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Wait Times, Patient Satisfaction Scores, and the Perception of Care
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Wait Times, Patient Satisfaction Scores, and the Perception of Care

Clifford Bleustein, MD, MBA; David B. Rothschild, BS; Andrew Valen, MHA; Eduardas Valaitis, PhD; Laura Schweitzer, MS; and Raleigh Jones, MD
Clinic wait times do not just affect overall patient satisfaction, but also specifically affect the perception of providers and the quality of care.
For each question and explanatory variable combination, we fitted a logistic regression model to predict the logit of the probability that the respondent gave a score of 5 (p5) for a particular explanatory variable. Table 3 interprets model coefficients from our univariate logistic regression study for all explanatory variables but gender. In summary, Table 3 shows that:
  • Waiting 10 minutes in the waiting room decreased p5 less than waiting 10 minutes in the exam room.
  • The effects of age were positive and significant for almost all questions. More specifically, older patients tended to assess the care received more favorably with the increase between 0.5 and 2.9 percent for each additional 10 years in age.
  • Patients visiting a care provider the first time were less likely to evaluate the care received with the highest score. In general, a care provider had about a 5% lower probability of receiving a score of 5 from a new patient than from a returning patient. Interestingly, first-time patients differed substantially from their peers who were not first-time patients in their assessment for questions cp9 (confidence in care provider) and cp10 (likelihood of recommending the care provider).


When survey respondents were patients themselves (ie, they were self-filling the questionnaire), they tended to evaluate the care received more favorably compared with respondents who were not the individuals receiving the care. Multivariate Logistic Regressions We have fitted multivariate logistic regression models in which the probability of receiving the highest satisfaction score (p5) was predicted by a number of explanatory factors for each of the studied questions. The following variables were used and general results obtained for the models:
  • Combined waiting time was considered instead of exam and waiting room times separately, so that a single model could be fitted for each question. The combined waiting time variable had a statistically significant negative effect on p5.
  • To account for the differences in the effects on satisfaction by exam and waiting room time, we included a “percent in waiting room” variable, which was calculated as a proportion of time spent in the waiting room. Consistent with our findings in the univariate models, the variable had a significant positive effect on satisfaction, implying that patients preferred to wait in the waiting room.
  • First visit had a negative effect on p5 for the majority of questions.
  • Age and self-filling indicator were considered jointly, as their interaction factor was statistically significant. This is mostly due to the fact that pediatric patient surveys were filled out by the parents or guardians and the satisfaction scores supplied by them were much higher than those received from patients in their 20s and 30s. We performed a multivariate regression model to interpret the waiting time effects on satisfaction scores for the same hypothetical person for likelihood of recommending practice. Waiting a combined time of 10 minutes results in about a 77% chance of receiving the highest satisfaction score. As the time of waiting is increased, the chance of obtaining the highest score decreased with the combined waiting times of 20 minutes, 40 minutes, and 60 minutes resulting in a decrease in the likelihood of recommending the practice to 69%, 59%, and 53% respectively.


DISCUSSION

Our study further confirms the strong relationship between patient wait times and patient satisfaction, yet the results go beyond this well-understood notion to provide actionable findings for clinicians and healthcare managers. Our results, while supportive of our hypothesis, were especially interesting with regard to the impact of wait times on perceived quality of care received from the clinician as opposed to simply “satisfaction” with the experience. Analyzing the relationship between wait times and patient evaluation of care provided—including “confidence in the care provider”—revealed significant declines in scores across all measures tested (Table 3). Thus, we are led to believe that wait times are not just a component of patient satisfaction, but an important component of quality care. In a new healthcare economy, minimizing wait times must be taken seriously in order to compete, manage costs, and retain clientele.

While the studies conducted by other researchers7-9 focused on total waiting times, we add to this body of literature: we evaluated the sensitivity of waiting times with respect to time spent in the waiting room, time spent in the exam room, and combined waiting time as separate data sets. Common to all studies is the negative impact that longer waiting times have on patient satisfaction; however our study also demonstrated that satisfaction scores are more sensitive to exam room waiting time than to time spent in the designated waiting room. Reasons for dissatisfaction with the exam room wait have not been examined fully, but we can surmise several explanations, including lack of material to engage the patient, an expectation of quicker service, and less comfortable surroundings. Our results demonstrate that in the realistic event that clinics fall behind schedule, it is better to allow patients to wait outside in the waiting room rather than to quickly place them in an exam room.

Our study also revealed a significant difference between new and returning patients, as the former gave significantly lower scores across all metrics. But, correspondingly, Leddy et al found that first-time patients waited significantly longer than follow-up patients.9 Our results support this finding, as first-visit patients waited an average of 23.1 minutes versus an average of 19.6 minutes for repeat patients. Furthermore, we found that a patient’s age also impacted satisfaction scores, as elderly patients gave higher physician scores than nonelderly patients,11 and the spread in satisfaction scores between elderly and nonelderly patients actually increased as wait times increase. Numerous case studies have shown methods to increase patient flow, reduce wait times, and augment satisfaction scores.10,12,13 Appointment schedule, physician tardiness, and patient complexity can all heavily impact wait times,14 but solutions do exist to improve patient throughput.

