Lung cancer

Study objectives: To compare the quality of non-small cell lung cancer (NSCLC) surgical care with patient satisfaction.

Design: Prospective study.

Setting: Academic hospital departments of thoracic oncology and surgery.

Patients and methods: Patients presenting with recently diagnosed NSCLC and eligible for front-line thoracic surgery were eligible. Patient satisfaction was assessed using the Questionnaire of Satisfaction of Hospitalized Patients. Quality of surgical care was evaluated using an original score built accordingly to British Thoracic Society guidelines. Univariate analysis used parametric (Pearson correlation, t test) and nonparametric tests (Mann-Whitney U test) according to test conditions. Probability of survival was estimated using the Kaplan-Meier method.

Results: Seventy patients (mean age, 63.7 years) were included. Lobectomy was performed in 62 cases, and pneumonectomy was performed in 8 cases. In all, 28 patients had a postoperative complication. One-year survival rates for patients with stage I-II and stage IIIA NSCLC were 84% and 58%, respectively. Mean patient satisfaction was 78 [+ or -] 13/100 and 69 [+ or -] 13/100 for global staff and structure index, respectively ([+ or -] SD). Mean score for quality of surgical care was 88.7/100 (range, 51 to 100). The absence of postoperative complication was significantly related to a high level of satisfaction regarding the structure (r = 0.30, p < 0.05). Other features of patient satisfaction did not show a significant correlation with the quality of the preoperative selection process or the surgical procedure itself (r < 0.20).

Conclusions: Considering the lack of significant correlation, the present study does not support a shortcut between quality of care and patient satisfaction. Nonetheless, patient satisfaction should be integrated into rather than substituted for the quality of health-care assessment, which also needs further development.

Key words: non-small cell lung cancer; patient satisfaction; postoperative complication; quality of care; thoracic surgery

Abbreviations: NSCLC = non-small cell lung cancer; QSH = Questionnaire of Satisfaction of Hospitalized Patients

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Continuous improvement in the quality of health care is a daily objective for health-care professionals and state agencies. Of course, continuous improvement in the quality of health care is also mainly expected by patients. One simple definition of good quality health care might be the achievement of "desired health outcomes" that are "consistent with current professional knowledge." However, quality of care is mostly associated by health-care professionals in keeping with the "state of the art," while patients highlighted their request for care that meets or exceeds their own expectations. (1,2)

The quality-of-care assessment is a challenge by itself. Indeed, health-care professionals miss rigorous criteria to define a medical procedure responding to the best quality of care that can be achieved. At the least, care of the best quality could be represented by procedure standardized under the authority of scientific medical societies or by procedures responding to published guidelines. (3)

Assessment of patient satisfaction, however, has been extensively studied in the past decades, as attested by the number of publications related to this topic (3,038 publications cited in PubMed from 1973 to 2004; 85% published since 1993). Consequently, validated instruments to measure patient satisfaction have been developed in the English (1,2) and French (4-6) languages.

Actually, patient satisfaction has been proposed as reflecting the quality of health care and is considered as a possible measure of the quality of care. Indeed, the widespread use of the satisfaction questionnaire and the trend to consider the goal of health care to respond directly to patient satisfaction are due to several reasons as the limitation of traditional indicators for health outcomes, the relative ease in using satisfaction indexes, the evolution of the relationship between patients and physicians, and the "democratization of health services." (7) Thus, a shortcoming has insidiously been introduced to assimilate the quality of care with patient satisfaction. Therefore, the present study was conducted to evaluate the reality of the relationship between quality of care and patient satisfaction in a sample of patients undergoing front-line thoracic surgery for non-small cell lung cancer (NSCLC).

MATERIALS AND METHODS

Patients,

This prospective study was conducted at a university hospital over a period of 24 months starting in May 2002. Patients > 18 years old and undergoing standard thoracic surgery as the sole treatment for a primary NSCLC were eligible to participate in the study. The study protocol was approved by institutional ethics review. All patients provided written informed consent.

Patient Satisfaction

Patient satisfaction was measured using the validated Questionnaire of Satisfaction of Hospitalized Patients (QSH) [Appendix]. (4) Patients were asked to complete the questionnaire on the last day of hospitalization. The QSH is a self-administered instrument that measures patient satisfaction with treatment in the medical or surgical wards. The QSH is an eight-level scale including 37 items: medical staff (7 items), nursing staff (7 items), other staff (5 items), staff identification (3 items), admittance (items), room arrangement (4 items), food (3 items), and waiting time (2 items). Furthermore, two composite scores are also calculated: the staff index, including medical staff; nursing staff, other staff, staff identification, and admittance dimensions; and the structure index, comprising room arrangement, food, and waiting time dimensions. Scores were calculated for the eight dimensions and the two composite scores based on the mean of the corresponding items. All dimensions scores were then standardized from 0 (poor) to 100 (excellent).

