Abstract
Background Patient satisfaction is an important measure for evaluating interventions in health care. No patient satisfaction questionnaire for physical therapy treatment has been validated to date for use in an Italian outpatient population.
Objective The aim of this study was to translate, culturally adapt, and validate the Italian version of the Physical Therapy Patient Satisfaction Questionnaire (PTPSQ-I).
Design A measurement study was conducted.
Methods The PTPSQ-I was developed through forward-backward translation, final review, and pre-final version. An acceptability analysis was first conducted. Reliability was measured by internal consistency (Cronbach α), and a factor analysis was applied to investigate the internal structure. Divergent validity was measured by comparing the PTPSQ-I with a visual analog scale (VAS) and with a 5-point Likert-type scale evaluating the global perceived effect (GPE) for the physical therapy treatment.
Results The process for developing the PTPSQ-I required 3 months using data on 315 outpatients. Based on our initial analyses, 5 items were deleted from the PTPSQ-I, which was renamed the PTPSQ-I(15). The PTPSQ-I(15) showed high internal consistency (α=.905). Divergent validity was moderate for the GPE (r=.33) but not significant for the VAS (r=−.07). A factor analysis revealed evidence for a 2-factor structure related to perceived “Overall Experience” and “Professional Impression” that explained 62% of the total variance. A third factor, “Efficiency and Convenience,” brought explained total variance to near 70%.
Limitations It may be necessary to add items to the PTPSQ-I(15) to assess other dimensions not currently represented by these 15 items.
Conclusion The PTPSQ-I(15) showed good psychometric properties, and its use can be recommended with Italian-speaking outpatient populations.
A patient's perceptions regarding the process, outcome, and quality of health care services are increasingly recognized as relevant to the evaluation of health care outcomes.1 This recognition has led to the use of surveys designed to measure a patient's experience.1,2 Patient satisfaction is generally recognized as multidimensional in nature and may be used as either a process or outcome measure,3 although satisfaction with care and with outcome may be distinct in certain conditions.4–6 Ellwood and Paul7 suggested that a dissatisfied patient is less inclined to follow professional advice, with negative consequences for primary and secondary prevention.
Some patient satisfaction measures have been used as proxies for treatment effectiveness, and positive results are used by some facilities to win the favor of the consumers.8,9 Satisfaction also has been linked to the relationship a patient has with the physical therapist and other staff members, as well as to environmental and economic factors (eg, clinic location, parking facilities, costs).9–12
Research on satisfaction with physical therapy is relatively undeveloped, especially when compared with medicine and nursing.9 Much of the work on patient satisfaction in physical therapy to date has centered on operationalizing the concept and developing reliable and valid instruments. There is no universal gold standard for measuring patient satisfaction, as the enormous patient variability and wide range of clinical conditions that require physical therapy make it difficult to identify a questionnaire suitable for all patients and situations. A totally comprehensive instrument would comprise an unmanageably high number of items. A useful questionnaire, therefore, should explore satisfaction across multiple domains, demonstrate strong psychometric properties, and use a limited number of items.
Even a brief review of the literature on existing instruments identifies substantial differences in structure and content across currently used questionnaires. One of the most studied instruments on satisfaction with physical therapy is the MedRisk Instrument for Measuring Patient Satisfaction With Physical Therapy Care (MRPS), which was initially developed for clients of a professional benchmarking service.11,13 This questionnaire consists of 12 items: 7 regarding patient-therapist factors, 3 related to non-therapist factors, and 2 global measures of satisfaction. The MRPS also was validated as a measure of patient satisfaction with chiropractic care.14 The Physical Therapy Outpatient Satisfaction Survey (PTOPS) measures 4 distinct dimensions partially adapted from concepts in industrial management: enhancers that increase satisfaction by enriching the patient's experience beyond an acceptable baseline and detractors that lessen satisfaction but do not enhance satisfaction when present.12 The PTOPS items are distributed across enhancers (10 items), detractors (10 items), location (7 items), and cost (7 items).
