Skip Navigation

This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrow Search for citing articles in:
ISI Web of Science (3)
Right arrowRequest Permissions
Google Scholar
Right arrow Articles by TOKUNAGA, J.
Right arrow Articles by IMANAKA, Y.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by TOKUNAGA, J.
Right arrow Articles by IMANAKA, Y.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?

International Journal for Quality in Health Care 14:493-502 (2002)
© 2002 International Society for Quality in Health Care

Paper

Influence of length of stay on patient satisfaction with hospital care in Japan

JUNYA TOKUNAGA1 and YUICHI IMANAKA2

1School of Nursing and Social Welfare, Kyushu University of Nursing and Social Welfare
2Department of Healthcare Economics and Quality Management, Graduate School of Medicine, School of Public Health, Kyoto University, Kyoto, Japan

Objective. The objective of this study was to identify specific patient satisfaction items related to overall satisfaction by different length of stay (LOS) for patients in Japanese hospital settings.

Methods. This cross-sectional study involved a participant sample, drawn from 77 voluntarily participating hospitals throughout Japan, of in-patients discharged to the community. Older patients and psychiatric, pediatric, obstetric and gynecologic patients were excluded. The 1050 respondents analyzed (response rate >=51.1%) were divided into three groups based on their LOS: group 1, LOS <=1 week; group 2, LOS <=1 month; and group 3, LOS >1 month. Using stepwise multiple regression analysis, we explored for each LOS group the relationship between overall patient satisfaction and satisfaction with 33 individual items, including three regarding perceived reputation of the hospital in question.

Results. Some unique satisfaction items for each group (e.g. ‘skill of nursing care’ in group 1, ‘Recovery of physical health’, ‘skill of nursing care’, and ‘respect for patients opinions and feelings’ in group 2, and ‘relief from pain’ and ‘respect for patients’ opinions and feelings’ in Group3) were significantly associated with overall satisfaction. In all three groups, common items (e.g. ‘recovery from distress and anxiety’ and ‘doctor’s clinical competence’) also related significantly to overall satisfaction. Two items pertaining to the hospital reputation dimension (e.g. ‘family member’s evaluation of the hospital’ and ‘hospital reputation among other patients’) were also significant predictors of overall satisfaction in all three groups.

Conclusion. The findings show that according to LOS, unique items could determine significantly the achievement of overall satisfaction, while some common predictors across all three LOS groupings also seemed to be indispensable for in-patient’s assessment of hospital care. It was also confirmed in this study that a positive perception of hospital reputation might have an important role in patient satisfaction in Japan.

Keywords: hospital reputation, length of hospital stay, patient satisfaction, quality of care

From among the member countries of the Organization for Economic Cooperation and Development (OECD), Japan has by far the longest average length of stay (LOS) for patients in hospital (41.9 days), whereas that of all OECD countries together is ~11.7 days [1]. Clarke classified the causes of variation in LOS according to supply and demand factors [2]. Another recent study reported that the differences in the medical insurance payment and reimbursement systems between Japan and the United States seem to have a major impact on the differences in LOS between the two countries, which are also partly mediated by differences in physicians’ patterns of practice, patients’ preferences, and hospital human and material resources [3].

To date, LOS has mainly been described and analyzed in terms of hospital expenses in the context of how to contain or reduce health care costs [2,3]. There has been less focus on the relationship between LOS and quality of care, especially in terms of patient satisfaction, which is considered to be one of the desired outcomes of health care—even an element of health status itself [4]. Carmel studied the relationship between LOS and patient satisfaction, exploring whether and to what extent satisfaction with three types of hospital services (medical, nursing, and supportive services) was differentially explained by patients’ sociodemographic, psychosocial, situational, and attitudinal characteristics; the study revealed a significant positive relationship between long LOS and patient satisfaction with the surgical ward nurses [5]. Rosenheck et al. reported a relationship between longer LOS and higher levels of general satisfaction among patients with psychiatric and substance use diagnoses [6]. Cleary et al., however, reported that when they controlled statistically for other predictors, no significant impact could be found of LOS on any of six health outcomes, including patient satisfaction with hospital care, for six medical and surgical conditions, although they identified several other significant correlations [7]. Other studies, using comprehensive meta-analytic approaches, also failed to identify any clear relationship between LOS and patient satisfaction [8,9]. In Japan, hospital stay is exceptionally long, and therefore it can be surmised that some predictors of overall patient satisfaction with hospital care are specific to LOS. An earlier study that assessed patient satisfaction with a hospital-based ambulatory service in Japan yielded some support for this hypothesis [10]. There have been some studies to date that have analyzed the relationship between specific aspects of hospital care and overall satisfaction [11–14]. Meanwhile, for some time now, one of the controversial issues in hospital care has been identifying the detailed relationship between LOS and patient satisfaction with hospital care. Understanding the relationship between LOS and specific contributors to overall satisfaction is indispensable for hospital personnel in planning their improvements to the quality of in-patient care. We should bear in mind, however, that simple comparison of patient satisfaction scores for various other OECD countries and Japan may lead us to draw inaccurate conclusions because of the large and significant differences in average LOS. To facilitate such comparisons among countries, we classified the participants in our study into groups on the basis of their LOS in hospital.

