Patient reported experience measures: a new scale that records another dimension of patient care quality important in clinical practice – Letter to the Editor

The perfect patient experience can be achieved by satisfying four fundamental human needs: Self-assurance, integrity, pride and enthusiasm [1]. Patient experience is defined as ‘view of patient’ on what happened in the process of receiving treatment, including the objective facts and their subjective perceptions [1]. Clinical efficacy, safety and patient experience are three pillars of National Health Service (NHS) framework for holistic patient management [1]. Patient-reported experience measures (PREMs) have gained prominence to monitor the quality of care in all three domains [1]. The NHS outlines eight domains, which formulate a ‘good’ patient experience, which are dignity, expertise, interpersonal interaction, physical ease, emotional assistance and access to care [1]. PREMs facilitate information from patients about their experiences while obtaining care [1,2]. PREMs can be of two types: relational or functional (Figure 1) [1,2].

Figure 1. Types of patient-reported experience measures.

Patient-reported experiences provide information on the patient-centeredness and it is considered a reliable quality of care parameter [2]. Patient-reported experience focuses on present situation of health care services and explores the domains for future developments [2]. PREMs have recently been utilised to inform performance-based compensation, strategies for benchmarking, effectiveness, health information technology and resource usage [2]. On the other hand, PREMs are a standard that has been critiqued by its opponents who identified two major drawbacks: First, the term patient-reported experience can be used interchangeably with the terms ‘patient satisfaction’ and ‘patient expectation’, both of which are subjective terms reflecting judgments on the appropriateness of health care rather than its efficacy [2]. Second, patients’ own hypotheses about their health condition are reflected in PREMs rather than their actual treatment experience [2]. These drawbacks reveal smudging of concept and abrupt notion changing [2]. This reflects a lack of idea maturation in terms of patient-reported experiences and, hence it becomes an area that should be further explored [2]. Despite these limitations, PREMs are internationally acclaimed as valid parameters to evaluate quality of care [2,3]. This is primarily due to the following reasons: PREMs (a) reflect the importance of quality assessment and care; (b) allow patients to precisely reflect on the interpersonal aspects of their care experience; and (c) can provide patient information that can be used to drive improvement strategies in care quality [2,3]. PREMs are definitely an indicator of patient care, but they do not directly quantify it [4]. They are usually in the form of questionnaires. In contrast to PROMs (patient reported outcome measures), PREMs focus on the impact of the care process on the patient’s experience, such as communication and care timeliness [4]. Patient experience comprises both patient’s experience of treatment and patient feedback on those experiences [4]. PREMs revolve around patient experience on both ‘what’ occurs to the patient and ‘how’ the patient reports that experience [4]. This underlines the foggy distinction between the ideas of ‘patient experience’ and ‘patient satisfaction’ [4]. Although the terms are frequently used interchangeably, they are different, and the nature and direction of their relationship are still contested [4].

How can we measure ‘patient experience’?

Data about patient experiences may be collected in a variety of ways. Patients’ perspectives are regularly explored via surveys in regular clinical practice [4]. However, technological advancements have made it swifter as the surveys can now be performed through patients’ phones (messages), internet, or the use of portable devices to collect data [4]. Researchers frequently opt for subjective interviews as consistently collecting and analysing data through surveys is costlier [4]. When compared to the findings of surveys, data acquired through interviews more commonly result in reports of negative experiences with care [4,5] Patient experience can influence clinical results [4,5]. Effective clinician-patient communication, for example, can influence health outcomes such as emotional health, pain beliefs, pain coping and function [5].

Tools to measure ‘patient experience’

The Nordic Patient Experiences Questionnaire (NORPEQ) (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3367149/; Appendix A) comprises a core set of questions that addresses the most important aspects of patient experiences [6]. Based on a rigorous questionnaire preparation and review approach that includes forward and backward translation, degrees of missing data analysis, dimensionality, internal and construct validity, the NORPEQ demonstrates good evidence of reliability and validity [6]. The Picker Patient Experience (PPE-15) (https://academic.oup.com/intqhc/article/14/5/353/1800673, Appendix B) showed acceptable validity and reliability [2]. While patients reported problems with all PPE-15 items, problems with discharge information were very common [2]. Education and information, coordinated care, respecting the patient’s wishes, emotional comfort, physical ease and involvement of significant ones are the fundamental components of PPE-15 [2]. It is a helpful method for assessing inpatient experience that is widely used to assess hospital service quality [2]. Concerns are raised by the fact that many PREMs have been produced for the same patient group with little regard for measure validation [2]. Future research should consider the most promising existing PREMs as a foundation for developing new measures [2]. Furthermore, research should focus on developing PREMs for a specific diseases or conditions [7]. The importance of ‘Context’ is undoubted in influencing the patient’s perception about the care they receive [7]. This signals the need of developing PREM tools that are ethno-culturally suited, are preferably in patients’ own language (regional language) and most importantly with which the community can relate [7]. These culturally sensitive PREM tools will lead to patient centred treatment approaches, improved clinical efficacy and quality of care [7].

Ethnic, racial and socioeconomic facets of patient experience

Although documenting patient experience can lead clinicians on the path of holistic patient care, it is critical to understand the complexities of the information gathered [8]. A group of younger patients from ethnic minorities and from lower socioeconomic status is likely to report more negative experiences [8]. This might be because they receive poorer treatment, or because the expectations of certain demographic groups differ, or because they perceive survey questions differently [8]. Various populations display wide-ranging care expectations [8].

