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© 1999 American Society for Clinical Oncology Development and Testing of a Visit-Specific Patient Satisfaction Questionnaire: The Princess Margaret Hospital Satisfaction With Doctor Questionnaire From the Departments of Radiation Oncology and Psychosocial Oncology, Princess Margaret Hospital/Ontario Cancer Institute, University of Toronto, Toronto, Ontario, Canada. Address reprint requests to Andrea Bezjak, MD, Department of Radiation Oncology, Princess Margaret Hospital, 5th Floor, 610 University Ave, Toronto, Ontario, Canada, M5G 2M9; email andrea_bezjak{at}pmh .toronto.on.ca
PURPOSE: To develop a psychometrically sound patient-satisfaction-with-physician questionnaire that can be used in an outpatient oncology setting. PATIENTS AND METHODS: The questionnaire was developed by a four-step process involving a total of 277 cancer patients. The item-generation process utilized input from 95 oncology outpatients, three medical researchers, and the relevant literature. Items were tested by 70 of the above patients. Initial item reduction was achieved by input from another eight patients. Factor analysis and validity testing used data derived from a different group of 174 oncology outpatients. Convergent validity was tested by correlating the Princess Margaret Hospital Patient Satisfaction with Doctor Questionnaire (PMH/PSQ-MD) with Rubin et al's Physician subscale of the Patient's Viewpoint Questionnaire (PS-PVQ) and Smith et al's Patient-Doctor Interaction Scale (PDIS). Divergent validity was tested by comparing these questionnaires with Spitzer's quality of life (QOL) questionnaire. RESULTS: The final PMH/PSQ-MD is a 29-item self-administered questionnaire with four response categories and a "does not apply" category. Four domains were confirmed by factor analysis: (1) information exchange, (2) interpersonal skills, (3) empathy, and (4) quality of time. The questionnaire has an overall Cronbach's alpha of 0.97; the values for each domain are, respectively, 0.92, 0.90, 0.88, and 0.88. The PMH/PSQ-MD correlated well with both the PDIS and the PS-PVQ (P < .001 for both). Divergent validity was confirmed with Spitzer's QOL questionnaire. CONCLUSION: The PMH/PSQ-MD is an outpatient satisfaction questionnaire specific to the patient-physician interaction that has shown excellent internal consistency, is feasible, and has strong support for validity in this oncology population.
INCREASING EMPHASIS IS being placed on patient-centered outcomes as an important step toward improving the quality of clinical care. These outcomes include physical function, psychologic well being, quality of life (QOL), and patient satisfaction. Outcomes as assessed from the patient's perspective have been accepted as valid, important, and standard indicators of quality of care.1-5 This is reflected in a study conducted by Covinsky et al,6 who assessed physician attitudes toward patient satisfaction. Eighty-six percent of the 343 internists who participated in the study agreed that patients' judgments are important in assessing quality of care. There was widespread agreement among these physicians as to four potential uses of patient judgments of the physician-patient encounter: changing specific physician behaviors (94%), receiving feedback from patients (90%), incorporating into physician education programs (81%), and educating students and housestaff (72%). This increase in the use of patient satisfaction questionnaires is likely multifactorial and is due in part to the growing industry of managed care and its resultant competitiveness in the health services market, a heightened sense of consumerism among people requiring health care, and the empowerment of patients (or "clients") fueled by the principles of informed consent. As a result, many aspects of the medical experience from the patient's perspective have been investigated, including the quality of care provided by a specific service,7 the cost and convenience of various health insurance plans,8 general attitudes toward primary care physicians,9-11 and attitudes about a particular physician-patient visit.8,12-21 Because the relationship between the patient and the physician provides the context in which caring and healing occur,22 patient satisfaction with the medical consultation is a critical core dimension of quality of care. Patient satisfaction with the doctor-patient visit has been shown to be an important outcome in health care for a number of reasons. First, it can be used to identify patients with different levels of satisfaction. This has obvious value to third-party payers and health care administrators. Second, it can predict patient outcomes: high satisfaction with the doctor-patient interaction is associated with increased compliance, better communication, and better continuity of care.10,15,23-26 As well, satisfaction with the medical consultation has been shown to influence