The aims of this study, therefore, were to identify specific patient satisfaction items related to overall satisfaction by different LOS for patients in Japanese hospital settings.

Methods

Participants
This study was based on the dataset of an earlier study that had examined the causal relationship between patients’ satisfaction and health care workers’ satisfaction [15]. Participants were drawn from in-patients discharged to the community from 77 hospitals voluntarily taking part in the study (33 public and 44 private) throughout Japan. Data were collected by the authors, who were neither in charge of the participants’ care nor in the same workplace. Sets of self-administered patient satisfaction questionnaires were mailed to the participating hospitals. All in-patients (n = 10 350) were given a copy of the questionnaire and a stamped, addressed envelope on discharge from hospital in February and March 1996. Donabedian has pointed out that patients might be reluctant to reveal their opinions to hospitals for fear of alienating their medical attendants [4]. Therefore, the questionnaires were returned to us directly. The overall response rate was 56.2%, representing 5814 respondents. Of the responses, patients hospitalized in the psychiatric, pediatric, and obstetrics/gynecology departments (n = 1071) were excluded due to the reasons given below, in order to strengthen validity as much as possible. In particular, psychiatric in-patients have extremely long LOS in Japan [16] and obstetrics/gynecology departments have many pregnant in-patients for delivery (normal delivery is not covered by the national health insurance and special amenity services are attached).

If we make a worst-case assumption that the response rate for the psychiatry, pediatrics and obstetrics/gynecology patients was 100%, the response rate for the medical/surgical patients would be 51.1% [(5814–1071)/(10 350–1071)]. If the response rate for the psychiatry, pediatrics and obstetrics/gynecology patients was <100%, then, by derivation, the response rate for medical/surgical patients would be correspondingly higher. For example, given a 50% response rate for the psychiatry, pediatrics and obstetrics/gynecology group, the response rate for the medical/surgical patients would be 57.1% [(5814–1071)/(10 350–2142)]. More than 95% of pediatric in-patients returned responses completed by their proxy, such as a parent. Respondents whose age was not in the range 16–64 years were also excluded, in as much as older patients generally have remarkably longer LOS [16]. Similarly, incomplete questionnaires and those that had blank or proxy responses in the variables used for the multivariate analysis were omitted. Finally, we analyzed 1050 questionnaires of respondents with complete data who were a subset of the 4743 patients in the medical/surgical group.

Measurements
On the basis of items identified by previous studies [17–22], and the particular characteristics of the Japanese hospital setting, our questionnaire incorporated six exploratory patient satisfaction dimensions: (1) improvement in health status, (2) attitude and performance of hospital staff, (3) emotional communication, (4) medical information, (5) provision of care, and (6) living arrangements. In addition to these six dimensions, the questionnaire included one dimension on overall satisfaction with hospital care, as well as three items concerning patients’ evaluation of their hospital’s reputation. The dimensions and items of the patient satisfaction questionnaire have been described in detail in our previous study [23].

The outcome measure was overall satisfaction with in-patient hospital care. This was calculated using a four-item, closed-format questionnaire. The four items were rated using a five-point Likert-type format, and they addressed satisfaction with hospital care, satisfaction with the outcome of care, intention to use that hospital again in case of sickness, and comfort in recommending that hospital to family members or friends. The overall satisfaction score is the sum of the scores on the four items; this can range between 4 and 20.