Finally, the Physical Therapy Patient Satisfaction Questionnaire (PTPSQ) was developed in 2000,15 comprises 26 items, and is divided into 2 parts. The first part contains 6 items concerning demographic information about the patient (eg, age, sex, location of the musculoskeletal problem), as well as some information about referral source and any previous care at that facility. For the second set of questions, PTPSQ items were developed to reflect 5 potential dimensions of patient satisfaction presumed to be related to quality: access, administrative technical management, clinical technical management, interpersonal management, and continuity of care.15 Participants rate their degree of satisfaction on 20 items regarding both the interaction with the staff (physical therapist, assistant, other staff members) and some environmental characteristics such as location, parking, and cost. The score of the PTPSQ is obtained by adding all of the scores for items not marked a “9” (not applicable) or missing and dividing the sum by the maximum possible score, which is the number of items in the numerator multiplied by 5 (the highest possible score on each item). Then the ratio is converted to a percentage (Marc S. Goldstein, EdD, Research, American Physical Therapy Association; personal communication; July 22, 2012). Goldstein et al15 tested the psychometric properties of the original version of the PTPSQ on 289 outpatients from 12 practice settings, including a hospital-based outpatient clinic and a private office.
Although patients with musculoskeletal conditions were most common across all clinics, patients with other conditions, including stroke, fibromyalgia, and pelvic dysfunction, were included in the study sample. Goldstein et al15 observed high internal validity and good content validity. Goldstein et al15 established concurrent validity by correlating a summary score of 17 items with 3 criteria that were arguably most related to overall satisfaction and found exceptionally high correlations between the summary score and each criterion variable. To evaluate the construct validity, a principal components analysis was conducted, and a unique factor was extracted accounting for nearly 83% of the total variance.
Cultural, economic, and social context influence patient satisfaction, and it is reasonable to assume that patients in different countries have different priorities with respect to the factors shaping and influencing satisfaction. Thus, instruments developed in one population have to be validated for cross-cultural use.16–21 To our knowledge, the PTPSQ has never been validated in other cultures outside of the United States or in languages other than English. As a consequence, its psychometric properties are not confirmed with different populations. To measure the results of physical therapy in Italy, many scales are currently used for pain, disability, function, and general health, but no physical therapy satisfaction questionnaire had been translated and validated for the Italian population when we began our study.
The aims of this study were: (1) to translate, culturally adapt, and validate (acceptability, reliability, and validity) the Italian version of the PTPSQ on a sample of outpatients and (2) to investigate the relationships between the characteristics of the patients and physical therapists and the indicators of satisfaction. We selected the PTPSQ for translation because it is brief, was based on 5 elements believed pertinent to patient satisfaction, had acceptable psychometric properties after testing under conditions we believed similar to ours, and allowed the user to collect both general information about respondents and judgments about satisfaction on issues that we believed would most likely be pertinent to the Italian social context.
Method
Translation and Cross-Cultural Adaptation of the PTPSQ
This stage followed the guidelines for the process of cross-cultural adaptation of self-report measures.22
Step 1: Forward translation.
The PTPSQ was forward translated from English into Italian with the intent to retain the meaning of the original questionnaire. Two translations were independently performed by translators whose first language is Italian. The first translator, who was not familiar with the scale, was a linguistics professor, and the other translator was a physical therapist in private practice. Translators aimed to keep the language colloquial and compatible with a reading age level of 14 years. When a concept had no equivalent in the Italian culture, the translators adapted the item to an appropriate cultural context. Translational choices about the most challenging terms were resolved in a discussion between the 2 translators. None of the original items was omitted.
Step 2: Backward translation.
Two bilingual native English-speaking translators backward translated the initial version to ensure the fidelity of the Italian version with the original questionnaire, while still considering social and cultural differences between the United States and Italy. The 2 translators were neither aware nor informed of the concepts being explored, and they did not have medical backgrounds to avoid information bias and to allow unexpected meanings of items in the translated questionnaire to emerge.22
Step 3: Expert committee.
Both forward and backward translations were submitted to a bilingual committee, which included our 4 translators. The committee discussed different options for items and responses, emphasizing meaning over literal translation to achieve conceptual equivalence. None of the items were omitted. This first culturally adapted translation was obtained in 3 months.
Step 4: Test of the pre-final version.