promptness in seeking help and increase the patient's understanding and retention of information.27 Third, patient satisfaction measures can identify potential areas for improving the process of the patient-physician relationship.1,5 Fourth, such an instrument can potentially be used to evaluate change in levels of quality of care from the patient's perspective after a defined intervention. This is of particular importance to researchers and administrators. Like QOL measures, there is consensus that measures of patient satisfaction should consist of multiple items,28 be a direct measure elicited from patients, and be multidimensional.29 Unlike QOL measures, however, where there are both generic and disease-specific types of questionnaires, the measurement of patient satisfaction thus far tended to be generic rather than disease-specific. There have been a few efforts directed at developing satisfaction measures specific to general practice,10,13,16,30,31 diabetes,32 and psychiatry.27,33 Since patients with cancer identify different needs and expectations compared with patients with other diseases,12 it may be more appropriate when measuring patient-centered outcomes in cancer patients to do so with disease-specific instruments. It cannot be assumed that a patient satisfaction measure, whether generic or specific to a disease other than cancer, is appropriate without psychometric testing of that measurement with a cancer population. We required a patient satisfaction questionnaire that would be able to discriminate between two groups of cancer patients who receive an intervention within the context of a randomized control trial based at several Canadian cancer centers. The goal of that trial was to evaluate whether the physician's use of QOL information increases the quality of care provided by the oncologist. In order to use patient satisfaction as an outcome measure, we required an instrument that met the criteria of being reliable, valid, specific to, or have as a component, physician-patient interaction, applicable to an outpatient setting, and tested with cancer patients. A systematic review of the literature on visit-specific, outpatient satisfaction questionnaire development was completed on MEDLINE from 1976 to 1996 using the medical subject headings "patient satisfaction" and "questionnaire." This search was augmented by a bibliographic review of select papers, consultation with experts, and correspondence with the authors for more information as required. Citations were manually searched by title and abstract to find those articles that fit the selection criteria. This strategy revealed nine instruments that were outpatient-focused and visit-specific.8,12-17,19,21 Only one of these articles reported research on outpatient satisfaction with an oncology population.12 However, the document did not report any reliability or validity testing. The primary goal of this project was to develop a visit-specific patient satisfaction questionnaire to be used in an oncology outpatient population that would be reliable, valid, feasible, and sensitive to detect a difference between the experimental and control groups in the trial described above. This article describes the development and testing of the Princess Margaret Hospital Patient Satisfaction with Doctor Questionnaire (PMH/PSQ-MD). The ability of the instrument to detect a clinically important difference will be tested in future work.
The following four steps were undertaken to develop the PMH/PSQ-MD: (1) item generation, (2) item reduction of repeat items, (3) item testing, and (4) factor analysis and reliability and validity testing. Support for the validity of the instrument was assessed by convergent, divergent, and construct validity testing. Convergent validity was tested by comparing the PMH/PSQ-MD with two valid and reliable patient satisfaction questionnaires; divergent validity was tested by comparing the PMH/PSQ-MD with a QOL instrument. Construct validity was tested by comparing domains generated a priori with those identified by principal component factor analysis. Reliability testing consisted of calculating the internal consistency of the instrument as a whole and within each domain. Oncologists were asked whether their patients could be approached to participate in this study. The patients of those who agreed were approached and given a written letter explaining the reason for the study, the time commitment required, and the fact that all information collected would be anonymous and kept confidential. All patients who participated agreed to do so verbally. Each step of the development and/or testing process is presented separately to preserve the temporal development of the instrument. All participants, unless otherwise stated, were outpatients at the Princess Margaret Hospital, Toronto, Ontario, Canada, who were either receiving radiation treatment or attending medical or radiation follow-up clinics.
