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Using a standardized assessment tool to measure patient experience on a seizure monitoring unit compared to a general neurology unit
Epilepsy & Behavior 24 (2012) 54–58
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Epilepsy & Behavior journal homepage: www.elsevier.com/locate/yebeh
Using a standardized assessment tool to measure patient experience on a seizure monitoring unit compared to a general neurology unit Jodie I. Roberts a, Khara Sauro a, Nathalie Jetté a, b, Karen Osiowy c, Jason Knox c, Samuel Wiebe a, b, Neelan Pillay a, Paolo Federico a, William Murphy a, Sophia Macrodimitris a, c,⁎ for the SMU QI Team a b c
Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Canada Department of Community Health Sciences and Calgary Institute for Population and Public Health, University of Calgary, Calgary, Canada Alberta Health Services, Calgary Zone, Calgary, Canada
a r t i c l e
i n f o
Article history: Received 6 January 2012 Revised 2 March 2012 Accepted 3 March 2012 Available online 4 April 2012 Keywords: Seizure monitoring unit Epilepsy monitoring unit Patient satisfaction Patient experience HCAHPS Epilepsy
a b s t r a c t Seizure monitoring unit (SMU) research typically focuses on diagnostic utility and medical management of epilepsy. However, patient safety and satisfaction are also imperative to high-quality SMU care. This study uses a standardized tool to evaluate patient experience on a SMU compared to a general neurology unit (GNU). The 27-item Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey was telephone-administered post-discharge to a sample of patients from our SMU and GNU. Data from a 33-month period were reviewed, encompassing 217 SMU patient admissions and 317 GNU patient admissions. On average, SMU patients were 14.7 years younger and stayed in the hospital 4.2 days longer than GNU patients. SMU patients provided lower overall mental health ratings (p b .001), perceived nursing staff to be more responsive to the call button (p b .001), and assigned higher overall ratings to their stay (p b 0.05). Lower education was associated with more favorable hospital ratings on both units (p b 0.05). © 2012 Elsevier Inc. All rights reserved.
1. Introduction Patient-centered care is rapidly becoming a mandate for all medical institutions. Patient-centered hospital care emphasizes optimizing patient experience at each level of service, including the provision of information between staff and patients [1], the quality of nursing care [2,3], and service-based issues such as the admission process or hospital environment factors [1]. This increased emphasis on patient-centered hospital care derives from literature demonstrating that high patient satisfaction with medical care increases patient intent to comply with medical treatment [4]. In addition, the results from patient satisfaction surveys can be used to direct quality improvement initiatives [5] and to evaluate the success of programs developed to improve patient care. Despite the increased focus on patient-centered care in hospital settings, there is a paucity of information related to patient satisfaction and experience in the seizure monitoring unit (SMU). To date, epilepsyspecific patient satisfaction and experience literature has largely focused on general practitioner [6] and specialist outpatient care [7]. Seizure monitoring unit research generally focuses on diagnostic utility and medical management of epilepsy [8,9]. Although some recent ⁎ Corresponding author at: The Department of Clinical Neurosciences, Foothills Medical Centre, 1403 29th Street NW, Calgary, AB, Canada T2N 2T9. Fax: +1 403 944 0988. E-mail address: [email protected] (S. Macrodimitris). 1525-5050/$ – see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.yebeh.2012.03.002
studies have examined patient safety [10] and other quality indicators [11] in the SMU, patient experience remains largely unexplored. Admission to a SMU differs from more typical hospital stays because SMU patients are subjected to discomforts that are unique to a SMU admission. First, medications are often reduced to provoke seizures rather than instituting treatments to stop symptoms, which is more typical of acute care hospital stays. Second, in order to provoke seizures, patients may be sleep deprived, exposed to strobe lighting, or undergo hyperventilation, each of which is not the “norm” in typical acute care hospital stays. Third, patients are not permitted to leave the SMU, apart for other investigations (e.g., neuroimaging) for which they are accompanied by medical staff, whereas other inpatient units permit medically stable patients to leave the unit (e.g., to smoke a cigarette). Finally, the nature of the SMU admission involves continuous video and electroencephalogram (VEEG) monitoring to confirm diagnosis of a seizure disorder, classify seizure types, and localize seizure origin [12,13]. This means that the patient is typically exposed to more specialized medical equipment, some of which compromises personal privacy and freedoms (e.g., video monitoring) compared to what is typical of other inpatient hospital stays. The primary purpose of our study was to address the paucity of literature exploring patient experience in SMUs by using a standardized hospital-based patient experience assessment tool, administered to patients post-discharge. Given that we propose that the SMU hospital stay is unique to other types of hospital admissions, a secondary
J.I. Roberts et al. / Epilepsy & Behavior 24 (2012) 54–58
purpose was to compare patient experience assessments of the SMU with another hospital unit that was most similar to our unit (e.g., shared staff; patients with neurological conditions but not necessarily epilepsy), namely the general neurology unit (GNU). We hypothesized that patient satisfaction would be higher in the SMU compared to the GNU primarily due to the higher nurse-to-patient ratio in the SMU.