The questionnaire then was administered to 50 patients randomly selected from all patients of the involved centers who met the inclusion and exclusion criteria to verify the meaning of each item and response choices. Patients filled in the questionnaire before a session of treatment, excluding the first session. Each patient marked the items that were not considered clear enough or had doubtful meaning. All items were re-evaluated by the committee of experts, and revisions were made. None of the items was omitted. At the end of this stage, which took 1 month, this version was named PTPSQ-I.
Participants
This study involved a university hospital and 2 physical therapy services, all chosen to represent different social and cultural contexts within different regions of Italy. All adult (18 years or older) physical therapy outpatients from April to September 2011 were eligible for the study if they were able to read and speak Italian. Patients who received only an evaluation or had psychiatric or cognitive deficits were excluded on the basis of the clinical documentation provided by a physician at the time of admission. All participants gave their written consent.
Examiners
Questionnaires were presented by research assistants to each participant, who was ensured that his or her physical therapist was blinded to the results. Questionnaires were administered before a session of treatment, excluding the first session, and in separate rooms, ensuring privacy. Items were presented to each participant in written form. Participants answered each question verbally, and research assistants filled in the answers on the PTPSQ-I. Research assistants could repeat questions but could not change wording. If a participant altered his or her response, the assistant noted the change on the form; if the participant did not choose any answer, the assistant did not mark any box. The levels of patient understanding and the time needed to answer were recorded for each item by the research assistant.
Administered Questionnaires
All participants completed a form requiring some demographic information not included in the first part of the PTPSQ-I (marital status, education, employment, mode of payment) and whether the participant attended all scheduled sessions. Furthermore, all participants completed a PTPSQ-I. A visual analog scale (VAS) and a 5-point Likert-type scale evaluating the global perceived effect (GPE) of physical therapy treatment were administered to evaluate concurrent validity. The VAS score was obtained from a 10-cm segmented line, whose extremes correspond to “no pain” (score=0) and “unbearable pain” (score=100). Participants were asked to identify the point on the 10-cm line indicating the pain felt at that moment. The VAS is a one-dimensional tool summarizing the subjective global perception of pain, including its physical, psychological, and cultural aspects, without distinguishing which of these components have greater relevance. It is widely used, simple, immediate, and reliable.23 The GPE questionnaire evaluates the patient's perception of the effectiveness of the treatment by asking “How do you rate the overall effectiveness of the treatment received with respect to your needs?” Respondents choose among 5 possible answers, ranging from “really helped” (score=1) to “made things worse” (score=5). This scale reliably measures the perceived improvement at the time of administration.24
Data Analysis
All statistical analyses were performed using PASW Statistics 18 (Release 18.0.3, SPSS Inc, Chicago, Illinois) and SAS (Release 9.2, SAS Institute Inc, Cary, North Carolina).
Acceptability.
We recorded the time needed to answer the questionnaire, and assistants noted any comprehension difficulties and verified missing, changed, or multiple responses.
Reliability.
Reliability was investigated with respect to internal consistency. Internal consistency reflects the extent to which different items in a questionnaire measure different aspects of the same general construct. Following common practice, we used Cronbach alpha (α), estimated for the whole questionnaire.
Internal structure and construct validity.
Factor analysis was used to evaluate the internal structure of the scale. This technique evaluates whether it is possible to extract a small number of factors explaining the correlations among the original items. If only one factor satisfactorily summarizes all items, the total (ie, the sum of the scores for all the items) can be used to summarize satisfaction. If instead more factors are necessary, each related to one particular aspect of the satisfaction itself (eg, satisfaction for the therapy versus satisfaction for the ambience where the therapy is received), it can be inferred that “satisfaction” is a multifaceted construct, and the total score can be broken down into more detailed components (subtotals).
Divergent validity.
Due to the lack of validated outcome measures concerning physical therapy patient satisfaction in Italian, direct study of convergent validity was not feasible. However, divergent validity could be investigated by comparing Pearson correlation (r<.30=low; .30<r<.60=moderate; r>.60=high) of the PTPSQ-I with the GPE, as a measure of the perception of the effectiveness of the treatment, and with the VAS, as a measure of pain perceived by the patient. It was hypothesized a priori that the correlation between the PTPSQ-I and the GPE would be moderate to low25 and the correlation between the PTPSQ-I and the VAS would be low.6
Dependency of satisfaction on explanatory variables.