Asian patients reported higher negative ratings of waiting times than White patients, even when the actual waiting durations reported by the groups were comparable [8]. Patient–physician racial/ethnic coherence is linked to patients’ perceived experience with their physicians [8]. Physicians in incompatible pairs were less likely to receive the highest patient rating than physicians in racially/ethnically compatible patient–physician interactions [8]. White patients who came to Asian or Black doctors were less likely to view their doctors positively than White patients who saw White doctors; the latter difference was statistically significant [8]. Black patients who saw White or Asian physicians were less likely to rate their physicians favourably compared with those who saw Black physicians [8]. Various demographic groups may place more emphasis on particular components of treatment than others – for example, less educated patients may place a higher relative value on continuity of care than more educated patients [8]. In addition to ethnicity, additional characteristics to evaluate in the context of case-mix include age, gender, self-reported health status, and the prevalence of persisting psychiatric or emotional problems [8]. Individuals with modest earnings had a much higher risk of experiencing difficulties receiving medical treatment, poor communication with medical professionals, low participation in decisions, delayed medical care, and decreased contentment with the care they received as compared to those with high income [9]. These inequalities are continued irrespective of the patient’s age, race or ethnic background, gender, co-morbidity load or insurance status [9]. There is an empathy gap for patients with socioeconomic disadvantage. Patients with low incomes had considerably lower patient-reported judgments of physician empathy than patients with higher socioeconomic status [9].

How can patient experience data be used to improve quality of care?

In 2001, the NHS in England was among the first to implement a national patient survey, with the United States following suit with its own national Hospital Consumer Assessment of Healthcare Providers and Systems (CAHPS) [10]. Nevertheless, collecting patient experience data is the initial but essential step to understanding challenges and opportunities to improve healthcare quality [10]. Public reporting of patient experience in combination with an array of interventions that take in to consideration the context of a healthcare system may have greater potential to stimulate providers to improve quality [10]. Patient experience is an important aspect of quality of care. There continues to be much work needed to refine our approaches to defining and measuring patient experience [10,11].

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The authors report there was no funding to declare.

Appendix A.

Eight Item NORPEQ Questionnaire

Table

To what extent…	Not at all	To a small extent	To some extent	To a large extent	To a very large extent
Did the doctors talk to you in a way you could understand?
Do you have confidence in the doctors’ medical competence?
Do you have confidence in the nursing staff’s medical competence?
Did you experience the nursing staff showed concern for you?
Did you experience that the doctors and nursing staff were interested in your description of your own situation?
Were you given the information you thought were necessary about how tests and examinations would be conducted?
Overall, was the treatment and care you received at the hospital satisfactory?
Do you believe you were in any way given the wrong treatment (as far as you are able to judge)?

Appendix B.

The Picker Patient Experience (PPE-15)

Table

1. When you had important questions to ask a doctor, did you get answers that you could understand?	Yes, always	Yes, sometimes	No	I had no need to ask
2. When you had important questions to ask a nurse, did you get answers that you could understand?	Yes, always	Yes, sometimes	No	I had no need to ask
3. Sometimes in a hospital, one doctor or nurse will say one thing and another will say something quite different. Did this happen to you?	Yes, often	Yes, sometimes	No
4. If you had any anxieties or fears about your condition or treatment, did a doctor discuss them with you?	Yes, completely	Yes, to some extent/	No	I didn’t have any anxieties or fears
5. Did doctors talk in front of you as if you weren’t there?	Yes, often	Yes, sometimes	No
6. Did you want to be more involved in decisions made about your care and treatment?	Yes, definitely	Yes, to some extent	No
7. Overall, did you feel you were treated with respect and dignity while you were in hospital?	Yes, always	Yes, sometimes	No
8. If you had any anxieties or fears about your condition or treatment, did a nurse discuss them with you?	Yes, completely	Yes, to some extent	No	I didn’t have any anxieties or fears
9.  Did you find someone on the hospital staff to talk to about your concerns?	Yes, definitely	Yes, to some extent	No	I had no concerns
10. Were you ever in pain? If Yes… Do you think the hospital staff did everything they could to help control your pain?	Yes Yes, definitely	No Yes, to some extent	No
11. If your family or someone else close to you wanted to talk to a doctor, did they have enough opportunity to do so?	Yes, definitely	Yes, to some extent	No	No family or friends were involved	My family didn’t want or need information	I didn’t want my family or friends to talk to a doctor
12. Did the doctors or nurses give your family or someone close to you all the information they needed to help you recover?	Yes, definitely	Yes, to some extent	No	No family or friends were involved	My family or friends didn’t want or need information
13. Did a member of staff explain the purpose of the medicines you were to take at home in a way you could understand?	Yes, completely	Yes, to some extent	No	I didn’t need an explanation	I had no medicines – go to question 15
14. Did a member of staff tell you about medication side effects to watch for when you went home?	Yes, completely	Yes, to some extent	No	I didn’t need an explanation
15. Did someone tell you about danger signals regarding your illness or treatment to watch for after you went home?	Yes, completely	Yes, to some extent	No