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square comparisons were calculated by grouping scores into categories of 0–7 and 8–10. These particular categories were selected as scores of 8–10 were shown to correlate with a rating of “excellent” by the Health Quality Council of Alberta. 3. Results 3.1. Patient demographics on the SMU and GNU
2. Methods 2.1. Measures 2.1.1. HCAHPS The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey (Appendix A) is a 27-item survey endorsed for use in acute care hospitals by the Agency for Healthcare Research and Quality [14]. Items were developed from a draft instrument of 66 questions and narrowed to 27 items deemed to be most relevant through an extensive pilot study involving three states and nearly 50,000 participants [14]. This standardized instrument has been widely adopted [14] and features key hospital-based quality indicators such as nursing care, physician care, and the hospital environment. Hospital Consumer Assessment of Healthcare Providers and Systems questions vary in the response scales used: seven items are dichotomous, twelve items use a four-point Likert scale, and three global items ask patients to assign ratings on a 0–10 scale (where 0 is the worst possible care and 10 is the best possible care). Additional demographic questions collect information related to citizenship, native language, education, marital status, and self-reported physical and mental health. 2.2. Procedure 2.2.1. Participant inclusion The Foothills Medical Centre (FMC) in Calgary, Alberta contains a four-bed SMU and a 32-bed GNU. This SMU is the only adult SMU in the Calgary region spanning a population of 1.4 million people. Patients eligible to complete the HCAHPS survey were required to have stayed a minimum of 24 h in the hospital, not been transferred from another hospital or another unit, and be at least 18 years of age. As the survey was only available in English, the ability to speak English was an additional requirement. Interviewees who were not able to complete the survey due to neurological deficits or other limitations were identified at the beginning of the interview as ineligible for the survey. There was no option for completion by proxy. A sample of eligible patients was contacted by telephone within six weeks post-discharge and asked to complete the survey after providing informed consent. A target completion rate was set at 10% of GNU patients (standard procedure in our hospital due to a large number of GNU admissions) and 100% of consecutive SMU patients. Interviews were conducted by eight core interviewers employed by the provincial health service who were specialized in the administration of the HCAHPS survey. 2.2.2. Ethics approval Ethics approval for this study was obtained from the Office of Medical Bioethics at the University of Calgary's Faculty of Medicine. 2.2.3. Statistical analysis Data were collected and stored using VOXCO, Interviewer 4.6 and transferred to SPSS 15.0 for Windows for analysis. Items using dichotomous or Likert response scales were compared between units using chi-square analysis. Significance was set at p ≤ 0.05. For the three items requiring participants to assign overall ratings between zero and ten, responses were analyzed using t-test for equality of means and categorical chi-square comparisons. Categorical chi-
The HCAHPS survey was completed by 217 patients discharged from the SMU and 317 patients discharged from the GNU over a 33-month period (January 1, 2007–September 1, 2009). This sample represents 68% of SMU admissions and 10% of GNU admissions over this period of time. Given that 100% of SMU patients were contacted to complete the survey, the response rate for this population was 68%. The response rate for GNU patients asked to complete the survey was estimated by the provincial health service to be approximately 50% based on usual response rates for HCAHPS surveys conducted in the province. Sex ratios and levels of education were similar between patients in each medical unit (Table 1); however, GNU patients were significantly older than SMU patients, and SMU patients were more likely to be single (never married) (Table 1). SMU patients reported lower ratings of overall mental health than GNU patients (Fig. 1). 3.2. Intensity of care Seizure monitoring unit patients were significantly less likely to require pain medication (χ 2 = 25.616, df = 1, p b 0.001), receive medication not taken previously (χ 2 = 13.098, df = 1, p b 0.001), and require help from staff in order to use the washroom (χ 2 = 14.260, df = 1, p b 0.001). On average, SMU patients stayed in hospital 4.2 days longer (9.72 days for SMU vs. 5.5 days for GNU, t = −4.301, df = 530, p b .001) than GNU patients. 3.3. Nursing care Patients from both units reported high levels of satisfaction with the nursing care they received during their stay. Seizure monitoring unit patients assigned an average rating of 8.6/10 to the quality of nursing care they received, and GNU patients assigned an average rating of 8.7/10. The majority of surveyed patients reported that they were “always” treated with courtesy and respect by the nurses
Table 1 Demographic characteristics of surveyed patients. Demographic characteristics Gender, n (%) Male Female Age⁎ Mean (SD) Education, n (%) Did not graduate high school High school graduate College/university graduate Post-graduate Marital status, n (%)⁎⁎ Single (never married) Married Common law/living with partner Divorced Separated Widowed
GNU
SMU
139 (43.8) 178 (56.2)
88 (40.6) 129 (59.4)
54.8 (17.8)
40.1 (15.9)
46 107 132 28
(14.7) (34.2) (42.2) (8.9)
34 73 97 10
(15.9) (34.1) (45.3) (4.7)
42 193 25 20 9 27
(13.3) (61.1) (7.9) (6.3) (2.8) (8.5)
73 103 14 16 5 6
(33.6) (47.5) (6.5) (7.4) (2.3) (2.8)
GNU = general neurology unit; SMU = seizure monitoring unit; SD = standard deviation; n = sample size. ⁎ t (532) = 9.774, p b 0.001. ⁎⁎ χ2 (5) = 35.651, p b 0.001.
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3.5. Hospital environment Patients discharged from the SMU were significantly more likely to report that the area around their room was quiet at night than GNU patients (Table 2). Seizure monitoring unit patients expressed that their room and bathroom were “always” kept clean more often than GNU patients; however, these differences were not statistically significant (Table 2). 3.6. Discharge information
Fig. 1. Response distribution for the HCAHPS survey question “In general, how would you rate your overall mental or emotional health?” SMU = seizure monitoring unit; GNU = general neurology unit. The overall response distribution was significantly different between units (χ2 (4) = 21.009, p b 0.001).
and that nurses “always” listened carefully to them (Table 2). The only aspect of nursing care that was significantly different between units was call-button response time. Seizure monitoring unit patients were more likely to respond that they “always” received help as soon as they wanted it after pressing the call button (Table 2).
3.4. Physician care Patients from both units reported high levels of satisfaction with the care they received from physicians during their stay (Table 2). General neurology unit patients assigned an average rating of 8.7/10 to the quality of care they received from physicians, and SMU patients assigned an average rating of 8.6/10. The majority of surveyed patients reported that they were “always” treated with courtesy and respect by doctors and that doctors “always” listened carefully to them (Table 2).
The majority of SMU (72.4%) and GNU (75.8%) patients reported that hospital staff spoke with them about whether they would have the help they needed when leaving the hospital. Fewer SMU patients (58.5%) reported that they received written information at discharge about symptoms or health problems than GNU patients (63.7%); however, these differences were not significant (p = 0.14). 3.7. Overall rating On average, patients discharged from the SMU endorsed higher ratings for their overall hospital stay (8.5/10) than GNU patients (8.2/10). These differences were statistically significant for t-test for equality of means (t = − 2.075, df = 530, p b 0.05) as well as Pearson chi-square comparisons (χ 2 = 1.551, df = 1, p b 0.01). Willingness to recommend the hospital was similar between units with 69.3% of SMU patients and 68.8% of GNU patients stating that they would “definitely” recommend this hospital to their friends and family. Lower education was associated with more favorable hospital ratings (p b 0.05); however, no such associations were found for age, length of stay, marital status, or overall physical and mental health. 4. Discussion This study addressed the paucity of literature exploring patient experience on SMUs by comparing SMU and GNU patient responses to a standardized hospital-based patient experience assessment tool (HCAHPS) administered post-hospital discharge. To our knowledge,
Table 2 Patient responses to HCAHPS questions for nursing care, physician care, and hospital environment. Question Nursing care How often did nurses treat you with courtesy and respect? How often did nurses listen carefully to you? How often did nurses explain things in a way you could understand? After you pressed the call button, how often did you get help as soon as you wanted it? Physician care How often did doctors treat you with courtesy and respect? How often did doctors listen carefully to you? How often did doctors explain things in a way you could understand? Care environment How often were your room and bathroom kept clean? How often was the area around your room quiet at night? How often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted? SMU = seizure monitoring unit; GNU = general neurology unit.
