Instruments for Measuring Satisfaction With Physical Therapy Care: A Systematic Review

, Clinimetric Group FE-14, Biomedical Research Institute of Malaga and Department of Occupational Therapy, Catholic University San Antonio de Murcia, Campus de Los Jerónimos s/n. Código Postal 30107, Población, Malaga,

, Clinimetric Group FE-14, Biomedical Research Institute of Malaga and Faculty of Health, Queensland University of Technology, Brisbane, Queensland,

Physical Therapy, Volume 100, Issue 9, September 2020, Pages 1690–1700, https://doi.org/10.1093/ptj/pzaa111

Cite

Daniel Gutiérrez-Sánchez, David Pérez-Cruzado, Antonio I Cuesta-Vargas, Instruments for Measuring Satisfaction With Physical Therapy Care: A Systematic Review, Physical Therapy, Volume 100, Issue 9, September 2020, Pages 1690–1700, https://doi.org/10.1093/ptj/pzaa111

Abstract

Several instruments to measure patient satisfaction have been developed to assess satisfaction with physical therapy care. The selection of the most appropriate instrument is very important. The purpose of this study was to identify instruments for assessing satisfaction with physical therapy care and their psychometric properties and to evaluate the methodological quality of studies on psychometric properties.

A systematic search was conducted in ProQuest Medline, SciELO, ProQuest PsycINFO, Theseus, Cochrane Library, and Google Scholar. Articles published from 1990 to 2019, in English and Spanish, were used as limits. This systematic review followed the Consensus-based Standards for the Selection of Health Measurement Instruments and Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards. The articles were evaluated by 2 independent reviewers using the Consensus-based Standards for the Selection of Health Measurement Instruments 4-point checklist. Eighteen studies were included.

Nine instruments were found to be specifically designed to assess satisfaction with physical therapy care. The methodological quality of the studies was “fair” for most of the psychometric characteristics analyzed (43 items), with 24 properties scored as “poor,” 5 as “good,” and 3 as “excellent.”

Different instrument characteristics—such as the scope and population with which the instrument will be used, its dimensions, the number of items, and the evidence shown in the evaluation of each psychometric property—should be considered by clinicians and researchers to decide which instrument is the best to measure the construct of patient satisfaction with physical therapy.

Evaluating patient satisfaction is very useful in clinical practice at the hospital, community, and primary care levels. Physical therapist clinicians and researchers can use this systematic review to select instruments whose characteristics will best measure their patients’ satisfaction with physical therapy care.

Patient satisfaction is an important component of the quality of care; therefore, it can be considered a measure of another broader concept. 1 Patient satisfaction is a multidimensional concept that is determined by 3 interrelated aspects of health care: the clinical outcome, the environment in which the care is developed, and the interpersonal relationships with the professionals who attend to them. Patient satisfaction is directly related to previous expectations of patients. 2–5 Interest in the measurement of patient satisfaction in health care has grown in recent years in both the clinical field and research. 6 , 7

The evaluation of satisfaction in physical therapy is considered an excellent indicator of the quality of care 8 and an essential element that affects the potential of treatment as well as its effectiveness, directly influencing the rehabilitation process. 9 , 10 Greater adherence to treatment is found in highly satisfied patients as compared with those who are not. 11

There are a great variety of instruments for measuring satisfaction in physical therapy, although no review has been published contrasting the psychometric properties of the instruments according to the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) standards. 4 , 12–15 Given this fact, a systematic review to identify instruments for measuring satisfaction in physical therapy and its psychometric properties, and to evaluate the methodological quality of the validation studies of these instruments, was carried out. Therefore, the objectives of this systematic review were to (1) identify instruments used to measure satisfaction in physical therapy and their psychometric properties, and (2) evaluate the methodological quality of the validation studies of these instruments.

Methods

Design

A systematic review was carried out on the instruments for measuring satisfaction with physical therapy care in accordance with the COSMIN and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards. 14–16 The protocol of this review was registered in the International Prospective Register of Systematic Reviews (registration number: CRD42016041561).