Quality of Care

Because there is no established definition of a "standard" quality of care in most fields covered by thoracic surgery, we distinguished the following: (1) the preoperative selection process, (2) the surgical procedure by itself and (3) the occurrence of postoperative complication. Concerning the preoperative selection process, the evaluation of the selection of candidates for surgery was based on the adherence to published guidelines. (8) Eighteen items were considered and represented a first score. The evaluation of the surgical procedure was done on the basis of the following principles. Firstly, anatomic resection (lobectomy or a pneumonectomy) was defined as the standard resection in fit patients, thus excluding atypical resection. (9) Secondly, routine reinforcement of the mainstem bronchus suture in case of right pnenmonectomy to minimize the particularly high risk of postoperative bronchial fistula on that side was considered as the willingness to prevent deleterious postoperative complications. (10) Thirdly, a routine mediastinal lymphadenectomy was considered an essential component of NSCLC thoracic surgery. (11,12) A second score considered all these items. Furthermore, the operative report had to include the description of the tumor and its connections with the surrounding anatomic structures, the justification by the surgeon for the choice of the resection finally done, the completeness of the resection, and the listing of lymph node stations dissected according to the American Joint Cominittee on Cancer classification. (13) Together with the evaluation of the surgical procedure, we looked on the pathology report, which had to include tumor location with respect to the fissure, the visceral pleura, the chest wall and hilar structures, and the presence of vascular invasion and/or satellite tumor nodule(s). The pathology report should also include a resection margins examination to detect a potentially microscopically incomplete resection. Finally, the pathology report should described the lymph node dissection product (location and ratio of involved/resected lymph nodes) classified as N0, N1, or N2. (13) A third score considered all these items. The occurrence of a postoperative complication was examined and subscored. Finally, the quality of the surgical care was expressed as a combination of each of these four abovementioned scores. The mean of these subscores was computed and resealed from 0 (poor quality) to 100 (excellent quality).

Postoperative Pain

All the patients were proposed postoperative IV fentanyl patient-controlled analgesia. Assessment of postoperative pain was done as in daily practice using a visual analog scale.

Statistical Analysis

After calculating quality-of care and patient satisfaction scores, an univariate analysis was performed using parametric (Pearson correlation, t test) and nonparametric tests (Mann-Whitney U test) according to the test conditions. Survival data were updated on November 2004. Two patients were unavailable for follow-up. The overall survival time was defined as the time from the date of surgery to date of death due to any cause. Patients who were alive at the date of last follow-up were censored on that date. Probability of survival was estimated using the Kaplan-Meier method. Statistical significance was defined at p < 0.05. Statistical analysis was performed using statistical software (SPSS version 10.1; SPSS; Chicago, IL).

RESULTS

Patients

A total of 70 inpatients participated in this prospective study. Major sociodemographic characteristics are summarized in Table 1. Mean age of patients was 63.7 years (range, 31 to 80 years). Twenty-one patients (30%) were active smokers (median, 39 pack-years; range, 5 to 120 pack-years). Forty-nine patients (74%) were married or coupled. Twenty patients (31%) had completed high school or higher. Overall, 52 patients (78%) were not working: 44 patients (66%) were retired, and 8 patients (12%) were unemployed. The median length of stay was 13 days.

Surgical Resection and Postoperative Complications

The surgical resection was lobectomy for 62 patients (89%) and pneumonectomy for 8 patients (11%). No patients died as a consequence of surgery. Overall, 28 patients (40%) had a postoperative complication. Four patients presented with a major complication: two required reoperation (hemothorax and bronchial fistula, respectively), and two other were medically treated (pneumonia requiring invasive ventilation). Twenty-four patients presented with minor complications: bronchial obstruction treated with physiotherapy (n = 10), arrhythmia (n = 7), recurrent nerve palsy (n = 6), and renal insufficiency (n = 1).

