Injury, Int. J. Care Injured (2007) 38, 1102—1108

www.elsevier.com/locate/injury

Factors predicting patient satisfaction followingmajor trauma

Ian Harris a,*, Alan Tien Thanh Dao a,1, Jane Young b, Michael Solomon b,Bin Badrudin Jalaludin c,2, Hamish Rae a

aOrthopaedic Department, Liverpool Hospital, Elizabeth Street, Liverpool, NSW 2170, Australiab Surgical Outcomes Research Centre, P.O. Box M157, Missenden Road, NSW 2050, AustraliacCentre for Research, Evidence Management and Surveillance, Liverpool Hospital, Locked Bag 7017,Liverpool, NSW 1871, Australia

Accepted 3 May 2007

KEYWORDSPatient satisfaction;Trauma;Outcome;Injury;Compensation

Summary

Introduction: Patient satisfaction is an intuitively important outcome measure andhas been previously linked to general health status. Previous research on patientsatisfaction after injury has concentrated on satisfaction with medical care. Thisstudy aims to explore possible predictors of patient satisfaction with outcomefollowing major trauma.Methods: A cross-sectional survey involving consecutive adult patients involved inmajor accidental trauma from a major metropolitan trauma centre, over a 5-yearperiod, was performed between 1 and 6 years post-injury. The outcome used waspatient satisfaction with progress since the injury. Multiple logistic regression wasused to develop a model of significant predictors of patient satisfaction.Results: The surveywasmailed to 728 eligible patients, 56were excluded due to deathor inability to complete the survey, 93 refused to participate and 90 were notcontactable. One hundred and thirty-four patients did not respond and 355 completedsurveys were returned. Patient dissatisfaction was found to be significantly associatedwith unemployment at the time of follow up (OR, 2.38; 95% CI, 1.38—4.08; p = 0.004),having one or more chronic illnesses at the time of injury (OR, 2.57; 95% CI, 1.45—4.55;p = 0.001), being involved in a motor vehicle accident (OR, 1.83; 95% CI, 1.02—3.30;p = 0.04) and having an unsettled compensation claim (OR, 5.19; 95% CI, 2.80—9.65;

* Corresponding authors. Tel.: +61 2 8777 5228; fax: +61 2 8777 5221.E-mail addresses: iaharris@optushome.com.au (I. Harris), alandao@optushome.com.au (A.T.T. Dao), jyoung@email.cs.nsw.gov.au

(J. Young), msolomon@med.usyd.edu.au (M. Solomon), b.jalaludin@unsw.edu.au (B.B. Jalaludin), hrae@gmp.usyd.edu.au (H. Rae).1 Tel.: +61 2 8777 5228; fax: +61 2 8777 5221.2 Tel.: +61 2 9828 6000; fax: +61 2 9828 6012.

0020–1383/$ — see front matter # 2007 Elsevier Ltd. All rights reserved.doi:10.1016/j.injury.2007.05.004

Factors predicting patient satisfaction 1103

p < 0.0001). Patient satisfaction was not significantly associated with any measure ofinjury severity.Conclusions: Having an unsettled compensation claim after major trauma is thestrongest predictor of patient dissatisfaction following major trauma, allowing forother factors.# 2007 Elsevier Ltd. All rights reserved.

Introduction

Outcomes following injury are often assessed byobjective measures such as functional scores, orby subjective patient-based health measures; thelatter usually being measures of health or quality oflife. Little attention has been given to patientsatisfaction as an outcome. This research attemptsto address this gap.

Although patient satisfaction is not a specificmeasure of health, it tends to be greater in thosepatients who report positive health.19 It has alsobeen shown to correlate highly with other generalhealth indicators such as the SF-36 general healthsurvey and baseline mental health indicators follow-ing elective surgery.14

Prior research into the determinants of patientsatisfaction has been performed.18 However, mostof the literature on patient satisfaction has focusedon the patient’s satisfaction with their medicalcare, rather than satisfaction with their conditionor treatment outcome. This study measures patientsatisfaction with the progress of recovery aftermajor trauma.