Unit
Never n (%)
Sometimes n (%)
Usually n (%)
Always n (%)
p
0.755
GNU SMU GNU SMU GNU SMU GNU SMU
1 (0.3) 2 (0.9) 0 (0) 0 (0) 6 (1.9) 2 (0.9) 4 (1.7) 2 (1.1)
18 10 26 17 23 24 37 15
(5.7) (4.6) (8.3) (7.9) (7.3) (11.3) (15.9) (8.3)
54 39 76 54 75 49 65 28
(17.0) (18.0) (24.1) (25.1) (23.8) (23.0) (28.0) (15.5)
244 166 213 144 211 138 126 136
(77.0) (76.5) (67.6) (67.0) (67.0) (64.8) (54.3) (75.1)
GNU SMU GNU SMU GNU SMU
1 (0.3) 2 (0.9) 2 (0.6) 6 (2.8) 6 (2.0) 3 (1.4)
18 13 38 20 32 27
(5.8) (6.1) (12.3) (9.4) (10.4) (12.6)
51 41 64 50 88 65
(16.3) (19.3) (20.6) (23.5) (28.7) (30.4)
242 156 206 137 181 119
(77.6) (73.6) (66.5) (64.3) (59.0) (55.6)
GNU SMU GNU SMU GNU SMU
6 (2.0) 2 (0.9) 30 (9.6) 5 (2.4) 3 (2.2) 3 (4.9)
44 (14.4) 24 (11.3) 86 (27.4) 28 (13.3) 17 (12.7) 4 (6.6)
100 58 88 71 39 12
(32.8) (27.2) (28.0) (33.8) (29.1) (19.7)
155 (50.8) 129 (60.6) 110 (35.0) 106 (50.5) 75 (56.0) 42 (68.9)
0.962 0.368 0.000
0.617 0.146 0.770
0.154 0.000 0.170
J.I. Roberts et al. / Epilepsy & Behavior 24 (2012) 54–58
this is the first study to explore patient experience in a SMU compared to a GNU. The characteristics of SMU patients differed from GNU patients, with SMU patients being significantly younger, more likely to be single or never married, and more likely to report lower overall mental health. Regarding hospital care, unlike the older, acute care GNU patients, SMU patients were less likely to require assistance with activities of daily living, to require pain medication, or to receive a new medication while in hospital. Seizure monitoring unit patient ratings of call-button responsiveness were higher than GNU patient ratings, likely reflecting the smaller area of the SMU and that at least one staff member is present on the unit at all times. The hospital environment was reported as quieter and cleaner by the SMU patients, also likely reflecting the smaller space assigned to the SMU. The only area in which SMU patients reported deficient care compared to the GNU was with discharge information: SMU patients were less likely than GNU patients to report receiving written discharge information, which is concerning given that this is a crucial component of the hospital process that helps to ensure optimal ongoing management of patient needs post-hospital discharge. Although differences in GNU and SMU patient responses existed on these specified rating items, there were several similarities across patient responses from both units. For example, most patients were extremely satisfied with nursing and physician care and perceived that they were treated with courtesy and respect while in the hospital. Additionally, patients on both units gave a higher than 8/10 average rating of their overall hospital stay although overall ratings were statistically higher for SMU patients. A major criticism of patient satisfaction surveys, such as the one administered here, is that they present a “limited and optimistic picture” [15]. For example, one study of hospital care in a general medical population reported that more than half of patients stated that they received excellent care [15]. However, when asked to complete a more detailed questionnaire, these patients specified at least four problems with their care [15]. Most studies of epilepsy patient satisfaction with medical care have reported high levels of satisfaction. A study comparing a hospital clinic for epilepsy patients with an epilepsy telemedicine clinic found that 90% of patients reported satisfaction with service quality regardless of which clinic they were assigned to [16], and another study reported that 67% of patients surveyed following contact with an epilepsy nurse specialist stated that they were extremely or very satisfied with their care [17]. The generally positive ratings obtained in our study may be a reflection of a bias toward providing high satisfaction scores, particularly because all responses were collected over the telephone. Mail and phone survey methods have been approved for HCAHPS administration [18]; however, one study using both paper and telephone survey methods noted that telephone respondents provided higher evaluations of their care in general [19]. Although social desirability is often used to explain the trend toward more positive results when surveying by telephone [20], this may not be the only factor. Other studies have attributed the positive bias of telephone surveys to a recency effect where respondents are more likely to choose latter response options [21]. Because more positive options are placed last on the HCAHPS survey, it is possible that recency effects contributed to our high satisfaction ratings in addition to social desirability. As a result, it is important that different modes of assessment be compared to determine which provide more accurate responses. Our finding that more educated patients tended to assign lower satisfaction scores to their hospital stay, regardless of the unit they were on, has been noted repeatedly in the literature [22–27]. Little to no explanation has been given for this association between hospital ratings and education, other than the possibility that more educated patients think more critically about their experiences in the health care system [23]. The literature reports many associations between demographics and ratings of care that we did not find in our study, including age [22,24,27], self-ratings of health status [22,23,26],
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and shorter length of stay [24], each shown in the literature to be positively associated with satisfaction. It will be important that we continue to capture information about patient demographics and aspects of their hospital stay (e.g., length of stay) to ensure that we assess whether SMU patient experience ratings vary according to these variables. Lower ratings of emotional health expressed by SMU patients compared to GNU patients in this study could be explained by the high prevalence of mood disorders in patients with epilepsy. A recent population-based study [28] demonstrated that epilepsy patients have an increased lifetime prevalence of mental health disorders compared to the general population (35.5% versus 20.7%). Because research suggests that seizures in patients with comorbid psychiatric disorders are more likely to fail antiepileptic pharmacotherapy [29] and that these patients have worse outcomes after surgical interventions [30], psychiatric care is a necessary and crucial component of epilepsy care. A SMU admission presents an excellent opportunity to identify potentially undetected mental health conditions in epilepsy patients. This could be accomplished by adding a simple mental health self-report screening questionnaire to the admission process in order to identify patients who may require a psychiatric or psychological consultation as part of their SMU admission. Limitations of our study include the absence of data regarding the number of times patients had been previously admitted to particular units and if patients had previously completed a HCAHPS survey for that unit. Because it has been found that repeat admissions can lower patient responses to satisfaction questionnaires [24] and repeat admissions may occur in SMUs when seizures do not occur at first admission [31], it is possible that previous admissions may have influenced our results. We were also unable to determine the precise response rate for our GNU sample or examine differences between responders and non-responders because these data were collected by a provincial health service that did not collect these variables. However, concerns related to response rates are negligible due to our large sample size, and a previous study found that increasing the response rate of a hospital satisfaction survey from 30% to 70% had minimal influence on overall conclusions [32]. This study acquired valuable information regarding patient experience on our SMU and how SMU patient satisfaction compares to patient satisfaction for a similar neurological