The independent variables included: the patient’s age (in years) and sex (coded 1 for male and 0 for female); the patient’s subjective evaluation of the state of his or her daily activities after discharge (ranging from 1 for completely normal to 5 for people needing rest and assistance; a higher score indicates worse health status); necessity for periodic follow-up medical examination (coded 1 if ‘yes’ and 0 if ‘no’); frequency of hospitalizations; surgical procedure (coded 1 for ‘yes’ and 0 for ‘no’); and hospital department (coded 1 for ‘internal medicine group’ and 0 for ‘surgery group’).

Patients’ satisfaction with hospital care and their evaluation of their hospital’s reputation were measured using a 5-point evaluation rating scale (poor, fair, good, very good, excellent) questionnaire, on which discharged patients gave a score for each of 33 items relevant to specific aspects of their care while in hospital. When compared with normal distribution, the distribution of values from the scales is highly acceptable, as confirmed by Ross et al., although the scale distribution was slightly skewed toward the positive [24]. According to Ware and Hays, this scale format yields a mean score closer to the midpoint of the scale’s range (i.e. a lower score), together with a greater variability of responses, than a 6-choice scale [17]. The 33 items were analyzed individually to identify specific aspects of patient satisfaction that affect overall satisfaction relative to different LOS.

To reduce recall bias and blank responses as much as possible, we used an ordinal scale to determine LOS. A number of studies on patient satisfaction have been conducted in North America and Europe, where the average LOS is ~1 week [1]. Average LOS in Japanese hospitals, excluding departments of psychiatry and other special chronic care units, is reported in official government statistics to be 32.8 days [16]. Therefore, to make our study more useful for OECD cross-country comparisons, we divided our respondents into three groups on the basis of LOS: group 1 comprised respondents who had been hospital in-patients for <=1 week; group 2 respondents who had been hospitalized for between 1 week and 1 month; and group 3 respondents who had been hospitalized for >1 month.

Analysis
No statistically significant differences appeared with regard to basic demographic variables between patients in public as opposed to private hospitals. The following analysis, therefore, was applied to all combined respondents. However, the distributions of some patient characteristics (e.g. age, surgical procedure, frequency of hospitalization, hospital department, and status of daily activity after discharge) were statistically significantly different between the 1050 cases in the analyzed sample and the other 3693 medical/surgical respondents: the analyzed sample had a higher surgical procedure rate and a higher daily activity status, and were younger, with a lower rate of entry to internal medicine, and were hospitalized less frequently (Table 1).


View this table:
[in this window]
[in a new window]
  		Table 1 Respondent characteristics for the excluded and analyzed groups1

 

One-way analysis of variance (ANOVA) and the chi-squared test were performed to compare means or proportions of basic sample characteristics and patient satisfaction in all LOS groups. After the comparison to clarify the distribution of these variables, stepwise multiple linear regression for each LOS group was conducted in order to identify determinants of overall satisfaction. The explanatory variables were basic sample characteristics and 33 patient satisfaction items described above. The modeling was started with the strongest univariate predictor, and then covariables were added if the change significantly improved the fit of the model, or were removed if their contribution was shown to be non-significant. The ordinary level of statistical significance (P < 0.05 in and P < 0.10 out, based on the corresponding F-statistic) was the criterion used to determine when to add or remove a predictor variable. We used the program SPSS 7.5 for the analysis [25].

Results

Alpha reliability (Cronbach’s alpha) for overall satisfaction in each LOS group was 0.80, 0.86, and 0.86 for groups 1, 2, and 3, respectively, and this indicates adequate internal consistency [26]. Table 1 shows the results of the bivariate analysis between each of the LOS groups. There were statistically significant differences among the three groups with respect to age, necessity for periodic follow-up examinations, and status of daily activity. The respondents in group 1 were significantly younger than those in the two other groups. The score for the item status of daily activity after discharge was also significantly lower for group 1 than for the two other groups, as were the rates of necessity for periodic follow-up examinations. There were no statistically significant differences in the score for overall satisfaction among the three groups, although significant differences were observed in some scores of patient satisfaction items: longer LOS patients were less satisfied.

The results of the stepwise multiple regression analysis, controlled by basic sample characteristics, are presented in Table 2. The adjusted R2 for the control variables was very small; 0.076, 0.066, and 0.054, in groups 1, 2, and 3, respectively. Overall satisfaction of the group 1 patients was significantly positively related to the satisfaction with ‘family member’s evaluation of the hospital’, ‘doctor’s clinical competence’, ‘skill of nursing care’, and ‘recovery from distress and anxiety’. In addition, some of the basic sample characteristics (e.g. patient’s age, surgical procedure rate, frequency of hospitalization) also related significantly to overall satisfaction with hospital care.