Regarding predictors of outcome after majortrauma, previous studies have concentrated onthe role of physical factors,4,6,23,29,30 but studiesthat have included psychosocial factors have alsoshown strong associations.7,11,17,20

This study aims to explore possible physical andpsychosocial predictors of patient-rated satisfactionin patients involved in major physical trauma.

The study was approved by the Human ResearchEthics Committees of the hospital and the sponsor-ing University.

Patients and methods

Patient selection

The patient population consisted of consecutiveadult (aged 18 and over) patients presenting to asingle trauma centre over a 5-year period withmajor trauma, defined as an Injury Severity Score(ISS)3 greater than 15. Patients were excluded fromthe study if their injury was non-accidental, if they

died after the injury, or if they were unable tocomplete the questionnaire.

Patient demographics and other data wereacquired from the hospital trauma registry and aquestionnaire, which was mailed to the patientsbetween 1 and 6 years after the injury. Reminderletters were sent if no responses were received after2 and 4 weeks. If there was still no response at 6weeks, telephone contact was attempted.

Outcome measures

The primary outcome measure was patient satisfac-tion, which was assessed by a single question: ‘‘Howsatisfied are you with your progress since theinjury?’’ The response was provided as a four-pointLikert scale with the responses ‘‘very satisfied’’,‘‘somewhat satisfied’’, ‘‘somewhat dissatisfied’’,and ‘‘very dissatisfied’’. Another outcome usedwas the SF-36 Short Form General Health Survey,31

from which the physical component summary (PCS)and the mental component summary (MCS) werecalculated. These results have been published else-where.10

Explanatory variables

The explanatory variables used were grouped asgeneral factors, injury severity factors, socio-eco-nomic factors, and compensation-related factors.These variables are listed in Table 1.

Among the group of general factors, the presenceof chronic illnesses was established by askingpatients to choose from a list of possible illnessesat the time of the questionnaire (heart disease,chronic bronchitis or asthma, kidney disease,stroke, cancer, high blood pressure, liver disease,and diabetes). Although measured at the time offollow-up, the illnesses were considered to be areflection of the pre-injury co-morbidities, as theconditions were likely to be present at the time ofthe injury, and were unlikely to be caused by theinjury.

For injury severity factors, the ISS was recordedalong with whether a significant head injury wassustained. A significant head injury was deemedpresent if the Abbreviated Injury Score2 (a measure

1104 I. Harris et al.

Table 1 Frequency and means of potential predictors

Variable Category N % Mean (range)

General factorsAge 355 47.8 years (19—91)Sex Male 256 72.1

Female 99 27.9Time since injury 41.0 months (12—74)Chronic illnesses None 146 41.1

One or more 209 58.9

Injury severity factorsInjury severity score 355 24.3 (16—66)Intensive care unit admission No 140 39.4

Yes 215 60.6Head injury No 173 48.7

Yes 182 51.3Mechanism MVA 225 63.4

Other 130 36.6

Socioeconomic factorsHighest education Primary 30 8.6

Secondary 189 54.2Certificate/diploma 100 28.7Bachelor degree 30 8.6

Annual household income $0—30,000 160 46.4$30,000—50,000 83 24.1$50,000—75,000 54 15.7$75,000+ 48 13.9

Employed prior to injury No 108 30.4Yes 247 69.6

Employed now No 193 54.4Yes 162 45.6

Compensation-related factorsClaim pursuit, settlement No 201 56.8

Yes, settled 70 19.8Yes, not settled 83 23.4

Claim type Workers comp. 48 31.4Third party 82 53.6Both 23 15.0

Lawyer used No 225 63.7Yes 128 36.3

Blame Self 129 36.7Someone else 113 32.1Do not know 110 31.3

Time to settlement 59 32.3 months (4—60)Time since settlement 59 19.2 months (1—65)

of severity ranging from 0 to 6) for the head injurywas 3 or higher.