Patient waiting times alone significantly impact all measured aspects of ambulatory patient experiences, including quality of care, as compiled in the Press Ganey survey responses. We know that exam room waiting times have a more pronounced negative effect on satisfaction scores than does time spent in the waiting room, and we know that first-time patients are particularly sensitive to longer wait times. Most importantly, however, we have shown that longer wait times can actually diminish patients’ perception of a physician’s capabilities, and decrease the stated confidence in care provided.

Our study does have some limitations that could be addressed with further research. We cannot differentiate between the effects of the explanatory factors and the actual quality of care, and we are unable to address the impact of actual time spent with the physician. As mentioned above, 14% of responses came from repeat patient visits: additional granularity on the reasons behind repeat visits, and, whether a correlation between the frequency of visits, severity of illness, and high satisfaction exists, was not available. While these factors somewhat limit the study, the Press Ganey surveys are currently used for evaluation of satisfaction both within the inpatient and outpatient settings and can give directional guidance about the performance of individual clinics.

While it has always been a goal of healthcare systems to provide quality care as efficiently as possible, this study further emphasizes the need to minimize wait times in order to retain first-time patients, increase referrals, maintain costs, and compete in an expanding, consumer-driven marketplace. As understanding of instructions or treatment directions, perceived quality of care, and confidence in the provider decrease, it could follow that the number of complaints, unnecessary tests, and even threats of malpractice suits could increase, and we encourage study of potential relationships between these cost drivers and patient satisfaction scores. Furthermore, with the growing number of “retail” healthcare providers, and the changing relationship between patient and provider, quality of care, specifically, will become an ever-increasing factor in the competition for clients.1 This study can provide intelligence to healthcare providers on how to prioritize a patient’s time, and the need to raise patient perceptions and win in a new marketplace.

Author Affiliations: PricewaterhouseCoopers, New York, NY (CB, DBR, EV, LS); JPMorgan Chase (AV); University of Kentucky Healthcare (RJ).

Source of Funding: None reported.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (CB, AV, RJ); acquisition of data (CB, AV, RJ); analysis and interpretation of data (CB, AV, EV, LS); drafting of the manuscript (CB, DR, EV, LS, RJ); critical revision of the manuscript for important intellectual content (CB); statistical analysis (EV, LS); provision of study materials or patients (RJ); supervision (CB, RJ).

Address correspondence to: Clifford Bleustein, MD, MBA, PricewaterhouseCoopers, 180 East End Ave, Apt 11H, New York, NY 10128. E-mail: cbleustein@aol.com.
1. PricewaterhouseCooper’s Health Research Institute. Healthcast 2010. PriceWaterhouseCoopers website. www.pwc.com/hri. Accessed August 18, 2010.

2. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001.

3. Centers for Medicare & Medicaid Services. CAHPS Hospital Survey. http://www.hcahpsonline.org. Accessed August 15, 2010.

4. Press Ganey Associates, Inc. http://www.pressganey.com. Accessed August 15, 2010.

5. Trout A, Magnusson AR, Hedges JR. Patient satisfaction investigations and the emergency department: what does the literature say? Acad Emerg Med. 2000;7(6):695-709.

6. Howard M, Agarwal G, Hilts L. Patient satisfaction with access in two interprofessional academic family medicine clinics. Fam Pract. 2009;26(5):407-412.

7. Dansky KH, Miles J. Patient satisfaction with ambulatory healthcare services: waiting time and filling time. Hosp Health Serv Adm. 1997;42(2):165-177.

8. Camacho F, Anderson R, Safrit A, Jones AS, Hoffmann P. The relationship between patient’s perceived waiting time and office-based practice satisfaction. M C Med J. 2006;67(6):409-413.

9. Leddy KM, Kaldenberg DO, Becker BW. Timeliness in ambulatory care treatment: an examination of patient satisfaction and wait times in medical practices and outpatient test and treatment facilities. J Ambul Care Manage. 2003;26(2):138-149.

10. Preyde M, Crawford K, Mullins L. Patients’ satisfaction and wait times at Guelph General Hospital Emergency Department before and after implementation of a process improvement project. CJEM. 2012;14(3):157-168.

11. Kong MC, Camacho FT, Feldman SR, Anderson RT, Balkrishnan R. Correlates of patient satisfaction with physician visit: differences between elderly and nonelderly survey respondents. Health Qual Life Outcomes. 2007;24(5):62.

12. Chand S, Moskowitz H, Norris JB, Shade S, and Willis DR. Improving patient flow at an outpatient clinic: study of sources of variability and improvement factors. Health Care Manag Sci. 2009;12(3):325-340.

13. Shortening waiting times: six principles for improved access. Institute for Healthcare Improvement website. http://www.ihi.org/ resources/Pages/ImprovementStories/ShorteningWaitingTimesSix- PrinciplesforImprovedAccess.aspx. Updated July 22, 2011. 14. Groome LJ, Mayeaux EJ Jr. Decreasing extremes in patient waiting time. Qual Manag Health Care. 2010;19(2):117-128.
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