View this table:
[in this window]
[in a new window]
  		Table 2 Basic sample characteristics and patient satisfaction items by LOS1

 


View this table:
[in this window]
[in a new window]
  		Table 3 Stepwise multiple regression of overall patient satisfaction for demographic and patient satisfaction items by length of stay (LOS)

 
For group 2 patients, there was a statistically significant relationship between overall satisfaction and the same items identified by group 1 (i.e. ‘skill of nursing care’, ‘doctor’s clinical competence’, ‘recovery from distress and anxiety’, and ‘family member’s evaluation of the hospital’), as well as with the additional items ‘recovery of physical health’ and ‘respect for patients’ opinions and feelings’. From among the demographic variables, age and sex were significantly related to overall satisfaction: older and female respondents were more satisfied. Furthermore, the analysis suggested a positive relationship between ‘comprehensive comfort during hospitalization’ (pertaining to the living arrangements dimension) and overall satisfaction with hospital care in this group, although this item was not included in the final model (P = 0.10, data not included shown).

Items such as ‘doctor’s clinical competence’ and ‘recovery from distress and anxiety’ were statistically significant in their association with overall satisfaction with hospital care for the respondents in all three groups. In addition, in group 3, other items had this statistically significant relationship, namely ‘respect for patients’ opinions and feelings’, ‘relief from pain’, and ‘hospital’s reputation among other patients’. The analysis of the data for group 3 respondents also suggested a positive relationship between some items, such as ‘nurses’ responsibility and dedication’ and ‘helping communication, difficulties asking questions’, and overall satisfaction (P = 0.058 and 0.074, respectively; data not shown). With respect to the demographic variables, in group 3 age showed a statistically significant relationship with overall satisfaction: the older the respondent, the higher the overall level of satisfaction with hospital care.

Each adjusted R2 for the three multivariate models was >0.53, and the increment in variance accounted for by the satisfaction items was statistically significant.

Discussion

The aims of this study were to identify specific patient satisfaction items related to overall satisfaction by different LOS for patients in the Japanese hospital setting. The bivariate analysis showed the differences in some of the basic characteristics to be statistically significant among the three LOS groups (e.g. patient’s age, necessity for periodic follow-up medical examinations, and status of daily activity after discharge). Indirectly, this might also show differences among the three groups with regard to the severity of the illnesses of the respondents comprising them. The amount of variance in overall satisfaction predicted by control variables, however, was very small (a maximum of ~7%) in each multiple regression model. These results indicate that these significant characteristics could be relatively trivial for the study findings, despite being statistically significant. The study reported here confirms the conclusions of Hall and Dornan, in that the relationship between overall satisfaction and patients’ demographic variables is extremely small, even when statistically significant [9].

The score for overall satisfaction with hospital care was not statistically significantly different among the three groups. An earlier study supports these trends, although it is not possible to make a strict comparison because of the differences in study design [7]. Additionally, patients in the longest LOS group were significantly less satisfied with some patient satisfaction items. In a study of patients hospitalized for a hysterectomy, Clarke found that short postoperative stays did not seem to be associated with any adverse outcomes, and they did result in modest financial savings to the health care system [27]. Together with our findings, this may imply that there is potential for the greater use of early discharge, although many important questions remain to be answered.

In group 1, the group with the shortest LOS, the specific item with a positive relationship with overall satisfaction was ‘skill of nursing care’. The items that were significant predictors of overall satisfaction in group 1 (e.g. ‘skill of nursing care’, ‘doctor’s clinical competence’, and age) have also been found to be positive predictors of patient satisfaction with hospital care by studies conducted in other OECD countries, where the LOS in hospital is much shorter [28–32]. This lends support to the validity of our results, as well as, perhaps, to their generalizability. Carmel indicated that ‘satisfaction with organizations in the past’ might contribute to the explanation of satisfaction in the present [5]. In this study, there is a possibility that the variables of past experience of hospitalization (e.g. ‘frequency of hospitalization’) may have related positively to overall satisfaction. Further research, however, is needed to elucidate the relationship between these variables and overall satisfaction in the short-LOS patient group in Japan.