Wilcoxon and Kruskal-Wallis tests were used to identify the extent to which satisfaction scores depend on the patient's sociodemographic characteristics (eg, sex, age class, marital status, education, working status), the characteristics of the therapy received (eg, the facility attended, the source recommending the facility, whether it was the first time the patient attended that facility or had an episode of care with a physical therapist), the regular attendance of the therapy, the therapist's sex and the combination of the therapist-patient sexes, and payment method.
Results
A total of 865 patients received physical therapy during the period of study, of whom 548 did not meet the inclusion criteria: 513 were younger than 18 years (most attended one facility), and 35 had psychiatric or cognitive deficits. A total of 317 outpatients were eligible and were asked to participate in the study. Of these outpatients, 2 refused, leaving a sample of 315 patients (211 [67%] female, 104 [33%] male; mean age=51.2 years, SD=13.1). In Table 1, the sociodemographic characteristics of these patients are reported, together with information about the therapy received, including facility attended, regularity of attendance, sex of the therapist, and payment method.
Sociodemographic Characteristics of the Patients and Information on Their Therapy
Acceptability
On average, the questionnaire was completed in 4.7 minutes (SD=1.65). Only 147 errors (eg, corrections, deletions) were noted, corresponding to 3.1% of the total number of answered questions (15 items for 315 patients, for a total of 4,725). Very few questions were left unanswered (9 out of the total of 4,725). No multiple answers were found. No problems with item comprehension were reported.
The “I do not know” responses equaled 19% (879 out of a total of 4,725). These responses were treated as equivalent to missing values. The frequency distributions of responses by item are reported in the eFigure. The height of each bar represents the number of nonmissing responses for the item itself. Some items were characterized by a very high proportion of missing values. The most critical variables are those related to costs: item Q16 (“My bills were accurate”) with 206 patients (65.4%) who did not express an opinion and item Q24 (“The cost of the physical therapy treatment received was reasonable”) with 195 such patients (61.9%), and to a lesser extent item Q25 (“If I had to, I would pay for these physical therapy services myself”) with 74 patients (23.5%) (Tab. 2). Also, a relatively high number of missing responses was observed for item Q17 (“I was satisfied with the services provided by my physical therapist assistants”) with 145 patients (46%) and item Q18 (“Parking was available for me”) with 105 patients (33.3%).
Number of Not Missing and Missing Values for Each Variable
The inclusion of these items in further analyses would have involved a large proportion of missing data, as only 39 participants answered all of the questions. In addition, we observed that the patients who did not respond to these questions had specific characteristics in terms of employment, mode of payment, and facility attended (Tab. 3). We decided, therefore, to delete these particular items from further analysis and to consider a 15-item PTPSQ-I, referred to as PTPSQ-I(15) (eAppendix).
Characteristics of the Patients Who Did Not Respond to the Critical Items
As indicated in the eFigure, most of the respondents chose the fourth or fifth levels of satisfaction, whereas responses indicating low satisfaction were very rare. The most relevant exceptions (disregarding deleted items) were observed for the items Q12 (“My first visit for physical therapy was scheduled quickly”) and Q15 (“The location of the facility was convenient for me”), which were characterized by a relatively higher proportion of scores of 3 or lower.
Reliability
Internal consistency.
The Cronbach α value after deleting items Q16, Q17, Q18, Q24, and Q25 was .905. The total score determined by summing the values observed for each item had a mean and variance of 70.44 and 44.45, respectively.
Table 4 displays results obtained by deleting one item at a time. Deleting only item Q15 (“The location of the facility was convenient for me”) or only item Q12 (“My first visit for physical therapy was scheduled quickly”) slightly increased the Cronbach α. Also, these 2 questionnaire items had the weakest item-total correlations. As noted above, Q12 and Q15 were the items characterized by the highest proportions of scores of 3 or lower. Also, from Table 4, it is possible to appreciate that item Q11 (“I was satisfied with the treatment provided by my physical therapist”) and items Q19 to Q26 (all explicitly referring to satisfaction) appear to be more interconnected: their deletion causes a relatively large decrease in Cronbach α, and they show a higher correlation with the total.