Socio-economic factors were recorded includingincome and education, which were referenced tothe time of the injury.

In relation to compensation related factors in thestate of New South Wales, third party compensationis a compulsory, fault-based insurance scheme cov-ering all registered motor vehicles. It coverspatients in motor vehicle accidents who are notat fault, such as passengers, and some drivers andpedestrians. All patients injured in the course of

their work are covered by the compulsory, no-faultWorker’s Compensation insurance scheme. Blamewas measured by asking patients who they person-ally blamed for the accident, themselves or others.

Statistical analysis

All statistical analyses were performed using SASstatistical software package, version 8.2 (Cary, NC).The main outcome (patient satisfaction) was trans-formed into a dichotomous variable (satisfied/dis-satisfied) by grouping the two ‘satisfied’ responses,

Factors predicting patient satisfaction 1105

and the two ‘dissatisfied’ responses, respectively. Aunivariate analysis was performed using the overallx2-test and the x2-test for trend (Mantel-Haenzel)for categorical variables, and Student’s t-test forcontinuous variables. Any variable with a signifi-cance level of 0.25 or lower was then included ina multiple logistic regression equation. Backwardstep-wise logistic regression was performed, andvariables with significance levels of 0.05 or less wereretained in the final model. Interaction terms wereintroduced into the final model and retained if theirsignificance level was less than or equal to 0.01.12

Differences between responding and non-respond-ing subjects were analysed using Student’s t-test orthe x2-test, using predictor variables that wereavailable.

Results

Of the 1156 major trauma patients admitted, 220were excluded as they died since the injury, 205were excluded because their injury was classified asnon-accidental, 2 were overseas visitors and 1 hadno known address. A questionnaire was mailed tothe remaining 728 patients. Forty-six were unable tocomplete the survey (due to language difficulties,being overseas, having dementia or having a severebrain injury) and a further 10 patients had died;these patients were excluded. Of the remaining 672patients, 90 questionnaires were returned withwrong addresses and no further contact could bemade, 93 refused to participate, and 134 did notrespond to all three mailings and one attemptedphone call. Three hundred and fifty-five question-naires were returned, and data regarding patientsatisfaction was available on 353 subjects (52.5% ofeligible patients).

An analysis of responding versus non-respondingsubjects showed that the non-responding subjectswere significantly younger (mean age 45 years,versus 48 years for responding subjects, p = 0.02)and had a longer time since injury (mean 45 monthsversus 41 months, p = 0.001). There was no signifi-cant variation in the gender or injury severity scoresbetween responders and non-responders.

Of the 353 patients answering the patient satis-faction question, 42.8% were very satisfied withtheir progress since the injury, 28.9% were some-what satisfied, 17.9% were somewhat dissatisfiedand 10.5% were very dissatisfied. The distributionof the explanatory variables is given in Table 1.

The unadjusted association for each variable andpatient satisfaction is provided in Table 2. Theresults of the logistic regression showing theadjusted effect of each of the remaining significant

variables are provided in Table 3. The significantpredictors of dissatisfaction, allowing for other vari-ables, were unemployment at the time of follow-up,being involved in a motor vehicle accident (com-pared to other mechanisms, mostly falls), havingone or more chronic illnesses, and having anunsettled compensation claim. Having a compensa-tion claim (settled or unsettled), and the type ofcompensation claim (third party versus workerscompensation) were not significantly associatedwith satisfaction.

Patient satisfaction was strongly associated withgeneral health, as shown in Table 4.