For group 2 respondents, not only ‘skill of nursing care’, but also ‘respect for patients’ opinions and feelings’ and ‘recovery of physical health’ were found to have a statistically significant relationship to patients’ overall satisfaction with their hospital care. It is reasonable to assume that when compared with patients hospitalized for only a few days, this patient group, generally, would have more opportunity, in collaboration with hospital staff, to decide what medical treatments they should receive and what living arrangements should be made. It could also be assumed, therefore, that the attitude of hospital staff members, such as their ‘respect for patients’ opinions and feelings’, would become significant for these patients. Living arrangements (i.e. ‘Comprehensive comfort during hospitalization’), understandably, also become a crucial factor for these patients, despite exclusion from final multivariate modeling (P = 0.10, data not shown), as they are compelled to acclimatise themselves to unfamiliar hospital life.

The findings specific for the respondents in group 3, however, indicate that for in-patients receiving long-term care it may become more important to receive pain relief than to experience an improvement in functional health status. Concomitantly, it may be also be concluded from these findings that patients in long-term care detest continuing painful treatments and/or ongoing painful symptoms, although it should not be inferred that they expect no improvement at all in the status of their physical health. Although some predictors, such as ‘nurses’ responsibility and dedication’ and ‘helping communication, difficulties asking questions’, were not included in the final model (P = 0.058 and 0.074, respectively), these findings may imply that for long-stay in-patients, interpersonal factors take on a greater importance than the more technical or scientific patient satisfaction items.

Some predictors were common to all three LOS groups. For example, in our study, ‘doctor’s clinical competence’ and ‘recovery from distress and anxiety’ had a statistically significant association with overall satisfaction with hospital care, regardless of LOS. Satisfaction with physicians has been reported previously to be the best predictor of patients’ general satisfaction with their hospital care, and the factor that best explains the variance in levels of overall satisfaction with hospitalization [5]. Williams and Calnan found that ‘confidence in hospital doctors’ was the only strong predictor of patients’ overall satisfaction with hospital care [33]. Of course, the competence of the doctors involved is one of the essential variables that contribute to patients’ overall satisfaction with hospital care. Nevertheless, it is a remarkable and meaningful finding of our study that ‘doctor’s clinical competence’ is a strong predictor of patient satisfaction, no matter what the LOS.

It is certainly natural that ‘recovery from distress and anxiety’ pertaining to the improvement in health status dimension was also a common determinant of overall satisfaction; this, too, is the case irrespective of the length of hospital stay. Using the same hospital settings as we did for the research reported here, a study by Carmel reported that improvement in health status has a statistically significant positive association (stronger than with any other variable) with patients’ general satisfaction with hospital care [5]. Covinsky et al., however, found in their prospective cohort study that there was no association between patient satisfaction at discharge and health status changes between admission and discharge [34]. Thus, they concluded that the relation was explained by the tendency of healthier patients to report greater satisfaction with health care, rather than an effect of the change in health status per se. Although patient satisfaction with ‘recovery from distress and anxiety’ in our study is not equivalent to the actual improvement or perception of improvement in health status, our results suggest that patients attach much importance to the satisfaction with relief of their psychological burden, irrespective of their LOS.

Furthermore, a number of other studies have revealed a positive relationship between overall satisfaction and aspects of nursing care [28–30]. This may be because nursing care is the major supportive service provided to in-patients, and nursing personnel comprise the largest proportion of the health service community [35]. Our study found a statistically significant relationship between the items about nursing personnel on our questionnaire and overall satisfaction with hospital care for all groups, regardless of length of stay, corroborating external validity.

Our results also show that it is crucial for hospital staff to adjust their decisions regarding which aspects of patient satisfaction to focus on and emphasize, in the service of patients’ overall satisfaction with their hospital stay, by paying attention to each patient’s anticipated LOS.

There was, for all groups, a statistically positive relationship between overall satisfaction and the two items on the questionnaire concerning the hospital’s reputation, namely ‘family members’ evaluation of the hospital’ and ‘hospital’s reputation among other patients’. This relationship was also identified in an earlier study in Japan, exploring the effects of patient demands on their satisfaction with hospital care [23]. Imanaka et al., who surveyed outpatients, also reported that patients’ assessment of their hospital’s reputation is one of the most important determinants of patient satisfaction in Japan [10,22]. For patients seeking hospital care, the general reputation of the hospital in which they are planning to have a consultation, or to which they may be admitted as in-patients, will provide them with enough preparatory information concerning the quality of the hospital care they will be receiving, and also a sense of relief. Furthermore, Imanaka’s group pointed out that in Japan this general reputation or evaluation of the hospital plays a meaningful role in patients’ subsequent judgment of the quality of their hospital care [10]. Thus, a positive relationship between patients’ overall satisfaction with their hospital care and some of the items on the questionnaire pertaining to their perception of their hospital’s reputation was confirmed in this study, irrespective of patients’ LOS. Nevertheless, further research is required to examine in detail both the causality in this relationship and the generalizability of this finding to different hospital settings in other OECD countries.

