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Insight Into Patient Dissatisfaction With Asthma Treatment
Leona E. Markson, ScD;
William M. Vollmer, PhD;
Leslye Fitterman, PhD;
Elizabeth O'Connor, PhD;
Siva Narayanan, MHS;
Marc Berger, MD;
A. Sonia Buist, MD
Arch Intern Med. 2001;161:379-384.
ABSTRACT
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Background Measures of patient satisfaction or dissatisfaction with treatment are
increasingly being used as indicators of quality of care. As these measures
become more widely used, it is important to know if patient dissatisfaction
is associated with important processes or outcomes of medical care.
Methods Survey of patient-reported asthma management issues using the Asthma
Therapy Assessment Questionnaire in a large health maintenance organization
in the Pacific Northwest. Associations between patient dissatisfaction with
asthma treatment and patient-reported measures of asthma control, patient-provider
communication, and belief in asthma medications (self-efficacy) were examined.
Results Of the 5181 adult members with asthma enrolled in the health maintenance
organization, 30% indicated dissatisfaction with current treatment. Dissatisfaction
was higher among patients with a higher number of asthma control problems,
patient-provider communication problems, or belief in medication problems
(eg, failure to believe their medications are useful and inability to take
asthma medications as directed). The odds of dissatisfaction with treatment
were 2.8 (95% confidence interval [CI], 2.4-3.3; P<.001)
for asthma control problems, 2.0 (95% CI, 1.6-2.6; P<.001)
for communication problems, and 8.0 (95% CI, 6.7-9.5; P<.001) for belief in medication problems compared with patients
without these perceived problems.
Conclusion Patient dissatisfaction with treatment may be related to important asthma
disease management issues.
INTRODUCTION
WITH THE prevalence of asthma on the rise1
and the annual cost associated with the disease exceeding $5.8 billion (in
1994 dollars),2 providers and payers are interested
in evaluating the outcomes of asthma care.3
In the past, clinical and economic outcomes of asthma care received attention.4, 5, 6, 7, 8
However, evaluation of patient care across a range of medical conditions increasingly
includes measures of patient satisfaction.9, 10, 11, 12, 13, 14, 15, 16, 17, 18
Managed care organizations have started to incorporate patient satisfaction
in their report cards to assess the performance of the plans and the quality
of patient management programs.17, 19, 20, 21
Added importance of patient satisfaction measures may result from the work
of the National Committee for Quality Assurance and the Foundation for Accountability,
since these organizations have suggested that health plans use patient satisfaction
to evaluate care.22, 23, 24, 25
In this context, the potential is large for measures of patient satisfaction
or evidence of dissatisfaction to drive accountability and infer level of
quality or value of health care.
Most health care research on patient satisfaction has focused on satisfaction
with generic aspects of patient care, such as office hours or helpfulness
of the staff. It is also reasonable to ask patients with chronic diseases
about their satisfaction with treatment, since it is the specific treatment
that will likely have the greatest impact on patient outcomes. In addition,
patients are generally asked about their overall level of satisfaction as
opposed to whether they are dissatisfied with any part of their care. It is
possible that the important improvements needed in health care may best be
obtained by assessing whether there is evidence of dissatisfaction. This study
extends the research on patient satisfaction by specifically studying whether
there is evidence of dissatisfaction with asthma treatment and then identifying
processes of care associated with treatment dissatisfaction. In addition,
we examine whether dissatisfaction is associated with level of asthma control
(an outcome of treatment). The findings from this study provide insights into
potential areas that may be targets for quality improvement programs.
MATERIALS AND METHODS
POPULATION
We studied factors associated with patient dissatisfaction with asthma
treatment at Kaiser Permanente, Northwest Region, a large group-model health
maintenance organization with approximately 430 000 covered lives, centered
in Portland, Ore. The study population was selected based on the following
criteria: age of 18 years or older, 2 or more anti-asthma medication dispensings
in 1996, and/or a hospital or emergency department visit in 1994, 1995, or
1996. In addition, all individuals needed to have current health plan coverage
as of June 1997. The Asthma Therapy Assessment Questionnaire (ATAQ), a 2-page
screening questionnaire designed to identify possible disease management problems
for patients diagnosed as having asthma, was sent between August and September
1997 to 13 964 members who met the selection criteria. Additional information
about the sampling design can be found elsewhere.26
Of the 62% of individuals who responded to the survey, we analyzed data for
the 5181 individuals (60%) who reported that they had physician-diagnosed
asthma and had taken asthma medications within the past 12 months. Further
analysis for this study is based on the results obtained from these 5181 respondents.