unit. We recommend that all SMU patients be screened for mental health problems as part of their admission and that all patients be provided with written documentation at discharge. The utility of the HCAHPS survey as a quality improvement measure for SMUs would likely be increased by the addition of SMU-specific items (e.g., did you believe/trust that you would be safe from harm if you had a seizure?). Additional unit-specific questions can easily be added to the existing HCAHPS survey, and integrated surveys using HCAHPS have been shown to be psychometrically sound [33]. As more medical centers acquire SMUs, it is important that existing sites determine how these unique units can best be managed to ensure optimal outcomes and experience for patients. We recommend that all sites collect ongoing, SMUspecific, patient satisfaction data with standardized instruments such as the HCAHPS survey in order to target quality improvement initiatives and to track the effectiveness of such initiatives over time. Acknowledgments This study was partially supported by a Department of Clinical Neurosciences, Alberta Health Services, ARP Retro Grant awarded to Drs. Macrodimitris, Pillay, Wiebe, and Jetté to support initiatives for the Seizure Monitoring Unit Quality Improvement Team (SMU QI Team). Jodie Roberts received a summer studentship from Alberta Innovates Health Solutions for this project. Dr. Nathalie Jetté is the recipient of an Alberta Innovates Health Solution (Population Health Investigator) and a Canada Research Chair Tier 2 in Neurological
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Population Health and Health Services Research. She also has operating funds from the Canadian Institutes of Health Research, the Public Health Agency of Canada, Alberta Health and Wellness and the University of Calgary Hotchkiss Brain Institute. She sits on the editorial board of Epilepsia. Dr. Samuel Wiebe receives research support from the Alberta Innovates Health Solutions, Canadian Institutes of Health Research, and University of Calgary (Hopewell Professorship of Clinical Neurosciences Research). Dr. Paolo Federico receives research support from the Canadian Institutes of Health Research and the University of Calgary. Appendix A. Supplementary data Supplementary data to this article can be found online at doi:10. 1016/j.yebeh.2012.03.002. References [1] Cheung CS, Bower WF, Kwok SC, van Hasselt CA. Contributors to surgical inpatient satisfaction—development and reliability of a targeted instrument. Asian J Surg 2009;32(3):143–50. [2] Thomas LH, MacMillan J, McColl E, Priest J, Hale C, Bond S. Obtaining patients' views of nursing care to inform the development of a patient satisfaction scale. Int J Qual Health Care 1995;7(2):153–63. [3] Laschinger HS, Hall LM, Pedersen C, Almost J. A psychometric analysis of the patient satisfaction with nursing care quality questionnaire: an actionable approach to measuring patient satisfaction. J Nurs Care Qual 2005;20(3):220–30. [4] Grosset KA, Grosset DG. Patient-perceived involvement and satisfaction in Parkinson's disease: effect on therapy decisions and quality of life. Mov Disord 2005;20(5):616–9. [5] Barr JK, Giannotti TE, Sofaer S, Duquette CE, Waters WJ, Petrillo MK. Using public reports of patient satisfaction for hospital quality improvement. Health Serv Res 2006;41(3 Pt 1):663–82. [6] Chappell B, Smithson WH. Patient views on primary care services for epilepsy and areas where additional professional knowledge would be welcome. Seizure 1998;7(6):447–57. [7] Jain P, Patterson VH, Morrow JI. What people with epilepsy want from a hospital clinic. Seizure 1993;2(1):75–8. [8] Smolowitz JL, Hopkins SC, Perrine T, Eck KE, Hirsch LJ, O'Neil Mundinger M. Diagnostic utility of an epilepsy monitoring unit. Am J Med Qual 2007;22(2):117–22. [9] Upton D, Thompson PJ, Duncan JS. Patient satisfaction with specialized epilepsy assessment and treatment. Seizure 1996;5(3):195–8. [10] Buelow JM, Privitera M, Levisohn P, Barkley GL. A description of current practice in epilepsy monitoring units. Epilepsy Behav 2009;15(3):308–13. [11] Perkins AM, Buchhalter JR. Optimizing patient care in the pediatric epilepsy monitoring unit. J Neurosci Nurs 2006;38(6):416–21 [34]. [12] Sarkissian S, Politzer N, Zahn C, Doran DI. Implementation of a change process to improve outcomes of patients admitted to epilepsy monitoring unit. Outcomes Manag Nurs Pract 2001;5(1):11–6 [quiz 6–7].
[13] Lagerlund TD, Cascino GD, Cicora KM, Sharbrough FW. Long-term electroencephalographic monitoring for diagnosis and management of seizures. Mayo Clin Proc 1996;71(10):1000–6. [14] Goldstein E, Farquhar M, Crofton C, Darby C, Garfinkel S. Measuring hospital care from the patients' perspective: an overview of the CAHPS hospital survey development process. Health Serv Res 2005;40(6 Pt 2):1977–95. [15] Jenkinson C, Coulter A, Bruster S, Richards N, Chandola T. Patients' experiences and satisfaction with health care: results of a questionnaire study of specific aspects of care. Qual Saf Health Care 2002;11(4):335–9. [16] Ahmed SN, Mann C, Sinclair DB, et al. Feasibility of epilepsy follow-up care through telemedicine: a pilot study on the patient's perspective. Epilepsia 2008;49(4): 573–85. [17] Hosking PG, Duncan JS, Sander JM. The epilepsy nurse specialist at a tertiary care hospital—improving the interface between primary and tertiary care. Seizure 2002;11(8):494–9. [18] Giordano LA, Elliott MN, Goldstein E, Lehrman WG, Spencer PA. Development, implementation, and public reporting of the HCAHPS survey. Med Care Res Rev 2010;67(1):27–37. [19] de Vries H, Elliott MN, Hepner KA, Keller SD, Hays RD. Equivalence of mail and telephone responses to the CAHPS hospital survey. Health Serv Res 2005;40(6 Pt 2):2120–39. [20] Burroughs TE, Waterman BM, Cira JC, Desikan R, Claiborne Dunagan W. Patient satisfaction measurement strategies: a comparison of phone and mail methods. Jt Comm J Qual Improv 2001;27(7):349–61. [21] Dillman DA, Brown TL, Carlson JE, et al. Effects of category order on answers in mail and telephone surveys. Rural Sociol 1995;60(4):674–87. [22] Bleich SN, Ozaltin E, Murray CJL. How does satisfaction with the health-care system relate to patient experience? Bull World Health Organ 2009;87:271–8. [23] Otani K. Enrollees' global rating process of health care with the national CAHPS Benchmarking Database. Health Care Manage Rev 2006;31(3):205–12. [24] Quintana JM, Gonzalez N, Bilbao A, et al. Predictors of patient satisfaction with hospital health care. BMC Health Serv Res 2006;6:102. [25] Bautista RE, Glen ET, Shetty NK. Factors associated with satisfaction with care among patients with epilepsy. Epilepsy Behav 2007;11(4):518–24. [26] O'Malley AJ, Zaslavsky AM, Elliott MN, Zaborski L, Cleary PD. Case-mix adjustment of the CAHPS hospital survey. Health Serv Res 2005;40(6 Pt 2):2162–81. [27] Hargraves JL, Wilson IB, Zaslavsky A, et al. Adjusting for patient characteristics when analyzing reports from patients about hospital care. Med Care 2001;39(6): 635–41. [28] Tellez-Zenteno JF, Patten SB, Jette N, Williams J, Wiebe S. Psychiatric comorbidity in epilepsy: a population-based analysis. Epilepsia 2007;48(12):2336–44. [29] Hitiris N, Mohanraj R, Norrie J, Sills GJ, Brodie MJ. Predictors of pharmacoresistant epilepsy. Epilepsy Res 2007;75(2–3):192–6. [30] Kanner AM, Byrne R, Chicharro A, Wuu J, Frey M. A lifetime psychiatric history predicts a worse seizure outcome following temporal lobectomy. Neurology 2009;72(9):793–9. [31] Zarkou S, Grade M, Hoerth MT, Noe KH, Sirven JI, Drazkowski JF. Indeterminate EMU admissions: does repeating the admission help? Epilepsy Behav 2011;20(4): 706–8. [32] Perneger TV, Chamot E, Bovier PA. Nonresponse bias in a survey of patient perceptions of hospital care. Med Care 2005;43(4):374–80. [33] Rothman AA, Park H, Hays RD, Edwards C, Dudley RA. Can additional patient experience items improve the reliability of and add new domains to the CAHPS hospital survey? Health Serv Res 2008;43(6):2201–22.