The COSMIN is one of the most widespread and comprehensive tools for assessing the measurement properties of existing patient-reported outcome measures and for selecting the most suitable outcome measurement instrument. 14 , 15

The aim of the PRISMA statement is to help authors improve the reporting of systematic reviews and meta-analyses. The use of checklists such as PRISMA is likely to improve the reporting quality of a systematic review and provides substantial transparency in the selection process of papers in a systematic review. 16

Search Method

A systematic search was performed in the ProQuest Medline, SciELO, ProQuest PsycINFO, Theseus, Cochrane Library, and Google Scholar databases using the following key terms: “Instrument” AND “Patient satisfaction” AND “Physiotherapy” OR “Physical Therapy.” Validation studies on physical therapy satisfaction measurement instruments published between 1990 and 2019 were selected. The search was limited to articles published in English and Spanish and was completed in October 2019.

Search Strategy

1. “Patient satisfaction” [MeSH]
2. “Physiotherapy” [tiab) “OR “Physical Therapy”[tiab]
3. “Instrument”[tiab] OR “Instruments”[tiab]
4. “Validation studies” [pt]
5. #1 AND #2 AND #3 AND #4
6. FILTER: Language (English and Spanish)
7. FILTER: Period (1990–2018)

Selection Criteria

The following inclusion criteria were used:

• Type of participants: patients and professionals.
• Type of results: satisfaction perceived by the patient.
• Type of studies: studies that had evaluated and described at least 1 psychometric property from the COSMIN checklist.
• Type of instruments: instruments that evaluated satisfaction in physical therapy.

Assessment of Methodological Quality

The included studies were evaluated by D.G.S., D.P.C., and A.I.C.V. using the COSMIN 4-point checklist. 15 The COSMIN checklist contains 9 boxes with 5 to 18 items, and each box provides a methodological quality score for internal consistency (the degree of correlation between the different items), reliability (stability of the measurement), measurement error (difference between the empirical score of a subject and its true score), content validity (property that evaluates whether all of the items included are relevant and comprehensive), structural validity (the extent to which the scores of an instrument adequately reflect the dimensionality of the construct to be measured), hypothesis testing (property that is analyzed to determine if the hypotheses were formulated a priori), cross-cultural validity (investigation of a phenomenon or theory that is compared in at least 2 different cultures), criterion validity (the degree to which the scores of an instrument are related to a “gold standard”), and response to change (the ability of a measure to detect change over time).

The content evaluated in each box can be described as “excellent,” “good,” “fair,” and “poor.” The score for each psychometric property was obtained by taking the lowest score of any item for each property. 15

Data Extraction

The articles were reviewed by 2 reviewers independently, and the discrepancies were resolved by consensus. All articles were selected by reviewing the title, abstract, and the full text. A form was developed to collect the information, and the following general characteristics of each study were extracted: name of the instrument and study year, place of validation and sample size (N), scope, type of respondents, description of the instrument, psychometric properties analyzed, and COSMIN score.

Data Synthesis and Analysis

Data on the psychometric properties of articles that met the inclusion criteria were scored according to the COSMIN checklist and the results of each.

Measurement property was rated according to the widely accepted quality assessment criteria for statistical outcomes. 15 The scores of each of the psychometric properties of each article were attributed by 2 independent reviewers, and the differences were resolved by discussion and consensus.