INSTRUMENTS
All data presented herein come from the ATAQ, which was developed as
a disease management tool to identify individuals whose asthma management
may be suboptimal. This brief, self-administered questionnaire assesses several
asthma management domains and levels of asthma control.26
It also includes several additional items, such as whether the patients have
been told by a provider that they have asthma, whether they have been told
they have chronic obstructive pulmonary disease (COPD), and whether they were
currently taking medication for asthma. For this study, we examined the relation
between patient treatment dissatisfaction and 3 patient-reported measures:
(1) level of asthma control, (2) patient-provider communication, and (3) belief
in medication.
Patient dissatisfaction was assessed by the question, "Are you dissatisfied
with any part of your current asthma treatment?" Patients could respond yes,
no, or unsure. We combined the yes and unsure response categories, so patients
expressing no dissatisfaction with asthma treatment were distinguished from
those who were or might be dissatisfied.
To assess level of asthma control, the ATAQ asks about the following:
(1) self-perception of asthma control; (2) missed work, school, or normal
daily activities due to asthma; (3) nighttime waking due to asthma symptoms;
and (4) use of "quick relief" inhaler medication (defined in terms of the
number of puffs a day the patient took the inhaler). All items ask about control
in the past 4 weeks. Respondents were assessed as either having or not having
a control problem in each of these dimensions, and the number of control problems
was then summed to provide an index ranging from 0 to 4.
To assess patient-provider communication, the ATAQ asks about the following:
(1) physician or medical provider review of medications, (2) physician or
medical provider involvement of the patient in decision making, (3) physician
or medical provider knowledge of patient medication preferences, (4) patient
having an action plan for asthma attacks, and (5) patient having an action
plan when not having an asthma attack. Respondents were assessed as either
having or not having a patient-provider communication problem in each of these
dimensions, and the number of problems was then summed to provide an index
ranging from 0 to 5.
To assess patients' belief in medication, the ATAQ asks about the following:
(1) patients' belief in the usefulness of their asthma medications to control
their asthma and (2) belief that they can take their medications as directed.
Respondents were assessed as either having or not having a belief in medication
problem in each of these dimensions, and the number of problems was then summed
to provide an index ranging from 0 to 2.
Most of the questions comprising the asthma control, patient-provider
communication, and belief in medications domains had yes, no, and unsure response
options. For some questions, a yes indicated a potential problem in asthma
management, whereas for other questions the no response was an indicator of
a potential asthma management problem. The unsure responses were grouped with
the question-specific answer that indicated a potential problem in asthma
disease management.
STATISTICAL METHODS
Bivariate associations were assessed between patient dissatisfaction
with their current asthma treatment and each of the individual questions that
comprise the asthma control, patient-provider communication, and belief in
medication domains as well as the count of the number of problems observed
within each domain.  2 Tests with continuity corrections were
used for the 2 x 2 tables. Mantel-Haenszel tests for trends were used
to evaluate treatment dissatisfaction by the number of problems observed within
each domain. Other bivariate associations were assessed with a general Pearson 2 test. Next, we ran a logistic regression analysis of patient dissatisfaction.
The logistic model included variables for patient age (18-25, 26-45, 46-55,
56-65, and >65 years), sex, coexistence of COPD and indicator variables for
the presence of asthma control problems, patient-provider communication problems,
and belief in medication problems (one or more issues = 1, no issues = 0).
Odds ratios (ORs) and 95% confidence intervals (CIs) are presented for the
logistic regression. A separate logistic regression model was also analyzed
to study the influence of the individual questions of the asthma control,
patient-provider communication, and belief in medication domains.
RESULTS
Sixty-seven percent of the respondents were female. The age distribution
of the study population was as follows: 36% were 18 to 45 years, 40% were
46 to 65 years, and 24% were older than 65 years. The proportion of the population
with both asthma and COPD was 19.4%. Overall, 30% of the patients were dissatisfied
with their asthma treatment as indicated by a yes or unsure response to the
question. The percentage dissatisfied did not vary significantly by patient
age (P = .10). Men were somewhat more dissatisfied
than women (32.1% vs 29.3%, respectively; P = .05).
A greater percentage of patients with asthma and COPD were dissatisfied compared
with those without COPD (33.5% vs 29.2%, respectively; P = .02).
Figure 1 shows the association
between the number of asthma disease management problems and patient dissatisfaction
with treatment. The proportion of respondents who reported dissatisfaction
with their asthma treatment was directly related to increasing numbers of
control problems. For example, among those who had no (0) control problems,
16% were dissatisfied, whereas among patients with 4 control problems, 70%
were dissatisfied. Similarly, the proportion of patients who reported dissatisfaction
increased with increase in communication and belief in medication problems.