Contents lists available at SciVerse ScienceDirect
Epilepsy & Behavior journal homepage: www.elsevier.com/locate/yebeh
Using a standardized assessment tool to measure patient experience on a seizure monitoring unit compared to a general neurology unit Jodie I. Roberts a, Khara Sauro a, Nathalie Jetté a, b, Karen Osiowy c, Jason Knox c, Samuel Wiebe a, b, Neelan Pillay a, Paolo Federico a, William Murphy a, Sophia Macrodimitris a, c,⁎ for the SMU QI Team a b c
Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Canada Department of Community Health Sciences and Calgary Institute for Population and Public Health, University of Calgary, Calgary, Canada Alberta Health Services, Calgary Zone, Calgary, Canada
a r t i c l e
i n f o
Article history: Received 6 January 2012 Revised 2 March 2012 Accepted 3 March 2012 Available online 4 April 2012 Keywords: Seizure monitoring unit Epilepsy monitoring unit Patient satisfaction Patient experience HCAHPS Epilepsy
a b s t r a c t Seizure monitoring unit (SMU) research typically focuses on diagnostic utility and medical management of epilepsy. However, patient safety and satisfaction are also imperative to high-quality SMU care. This study uses a standardized tool to evaluate patient experience on a SMU compared to a general neurology unit (GNU). The 27-item Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey was telephone-administered post-discharge to a sample of patients from our SMU and GNU. Data from a 33-month period were reviewed, encompassing 217 SMU patient admissions and 317 GNU patient admissions. On average, SMU patients were 14.7 years younger and stayed in the hospital 4.2 days longer than GNU patients. SMU patients provided lower overall mental health ratings (p b .001), perceived nursing staff to be more responsive to the call button (p b .001), and assigned higher overall ratings to their stay (p b 0.05). Lower education was associated with more favorable hospital ratings on both units (p b 0.05). © 2012 Elsevier Inc. All rights reserved.
1. Introduction Patient-centered care is rapidly becoming a mandate for all medical institutions. Patient-centered hospital care emphasizes optimizing patient experience at each level of service, including the provision of information between staff and patients [1], the quality of nursing care [2,3], and service-based issues such as the admission process or hospital environment factors [1]. This increased emphasis on patient-centered hospital care derives from literature demonstrating that high patient satisfaction with medical care increases patient intent to comply with medical treatment [4]. In addition, the results from patient satisfaction surveys can be used to direct quality improvement initiatives [5] and to evaluate the success of programs developed to improve patient care. Despite the increased focus on patient-centered care in hospital settings, there is a paucity of information related to patient satisfaction and experience in the seizure monitoring unit (SMU). To date, epilepsyspecific patient satisfaction and experience literature has largely focused on general practitioner [6] and specialist outpatient care [7]. Seizure monitoring unit research generally focuses on diagnostic utility and medical management of epilepsy [8,9]. Although some recent ⁎ Corresponding author at: The Department of Clinical Neurosciences, Foothills Medical Centre, 1403 29th Street NW, Calgary, AB, Canada T2N 2T9. Fax: +1 403 944 0988. E-mail address: [email protected] (S. Macrodimitris). 1525-5050/$ – see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.yebeh.2012.03.002
studies have examined patient safety [10] and other quality indicators [11] in the SMU, patient experience remains largely unexplored. Admission to a SMU differs from more typical hospital stays because SMU patients are subjected to discomforts that are unique to a SMU admission. First, medications are often reduced to provoke seizures rather than instituting treatments to stop symptoms, which is more typical of acute care hospital stays. Second, in order to provoke seizures, patients may be sleep deprived, exposed to strobe lighting, or undergo hyperventilation, each of which is not the “norm” in typical acute care hospital stays. Third, patients are not permitted to leave the SMU, apart for other investigations (e.g., neuroimaging) for which they are accompanied by medical staff, whereas other inpatient units permit medically stable patients to leave the unit (e.g., to smoke a cigarette). Finally, the nature of the SMU admission involves continuous video and electroencephalogram (VEEG) monitoring to confirm diagnosis of a seizure disorder, classify seizure types, and localize seizure origin [12,13]. This means that the patient is typically exposed to more specialized medical equipment, some of which compromises personal privacy and freedoms (e.g., video monitoring) compared to what is typical of other inpatient hospital stays. The primary purpose of our study was to address the paucity of literature exploring patient experience in SMUs by using a standardized hospital-based patient experience assessment tool, administered to patients post-discharge. Given that we propose that the SMU hospital stay is unique to other types of hospital admissions, a secondary
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purpose was to compare patient experience assessments of the SMU with another hospital unit that was most similar to our unit (e.g., shared staff; patients with neurological conditions but not necessarily epilepsy), namely the general neurology unit (GNU). We hypothesized that patient satisfaction would be higher in the SMU compared to the GNU primarily due to the higher nurse-to-patient ratio in the SMU.
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square comparisons were calculated by grouping scores into categories of 0–7 and 8–10. These particular categories were selected as scores of 8–10 were shown to correlate with a rating of “excellent” by the Health Quality Council of Alberta. 3. Results 3.1. Patient demographics on the SMU and GNU
2. Methods 2.1. Measures 2.1.1. HCAHPS The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey (Appendix A) is a 27-item survey endorsed for use in acute care hospitals by the Agency for Healthcare Research and Quality [14]. Items were developed from a draft instrument of 66 questions and narrowed to 27 items deemed to be most relevant through an extensive pilot study involving three states and nearly 50,000 participants [14]. This standardized instrument has been widely adopted [14] and features key hospital-based quality indicators such as nursing care, physician care, and the hospital environment. Hospital Consumer Assessment of Healthcare Providers and Systems questions vary in the response scales used: seven items are dichotomous, twelve items use a four-point Likert scale, and three global items ask patients to assign ratings on a 0–10 scale (where 0 is the worst possible care and 10 is the best possible care). Additional demographic questions collect information related to citizenship, native language, education, marital status, and self-reported physical and mental health. 