Patient Satisfaction

The results for patient satisfaction are given in Tables 2, 3. Gender, age, or marital status did not significantly influence patient satisfaction. However, lowest educational level significantly related with a better patient satisfaction regarding nurses (mean satisfaction score of 83 for patients with a low educational level vs 72 for patients with a higher educational level, p = 0.05 using Mann-Whitney U test) and other staff (mean satisfaction score of 81.4 for patients with low educational level vs 72 for patients with higher educational level, p = 0.05 using Mann-Whitney U test). Educational level also influenced patient satisfaction regarding medical staff (mean satisfaction score of 83 for patients with low educational level vs 76 for patients with higher educational level, p = 0.09 using Mann-Whitney U test) without reaching significance.

Quality of Care

The results for the quality-of-care evaluation are presented in Table 4. A significant correlation between the quality of the preoperative selection process and the quality of the surgical procedure was found (r = 0.475, p < 0.0001). The global score for the quality of care was correlated with the quality of the preoperative selection process (r = 0.76, p < 0.0001), the quality of the surgical procedure (r = 0.85, p < 0.0001) and the quality of the postoperative course (r = -0.33, p = 0.004).

Relationship Between Quality of Care and Patient Satisfaction

On univariate analysis, a significant positive correlation was found between the quality-of-care score for the postoperative period and the global structure index (r = 0.30, p < 0.05), meaning that patients are more satisfied regarding the structure when no postoperative complication occurs. No one other feature of patient satisfaction showed a significant correlation with the quality of the preoperative selection process or the surgical procedure by itself (r < 0.20).

Postoperative Pain

All the patients included in the study reported good control of postoperative pain with reported visual analog scale [less than or equal to] 3 after treatment was balanced.

Survival

At the time of analysis, there were 14 deaths. Median follow-up was 20.1 months. Median survival for patients with stage I-II and IIIA NSCLC were 28.9 months (95% confidence interval, 25.9 to 32.08 months) and 12.5 months (95% confidence interval, 5.06 to 16.2 months), respectively. One-year survival rates for patients with stage I-II and stage IlIA NSCLC were 84% and 58%, respectively.

DISCUSSION

Health-care state agencies and professionals wish to improve the quality of health care. However, assessing quality of care integrates several dimensions, making global and indisputable evaluation really difficult to accomplish. Then, considering the legitimate place currently given to the patients' point of view, a shortcut has been insidiously introduced to assimilate quality of care and patient satisfaction. Conversely, the present study does not support such a link between quality of care and patient satisfaction. No one feature of patient satisfaction showed a significant correlation with the quality of the preoperative selection process or the surgical procedure by itself (r < 0.20). Only one aspect of patient satisfaction seems to be correlated with the quality of care, inasmuch as the absence of postoperative complication was significantly related to a high level of satisfaction regarding the structure (r = 0.30, p < 0.05).

NSCLC patients who participated in this prospective study were predominantly male, active or former smokers, had a good performance status, and underwent surgical resection, which was mainly a lobectomy. Thus, despite a slightly higher rate of adenocarcinoma, these patients showed similar profile as those usually described in the literature. (14) In addition, 1-year survival rates of 85% and 58% for stage I-II and stage IIIA patients, respectively, are in accordance with previously published results. (15) In summary, while a relatively small number of patients participated in this study, they should be regarded as representative of NSCLC patients who are treated with surgery.

Six multidimensional major instruments measuring inpatient satisfaction have been identified in the literature. Three of them were developed in English language, the "Patient Judgment of Hospital Quality," (16,17) the "Quality of Care Questionnaire," (18) and the "La Monica Oberst Patient Satisfaction Scale" (19); and three were designed in French language, including the QSH4 and two other inpatient questionnaires. (5,6) We preferred a French questionnaire for this study. In fact, the patient's expectation, perception, and priority broadly vary from one country to another in keeping with difference in cultural backgrounds and health-care systems. Due to the French health-care system specificity (free choice of physicians, health care insurance system), it seemed not easy to adapt a North American questionnaire. Furthermore, because patients are only able to supply relevant information about their satisfaction, its assessment should directly derive from patient's concern and perception. Inasmuch as expert opinions were included in item generation of all the questionnaires except for the QSH, we prefer this instrument.

Assessment of the quality of thoracic surgery should be regarded with caution. In fact, heterogeneity of NSCLC patients leads to the lack of an established definition for "good" or "best" thoracic surgery to be performed. Thus, thoracic societies worldwide developed guidelines summarizing standards (when available) but also options and recommendations. (8,20-23) Therefore, these guidelines might be regarded as reflecting thoracic surgery of good quality. We chose British Thoracic Society guidelines for two reasons. Firstly, they were the most recently published guidelines at the time when the study was designed. Secondly, they concomitantly reported guidelines for the preoperative selection process as well as elements for the surgical procedure by itself. One should note that guidelines subsequently published did not report major difference with those of the British Thoracic Society. (24-26) Thus, while debatable, assessment of the quality of surgery through the concordance between surgical procedure and recognized guidelines might be valuable.