All 3 associations were significant (P = .001). Table 1,
Table 2, Table 3, and
Table 4
explore these associations in greater
detail by looking at the association of dissatisfaction with each component
of these 3 indices.
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Treatment dissatisfaction among patients with asthma disease management
problems (asthma control, patient-provider communication, and belief in medication).
Asthma control is scored 0 (no problems) to 4 (maximum number of problems
assessed). Patient-provider communication is scored 0 (no problems) to 5 (maximum
number of problems assessed). Belief in medications is scored 0 (no problems)
to 2 (maximum number of problems assessed). Data show percentage dissatisfied
within each level of disease mangement construct. For example, among patients
with "2" belief in medication problems, 79.2% were dissatisfied.
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Table 1. Association of Asthma Control Issues With Treatment Dissatisfaction*
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Table 2. Association of Patient-Provider Communication Issues With
Treatment Dissatisfaction*
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Table 3. Association of Patient Belief in Medications (Self-efficacy)
Issues With Treatment Dissatisfaction*
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Table 4. Odds Ratios for Dissatisfaction With Asthma Treatment From
Multiple Logistic Regression Model
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Analysis of individual asthma control problems (Table 1) revealed more than half of the patients being dissatisfied
with their asthma treatment if they thought in the past 4 weeks their asthma
was not controlled (58.5%), they missed activities due to asthma (50.5%),
or they were high users of quick relief medication (53.9%). Interestingly,
only 41.8% of patients waking up at night because of their asthma were dissatisfied
with their treatment. In contrast, between 18% and 29% of the patients were
dissatisfied with their treatment when they did not have one of these asthma
control problems.
Table 2 shows the distribution
of patient-provider communication problems. Among all the patient-provider
communication issues studied, the highest percentage of treatment dissatisfaction
was observed among patients who reported that their physician or medical provider
did not involve them in treatment decisions (49.8%) and among patients who
reported that their physician or medical provider did not know their medication
preferences (46.7%).
Table 3 summarizes the association
of dissatisfaction with the 2 beliefs in medication issues: ability to take
medications as directed and belief that medication is useful in controlling
asthma. These 2 problems exhibited the strongest associations with dissatisfaction,
with 64.6% and 74.9% of the patients who reported these problems, respectively,
indicating dissatisfaction with their current asthma treatment.
The presence of asthma control problems, patient-provider communication
problems, and belief in medication problems was significantly associated with
treatment dissatisfaction in logistic regression analysis that adjusted for
patient age, sex, and coexistence of asthma and COPD (Table 4). The odds of dissatisfaction with asthma treatment were
almost 3 times higher for patients with asthma control issues (OR, 2.8; 95%
CI, 2.4-3.2; P<.001) and 2 times higher for patients
with patient-provider communication issues (OR, 2.0; 95% CI, 1.6-2.6; P<.001) compared with patients without these perceived
problems. Patients with belief in medication issues had an odds of dissatisfaction
that was 8 times higher (95% CI, 6.7-9.5; P<.001)
than patients without these medication problems. The C statistic27
for the logistic regression model was 0.77, indicating a good fit of the model
to the study population.
Not shown, a separate logistic regression model was used to analyze
the influence of individual components of the asthma control, patient-provider
communication, and belief in medication domains. Three items in the patient-provider
communication domain were not significantly associated with treatment dissatisfaction:
(1) if the physician or medical provider had reviewed medications with the
patient in the last year, (2) if the patient had a written treatment plan
for asthma attacks, and (3) if the patient had a written treatment plan when
not having an asthma attack. All other questions comprising the patient-provider
communication domain and all questions of the asthma control and belief in
medications domains were significantly associated with treatment dissatisfaction
in the direction anticipated.
COMMENT
Thirty percent of the adult patients with asthma in our study population
were dissatisfied with their current asthma treatment. Dissatisfaction was
significantly associated with asthma control problems, patient-provider communication
problems, and issues with the patients' belief in their medication. The findings
of this study suggest that important aspects of care are associated with patient
dissatisfaction with asthma treatment, implying that evidence of patient dissatisfaction
may warrant serious consideration in quality improvement programs.
Insufficient knowledge and inappropriate beliefs about asthma are considered
major barriers to self-management of asthma.28, 29
Our study suggests that patient confidence in their medications and their
ability to take the medications as directed have a profound influence on dissatisfaction
with treatment. The odds of treatment dissatisfaction were 8 times higher
among patients who reported uncertainty about the efficacy of their asthma
medication or their ability to take the medication as directed than those
without these disease management problems. Given the current state of asthma
treatment, it should be possible to identify regimens that patients believe
will control their disease and that they can follow as directed by their providers.
