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Chiropractic Journal of Australia : CJA June 2013
Chiropractic Journal of Australia Volume 43 Number 2 June 2013 67 PATIENT SATISFACTION: SUGGESTED MODIFI- CATION TO CURRENT CRITERIA FOR EBP The validity of various patient satisfaction questionnaires has been established. "This study shows that the applied patient satisfaction questionnaire has high validity and reliability. It also has high sen sitivity fo r lo ngitudinal measurements, as well as good discriminatory power in measuring the different levels of patient satisfaction." 5 Patient input is evolving in importance. Eriksen et al provide an example of its use by explaining that: "Satisfaction was measured at the end of the treatment period by a question that asked, ‘How satisfed are you with the treatment by your chiropractor?' An 11-point NRS (ranging from 0 = very dissatisfed to 10 = very satisfed) was privately scored by each patient. All of these forms were to be given to the patients by either the PM (practice manager) or they were flled out without the doctor present to help prevent any bias." 4 As an indication of the growing awareness of this emerging feld, there are over 4,000 title listings on PubMed in using the search term 'Patient Satisfaction' in the title. The term does not appear before 1965. In addition, the term 'self assessment' appears 2,428 times. In 2000, an authorative EBP text by Yeoman prepared the chiropractic profession for the emergence of patient-centred assessments and satisfaction determinants by including them in a signifcant section on those topics.44 Since at least 1993, outcome measures displaced the compliance with standards model of clinical standards (peer review - practices). A Canadian chiropractic document raised the topic of the patients' own input as to their personal sense of well being following treatment under ‘Patient Perception Outcomes'. This document is available online - www.chiro. org/LINKS/FULL/CANADA/index.html. This author (PLR) was unable to access the updated version however.55 This document questions why such patient input has not attracted greater consideration in the past and suggests that this is due to it being seen as too subjective. They note however that the attitude in favour of such input is now viewed much more favourably. It recognises that patient perceptions and satisfaction can play a positive role in a variety of ways and is supportive of its implementation.55 Given the plethora of opinions, evidence assessment systems, and the question as to the applicability of a primary evidence-base system of best practices in a clinical setting, a new system is proposed. This system emphasises, and is based on self-assessing patient-outcomes, and is essentially monitoring patient satisfaction. It does not however obviate the need for other forms of evidence in practice. As an example, in relation to effcacy of drugs, patients were given a tacit ‘vote’ when Scudder implied "...it may be a major factor with agents (i.e. drugs – au) for which patients report of effcacy, such as less anxiety or pain, is the determinant of effectiveness." 56 It is not a matter of replacing the evidence based clinical practices, but strengthening the emphasis on the objective and subjective monitoring of a patient’s outcome to at least 30% of optimal outcome measures -- rather than the other way around. There will of course unfortunately, always be extreme cases, and cases that do not ft the so-called ‘norm.’ However, if a practitioner can demonstrate that there is reasonable evidence, effcacy as well as safety, and as long as the informed patient’s progress is recorded as assessed by the patient and the practitioner, these should be reasonable indications in conjunction with other outcome measures. A greater emphasis must also be placed on empirical evidence as it has with other professions. It is appropriate to visit the hierarchical pyramid of evidence of which there are many, but all stand on a broad base of fundamental evidence. One even states “Personal information.” 36 It has been declared that “anecdotal evidence is the basis of all knowledge,” 57 and that “anecdotal evidence is a special kind of empirical evidence." 5 8 Indeed, in an insightful paper, Stevenson goes further by stating “Doctors effectively and necessarily use anecdotal evidence every day. These bastions of evidence-based medicine actually base most of their practices on anecdotes…”and further that “Ultimately, the only evidence that truly matters is anecdotal: what a treatment does to the individual." 57 It is imperative that the emphasis of patient centred care should be just that. Thus, the focus must be more on the patient’s own assessed outcomes in the clinical setting, rather than on severe, and not always appropriate 'academic' studies. After all, what is the point in an academically assessed outcome if the patient does not think they have improved, especially when it is the patient that (normally) initiates their presentation for care at a clinic, based on how they see their response. As there needs to be a baseline to be able to measure patient progress in these proposals where patients are undergoing a series of treatments, it would be necessary for the practitioner to track patient progress on a purpose-specifc Visual Analogue Scale (VAS - C) at each visit. The patient would also assess themselves on a VAS-PSAS (Patient Self-Assessed -- Satisfaction)) and both scores noted on the practitioner's records. As an example, the clinician may assess the patient as say 6/10, while the patients may assess themselves as 2/10. This has the potential to be an effcient form of clinical assessment monitoring of the patient’s progress. In cases where occasional care takes place, the same assessment should also be made. The patient's condition would also be refected by the frequency of recurrent visits. Patients are already involved, when they are sometimes offered a choice in, for instance surgical decisions - where a surgeon offers a range of options. If they are eligible to express an invited opinion of choice here, they would be just as qualifed to assess their own sense of well-being. This is nominated as patient preferences.59 As listed on the Cochrane Database, shared decision-making and decision aids for patients are also receiving attention as an emerging possibility for optimal patient care. While it appears early in development, this idea may gain traction as it already is an informal part of practice.60,61 PATIENT-ORIENTED EBP ROME
CJA March 2013
CJA September 2013