2.2. Procedure 2.2.1. Participant inclusion The Foothills Medical Centre (FMC) in Calgary, Alberta contains a four-bed SMU and a 32-bed GNU. This SMU is the only adult SMU in the Calgary region spanning a population of 1.4 million people. Patients eligible to complete the HCAHPS survey were required to have stayed a minimum of 24 h in the hospital, not been transferred from another hospital or another unit, and be at least 18 years of age. As the survey was only available in English, the ability to speak English was an additional requirement. Interviewees who were not able to complete the survey due to neurological deficits or other limitations were identified at the beginning of the interview as ineligible for the survey. There was no option for completion by proxy. A sample of eligible patients was contacted by telephone within six weeks post-discharge and asked to complete the survey after providing informed consent. A target completion rate was set at 10% of GNU patients (standard procedure in our hospital due to a large number of GNU admissions) and 100% of consecutive SMU patients. Interviews were conducted by eight core interviewers employed by the provincial health service who were specialized in the administration of the HCAHPS survey. 2.2.2. Ethics approval Ethics approval for this study was obtained from the Office of Medical Bioethics at the University of Calgary's Faculty of Medicine. 2.2.3. Statistical analysis Data were collected and stored using VOXCO, Interviewer 4.6 and transferred to SPSS 15.0 for Windows for analysis. Items using dichotomous or Likert response scales were compared between units using chi-square analysis. Significance was set at p ≤ 0.05. For the three items requiring participants to assign overall ratings between zero and ten, responses were analyzed using t-test for equality of means and categorical chi-square comparisons. Categorical chi-
The HCAHPS survey was completed by 217 patients discharged from the SMU and 317 patients discharged from the GNU over a 33-month period (January 1, 2007–September 1, 2009). This sample represents 68% of SMU admissions and 10% of GNU admissions over this period of time. Given that 100% of SMU patients were contacted to complete the survey, the response rate for this population was 68%. The response rate for GNU patients asked to complete the survey was estimated by the provincial health service to be approximately 50% based on usual response rates for HCAHPS surveys conducted in the province. Sex ratios and levels of education were similar between patients in each medical unit (Table 1); however, GNU patients were significantly older than SMU patients, and SMU patients were more likely to be single (never married) (Table 1). SMU patients reported lower ratings of overall mental health than GNU patients (Fig. 1). 3.2. Intensity of care Seizure monitoring unit patients were significantly less likely to require pain medication (χ 2 = 25.616, df = 1, p b 0.001), receive medication not taken previously (χ 2 = 13.098, df = 1, p b 0.001), and require help from staff in order to use the washroom (χ 2 = 14.260, df = 1, p b 0.001). On average, SMU patients stayed in hospital 4.2 days longer (9.72 days for SMU vs. 5.5 days for GNU, t = −4.301, df = 530, p b .001) than GNU patients. 3.3. Nursing care Patients from both units reported high levels of satisfaction with the nursing care they received during their stay. Seizure monitoring unit patients assigned an average rating of 8.6/10 to the quality of nursing care they received, and GNU patients assigned an average rating of 8.7/10. The majority of surveyed patients reported that they were “always” treated with courtesy and respect by the nurses
Table 1 Demographic characteristics of surveyed patients. Demographic characteristics Gender, n (%) Male Female Age⁎ Mean (SD) Education, n (%) Did not graduate high school High school graduate College/university graduate Post-graduate Marital status, n (%)⁎⁎ Single (never married) Married Common law/living with partner Divorced Separated Widowed
GNU
SMU
139 (43.8) 178 (56.2)
88 (40.6) 129 (59.4)
54.8 (17.8)
40.1 (15.9)
46 107 132 28
(14.7) (34.2) (42.2) (8.9)
34 73 97 10
(15.9) (34.1) (45.3) (4.7)
42 193 25 20 9 27
(13.3) (61.1) (7.9) (6.3) (2.8) (8.5)
73 103 14 16 5 6
(33.6) (47.5) (6.5) (7.4) (2.3) (2.8)
GNU = general neurology unit; SMU = seizure monitoring unit; SD = standard deviation; n = sample size. ⁎ t (532) = 9.774, p b 0.001. ⁎⁎ χ2 (5) = 35.651, p b 0.001.
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3.5. Hospital environment Patients discharged from the SMU were significantly more likely to report that the area around their room was quiet at night than GNU patients (Table 2). Seizure monitoring unit patients expressed that their room and bathroom were “always” kept clean more often than GNU patients; however, these differences were not statistically significant (Table 2). 3.6. Discharge information
Fig. 1. Response distribution for the HCAHPS survey question “In general, how would you rate your overall mental or emotional health?” SMU = seizure monitoring unit; GNU = general neurology unit. The overall response distribution was significantly different between units (χ2 (4) = 21.009, p b 0.001).
and that nurses “always” listened carefully to them (Table 2). The only aspect of nursing care that was significantly different between units was call-button response time. Seizure monitoring unit patients were more likely to respond that they “always” received help as soon as they wanted it after pressing the call button (Table 2).
3.4. Physician care Patients from both units reported high levels of satisfaction with the care they received from physicians during their stay (Table 2). General neurology unit patients assigned an average rating of 8.7/10 to the quality of care they received from physicians, and SMU patients assigned an average rating of 8.6/10. The majority of surveyed patients reported that they were “always” treated with courtesy and respect by doctors and that doctors “always” listened carefully to them (Table 2).
The majority of SMU (72.4%) and GNU (75.8%) patients reported that hospital staff spoke with them about whether they would have the help they needed when leaving the hospital. Fewer SMU patients (58.5%) reported that they received written information at discharge about symptoms or health problems than GNU patients (63.7%); however, these differences were not significant (p = 0.14). 3.7. Overall rating On average, patients discharged from the SMU endorsed higher ratings for their overall hospital stay (8.5/10) than GNU patients (8.2/10). These differences were statistically significant for t-test for equality of means (t = − 2.075, df = 530, p b 0.05) as well as Pearson chi-square comparisons (χ 2 = 1.551, df = 1, p b 0.01). Willingness to recommend the hospital was similar between units with 69.3% of SMU patients and 68.8% of GNU patients stating that they would “definitely” recommend this hospital to their friends and family. Lower education was associated with more favorable hospital ratings (p b 0.05); however, no such associations were found for age, length of stay, marital status, or overall physical and mental health. 4. Discussion This study addressed the paucity of literature exploring patient experience on SMUs by comparing SMU and GNU patient responses to a standardized hospital-based patient experience assessment tool (HCAHPS) administered post-hospital discharge. To our knowledge,
Table 2 Patient responses to HCAHPS questions for nursing care, physician care, and hospital environment. Question Nursing care How often did nurses treat you with courtesy and respect? How often did nurses listen carefully to you? How often did nurses explain things in a way you could understand? After you pressed the call button, how often did you get help as soon as you wanted it? Physician care How often did doctors treat you with courtesy and respect? How often did doctors listen carefully to you? How often did doctors explain things in a way you could understand? Care environment How often were your room and bathroom kept clean? How often was the area around your room quiet at night? How often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted? SMU = seizure monitoring unit; GNU = general neurology unit.