We also reviewed the reliability and external validity of our findings. With regard to the reliability of overall satisfaction scale, the constructed scores showed satisfactorily high internal consistency (Cronbach’s {alpha} >0.85) [26]. In our study, 53.4% (39 of 77) participating hospitals had >=500 beds. When this proportion is compared with that for Japan overall (5.4%) [16], it can be assumed that many hospitals that participated in this study are probably the principal hospital in a particular ‘medical zone‘(area for regional health care) [36]. The average LOS in hospital for the respondents that we studied cannot be known precisely because of the ordinal scale format of our investigation. Nevertheless, it is known that in Japan the bigger general hospitals, by and large, have been requested to shorten in-patients’ LOS [37]. Therefore, the average LOS of our sample may be shorter than that of the national in-patient population. It is possible, albeit unlikely, that our study findings were distorted by the LOS distribution.

Content validity was ensured through the comprehensive review of the multiple sources of documented information consulted in the process of constructing the questionnaire.

Lasek et al. reported that responses to the mailed patient satisfaction survey were obtained from 54% of patients (range 40–63% at individual hospitals) [38]. In addition to this, in their study examining the quality of response rate reporting in 210 published patient satisfaction studies, Sitzia and Wood indicated that questionnaire surveys conducted by mail produced a mean response rate of 66%, with 70% of such studies recording a rate of >=60% [39]. Other patient satisfaction studies also reported similar response rates [11–14]. In terms of study implementation and methodology, the validity of our study seems to be almost satisfactory, in as much as our response rate was close to those of these other studies. The adjusted R2 for the model, and its significant increment in variance accounted for by the satisfaction items, indicated that >50% of the variance in overall satisfaction could be explained by the significant predictors, suggesting that the exploratory questionnaire items had satisfactory validity.

Nevertheless, there are some limitations in interpreting the results of our study. All patient satisfaction items and dimensions incorporated into our questionnaire were selected in an exploratory manner on the basis of the content validity. Therefore, further study is required to confirm whether there are other aspects of patient satisfaction in Japanese hospital care not included in the questionnaire and whether each battery in this present study has sufficient internal consistency and validity. Sociodemographic variables, such as social class, type of medical insurance, level of education attained, race, and access to the health care facility, were not incorporated in our questionnaire, because an earlier study identified these as not being significant predictable variables for patient satisfaction with hospital care in Japan [10,22]. It will be necessary, however, to confirm in future studies that these variables may have a relationship to LOS and/or may mediate the relationship between LOS and patient satisfaction. The distribution of some basic characteristics was statistically significantly different between the analyzed sample and the other respondents. We can surmise that the reason for this significance is that we excluded older respondents (>64 years) from the analyzed sample so as to establish the validity of comparison among LOS groups. However, further studies are necessary, which are designed not only to adjust these differences between LOS groups, but also to explore the detailed relationship between medical treatments (e.g. surgical procedures) or hospital departments and overall satisfaction.

Conclusion

The major findings of this study are as follows. Firstly, to appraise patients’ overall satisfaction with their hospital care, it is essential to evaluate some particular patient satisfaction items. Thus, for patients having a hospital stay of <=1 week (group 1), investigating their satisfaction with ‘skill of nursing care’ is essential, while for patients whose stay is >1 week but <=1 month (group 2), ‘recovery of physical health’ and ‘respect for patients’ opinion and feelings’ are of particular importance, and for patients in hospital for >1 month (group 3), ‘relief from pain’ and ‘respect for patients’ opinion and feelings’ are the most important aspects of their overall satisfaction with hospital care. Secondly, some predictors of overall patient satisfaction are common to all patient groups, regardless of their length of hospital stay. These are ‘recovery from distress and anxiety’ and ‘doctor’s clinical competence’. Thirdly, in Japan, patients’ evaluation of their hospital’s reputation (on the basis of ‘family member’s evaluation of the hospital’ and ‘hospital’s reputation among other patients’, for example) might have an important role in their overall satisfaction with their hospital care.