Step I: Item Generation
Step II: Item Reduction of Repeat Items
Step III: Clarity, Importance, and Response Testing One group of patients (n = 49) was asked to rate how strongly they agreed or disagreed with each of the items (the "agree" version of the questionnaire). The items were followed by a four-point Likert scale (strongly agree, agree, disagree, and strongly disagree) as well as "does not apply" and "statement not clear" response boxes. Thirty-one patients (63%) returned the questionnaire completed (an additional four patients returned it blank; these were excluded from the analysis). A second group of patients (n = 47) was asked to rate how important the answers to these statements were in determining satisfaction with their visit with the doctor (the "importance" version of the questionnaire). They were given the same items as in the "agree" version of the questionnaire and asked to respond on a 10-point scale. The scale was anchored by "1 = extremely important" and "10 = not at all important"; interval anchors were not given. In addition, a "not clear" response category was included. Thirty-nine (83%) of these questionnaires were returned completed. Explicit instructions and illustrative examples were given on a separate cover page for both questionnaires. Data were entered into the SPSS statistical software program (SPSS, Inc, Chicago, IL) and independently verified. The items were judged on the following four criteria: (1) the percentage of respondents who found the item clear (clarity rate); (2) a three-point score on the response rate to the item (taking into account missing data and "does not apply" rates—referred to as the response score); (3) the median score of the importance questionnaire (importance score); and (4) the variance of the responses to the statements using the agree questionnaire data (variance). The median score was deemed more relevant than the mean score because it is less affected by extreme scores. The response score was generated by four study collaborators (three researchers and a statistician) using a modified nominal group method35 to reach consensus. The items were ranked using the four criteria described. The cutpoint criteria were set to (1) choose those items that had the greatest variance, were important in the determination of the patients' satisfaction, were clear, and were answered the most completely; (2) maintain an acceptable respondent burden of the final questionnaire; and (3) leave the questionnaire with enough items in each domain to give good internal consistency. The reduced number of items was then grouped into hypothetical domains and assigned names by the researchers. This was achieved using the modified nominal group method.
Step IV: Factor Analysis and Reliability and Validity Testing
The patient satisfaction questionnaires used for testing the convergent validity were, in part, chosen on the basis of a criteria-based systematic review of the visit-specific patient satisfaction literature.38 This review identified Smith et al's PDIS as the questionnaire with the highest reported reliability testing, strongest validity support, and an acceptable respondent burden. Rubin et al's PS-PVQ was not identified in the above review; however, the Physician subsection of this instrument was also included as a measure of convergent validity because it has strong validity testing, good reliability, and low respondent burden. Items of the preliminary PMH/PSQ-MD questionnaire with "not applicable" and missing data rates greater than 10% were eliminated before the analysis. The data were entered into the SPSS program and verified independently, negatively worded questions were rescaled, and statistical summaries were generated. A principal component, orthogonal, varimax-rotated factor analysis was performed to identify the domains of the questionnaire. Measures of internal consistency within the resulting domains were determined by calculating Cronbach's alpha.39
Pearson's correlation coefficients were calculated between the overall satisfaction scores of the PMH/PSQ-MD, Smith et al's PDIS, and Rubin et al's PS-PVQ; between Spitzer's QOL score and the three satisfaction scores; and between the PMH/PSQ-MD score and the demographic information. Missing data from each of the questionnaires was censored for the correlation calculations. A priori hypotheses for these correlations were as follows: (1) the PMH/PSQ-MD would correlate strongly (r
Step I: Item Generation Sixty-seven items were generated and grouped by the three researchers according to their context into 13 aspects of the visit with the physician. These aspects were entitled "understanding the patient's situation," "can talk about personal things," "consider needs," "interest in patient," "assessment (look into problems)," "treatment," "competence," "explain (give information)," "patient role in communication," "patient understanding," "time issue," "respectful/caring," and "social/family well-being." In addition, there were seven items that pertained to the patient's general satisfaction with the physician encounter.
Step II: Item Reduction of Repeat Items
Step III: Clarity, Importance, and Response Testing
Thirty-nine items satisfied the cutoff criteria: a clarity rate greater than 94%, median importance score of less than 4 (ie, very important), variance
The remaining 39 items were grouped by the researchers into five hypothetical domains. These domains were named "global satisfaction," "professional competence," "communication," "interpersonal skills/empathy," and "time." Only three items were contained in the global satisfaction domain, a number that was believed to be insufficient to reliably assess global satisfaction. Therefore, four more items that pertained to global satisfaction were added from the previous list. These items satisfied all the above criteria with the exception of clarity, for which the criterion had to be changed to
Step IV: Factor Analysis and Reliability and Validity Testing
Twelve items had combined "not applicable" and missing data rates greater than 10%. These were dropped from the principal components factor analysis. Thus, 29 items were entered into an orthogonal, varimax-rotated factor analysis. The correlation matrix was
These four factors were named on the basis of the items contained in them: information exchange, interpersonal skills, empathy, and quality of time. The number of items in each domain was, respectively, 10, eight, six, and five. Internal consistency was measured by calculating Cronbach's alpha. This was 0.97 for the total instrument, and 0.92, 0.90, 0.88, and 0.88, respectively, for each of the domains. Sixty-one percent of the variance was explained by the variance of the identified four factors. The PMH/PSQ-MD correlated well with both Smith et al's PDIS (r = .86) and Rubin et al's PS-PVQ (r = -.71, P < .001 for both). The PMH/PSQ-MD did not correlate significantly with Spitzer's QOL questionnaire (r = .005, P = .94), but neither did the PS-PVQ (r = .05, P = .56) or the PDIS (r = .01, P = .90). There was no significant correlation (by Pearson's correlation coefficient) between the PMH/PSQ-MD score and age, education, sex, or reason for visit. Table 3 summarizes the correlations.