Results

We identified 432 articles, of which 377 titles and abstracts were examined. Of these, 355 articles were excluded after screening. Twenty-two full-text articles were evaluated. Of these, 4 articles were excluded after reviewing the full text. 8 , 17–19 Finally, 18 studies were included in this systematic review. The flowchart of this review is provided in Figure. Nine instruments specifically designed to assess satisfaction with physical therapy care were identified: the Satisfaction Survey of Rehabilitation Services, 20 Physical Therapy Outpatient Satisfaction Survey (PTOPS), 12 , 21 , 22 Chest Physiotherapy Satisfaction Survey, 23 the Physical Therapy Patient Satisfaction Questionnaire, 13 Patient Satisfaction with Physical Therapy, 24 MedRisk, 4 , 25–31 Patient Satisfaction with Outpatient Physiotherapy Questionnaire, 32 the User Service Questionnaire (CAU) 33 and the Treatment Outcome Satisfaction Questionnaire 34 ( Tab. 1). Although English was the original language used for most of the instruments, 3 instruments were available in Spanish, 1 in Italian, 1 in Gujarati, 1 in Korean, 1 in Sinhalese, 1 in Brazilian Portuguese, and 1 in Swedish. A 5-point Likert scale was used in most of the questionnaires as a scoring method. In most studies, the information provided by the patient was used to evaluate satisfaction with physical therapy care.

Study selection flow diagram.

The majority of the studies were performed in a hospital and outpatient setting with patients with musculoskeletal problems. The Chest Physiotherapy Satisfaction Survey was the only instrument validated in a population of patients with a specific pathology (cystic fibrosis).

Instruments for Measuring Satisfaction

The main properties evaluated were internal consistency, structural validity, hypotheses testing, and criterion validity. The results of the 4-point COSMIN checklist of the instruments for measuring satisfaction with physical therapy care are shown in Table 2.

Rehabilitation Services Satisfaction Survey

Only 1 study described the psychometric properties of the Rehabilitation Services Satisfaction Survey. 20 This questionnaire scored poor for 3 properties and fair for 1 of the analyzed properties due to the lack of description of percentages, management of missing values, and the lack of evaluation of the relevance of the items in the study population. However, this survey showed an excellent Cronbach alpha value of .932.

Physical Therapy Outpatient Satisfaction Survey

The psychometric properties of this survey were analyzed in 3 studies 12 , 21 , 22 scoring poor or fair in the variables analyzed except for criteria validity, which scored good in 1 study. 22 Cronbach alpha for this survey ranged between .70 12 and .88. 22 Test-retest reliability was measured in 1 study 22 in which some coefficients appeared to be not particularly high (around .5). The lack of evaluation of the relevance of the items in the study population (only a physical therapist expert in patient satisfaction) 12 scored fair for this property. Confirmatory factor analysis was carried out in 2 studies 12 , 22 for structural validity. The PTOPS was adapted for population in Ireland 21 and Italy 22 by expert physical therapists, and criteria validity was assessed by comparing the domains with those of the MedRisk questionnaire and with the Multiple Sclerosis Societies of Connecticut in the 3 studies that assessed this property.

Chest Physiotherapy Satisfaction Survey

This survey was assessed in only 1 study in which 6 psychometric properties were rated between poor and fair 23 due to the management of missing values and lack of evaluation of relevance of the items in the study population. Internal consistency showed an overall Cronbach alpha value of .87 and test-retest reliability for the total score was .63.

Physical Therapy Patient Satisfaction Questionnaire

This questionnaire was assessed in the study of Goldstein et al, 13 where 5 psychometric properties were scored (between fair and poor) and an excellent Cronbach alpha value of .99 was obtained.

Patient Satisfaction With Physical Therapy

This questionnaire was evaluated in 1 study in which 4 psychometric properties were assessed. 24 Internal consistency varied between 0.77 and 0.90 and was assessed using an adequate sample size and factor analysis, scoring excellent in the COSMIN checklist. Structural validity also was scored as excellent because the sample size was adequate and exploratory factor analysis was carried out, with the factorial structure being statistically representative. Hypotheses testing and criterion validity were also evaluated for this questionnaire.

Characteristics of the Studies on Patient Satisfaction with Physical Therapy Care Instruments That Were Included in This Review a

a CAU = User Service Questionnaire.

Characteristics of the Studies on Patient Satisfaction with Physical Therapy Care Instruments That Were Included in This Review a

a CAU = User Service Questionnaire.