Reliability Analysis With Each Question Deleteda
Internal structure and construct validity.
To investigate the relationships among the 15 items in PTPSQ-I(15), we applied factor analysis, using the principal components extraction method. Three factors met the standard rule of an eigenvalue of 1 or higher. The first factor, explaining about 51% of the total variance, was the dominant one. Nonetheless, the second and third factors, explaining 11% and 7% of the total variance, respectively, also contributed to a cumulative proportion of nearly 70% explained.
To individuate the dimensions underlying respondent satisfaction, factors were extracted and rotated using the varimax criterion for ease of interpretation. Table 5 presents the correlations (loadings) between the PTPSQ-I(15) and the extracted factors. The data in Table 5 support the notion that “satisfaction” is a multifaceted phenomenon, which can be parceled into at least 2 components described by the first 2 factors in Table 5. The first subtotal, obtained by summing the scores of items Q11, Q20 to Q23, and Q26, is clearly a summary judgment about the value of the overall experience. We named this subtotal “Overall Experience.” The second subtotal, obtained by summing the scores of items Q07 to Q09, Q14, and Q19, relates to the immediate experience of therapy at each visit, particularly at the start of therapy. We propose it captures “Professional Impression.” Although the loadings on the third factor were not particularly high, we built a third subtotal based on 4 items (Q10, Q13, Q12, and Q15), which we named “Efficiency and Convenience.”
Factor Analysis Loadingsa (Model With 2 and 3 Factors; Extraction Method: Principal Components; Rotation Method=Varimax)
Divergent validity.
The divergent validity was measured by calculating the Pearson correlation coefficient between the totals of the PTPSQ-I(15) and the scores of the VAS and GPE. The PTPSQ-I(15) total was moderately correlated with GPE (r=−.33). Also, the correlations of “Overall Experience” and “Efficiency and Convenience” showed similar results (r=−.420 and −.316, respectively). However, the correlation between “Professional Impression” and GPE was low (r=−.09). The correlations between the total and the 3 subtotals and VAS were close to zero and not significant (the 4 correlations were −.07, −.10, −.04, and −.09, respectively).
Dependency of satisfaction on explanatory variables.
We also explored whether satisfaction, measured by the total score of the PTPSQ-I(15), broken down into its component “Overall Experience,” “Professional Impression,” and “Efficiency and Convenience” subscores, varied according to the levels of the possible explanatory variables listed in Table 1.
Because a preliminary analysis showed non-normal distributions of the total satisfaction score and of the subscores, we used a nonparametric approach: the Kruskal-Wallis test. The Wilcoxon test was used for explanatory variables having only 2 levels. Instead of being based on the means of the observed response values, these tests are based on the means of the ranked values (ie, the position of a value in the ordered sequence of values).
Table 6 presents the means of the totals within the groups described by the levels of the explanatory variables and the P values of the Kruskall-Wallis or Wilcoxon tests based on the ranks' means. Groups with very small frequencies (the group of patients aged 18–25 years with only 8 valid cases and the group of patients who partially paid for the therapy with only 2 valid cases) were not analyzed. For each satisfaction score and for each explanatory variable, the P value for testing the null hypothesis is reported. For the explanatory variables with more than 2 levels, a further Wilcoxon test was applied to test the differences between all the pairs of means in order to identify which means were statistically different from one another.
Means of the Totals Within Groups of Patients and Results of Tests on the Equality of the Means (of the Ranks, Kruskal-Wallis or Wilcoxon Test)
Considering sociodemographic characteristics (sex, education level, age class, and working status), we observed differences in satisfaction scores across age classes: both total score and subscores increased with age, on average. The total satisfaction score and the “Overall Experience” and “Efficiency and Convenience” subscores also differed depending on working status: retired patients and nonworkers reported more satisfaction than workers.