Unit
Never n (%)
Sometimes n (%)
Usually n (%)
Always n (%)
p
0.755
GNU SMU GNU SMU GNU SMU GNU SMU
1 (0.3) 2 (0.9) 0 (0) 0 (0) 6 (1.9) 2 (0.9) 4 (1.7) 2 (1.1)
18 10 26 17 23 24 37 15
(5.7) (4.6) (8.3) (7.9) (7.3) (11.3) (15.9) (8.3)
54 39 76 54 75 49 65 28
(17.0) (18.0) (24.1) (25.1) (23.8) (23.0) (28.0) (15.5)
244 166 213 144 211 138 126 136
(77.0) (76.5) (67.6) (67.0) (67.0) (64.8) (54.3) (75.1)
GNU SMU GNU SMU GNU SMU
1 (0.3) 2 (0.9) 2 (0.6) 6 (2.8) 6 (2.0) 3 (1.4)
18 13 38 20 32 27
(5.8) (6.1) (12.3) (9.4) (10.4) (12.6)
51 41 64 50 88 65
(16.3) (19.3) (20.6) (23.5) (28.7) (30.4)
242 156 206 137 181 119
(77.6) (73.6) (66.5) (64.3) (59.0) (55.6)
GNU SMU GNU SMU GNU SMU
6 (2.0) 2 (0.9) 30 (9.6) 5 (2.4) 3 (2.2) 3 (4.9)
44 (14.4) 24 (11.3) 86 (27.4) 28 (13.3) 17 (12.7) 4 (6.6)
100 58 88 71 39 12
(32.8) (27.2) (28.0) (33.8) (29.1) (19.7)
155 (50.8) 129 (60.6) 110 (35.0) 106 (50.5) 75 (56.0) 42 (68.9)
0.962 0.368 0.000
0.617 0.146 0.770
0.154 0.000 0.170
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this is the first study to explore patient experience in a SMU compared to a GNU. The characteristics of SMU patients differed from GNU patients, with SMU patients being significantly younger, more likely to be single or never married, and more likely to report lower overall mental health. Regarding hospital care, unlike the older, acute care GNU patients, SMU patients were less likely to require assistance with activities of daily living, to require pain medication, or to receive a new medication while in hospital. Seizure monitoring unit patient ratings of call-button responsiveness were higher than GNU patient ratings, likely reflecting the smaller area of the SMU and that at least one staff member is present on the unit at all times. The hospital environment was reported as quieter and cleaner by the SMU patients, also likely reflecting the smaller space assigned to the SMU. The only area in which SMU patients reported deficient care compared to the GNU was with discharge information: SMU patients were less likely than GNU patients to report receiving written discharge information, which is concerning given that this is a crucial component of the hospital process that helps to ensure optimal ongoing management of patient needs post-hospital discharge. Although differences in GNU and SMU patient responses existed on these specified rating items, there were several similarities across patient responses from both units. For example, most patients were extremely satisfied with nursing and physician care and perceived that they were treated with courtesy and respect while in the hospital. Additionally, patients on both units gave a higher than 8/10 average rating of their overall hospital stay although overall ratings were statistically higher for SMU patients. A major criticism of patient satisfaction surveys, such as the one administered here, is that they present a “limited and optimistic picture” [15]. For example, one study of hospital care in a general medical population reported that more than half of patients stated that they received excellent care [15]. However, when asked to complete a more detailed questionnaire, these patients specified at least four problems with their care [15]. Most studies of epilepsy patient satisfaction with medical care have reported high levels of satisfaction. A study comparing a hospital clinic for epilepsy patients with an epilepsy telemedicine clinic found that 90% of patients reported satisfaction with service quality regardless of which clinic they were assigned to [16], and another study reported that 67% of patients surveyed following contact with an epilepsy nurse specialist stated that they were extremely or very satisfied with their care [17]. The generally positive ratings obtained in our study may be a reflection of a bias toward providing high satisfaction scores, particularly because all responses were collected over the telephone. Mail and phone survey methods have been approved for HCAHPS administration [18]; however, one study using both paper and telephone survey methods noted that telephone respondents provided higher evaluations of their care in general [19]. Although social desirability is often used to explain the trend toward more positive results when surveying by telephone [20], this may not be the only factor. Other studies have attributed the positive bias of telephone surveys to a recency effect where respondents are more likely to choose latter response options [21]. Because more positive options are placed last on the HCAHPS survey, it is possible that recency effects contributed to our high satisfaction ratings in addition to social desirability. As a result, it is important that different modes of assessment be compared to determine which provide more accurate responses. Our finding that more educated patients tended to assign lower satisfaction scores to their hospital stay, regardless of the unit they were on, has been noted repeatedly in the literature [22–27]. Little to no explanation has been given for this association between hospital ratings and education, other than the possibility that more educated patients think more critically about their experiences in the health care system [23]. The literature reports many associations between demographics and ratings of care that we did not find in our study, including age [22,24,27], self-ratings of health status [22,23,26],
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and shorter length of stay [24], each shown in the literature to be positively associated with satisfaction. It will be important that we continue to capture information about patient demographics and aspects of their hospital stay (e.g., length of stay) to ensure that we assess whether SMU patient experience ratings vary according to these variables. Lower ratings of emotional health expressed by SMU patients compared to GNU patients in this study could be explained by the high prevalence of mood disorders in patients with epilepsy. A recent population-based study [28] demonstrated that epilepsy patients have an increased lifetime prevalence of mental health disorders compared to the general population (35.5% versus 20.7%). Because research suggests that seizures in patients with comorbid psychiatric disorders are more likely to fail antiepileptic pharmacotherapy [29] and that these patients have worse outcomes after surgical interventions [30], psychiatric care is a necessary and crucial component of epilepsy care. A SMU admission presents an excellent opportunity to identify potentially undetected mental health conditions in epilepsy patients. This could be accomplished by adding a simple mental health self-report screening questionnaire to the admission process in order to identify patients who may require a psychiatric or psychological consultation as part of their SMU admission. Limitations of our study include the absence of data regarding the number of times patients had been previously admitted to particular units and if patients had previously completed a HCAHPS survey for that unit. Because it has been found that repeat admissions can lower patient responses to satisfaction questionnaires [24] and repeat admissions may occur in SMUs when seizures do not occur at first admission [31], it is possible that previous admissions may have influenced our results. We were also unable to determine the precise response rate for our GNU sample or examine differences between responders and non-responders because these data were collected by a provincial health service that did not collect these variables. However, concerns related to response rates are negligible due to our large sample size, and a previous study found that increasing the response rate of a hospital satisfaction survey from 30% to 70% had minimal influence on overall conclusions [32]. This study acquired valuable information regarding patient experience on our SMU and how SMU patient satisfaction compares to patient satisfaction for a similar neurological