Our results generally support the internal validity of the Swedish adapted version of the PPE-15. Construct validity was supported by a high correlation between general care satisfaction ratings and PPE-15 scores. Patient characteristics such as self-rated health and functional impairment had the highest relationship with the PPE-15 total score. The explanatory value of the examined patient socio-demographic and health characteristics was low, suggesting the need for exploring other patient-related determinants of care experiences such as previous hospital experiences/expectations of care and self-efficacy. Vulnerable patients, defined as having poor SRH and some degree of functional impairment, reported their care experience significantly less positive when compared with healthier and less functionally impaired patients.
Our results for the Swedish adapted version were similar to those reported for the original Picker PPE-15
] regarding internal consistency reliability (Cronbach alpha =0.87 vs 0.80). Interestingly, in the original PPE-15 the item-total score correlation of item 5 (staff talking as if I wasn´t there) was below generally accepted limits (r
0.30), and in the Swedish version it also had the lowest correlation. The item remained in the original PPE-15 survey because the removal of the item did not appreciably improve alpha
], yet it could be questioned if the item should be retained in the PPE-15.
Benchmarking care experiences is increasingly prioritized by governmental agencies, and may in the future become an important evaluation tool for patients when comparing treatment and care options
]. National care experience surveys are important tools for assessing and monitoring healthcare quality and the widespread international usage of the Picker in-patient survey also enables countries to compare themselves on an international level as well.
The present study demonstrated an association between care experience and patient characteristics such as SRH and functional impairment. Studies have previously shown an association of SRH and physical function with mortality and morbidity
]. Particular emphasis has been placed on investigating relationships between general health and clinical outcomes
]. Consequently, greater focus has been put on patient-reported outcomes as recognised by the European Medicines Agency (EMA)
] and The Patient-Centered Outcomes Research Institute in the USA
]. Our findings showed that SRH had the highest impact on the patients’ care experience. In this study demographic characteristics such as age had a weak association with care experience. While previous studies have suggested an association between increasing age and higher care satisfaction
], it has also been suggested that this association declines in patients above 80
]. Overall, we found that various socio-demographic and health characteristics could explain merely seven percent of the variance in the PPE-15 scores. This shows the complexity of measuring care experience, and suggests that external factors may have a greater impact on care experiences than socio-demographic and health characteristics. For the patient, hospitalisation involves a constant interaction and adjustment to the structures of the care environment, including the attitudes and belief systems of the nurses, physicians and other staff that work there. It has been suggested that health care professionals adapt their communication style and care strategies to the social, emotional and physiological characteristics of their patients
]. An important finding was that vulnerable and non-vulnerable patients differ substantially in their experiences of the quality of their care. The mean 10-point difference between the two groups may also be relevant in term of the effect size (PPE-15 total score Cohen's d
0.58). Healthcare professionals may view vulnerable patients as having more complex and demanding support needs and hence may give priority to meeting such needs at the expense of other aspects of quality care, such as involving patients in care decision making. Previous research has shown that patients who demonstrate more rapid adaptation to the present care structures, that are perceived as more satisfied and more adherent receive more information, empathy and are more involved in care decisions
]. A cause of particular concern in the present study is that vulnerable patients, who were older and utilized more healthcare resources, reported worse care experiences than the non-vulnerable patient. Therefore, care experience may be seen as a continuum of events, hence factors such as the patient’s previous hospital experiences/expectations of care, self-efficacy level and notion of shared decision making may constitute important aspects in evaluating care experience that should be further explored. This is particularly relevant in chronic conditions where care efforts often focus primarily on providing support in self-management. Although these factors are not directly healthcare quality indicators, indirectly they reflect the effectiveness of the support programs offered the patient and should therefore be regularly monitored.
Effective care is widely considered a collaborative process between all concerned stakeholders, and in particular the patient
]. Care communication and patient participation are part of a complex system which requires co-operation and respect between the patients and caregivers
]. As such this collaborative process should be built upon increased patient participation and dialog, in order to find common ground and understanding about the direction and goals of the care. One example of the difficulty of health care providers to communicate with patients is the marked discrepancy between the perceptions of patients and the physicians regarding the content of treatment information
]. Although the patients understood the treatment information, they still needed guidance and advice on how to follow the treatment plan. The physicians, on the other hand, assumed that the patients’ non-adherence to the treatment plan was due to the difficult nature of the information. In the present study, the lowest care experience scores for both vulnerable and non-vulnerable patients were seen in the same domain, namely continuity and transition (Figure
). Overall. it seems that quality hospital care experience from the patients’ view, regardless of the patient’s health or functional status, is one that supports the patient throughout the entire care continuum, both at the hospital and in the transition back to the patient’s home.
Our study has several limitations. Our classification of functional impairment was based on patients’ reports of need for assistance when toileting. The present study was not designed to determine the actual cause of the patients’ need for assistance when toileting (e.g., mobile surveillance, urine catheters or impaired functional status) and space and logistic restraints in the survey prohibited more comprehensive assessments of physical impairment. Nevertheless, being dependent on someone for help with toileting should reflect physical impairment and may be an easy and practical way of assessing functional impairment.
The associations between various socio-demographic and health characteristics were significant yet low and given the cross-sectional nature of this study, no conclusions can be drawn regarding causality. Furthermore, owing to the large size of the survey sample, small correlations were still statistically significant; hence, the clinical significance of the reported correlations is unclear.