Despite similarities between chronic illnesses, such as fatigue, the experience,12 treatment, and organization of care for cancer patients is substantially different, and it is likely that cancer patients may have different needs and expectations with regard to their medical care. Thus, when measuring satisfaction in an oncology outpatient population, it may be more appropriate to use a satisfaction instrument that has at the very least been tested, and preferably developed, in the oncology outpatient setting. There are many aspects of patient satisfaction that have been measured, including satisfaction with support staff, nursing care, hospital environment, parking, convenience of services,1,8,40 physician,12-16 the decision about treatment itself.41 Although all of the above aspects may have an impact on a patient's perceived quality of care, several authors have found that satisfaction with physician care is a major factor in determining consumer satisfaction.42,43 It is this aspect of the patient's quality of care that is addressed by the PMH/PSQ-MD. To our knowledge, there are no reported visit-specific, oncology outpatient satisfaction questionnaires with reported validity and reliability testing. Wiggers et al12 have published some work using an oncology outpatient population, but their report only documents the results regarding the stage of initial item generation. Davis et al40 published the results of a questionnaire that was applied in an outpatient oncology setting. Their questionnaire, however, contained questions that were not specific to the physician-patient interaction and has no measures of reliability reported. The PMH/PSQ-MD, on the other hand, was developed to be valid, reliable, and specific to patient-physician interaction. Our results show that the PMH/PSQ-MD has high internal consistency, shows excellent support for validity, has acceptable respondent burden, and has been developed and tested using 277 oncology outpatients. When compared with the visit-specific patient satisfaction questionnaires developed by Rubin et al36 and Smith et al,15 both of which are not cancer-specific, the PMH/PSQ-MD has shown excellent convergent validity. With regard to construct validity, we found that the domains generated a priori were similar to those determined by the factor analysis. This similarity reinforces the validity of the statistical process. Construct validity is further supported by the fact that domains similar to these have also been cited in the literature in which instruments were developed using various methodologies and varied patient populations. These domains include interpersonal skills,18,20,27,30 time spent with physician,11,44-46 information,44 and physician relationship.44 This consistency reinforces the robustness of these domains. Another way to test the construct validity is to compare groups with known differences in satisfaction. If the PMH/PSQ-MD were administered to patients who write letters of complaint and their results were compared with the results of those who write letters of praise, the instrument should be able to show a difference in their satisfaction scores. Unfortunately, this was not feasible during this set of studies because of confidentiality limitations. This could, however, be addressed in future work. In all, there is good support for the construct validity of this instrument. The content validity of our measure is supported by the fact that: (1) the items were generated by three health care professionals and augmented with input from 95 oncology outpatients as well as with questions from the published patient satisfaction literature; (2) the questionnaire was developed using a population of patients with wide range of age, educational level, tumor type, and modality of treatment; and (3) the scoring of the items is summative and the factors with the highest eigenvalues (correlates most strongly with the overall score) also have the most number of items, meaning that they will contribute more to the final score. This questionnaire was developed at a comprehensive cancer center in Canada. One may ask whether the questionnaire is generalizable to community oncology clinics or clinics in other countries. We hypothesize that the domains in the questionnaire (mainly focused on the aspects of the relationship between patient and physician, rather than on technical expertise) would likely be as or more important to patients attending a community oncology clinic than those attending an academic cancer center. We believe that the questionnaire could reasonably be applied in the community setting but that further research would need to be done to address the question formally. Cross-cultural differences are known to influence the validity of a questionnaire, and these differences are compounded if the questionnaire needs to be translated into a different language.47 Some different cultures have been shown to have different expectations about the care they receive. Patient satisfaction, which reflects the degree to which patients' expectations of care have been met, may be based on different attributes of care in different cultures.48 Although this questionnaire was developed in an area of Canada rich in cultural diversity, formal validity