unit. We recommend that all SMU patients be screened for mental health problems as part of their admission and that all patients be provided with written documentation at discharge. The utility of the HCAHPS survey as a quality improvement measure for SMUs would likely be increased by the addition of SMU-specific items (e.g., did you believe/trust that you would be safe from harm if you had a seizure?). Additional unit-specific questions can easily be added to the existing HCAHPS survey, and integrated surveys using HCAHPS have been shown to be psychometrically sound [33]. As more medical centers acquire SMUs, it is important that existing sites determine how these unique units can best be managed to ensure optimal outcomes and experience for patients. We recommend that all sites collect ongoing, SMUspecific, patient satisfaction data with standardized instruments such as the HCAHPS survey in order to target quality improvement initiatives and to track the effectiveness of such initiatives over time. Acknowledgments This study was partially supported by a Department of Clinical Neurosciences, Alberta Health Services, ARP Retro Grant awarded to Drs. Macrodimitris, Pillay, Wiebe, and Jetté to support initiatives for the Seizure Monitoring Unit Quality Improvement Team (SMU QI Team). Jodie Roberts received a summer studentship from Alberta Innovates Health Solutions for this project. Dr. Nathalie Jetté is the recipient of an Alberta Innovates Health Solution (Population Health Investigator) and a Canada Research Chair Tier 2 in Neurological
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Population Health and Health Services Research. She also has operating funds from the Canadian Institutes of Health Research, the Public Health Agency of Canada, Alberta Health and Wellness and the University of Calgary Hotchkiss Brain Institute. She sits on the editorial board of Epilepsia. Dr. Samuel Wiebe receives research support from the Alberta Innovates Health Solutions, Canadian Institutes of Health Research, and University of Calgary (Hopewell Professorship of Clinical Neurosciences Research). Dr. Paolo Federico receives research support from the Canadian Institutes of Health Research and the University of Calgary. Appendix A. Supplementary data Supplementary data to this article can be found online at doi:10. 1016/j.yebeh.2012.03.002. References [1] Cheung CS, Bower WF, Kwok SC, van Hasselt CA. Contributors to surgical inpatient satisfaction—development and reliability of a targeted instrument. Asian J Surg 2009;32(3):143–50. [2] Thomas LH, MacMillan J, McColl E, Priest J, Hale C, Bond S. Obtaining patients' views of nursing care to inform the development of a patient satisfaction scale. Int J Qual Health Care 1995;7(2):153–63. [3] Laschinger HS, Hall LM, Pedersen C, Almost J. A psychometric analysis of the patient satisfaction with nursing care quality questionnaire: an actionable approach to measuring patient satisfaction. J Nurs Care Qual 2005;20(3):220–30. [4] Grosset KA, Grosset DG. Patient-perceived involvement and satisfaction in Parkinson's disease: effect on therapy decisions and quality of life. Mov Disord 2005;20(5):616–9. [5] Barr JK, Giannotti TE, Sofaer S, Duquette CE, Waters WJ, Petrillo MK. Using public reports of patient satisfaction for hospital quality improvement. Health Serv Res 2006;41(3 Pt 1):663–82. [6] Chappell B, Smithson WH. Patient views on primary care services for epilepsy and areas where additional professional knowledge would be welcome. Seizure 1998;7(6):447–57. [7] Jain P, Patterson VH, Morrow JI. What people with epilepsy want from a hospital clinic. Seizure 1993;2(1):75–8. [8] Smolowitz JL, Hopkins SC, Perrine T, Eck KE, Hirsch LJ, O'Neil Mundinger M. Diagnostic utility of an epilepsy monitoring unit. Am J Med Qual 2007;22(2):117–22. [9] Upton D, Thompson PJ, Duncan JS. Patient satisfaction with specialized epilepsy assessment and treatment. Seizure 1996;5(3):195–8. [10] Buelow JM, Privitera M, Levisohn P, Barkley GL. A description of current practice in epilepsy monitoring units. Epilepsy Behav 2009;15(3):308–13. [11] Perkins AM, Buchhalter JR. Optimizing patient care in the pediatric epilepsy monitoring unit. J Neurosci Nurs 2006;38(6):416–21 [34]. [12] Sarkissian S, Politzer N, Zahn C, Doran DI. Implementation of a change process to improve outcomes of patients admitted to epilepsy monitoring unit. Outcomes Manag Nurs Pract 2001;5(1):11–6 [quiz 6–7].
[13] Lagerlund TD, Cascino GD, Cicora KM, Sharbrough FW. Long-term electroencephalographic monitoring for diagnosis and management of seizures. Mayo Clin Proc 1996;71(10):1000–6. [14] Goldstein E, Farquhar M, Crofton C, Darby C, Garfinkel S. Measuring hospital care from the patients' perspective: an overview of the CAHPS hospital survey development process. Health Serv Res 2005;40(6 Pt 2):1977–95. [15] Jenkinson C, Coulter A, Bruster S, Richards N, Chandola T. Patients' experiences and satisfaction with health care: results of a questionnaire study of specific aspects of care. Qual Saf Health Care 2002;11(4):335–9. [16] Ahmed SN, Mann C, Sinclair DB, et al. Feasibility of epilepsy follow-up care through telemedicine: a pilot study on the patient's perspective. Epilepsia 2008;49(4): 573–85. [17] Hosking PG, Duncan JS, Sander JM. The epilepsy nurse specialist at a tertiary care hospital—improving the interface between primary and tertiary care. Seizure 2002;11(8):494–9. [18] Giordano LA, Elliott MN, Goldstein E, Lehrman WG, Spencer PA. Development, implementation, and public reporting of the HCAHPS survey. Med Care Res Rev 2010;67(1):27–37. [19] de Vries H, Elliott MN, Hepner KA, Keller SD, Hays RD. Equivalence of mail and telephone responses to the CAHPS hospital survey. Health Serv Res 2005;40(6 Pt 2):2120–39. [20] Burroughs TE, Waterman BM, Cira JC, Desikan R, Claiborne Dunagan W. Patient satisfaction measurement strategies: a comparison of phone and mail methods. Jt Comm J Qual Improv 2001;27(7):349–61. [21] Dillman DA, Brown TL, Carlson JE, et al. Effects of category order on answers in mail and telephone surveys. Rural Sociol 1995;60(4):674–87. [22] Bleich SN, Ozaltin E, Murray CJL. How does satisfaction with the health-care system relate to patient experience? Bull World Health Organ 2009;87:271–8. [23] Otani K. Enrollees' global rating process of health care with the national CAHPS Benchmarking Database. Health Care Manage Rev 2006;31(3):205–12. [24] Quintana JM, Gonzalez N, Bilbao A, et al. Predictors of patient satisfaction with hospital health care. BMC Health Serv Res 2006;6:102. [25] Bautista RE, Glen ET, Shetty NK. Factors associated with satisfaction with care among patients with epilepsy. Epilepsy Behav 2007;11(4):518–24. [26] O'Malley AJ, Zaslavsky AM, Elliott MN, Zaborski L, Cleary PD. Case-mix adjustment of the CAHPS hospital survey. Health Serv Res 2005;40(6 Pt 2):2162–81. [27] Hargraves JL, Wilson IB, Zaslavsky A, et al. Adjusting for patient characteristics when analyzing reports from patients about hospital care. Med Care 2001;39(6): 635–41. [28] Tellez-Zenteno JF, Patten SB, Jette N, Williams J, Wiebe S. Psychiatric comorbidity in epilepsy: a population-based analysis. Epilepsia 2007;48(12):2336–44. [29] Hitiris N, Mohanraj R, Norrie J, Sills GJ, Brodie MJ. Predictors of pharmacoresistant epilepsy. Epilepsy Res 2007;75(2–3):192–6. [30] Kanner AM, Byrne R, Chicharro A, Wuu J, Frey M. A lifetime psychiatric history predicts a worse seizure outcome following temporal lobectomy. Neurology 2009;72(9):793–9. [31] Zarkou S, Grade M, Hoerth MT, Noe KH, Sirven JI, Drazkowski JF. Indeterminate EMU admissions: does repeating the admission help? Epilepsy Behav 2011;20(4): 706–8. [32] Perneger TV, Chamot E, Bovier PA. Nonresponse bias in a survey of patient perceptions of hospital care. Med Care 2005;43(4):374–80. [33] Rothman AA, Park H, Hays RD, Edwards C, Dudley RA. Can additional patient experience items improve the reliability of and add new domains to the CAHPS hospital survey? Health Serv Res 2008;43(6):2201–22.