The way physicians or medical providers interact with patients appears
to have an important influence on patient dissatisfaction. Among patients
who believed that they were not involved in decision making, half were dissatisfied
with their current treatment. This could be partly because of restriction
in time that physicians spend with their patients during a regular visit and
current pressure to improve the efficiency of health care provision.30, 31, 32 In another study,
assessing the effectiveness of a one-on-one nurse education program, Forshee
at al33 found that better patient education
and improved communication between patient and provider were associated with
decreased urgent care utilization and hospital admission rates. If there is
a link between lack of patient-provider communication, dissatisfaction with
treatment, and resource use, approaches to improving communication should
be explored. Interestingly, lack of written treatment plans was not associated
with treatment dissatisfaction in our multiple logistic regression models.
Lieu and colleagues4 showed that having a written
treatment plan is associated with reduced health care utilization. These findings
raise the possibility that the verbal communication between the patient and
provider that accompanies the treatment plan may be as important as the written
document. Provider education and availability of office-based tools such as
templates for treatment plans could foster communication and possibly decrease
patient dissatisfaction, particularly if actual communication is fostered
by having these office-based tools.15, 32
Although patient-provider communication and belief in medications are
measures of process of care, level of asthma control is a measure of the outcome
of care. In this study, patients with worse clinical outcomes, as measured
by asthma control problems, were more dissatisfied with their treatment than
patients with better clinical outcomes. A study by Vollmer et al26
demonstrated the cross-sectional association of asthma control issues with
quality of life and self-reported health care utilization. Although the relation
between satisfaction and resource use was not assessed in that study, Druss
et al,34 found patient dissatisfaction (in
terms of low level of satisfaction) to be associated with health care utilization.
The results from these 2 studies indicate the potential for the measures of
dissatisfaction to be associated with other important outcomes of care.
The findings from this study raise concern about whether or not patients
are reluctant to express dissatisfaction with treatment. Not all patients
with disease management problems were dissatisfied. For example, about half
of the patients with nocturnal asthma did not report dissatisfaction, indicating
that perhaps patients with asthma may accept a lower level of functioning
than possible.
A study by Osman35 suggests that patients
are not always able to raise to their providers all the asthma-related issues
that are important to them. In addition, past studies9, 11
suggest that patients want more information on the nature of their disease
and medication use and seek better relationships with their physicians. In
this context, a disease management tool such as the ATAQ may be useful to
evaluate asthma management problems that may influence treatment dissatisfaction
and that can be verified and followed up by a health care provider.
The results of this study only represent the perspective and disease
management problems experienced by the responders of the survey. Whether the
nonresponders are more or less dissatisfied with their current asthma treatment
is unknown. Also, the outcome measure (patient dissatisfaction with asthma
treatment) and the tools for measuring the 3 disease management constructs
are both subjective measures and subject to the same limitations associated
with patient-reported data. Although the study results have depicted a distinctive
relation between patient dissatisfaction and the 3 asthma disease management
constructs, only future research can quantify whether positive steps contributing
to improvement in each of these 3 disease management domains can decrease
patient dissatisfaction. In addition, disease management constructs (such
as patient concern with involvement in decision making) may be another measure
of dissatisfaction. There is not a clear conceptual framework for the factors
that influence patient dissatisfaction with asthma treatment. It is possible
that other important factors associated with treatment dissatisfaction were
not measured in this study.
Apart from marketing research, patient satisfaction is increasingly
being used as an outcome measure for clinical trials and disease management
programs,36 and further consideration should
be given to the distinctions between measures of satisfaction and evidence
of dissatisfaction. This study has highlighted the fact that patient dissatisfaction
can reflect poor disease outcome (ie, poor asthma control), problems with
the process of care (in terms of communication issues such as physician understanding
of patient preference), and problems related to the patients' belief in their
medication. The findings further support the idea that concentrating on more
personal care would result in better communication and more patient involvement,
resulting in better quality of care and hence decreased patient dissatisfaction.37 Overall, our findings suggest that when patients
express dissatisfaction with current asthma treatment, there may be disease
management problems that can be rectified to potentially improve patient outcomes.
AUTHOR INFORMATION
Accepted for publication August 31, 2000.
From Merck & Co, Inc, West Point, Pa (Drs Markson, Fitterman, and
Berger and Mr Narayanan), Kaiser Permanente Center for Health Research, Portland,
Ore (Drs Vollmer and O'Connor), and Oregon Health Sciences University, Portland
(Dr Buist).
Corresponding author and reprints: Leona E. Markson, ScD, Outcomes
Research and Management, Merck & Co, Inc, PO Box 4, WP39-164, West Point,
PA 19486-0004.
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