We would like to thank all the patients who took part in the study and gratefully acknowledge the assistance of Professor Sakai Iwasaki, MD, PhD (Nippon Medical School, Japan). This research was supported by the Toyota Foundation and the Universe Foundation (93-01-007).

Address reprint requests to Junya Tokunaga, School of Nursing and Social Welfare, Kyushu University of Nursing and Social Welfare, 888 Tomio, Tamana, Kumamoto, 865-0062, Japan. E-mail: tokunaga{at}kyushu-ns.ac.jp Back

Accepted for publication July 29, 2002.

References

  1. Organization for Economic Cooperation and Development (OECD). Health Data. Paris: OECD, 1997.

  2. Clarke A. Why are we trying to reduce length of stay? Evaluation of the costs and benefits of reducing time in hospital must start from the objectives that govern the change. Qual Health Care 1996; 5: 172–179.[Free Full Text]

  3. Muramatsu N, Liang J. Comparison of Hospital Length of Stay and Charges between Japan and the United States. In: Ikegami N, Campbell JC, eds. Containing Health Care Costs in Japan. Ann Arbor, MI: University of Michigan Press, 1996, pp. 184–192.

  4. Donabedian A. The quality of care: how can it be assessed. J Am Med Assoc 1988; 260: 1743–1748.[Abstract/Free Full Text]

  5. Carmel S. Satisfaction with hospitalization: a comparative analysis of three types of services. Soc Sci Med 1985; 21: 1243–1249.

  6. Rosenheck R, Wilson NJ, Meterko M. Influence of patient and hospital factors on consumer satisfaction with inpatient mental health treatment. Psychiatr Serv 1997; 48: 1553–1561.[Abstract/Free Full Text]

  7. Cleary PD, Greenfield S, Mulley AG et al. Variations of length of stay and outcomes for six medical and surgical conditions in Massachusetts and California. J Am Med Assoc 1991; 266: 73–79.[Abstract/Free Full Text]

  8. Hall JA, Dornan MC. Meta-analysis of satisfaction with medical care: description of research domain and analysis of overall satisfaction levels. Soc Sci Med 1988; 27: 637–664.

  9. Hall JA, Dornan MC. Patient sociodemographic characteristics as predictors of satisfaction with medical care: a meta-analysis. Soc Sci Med 1990; 30: 811–818.

  10. Imanaka Y, Araki S, Murata K et al. Patient judgment of the quality of ambulatory care in a Japanese setting. Clin Perform Qual Health Care 1995; 3: 197–208.[Medline]

  11. Cleary PD, Keroy L, Karapanos G, McMullen W. Patient assessments of hospital care. QRB Qual Rev Bull 1989; June: 172–179.

  12. Doering ER. Factors influencing inpatient satisfaction with care. QRB Qual Rev Bull 1983; October: 291–299.

  13. Nelson EC, Hays RD, Larson C, Batalden PB. The patient judgement system: reliability and validity. QRB Qual Rev Bull 1989; June: 185–191.

  14. Ben-Sira Z. The structure of a hospital’s image. Med Care 1983; 21: 943–954.[Web of Science][Medline]

  15. Imanaka Y. Customers of health care organization. Byouin [Hospitals] 1997; 56: 87–91[in Japanese].

  16. Health and Welfare Statistics Association. Kokumin Eisei no Dou Kou (J Health Welfare Stat) 1999; 46: 196–211 [in Japanese].

  17. Wolf MH, Putnam SM, James SA et al. The medical interview satisfaction scale: development of a scale to measure patient perceptions of physician behavior. J Behav Med 1978; 1: 391–401.[Medline]

  18. Linder-Pelz S, Struening EL. The multidimensionality of patient satisfaction with a clinic visit. J Community Health 1985; 10: 42–54.[Medline]

  19. Ware JE, Hays RD. Methods for measuring patient satisfaction with specific encounters. Med Care 1988; 26: 393–402.[Web of Science][Medline]

  20. Hall JA, Dornan MC. What patients like about their medical care and how often they are asked: a meta-analysis of the satisfaction literature. Soc Sci Med 1988; 27: 935–939.