Discussion

Patient satisfaction is an important outcome mea-sure that is often overlooked in the clinical setting,despite an increase in the use of patient-basedoutcomes in clinical research. Patient satisfactionhas been advocated as an aid to provide betterunderstanding of the outcomes of treatment fromthe patient’s perspective.18,26,28 It complementsand enhances information provided by objectiveclinical measures by adding patient-relevant out-come data.34 Furthermore, patient satisfaction iswell known to increase compliance with furthertreatment, improve patient loyalty, and improvehealth outcomes.16 Conversely, patient dissatisfac-tion may be a potential barrier to seeking treat-ment15 and may possibly lead to litigation.21

Assessing patient satisfaction with outcome is arelatively new field of research and, as yet, thereare no standard measurement tools. The measure-ment tool used in this study related to the patient’sperception of their progress since the injury. Whilethis tool only measures one aspect of satisfaction(satisfaction with progress), we consider this animportant parameter. The importance of this mea-sure is supported by the high correlation with gen-eral health.

Our measure of patient satisfaction was found tobe strongly associated with general health, and thisassociation was shown to be stronger for mentalhealth than physical health. This latter finding isconsistent with previous studies that have shownstrong links between patient satisfaction and gen-eral health1,14,24 and studies that have shown astronger association with mental health than withphysical health.19,24

The rate of patient satisfaction found in thisstudy was lower than those described in otherpapers.18,22,26,32,36 This may be due to differencesin the populations studied. In previous papers, thepopulation consisted usually of older patients

1106 I. Harris et al.

Table 2 Unadjusted association between potential predictors and patient satisfaction

Explanatory variable Category (if applicable) %Satisfied p-Value

General factorsAge 0.45Sex Male 71.8 0.80

Female 70.4Time since injury 0.002Chronic illnesses None 80.1 0.002

One or more 65.2

Injury severity factorsISS 0.81Intensive care unit admission No 69.8 0.59

Yes 72.4 0.68 (MH)Head injury No 72.7 0.60

Yes 70.2Mechanism MVA 66.5 0.008

Other 79.8

Socioeconomic factorsEducation Primary 63.3 0.65

Secondary 71.8 0.71 (MH)Certificate/diploma 74.0Degree 66.7

Income $0—30,000 67.5 0.39$30,001—50,000 73.5 0.19 (MH)$50,001—75,000 79.2Over $75,000 72.9

Employed prior Employed 74.5 0.05Unemployed 64.2

Employed now Employed 82.1 <0.0001Unemployed 63.3

Claim-related factorsClaim made No 81.0 <0.0001

Yes 58.6Claim settled No 43.9 <0.0001

Yes 75.7Claim type Workers compensation 68.7 0.07

Third party 54.9Lawyer involvement No 79.9 <0.0001

Yes 55.9Blame Self 83.7 <0.0001

Someone else 58.9Time to settlement 0.08Time since settlement 0.92

MH: Mantel-Haenzel.

undergoing elective joint replacement surgery, apopulation that would be expected to have differentpsychosocial circumstances to a population oftrauma patients. In one study of injured workers(a study population that may be considered demo-graphically closer to the subjects in our study) whichexamined patient satisfaction with care, a satisfac-tion rate of 76.5% was found,27 similar to the rateseen in this study.

The majority of major trauma is caused by trafficaccidents, falls and work-related injuries,13,33 andmany of these patients are eligible to claim compen-

sation. Numerous studies in the past have shown thatinvolvement with compensation has generally led topoorer objective and functional outcomes both in theshort and long terms.8,9,32,37,38 In this study,we foundinvolvement in an unsettled compensation claim tobe the strongest predictor of patient dissatisfaction,yet patients whose claims had settled had similarsatisfaction to patients who had not pursued a claim.This finding indicates that patient dissatisfactionmaystem from aspects of the claims process, such as theadversarial nature of the process, or the uncertaintyassociated with an unsettled claim.