With respect to facility and characteristics of the therapy and of the therapist, the “Professional Impression” subscore did not vary across the levels of the explanatory variable (focusing only on P values less than .05). The total satisfaction score and the “Overall Experience” subscore differed according to facility attended, regularity of attendance, payment method, recommendation source, therapist's sex, and the combination of the therapist-patient sexes. Notably, the levels of each explanatory variable can be partitioned into 2 groups of statistically different means (ranks). The most satisfied patients were those attending the facilities in Castenaso and in Rome; those referred to the facility by their physician, by friends, or by other patients; those regularly attending the therapy; and those who paid for the therapy directly or were fully covered by the National Health System. Interestingly, patients treated by female physical therapists are more satisfied, irrespective of the patient's or therapist's sex. Similar patterns also were observed for the “Efficiency and Convenience” subscore. Nonetheless, the level of satisfaction of female patients treated by female physical therapist was not statistically different, on average, from that of male patients treated by male physical therapist.
Discussion
We described a cross-cultural adaptation, reliability, and validity study of the Italian version of the PTPSQ in a sample of outpatients that was balanced with respect to sex and conducted in facilities in different parts of Italy. The original questionnaire was first translated (PTPSQ-I) and administered to a sample of Italian outpatients. Based on these initial results, we deleted 5 items to develop the PTPSQ-I(15). Like other instrument developers, we needed to exclude certain items in order to adapt the original questionnaire to the Italian cultural and social context.26
A possible explanation for this high number of “I do not know” answers resides in differences between the United States and Italy in their economic and social organization. The health care system in Italy is complex. Depending of their clinical or social situation, in some cases, patients can have access to completely free medical care; in other cases, physical therapy treatments are reimbursed by private insurance; and in still other cases, patients directly pay for the treatment received. As a consequence, items related to payments and costs in the initial translation received a substantial proportion of “I do not know” answers in our sample.
We also found a cultural difference in item Q17, most likely due to the lack of an equivalent worker to an American “physical therapist assistant” in Italy. Finally, the item referring to the availability of the parking was not answered by several participants, probably because they were taken to the physical therapy facility by another person. Thus, the translated PTPSQ-I using all of the items of the original US version, did not have sufficient reliability and validity to be used to evaluate physical therapy patient satisfaction in Italian health care facilities.
Our final translated questionnaire demonstrated strong psychometric properties. The Cronbach α index (.905) was very high, indicating strong internal consistency among the items selected for the final version. Divergent validity and construct validity were satisfactory for all items. The PTPSQ-I(15) version was easily understood and required only a few minutes to be completed.
With respect to construct validity, we found that the first factor estimated using the principal components method accounted for only 51% of the total variance in contrast to 83% observed by Goldstein et al15 for the US questionnaire. Although Goldstein et al15 extracted only one factor from their data, they noted that several researchers have hypothesized that patient satisfaction is a multidimensional phenomenon, and our results appear to confirm this belief.27–30 Also, in studies by Monnin and Perneger21 and Franchignoni et al,31 patient satisfaction appeared split into several factors.
These differences in factor structure between the original US instrument and its Italian derivative could be easily misinterpreted as one or the other is “better.” However, these differences actually hold some critical lessons about construct validation and the relationship between the sociocultural context and the concept of “satisfaction” itself. Construct validity of an instrument is not established by a single study or even a series of studies. Further work on the English-language version of the PTPSQ using a different population may identify a more complex factor structure for this instrument, given that its items were drawn from several hypothesized domains of satisfaction.
We do not recommend that investigators of complex phenomena such as “patient satisfaction” should avoid using any instrument whose psychometric properties are known and sufficient for their particular research interests. We do recommend that researchers and clinicians be very clear about the questions they are asking and carefully examine whether a proposed instrument will answer their questions as fully or with sufficient granularity to be useful to making the kinds of inferences from the data that they would like to make. Furthermore, we must be alert to the possibility, particularly as cross-cultural research opportunities expand, that fundamental assumptions regarding our constructs, methods, and instruments may not hold exactly as previous experiences might suggest.
