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Perceived needs, expectations and experiences of care influence patient satisfaction (Aasland et al, 1998).

Implications of patient satisfaction with care

Patients with chronic diseases, such as rheumatology patients, "are strongly motivated to assume that they are being treated in the best possible way" (Haslock, 1996: 383). In addition, as patients with chronic diseases generally need long-term care the quality of the care which they receive often becomes synonymous with their quality of life (Hill, 1997).

Structure, process and outcomes of care

The quality of health care is influenced by dimensions such as: the availability of care (access), empathy of health care providers, quality of information provided, continuity of care and the quality of medical treatment (Aasland et al, 1998). In an evaluation of specialists' outreach clinics in general practice (including rheumatology), the aspects relating to the process of care which were examined included: waiting lists; waiting times in clinics; number of follow-up visits; investigations and procedures performed; treatment; health status; patients' travelling times and attitudes to, and satisfaction with, the clinic (Bowling et al, 1996). Similarly, the Medical Outcomes Study Patient Satisfaction Questionnaire explored six areas of satisfaction: general satisfaction, technical competence (diagnosis and management), interpersonal satisfaction, communication satisfaction, time spent with the doctor and access to care (Sutcliffe et al, 1999).

A study of outpatient satisfaction in a general hospital found that the majority of patients had received sufficient notice of the date and time of their appointments (Peck, 1993). However, another study showed that patients attending a rheumatology outpatient clinic expressed the greatest dissatisfaction with the time spent in the waiting area prior to consultations (Hill et al, 1992). Indeed, in the study of outpatient satisfaction in a general hospital, most of the patients said the receptionist had not indicated how long they might have to wait to be seen (Peck, 1993).

Bowling et al (1996) found that patients were more satisfied with care in specialists' outreach clinics compared with outpatients' clinics. Specifically, it was found that the processes of care - waiting times, patient satisfaction, convenience to patients and follow-up attendances - were better in outreach than in outpatients' clinics. The outreach patients were more satisfied than the outpatients with the length of time waited for appointments with specialists; the convenience of the day and time of the appointments and the waiting times at the clinics. In particular, outpatients were more likely to wait at the clinics for an hour or more after their specified appointment times, compared with outreach patients. (Bowling et al, 1996).

Travel to clinics

Both specialists and GPs saw the main advantage of outreach clinics in terms of their greater convenience and better access to care for patients. Indeed, when specialists' outreach clinics were compared with outpatients' clinics it was found that the outreach patients had shorter journey times than outpatients. In addition, the outreach patients were more likely to rate the length of their journeys as 'very convenient' which, in turn, reduced their travelling costs, as well as childcare expenses and time off work (Bowling et al, 1996).

Clinic facilities

In a study comparing specialists' outreach clinics with outpatients' clinics, the outreach patients were more satisfied than the outpatients with the convenience of the clinic locations and the waiting areas and facilities (Bowling et al, 1996). In a study of outpatient satisfaction in a general hospital, most of the respondents knew that there was a café near the waiting area and there were public telephones in the Department. However, whilst the majority of them said the waiting area was pleasant, over a fifth of them said there were not enough seats available. In addition, most of the patients who used the toilets provided said they were clean and easy to find (Peck, 1993).

Continuity of care

In a study of health care provision, both patients with juvenile rheumatic disease and their parents expressed satisfaction with the continuity of care (Aasland et al, 1998). On the other hand, in a study of a rheumatology outpatient clinic, least satisfaction was expressed with the continuity of care and access. Specifically, less than half of the patients saw the same person at each visit to the clinic (Hill et al, 1992).

Communication with patients and information-giving

The communication aspects of consultations are important to rheumatology patients. Indeed, in a Dutch study of rheumatic patients' perceptions of the quality of health care, the respondents attached the highest importance to the indicator 'to be taken seriously by health professionals and institutions' (Van Campen et al, 1998). However, Hall et al (1998) found that patients in better health received more social conversation from their doctors, which influenced their ratings of the doctors' psychosocial responsiveness and, in turn, affected their satisfaction with medical care. Indeed, the significance of social conversation may be that it is important for the "patient's sense of acknowledgement as a valuable human being rather than simply an anonymous 'case' or a set of symptoms" (Hall et al, 1998: 73).

Whilst the majority of respondents in a study of outpatient satisfaction in a general hospital said the doctors either introduced themselves or wore name badges, only half of the patients said the doctors introduced other people who were present during the consultation. However, the majority of respondents in the same study said there were few interruptions by others entering during consultations (Peck, 1993).

