (in North East India) was done by Rajkumari and Nula in 2017.[15] They formulated a new questionnaire based on admission procedure, physician care, nursing care, comfort and cleanliness, patient education, and food service in the hospital. They used Likert scale to score (1–3 or 1–5) the responses and categorized them as satisfied (>75th percentile), average satisfaction (25–75th percentile), and unsatisfied (<25th percentile). They reported a 32.5% overall satisfaction score with most satisfaction during admission procedure (51.7%). Our heart transplant recipients report directly to ward, and if required, admission procedure is finished in the ward itself. This arrangement might be responsible for the high satisfaction scores in our heart transplant recipients.

Another study done by Saini et al. compared the satisfaction levels among patients visiting secondary care and the only tertiary care hospital of North-East Delhi.[16] They used a patients perception of quality questionnaire developed and validated by Rao et al.[17] in their study to measure patient perception of quality of healthcare services in the state of Uttar Pradesh, India. The results of the study by Saini et al. showed better satisfaction with secondary hospital (not <75% in all aspects) compared to tertiary healthcare (16.9%–36.8%). The authors justified this disparity by patient load and lack of proper referral system in India. All the studies discussed have used indigenous questionnaires instead of an established standard PSQ like the one we used in our study. Moreover, we sought participation from heart transplant recipients who need much more intensive and long-term management than routine patients.

Limitation

The number of participants in this study is only 20. We have not performed the evaluation of the previous system of follow-up for heart transplant recipients so a comparison cannot be done between both the arrangements. The authors did not purposefully study the correlation between demographic variables and the satisfaction rates because of small sample size and to maintain anonymity of the participants. The pro forma was translated to Hindi to keep uniformity in the study. However, it is not always possible to convey the exact same meaning when translating from one language to another.


  Conclusion Top


The average satisfaction level of heart transplant recipients for the medical care they receive at AIIMS, New Delhi (as evaluated by the help of long form PSQ III) was 80%. All the grouped items - general satisfaction (82.4%), technical competence (82.4%), interpersonal aspects (79.1%), communication (84%), financial aspects (76.7%), time spent with the doctor (84%), and access to care (77.3%) had similar satisfaction levels.

Ethics clearance

Ethical clearance taken from institute ethics committee vide no IEC 280/03.05.2019, Rp -14/2019. Written informed consent was taken from all participants.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.




  Annexure Top


Long-Form Patient Satisfaction Questionnaire III (PSQ III)

These next questions are about how you feel about the medical care you receive.

On the following pages are some things people say about medical care. Please read each one carefully, keeping in mind the medial care you are receiving now. (If you have not received care recently, think about what you would expect if you needed care today). We are interested in your feeling, good and bad, about the medial care you have received.

How strongly do you AGREE or DISAGREE with each of the following statements?

Circle one number on each line



 
  References Top

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Thomas G. The Public – Private Gap in Healthcare. The Hindu; 01 August, 2018. Available from: https://www.thehindu.com/opinion/op-ed/the-public-private-gap-in-health-care/article24566398.ece. [Last accessed on 2019 Mar 25].  Back to cited text no. 1
    
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Bhattacharjee A, Mohan D. India's Healthcare System Is Becoming More and More Unequal. The Wire; 12 June, 2017. Available from: https://thewire.in/health/india-healthcare-system-inequality. [Last accessed on 2019 Mar 25].  Back to cited text no. 2
    
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Varma S. It's official: Private Hospitals Charge 3 Times more than Government Facilities. The Times of India; 2015. Available from: https://timesofindia.indiatimes.com/india/Its-official-Private-hospitals-charge-3-timesmore-than-govt-facilities/articleshow/47970870.cms. [Last accessed on 2019 Mar 25].  Back to cited text no. 3
    
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Airan B, Singh SP, Seth S, Hote MP, Sahu MK, Rajashekar P, et al. Heart transplant in India: Lessons learned. J Pract Cardiovasc Sci 2017;3:94-9.  Back to cited text no. 4
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Crawford TC, Magruder JT, Grimm JC, Suarez-Pierre A, Patel N, Sciortino CM, et al. Acomprehensive risk score to predict prolonged hospital length of stay after heart transplantation. Ann Thorac Surg 2018;105:83-90.  Back to cited text no. 6
    
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Dhaor A. With over 10,000 OPD patients, many die waiting at crowded AIIMS. The Hindustan Times; 09 July, 2015. Available from: https://www.hindustantimes.com/delhi-news/with-over-10-000-opd-patients-many-die-waiting-at-crowded-aiims/story-uIOPzEwsBRNEgvxQrumqoJ.html. [Last accessed on 2019 Mar 26].  Back to cited text no. 7
    
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Hagedoorn M, Uijl SG, Van Sonderen E, Ranchor AV, Grol BM, Otter R, et al. Structure and reliability of ware's patient satisfaction questionnaire III: Patients' satisfaction with oncological care in the Netherlands. Med Care 2003;41:254-63.  Back to cited text no. 10
    
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Hays RD, Davies AR, Ware JE. MOS Memorandum; 19 August, 1987. Available from: https://www.rand.org/content/dam/rand www/external/health/surveys_tools/psq/psq3_scoring.pdf. [Last accessed on 2019 Mar 26].  Back to cited text no. 11
    
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Ware JE, Snyder MK, Wright WR. Development and validation of scales to measure patient satisfaction with healthcare services. Vol. 1: [Final report] part B: Results regarding scales constructed from the Patient Satisfaction Questionnaire and measures of other health care perceptions (NTIS Publ No PB 288-330). Springfield, VA: National Technical Information Service; 1976.  Back to cited text no. 12
    
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[PUBMED]  [Full text]  
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  [Table 1], [Table 2], [Table 3]



 

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