  21. Billinghurst B, Whitfield M. Why do patients change their general practitioner? A postal questionnaire study of patients in Avon. Br J Gen Pract 1993; 43: 336–338.[Web of Science][Medline]

  22. Imanaka Y, Araki S, Murata K, Nobutomo K. Determinants of patient satisfaction and intention to continue service utilization: analysis of survey of outpatients at a general hospital. Nippon Koshu Eisei Zasshi (Japanese Journal of Public Health) 1993; 40: 624–635.[Medline]

  23. Tokunaga J, Imanaka Y, Nobutomo K. Effects of patient demands on satisfaction with Japanese hospital care. Int J Qual Health Care 2000; 12: 395–401.[Abstract/Free Full Text]

  24. Ross CK, Steward CA, Sinacore JM. A comparative study of seven measures of patient satisfaction. Med Care 1995; 33: 392–406.[Web of Science][Medline]

  25. SPSS Inc. SPSS for Windows User’s Guide, Release 7.5. Chicago, IL: SPSS Inc., 1997.

  26. Cronbach LJ. Coefficient alpha and the internal structure of tests. Psychometrika 1951; 16: 297–334.[Web of Science]

  27. Clarke A. Does a shorter length of stay hospital stay affect the outcome and costs of hysterectomy in southern England? J Epidemiol Community Health 1996; 50: 545–550.[Abstract/Free Full Text]

  28. Abramowitz S, Cote AA, Berry E. Analyzing patient satisfaction: a multianalytic approach. QRB Qual Rev Bull 1987; 13: 122–130.[Medline]

  29. Graveley E, Littlefield J. A-cost effectiveness analysis of three staffing models for the delivery of low-risk prenatal care. Am J Public Health 1992; 82: 180–184.[Abstract/Free Full Text]

  30. Mahon PY. An analysis of the concept ‘patient satisfaction’ as it relates to contemporary nursing care. J Adv Nurs 1996; 24: 1241–1248.[Web of Science][Medline]

  31. Hays RD, Nelson EC, Rubin HR et al. Further evaluations of the PJHQ scale. In: Meterko M, Nelson EC, Rubin H, eds. Patient judgments of hospital quality, report of a pilot study. Med Care 1990; 28 (9 Suppl): S29–S39.[Web of Science][Medline]

  32. Woodside AG, Frey LL, Daly RT. Linking service quality, customer satisfaction, and behavioral intention. J Health Care Mark 1989; 9: 5–17.

  33. Williams SJ, Calnan M. Convergence and divergence: assessing criteria of consumer satisfaction across general practice, dental and hospital care settings. Soc Sci Med 1991; 33: 707–716.

  34. Covinsky KE, Rosenthal GE, Chren MM et al. The relationship between health status changes and patient satisfaction in older hospitalized medical patients. J Gen Intern Med 1998; 13: 223–229.[Web of Science][Medline]

  35. Like R, Zyzanski SJ. Patient satisfaction with the clinical encounter: social psychological determinants. Soc Sci Med 1987; 24: 351–357.

  36. Yoshikawa A, Bhattacharya J, Vogt WB (editors). Health Economics of Japan: Patients, Doctors and Hospitals Under a Universal Health Insurance System. Tokyo: University of Tokyo Press, 1996, pp. 3–37.

  37. Hasegawa T. Length of stay in Japanese hospital. Byouin [Hospitals] 1999; 58: 120–126 [in Japanese].

  38. Lasek RJ, Barkley W, Harper DL, Rosenthal GE. An evaluation of the impact of nonresponse bias on patient satisfaction surveys. Med Care 1997; 35: 646–652.[Web of Science][Medline]

  39. Sitzia J, Wood N. Response rate in patient satisfaction research: an analysis of 210 published studies. Int J Qual Health Care 1998; 10: 311–317.[Abstract/Free Full Text]


Add to CiteULike CiteULike   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us    What's this?


This article has been cited by other articles:


Home page
 Scand J Public HealthHome page
S. Oltedal, A. Garratt, O. Bjertnaes, M. Bjornsdottir, M. Freil, and M. Sachs
The NORPEQ patient experiences questionnaire: Data quality, internal consistency and validity following a Norwegian inpatient survey
Scand J Public Health, October 1, 2007; 35(5): 540 - 547.
[Abstract] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrow Search for citing articles in:
ISI Web of Science (3)
Right arrowRequest Permissions
Google Scholar
Right arrow Articles by TOKUNAGA, J.
Right arrow Articles by IMANAKA, Y.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by TOKUNAGA, J.
Right arrow Articles by IMANAKA, Y.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?