MedRisk

The MedRisk was the questionnaire whose psychometric properties were evaluated in a large number of studies (8 studies) 4 , 25–31 in which the original English questionnaire was translated into Spanish, 26 Korean, 29 Gujarati, 28 Sinhalese , 30 and Brazilian Portuguese. 31 For MedRisk, all the psychometric properties included in the COSMIN checklist were evaluated except “sensitivity to change.” Internal consistency showed excellent Cronbach alpha values between .94 and .86. 27 , 29 In the Brazilian Portuguese version, however, these values were lower, with an adequate internal consistency in the range .63 to .77 . 31 The reliability of the Brazilian Portuguese version of MedRisk was evaluated as having high test–retest reliability, as shown by the intraclass correlation coefficient value of ≥0.70. Four studies evaluated the measurement error of MedRisk , 4 , 25 , 26 , 29 the standard error being 0.19 to 0.45 for the original version, 25 0.31 to 0.49 for the Spanish version , 26 and 0.31 to 0.49 for the Korean version. 29 In the study by Beattie et al , 4 the content validity of MedRisk was evaluated by item correlation using principal component analysis, and, because no specific gold standard was used as a criterion, the validity of MedRisk was demonstrated by comparison with items that measured general satisfaction.

Patient Satisfaction With Outpatient Physiotherapy Questionnaire

This questionnaire was used in 1 study in which 3 psychometric properties of the COSMIN checklist 32 were evaluated, scoring fair for internal consistency and structural validity and excellent for content validity. Cronbach alpha was .80 for this questionnaire.

User Attention Questionnaire

In this questionnaire, only content validity was evaluated, with a resulting score of fair. 33

Treatment Outcome Satisfaction Questionnaire

Four properties were evaluated for this questionnaire in the study of Lo Martire et al 34 in which 3 of the analyzed properties were scored as fair and 1 as poor. The intraclass correlation coefficient was 0.79, and the standard measurement error was approximately 6.6. This questionnaire was adapted for the Swedish population.

Discussion

The main objective of this systematic review was to identify the instruments used to assess satisfaction with physical therapy care and to evaluate the methodological quality of the validation studies of these instruments in accordance with the COSMIN checklist. This study identified 9 instruments that were specifically designed to evaluate this construct.

Different characteristics, such as the scope and population where the instrument will be used, its dimensions, the number of items, and the evidence shown in the evaluation of each psychometric property should be considered by clinicians and researchers to decide which instrument is the best to measure this construct. In addition, the language and culture of the original version of the instrument to be used must be considered.

The results of this systematic review indicate that measurement error and cross-cultural validity obtained the lowest scores of the psychometric properties that were evaluated. However, the methodological quality of the studies was “fair” for most of the psychometric characteristics analyzed. In this sense, the lack of description of the percentage and management of the lost values contributed to a lower quality rating.

COSMIN Checklist With 4-Point Scale Rating of Satisfaction With Physical Therapy Care Instruments a

a + = Poor; ++ = Fair; +++ = Good; ++++ = Excellent; Empty = not evaluated.

COSMIN Checklist With 4-Point Scale Rating of Satisfaction With Physical Therapy Care Instruments a

a + = Poor; ++ = Fair; +++ = Good; ++++ = Excellent; Empty = not evaluated.

The lack of analysis of properties, such as sensitivity to change, is a limitation of the instruments currently available. In this review, no study was identified in which this psychometric property was evaluated. Moreover, instruments assessing satisfaction with physical therapy care have serious issues (eg, ceiling effects, lack of description of percentages, and management of lost values). A potential explanation is that instruments assessing satisfaction with physical therapy come from other fields and are not appropriate to physical therapy settings. In this sense, more studies of high methodological quality are required that evaluate the psychometric properties of the instruments used for measuring patient satisfaction with physical therapy care.

The MedRisk instrument has been widely used in the evaluation of satisfaction with physical therapy care. This instrument was used in 8 of the 18 reviewed articles, and it is the most widely validated and published instrument to date. In addition, this instrument is the measure of satisfaction with physical therapy care that has evaluated the most psychometric properties. 25 , 25–31 In this context, the methodological quality was good for internal consistency, structural validity, and criterion validity. Thus, the MedRisk was found to be the most robust instrument identified in this systematic review.