In a comparison of specialists' outreach clinics with outpatients' clinics, it was found that the outreach patients were more satisfied than the outpatients with the amount of time spent with the specialists and the attention given to what the patient had to say (Bowling et al, 1996). In addition, Hill et al (1992) carried out a study of patient satisfaction with care in a rheumatology clinic and found that most of the patients were satisfied with the length of the consultations and felt they had been listened to. However, Hill et al (1992) also found that over 40% of the patients in the same study did not feel they had been encouraged to ask question, although when they did ask questions most of them were given answers which they understood. In addition, whilst the majority of respondents felt their feelings about their treatment had been taken into consideration, only a third of the patients agreed that they had been consulted regarding their preferences for treatment (Hill et al, 1992).

Research into patient satisfaction with in-patient hospital care has tended to highlight a lack of information provision generally (Hill, 1997). A follow-up study of a cohort of patients with juvenile rheumatoid disease and parents found that they were least satisfied with the information which they had received (Aasland et al, 1998). However, the majority of respondents in a study of outpatient satisfaction in a general hospital said the doctors explained planned tests or investigations to their satisfaction and most of them understood all that the doctors told them (Peck, 1993).

As regards information provision relating to medication, a Dutch study of rheumatic patients' perceptions of the quality of health care found that the second-most important indicator highlighted by patients was 'tell me what to do if I use other medicines besides the prescribed ones' (Van Campen et al, 1998). Indeed, the study by Hill et al (1992) showed that over half of the patients were satisfied that the side-effects of tablets had been discussed with them.

The majority of respondents in a study of outpatient satisfaction in a rheumatology clinic felt that the member of staff whom they saw in the clinic knew what it was like to have arthritis. Similarly, most of the patients were satisfied that they were treated as people rather than as a disease. However, only a third of the patients felt that any interest had been shown in the way that arthritis affects family relationships (Hill et al, 1992).

Technical quality of care

Hill et al (1992) carried out a study of patient satisfaction with care in a rheumatology clinic and most satisfaction was expressed with the technical quality of care. Similarly, in a study of health care services provided to patients with juvenile rheumatic disease, the respondents expressed most satisfaction with the quality of the medical treatment provided (Aasland et al, 1998). However, it is doubtful whether patients are, in fact, able to discriminate between doctors on the basis of their technical ability (Haslock, 1996).

The contributions made by other team members is an area which has been relatively unevaluated, even though interactions within the team and between the team members and the patient are important aspects of patient satisfaction and the overall quality of care (Haslock, 1996).

Psychological care

Addressing patients' psychosocial needs is likely to improve the quality of care (Da Costa et al, 1999).

The study by Hill et al (1994) examined patients' levels of pain, anxiety and depression and it was found that the rheumatology nurse practitioner was more successful, to some extent, at improving the patients' psychological status, teaching them about disease and managing their symptoms.

In a follow-up study of paediatric patients with rheumatoid disease and their parents it was found that chronic family difficulties were significant predictors of satisfaction with care among the children (under 18 years of age) and their parents, indicating that the families had unmet needs for support (Aasland et al, 1998).

Influence of physical and mental health status

Attendance at an outpatient department in the previous year was related to poor mental health status among older people in a study by Lyons et al (1994). In addition, previous research has shown that patients in poor health - either emotionally or physically - are less satisfied with their medical care (Hall et al, 1998). Consequently, Da Costa et al (1999) emphasised the importance of distinguishing between mental and physical health when interpreting satisfaction with health care.

Indeed, a study of the associates of health status in patients with S.L.E. found that satisfaction with care was related to better general health (Sutcliffe et al, 1999). Similarly, in a follow-up study of paediatric patients with rheumatoid disease and their parents, it was found that the degree of the child's physical disability was a significant determinant of satisfaction with care among the parents, but not the children themselves (Aasland et al, 1998). Whilst mental health status did not influence satisfaction with care among the same patients, nevertheless, the level of chronic family difficulties affected their psychosocial outcomes (Aasland et al, 1998). In addition, a study among patients with S.L.E. found that both self-reported physical and mental health status were significant predictors of satisfaction with health care (Da Costa et al, 1999). Consequently, satisfaction with health care is not simply a reflection of the health care received but is also a reflection of psychological factors such as psychological distress, depression and poor social support (Da Costa et al, 1999).