For Italian patients, the more relevant factors for satisfaction with physical therapy appeared to be those related to the physical therapist and to the staff, both from a technical and from a relationship point of view, summarized by the factor we named “Overall Experience.” This technical factor appears related to global and retrospective judgments about the quality of physical therapy treatment and usefulness of the instructions, which appeared strongly linked to overall satisfaction and to positive judgment about the facility. “Professional Impression” seems related to the immediate experience of therapy and impression the physical therapist and the other members of staff make on the patient from the beginning (prompt, courteous, respectful). The third factor, “Efficiency and Convenience,” is related to convenient scheduling of appointments and facility location. The 3-factor solution, having previously removed the items related to costs, bears some similarity to the factor structure of another questionnaire, the PTOPS.12
Within Italian culture, the professional aspect appeared more relevant than those related to ”Efficiency and Convenience” items in influencing satisfaction, perhaps explaining why the variable related to facility location was more weakly related to the factors than other variables. These results are consistent with those of Beattie et al,11 who reported that being treated with respect by health care providers and being involved in treatment decisions are strongly linked to patient satisfaction.20 Overall, satisfaction appears strongly linked to the professional behavior of the clinician (ie, treating the patient with respect and providing meaningful information), considering the courtesy aspect together with the technical factor.11,20
In the evaluation of divergent validity, we observed moderate to low correlations between PTPSQ-I(15) total and subtotals and GPE and a nonsignificant correlation with the VAS. These results, which are oriented to the care received rather than specifically to the outcome of the care received, are in line with the systematic review of Hush and colleagues,25 who concluded that the relationship between satisfaction and clinical outcome is weak. The nonsignificant correlation between patient satisfaction and amount of pain corroborates the results obtained by Kelly6 in a different population.
We could not perform any analysis on convergent validity because there is no other Italian-language questionnaire that investigates the same construct. Other existing instruments investigating patient satisfaction refer to completely different clinical settings, and their use would not be suitable for this purpose.
Some limitations of the study must be reported. Our sample size was greater than that used by Goldstein and colleagues,15 but less than that of many other studies on physical therapy patient satisfaction. In our sample, we observed a high amount of “I do not know” answers to 5 questions (Q16, Q17, Q18, Q24, and Q25) from patients with specific characteristics in terms of employment and mode of payment. We do not know whether a larger sample would lead to the same result or whether the differences between the United States and Italy with respect to their economic and social organization alone are sufficient to explain the large number of “I do not know” answers. As “patient satisfaction” is multidimensional, it also may be necessary to add items to the PTPSQ-I(15) to assess other dimensions not currently represented for specific research aims.
The measurement properties were evaluated based on verbal answer to a research assistant, which may have increased the effects of social desirability. We do not know whether a self-administration would yield the same results. The PTPSQ-I(15) can be recommended for administrative and research purposes, for outpatients, and for adult male and female patients. Further studies focusing on construct validity and on the relationship between satisfaction and severity of the patient's clinical condition across various diseases, disorders, and impairments should be conducted.
Footnotes
Ms Vanti, Dr Monticone, Ms Ceron, Ms Bonetti, and Professor Pillastrini provided concept/idea/research design. Ms Vanti, Dr Monticone, Ms Ceron, Dr Piccarreta, Dr Guccione, and Professor Pillastrini provided writing. Dr Monticone, Ms Ceron, and Ms Bonetti provided data collection. Ms Vanti, Dr Piccarreta, and Dr Guccione provided data analysis. Ms Vanti provided project management. Ms Vanti and Ms Bonetti provided study participants. Ms Bonetti provided facilities/equipment and institutional liaisons. Ms Vanti, Ms Ceron, Ms Bonetti, Dr Piccarreta, Dr Guccione, and Professor Pillastrini provided consultation (including review of manuscript before submission). The authors thank Maurizio Conti, Jacopo Deserti, Marina D'Onofrio, Sabrina Lambrilli, Elisabetta Pulice, and Barbara Rocca for the assistance provided with this research.
The Ethics Committee of the University Hospital S. Orsola-Malpighi of Bologna (Italy) approved the trial (code 32/2011/U/OssN).
- Received April 13, 2012.
- Accepted April 1, 2013.
- © 2013 American Physical Therapy Association
References
Issue highlights