Factors predicting patient satisfaction 1107

Table 3 Significant predictors of patient dissatisfaction

Variable Group Adjusted odds ratio (95% CI) p-Value

Current employment Unemployed 2.38 (1.38—4.08) 0.002Mechanism MVA 1.83 (1.02—3.30) 0.04Chronic illness Present 2.57 (1.45—4.55) 0.001

Claim No claim made 1.00Claim settled 1.23 (0.61—2.48) 0.56Claim not settled 5.19 (2.80—9.65) <0.0001(Overall) <0.0001

Some confounding may exist, as patients who arenot satisfied with their outcome may be more likelyto pursue litigation. Although the effect of the typeof claim (between the no-fault Worker’s Compensa-tion system and the fault based Third party system)was not significant, the study may have been under-powered to detect a significant difference in thissub-group of patients with claims.

The association between dissatisfaction andunemployment at the time of follow-up may bebecause patients with less satisfaction (which isassociated with a lower perceived level of health)were less likely to pursue employment or return toemployment. Alternatively, an inability to return towork may lower a patient’s perception of satisfac-tion.

The presence of chronic illnesses would beexpected to be associated with lower self-reportedhealth, and therefore with satisfaction. The asso-ciation with motor vehicle accidents may be due tothe patients’ perception of the severity of theinjury, as this predictor was independent of mea-sures of physical injury severity. Furthermore, invol-vement in motor vehicle accidents will more likelyresult in a third party insurance claim. One studysuggested that road accident injury compensationclaims are often prolonged, settlements are oftenmodest and late in relation to the losses sufferedand that there is often considerable dissatisfactionwith the procedures for obtaining compensation.5

However, the effect of involvement in a motorvehicle accident was independent of these otherfactors.

Interestingly, patient satisfaction was not relatedto any of the measures of injury severity such as theinjury severity score or admission to intensive care.This may be explained by the previously reported

Table 4 Associations between the SF-36 summaryscores and patient satisfaction

Group Mean PCS (95% CI) * Mean MCS (95% CI) *

Satisfied 44.8 (43.4—46.3) 47.6 (46.0—49.1)Dissatisfied 34.6 (32.7—36.4) 32.3 (29.9—34.7)* The p-value for each association was <0.0001.

association between satisfaction and patient expec-tation.15,21,35,36 In this regard, patients with moreserious injuries may not expect to have as muchimprovement in function and may be more likely tobe satisfied with poorer outcomes than if they wereless severely injured. Also, as shown in this studyand in previous studies,19,24 satisfaction is morehighly associated with mental health rather thanphysical health. A previous study of outcome follow-ing knee arthroplasty demonstrated that satisfac-tion was a great predictor of overall function butfound no association between satisfaction and themeasured range of motion of the knee, an objectivemeasure that is typically used following knee sur-gery.25 These findings suggest that patient satisfac-tion is closely related to psychological factors, andthat physical factors may be less important.

A limitation of this study is its retrospectivenature, and the lower than expected response rate.A strength of this study is the inclusion of a largenumber of possible predictors and confounders.

Future research should be directed at evaluatingthe relative importance of patient satisfaction,compared to other common outcomes such as gen-eral health. Comparison between patient satisfac-tion and other patient-based outcomes may beuseful, particularly outcomes related to mentalhealth such as depression, anxiety, sleep distur-bance, chronic pain, and substance abuse.

Future similar research may benefit from a pro-spective longitudinal design to demonstrate whetherthose patients whowere dissatisfied due to unsettledcompensation claims became more satisfied oncetheir claim was settled. Further exploration of fac-tors relating to the claims process, such aswhether ornot a claim is challenged, may also yield importantinformation.

Conclusions

In summary, our study found that having anunsettled compensation claim was strongly asso-ciated with patient dissatisfaction after majortrauma, and that measures of injury severity did

1108 I. Harris et al.

not predict patient satisfaction. The relative impor-tance of patient satisfaction as an outcome toolrequires further research.

Conflict of interest statement

The authors of this study have not nor will notreceive any financial benefits from any parties nordo they have any conflicts of interest in relation tothe conducting of this study.

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