testing would have to be undertaken to confirm the validity of this questionnaire in another culture. In all, the content validity has strong support for its application in an oncology center and could reasonably be applied in a community setting. Additional validity testing should be undertaken if the questionnaire is to be applied to a different culture, especially if it is translated into a different language. The questionnaire's respondent burden was minimal. The initial questionnaire (which had 69 items) only took between 10 and 15 minutes to complete. The final questionnaire takes less than 10 minutes to complete. Each question was clear to more than 90% of respondents. There were no significant correlations with any of the demographic variables tested. This supports the applicability of this questionnaire to oncology patients from any background, with any tumor type, receiving chemotherapy, radiotherapy, or both. The internal consistency of the PMH-PSQ-MD was supported by high Cronbach's alpha values for the total scale and the subscales. In fact, the overall score is superior to any visit-specific patient satisfaction questionnaire that we found in the literature.38 It has not, however, been assessed with regard to test-retest or alternative-forms reliability; this will form the basis for future work. The goal of this endeavor was to develop an instrument that was reproducible, feasible, valid, and sensitive to the intervention within the setting of a randomized clinical trial. To date, the data support its reliability and feasibility as well as its face, convergent, and construct validity. Its reliability would be further supported if alternative forms or test-retest correlations are favorable. To our knowledge, its reliability is superior to any other published patient satisfaction questionnaire that is visit-specific and outpatient-based. Therefore, pilot testing of the questionnaire in other populations of chronically ill patients may be fruitful. Some authors have suggested that instruments with an overall Cronbach's alpha greater than 90% are sensitive enough to measure the attribute of interest on an individual level, ie, group comparisons would not be needed. This broadens the potential applications of our questionnaire because it could potentially identify individuals with low satisfaction rather than groups of individuals. Specific interventions could potentially be designed to evaluate this dissatisfaction and intervene if possible to improve the process of care. To that end, this questionnaire may also prove to be useful as an evaluative index49 (ie, one that can measure change of an attribute over time). Future research is needed to establish the PMH/PSQ-MD's ability to measure change over time (responsiveness). In conclusion, patient satisfaction is an important patient-centered outcome to measure, is accepted as a standard measure of quality of care, and is steadily gaining in popularity. Cancer patients have circumstances and stresses that are different than those of noncancer patients. Thus, when measuring patient satisfaction, a questionnaire that has been developed, or at the very least tested, in an oncology population may increase the accuracy of the measurement. The PMH/PSQ-MD has been shown to be a reliable, feasible, visit-specific outpatient satisfaction questionnaire with excellent initial testing of validity. It has been developed in the context of an outpatient oncology population and would be appropriate for use as a discriminative instrument within that population. It represents the first reported patient satisfaction questionnaire to our knowledge that has been developed and/or tested in an oncology population. As such, it should be considered for use in the evaluation of patient satisfaction in the oncology population.
The following items of the preliminary PMH-PSQ-MD were not entered into the factor analysis or validity testing because the "not applicable" and missing data rate for these items was greater than 10%.
2. The doctor understood that pain is a problem for me. 3. I felt the doctor did not spend enough time assessing my pain. 4. Nothing was done about my emotional well-being (feeling anxious, worrying). 5. I felt able to tell this doctor about very personal things. 6. I felt free to talk to the doctor about my private thoughts. 7. Nothing was done about my physical well-being. 8. The doctor should have been more thorough today. 9. The doctor did not explain what could or could not be done about my pain. 10. The doctor did not seem to really consider my needs. 11. The doctor looked into all the problems I mentioned. 12. I would find it difficult to tell this doctor about some private things.
This article is dedicated to the memory of Dr Terry Bunston, who passed away unexpectedly September 3, 1998.
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Copyright © 1999 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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ABSTRACT
INTRODUCTION
.7) with the PDIS and the PS-PVQ; (2) the PMH/PSQ-MD, PDIS, and PS-PVQ would all have weak (r 
.3) positive correlations with Spitzer's QOL questionnaire; and (3) all of the demographic variables would not correlate significantly with the PMH/PSQ-MD. 