However, regarding the results reported herein, the substitution of the quality-of-care assessment by patient satisfaction would be baseless. Patient satisfaction is a reflection of a customer's evaluation of the quality of care they receive comparing to a subjective standard reflecting overall their expectations. In fact, patient satisfaction is affected by several factors. Firstly, poorer physical health status and disease severity are frequently associated with a lesser degree of satisfaction. (3,27,28) Understandably, satisfaction was badly influenced for those of our patients who had postoperative complications (r = 0.30, p < 0.05). Nonetheless, postoperative complication was unlikely to be systematically related to a lower quality of care. (29) Secondly, patient satisfaction is more likely influenced by present health status rather than by potential long-term health improvement. (30,31) However, thoracic surgery for lung cancer is aimed at reaching long-term survival in spite of short-term, sometimes severe, side effects. Thirdly, patient satisfaction is strongly affected by patient/practitioner relationship (32), which, however represents only a part of health care. In summary, patient satisfaction should be regarded more as a supplement rather than a substitute to the assessment of quality of care.

Despite restriction concerning its correlation with the quality of care, the study of patient satisfaction remains important, firstly, for health purpose, inasmuch as patient satisfaction positively influences treatment adherence, (33) and secondly, for the treatment evaluation, as the patient's perspective about the experience of care or outcomes can markedly vary from those of health-care professionals and might represent a tool to contribute to improvement in quality of care. (34,35) In this way, a repeated measure of patient satisfaction over the treatment should be evaluated. In conclusion, patient satisfaction should be integrated into rather than substituted for the quality of health-care assessment, which also needs further development.

APPENDIX

The QSH

Answer each question on a scale of 1 to 5: 1 = better than expected; 2 = as expected; 3 = little bit worse than expected; 4 = worse than expected; 5 = greatly worse than expected. When arriving at the hospital, administrative staff:

1. Quickly registered me

2. Was helpful and kind

When arriving at the hospital:

3. I felt a good coordination between administrative wards

When arriving at the department, staff:

4. Quickly took me in

5. Heartily welcomed me

When arriving at the hospital, I:

6. Believed that the staff knew I was arriving

During my hospital stay, medical staff:

7. Identified themselves (name, function)

8. Communicated with me in a comprehensive manner

9. Gave me attention and considered my needs

10. Won my trust and reassured me

11. Regularly came to see me

12. Came each time I needed them

13. Gave me full attention

14. Answered all of my questions

During my hospital stay, nurses:

15. Identified themselves (name, function)

16. Communicated with me in a comprehensive manner

17. Gave me attention and considered my needs

18. Won my trust and reassured me

19. Gave me a full attention

20. Shared information about myself with other nurses of the team

21. Helped me with daily activities

22. Respected my privacy

During my hospital stay, other staff:

23. Identified themselves (name, function)

24. Gave me attention and considered my needs

25. Quickly came in my room when needed

26. Kindly welcomed me

27. Helped me with daily activities

28. Conscientiously did their work

During my hospital stay, waiting time was appropriate:

29. Before going or coming back from clinics, operative room

30. When being received in clinics, operative room

During my hospital stay, my room:

31. Was appropriately cleaned

32. Was well equipped

During my hospital stay, my restrooms:

33. Were appropriately cleaned

34. Were in or close to my room

During my hospital stay, the food:

35. Was of good quality

36. Was in good quantity

37. Was appropriate for me (religion, treatments, comorbidity)

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* From the Faculty of Medicine, Universite de la Metiterranee, Assistance Publique Hopitaux de Marseille, Departments of Thoracic Oncology (Dr. Barlesi) and Thoracic Surgery (Drs. Doddoli, Thomas), Hopital Sainte-Marguerite, Marseille; and Faculty of Medicine, Universite de la Mediterranee, Laboratoire de Sante Publique (Drs. Barlesi, Boyer, Antoniotti, and Auquier), Evaluation Hospitaliere EA3279, Marseille, France.

Manuscript received February 2, 2005; revision accepted May 28, 2005.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/mise/reprints.shtml).

Correspondence to: Fabrice Barlesi, MD, Service d'Oncologie Thoracique, Fedeation des Maladies Respiratoires, Hopital Sainte-Marguerite, 270, Bd de Sainte-Marguerite, 13274 Marseille Cedex 09, France; e-mail: fabrice.barlesi@mail.ap-hm.fr

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