Satisfaction with physical therapy care is a multidimensional concept; therefore, it is established that a questionnaire that aims to measure this construct must consist of at least 2 dimensions. 8 In most studies, a 3-factor structure was obtained. The Chest Physiotherapy Satisfaction survey, Patient Satisfaction with Physical Therapy, and MedRisk were the instruments that informed on a structure of 3 factors.

The Survey of Satisfaction in Rehabilitation Services, Chest Physiotherapy Satisfaction Survey, Physical Therapy Patient Satisfaction Questionnaire, Patient Satisfaction with Physical Therapy, Patient Satisfaction with Outpatient Physiotherapy Questionnaire, CAU, and the Treatment Outcome Satisfaction Questionnaire have been evaluated in a single study. Therefore, additional studies evaluating the psychometric properties of these instruments are necessary. 13 , 20 , 23 , 24 , 32–34

PTOPS has been adapted and validated to several cultures, but additional studies are necessary to evaluate the measurement error and the sensitivity to change. 21 , 22 In this review, 3 instruments used for measuring satisfaction with the care received in physical therapy, available in Spanish, were identified: the Satisfaction Survey in Rehabilitation Services, MedRisk, and CAU. 20 , 26 , 27 , 33

Strengths and Limitations

This is the most current systematic review that identifies, evaluates, and summarizes the evidence with respect to instruments used for measuring satisfaction with physical therapy care. This revision was made in accordance with the COSMIN and PRISMA standards; thus, an appropriate method was used following the recommendations of the experts. 14 , 16 Although a meticulous search was conducted in several databases, it is possible that not all the instruments available for the measurement of this construct have been identified in this review. 35 Due to the limitation in the search strategy to only evaluate articles published in English and Spanish, it is possible that articles on instruments developed and used in other languages have not been identified. Moreover, the limited descriptors used can be considered as a potential limitation of this systematic review.

Conclusions

Many instruments have been developed to evaluate satisfaction with physical therapy care. The evaluation of this construct can be useful both in the clinical field and in research, which are areas where new knowledge is needed. The evaluation of this construct is essential since it allows the identification and evaluation of interventions that improve care. If we want to identify these interventions, we must have valid and reliable instruments. The lack of responsiveness to change is a limitation of the currently available satisfaction with physical therapy care instruments.

MedRisk was used in 8 of the articles reviewed, and it is the most widely validated and published measure of satisfaction with physical therapy care. In addition, MedRisk evaluated 8 different psychometric properties according to the COSMIN checklist.

While it is true that the MedRisk tool is the most referenced (8 articles), it is not the 1 that has the most quality for the different items. Some other measuring instruments have greater internal consistency and greater structural validity.

Therefore, the conclusion that MedRisk is the best instrument available to assess satisfaction with physical therapy care is debatable. We recommend that your choice be justified for use as a tool according to the psychometric properties shown in this systematic review.

Author Contributions

Concept/idea/research design: A.I. Cuesta-Vargas

Writing: D. Gutiérrez Sánchez, D. Pérez Cruzado, A.I. Cuesta-Vargas

Data collection: D. Gutiérrez Sánchez, A.I. Cuesta-Vargas

Data analysis: D. Gutiérrez Sánchez, D. Pérez Cruzado, A.I. Cuesta-Vargas

Project management: A.I. Cuesta-Vargas

Fund procurement: A.I. Cuesta-Vargas

Providing facilities/equipment: A.I. Cuesta-Vargas

Consultation (including review of manuscript before submitting): D. Gutiérrez Sánchez, A.I. Cuesta-Vargas

Ethics Approval

Funding

This study was funded in part by a grant from Catedra de Fisioterapia y Discapacidad, University of Malaga (8.06/5.87.50300).

Systematic Review Registration

This review was registered in the International Prospective Register of Systematic Reviews (CRD42016041561).

Disclosures

The authors completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported no conflicts of interest.