Patients’ experience of outsourcing and care related to magnetic resonance examinations Upsala Journal of Medical Sciences. 2014; 119: 343–349 ORIGINAL ARTICLE Patients’ experience of outsourcing and care related to magnetic resonance examinations PARVIN TAVAKOL OLOFSSON1, PETER ASPELIN1, LOTT BERGSTRAND2 & LENNART BLOMQVIST3 1Department of Clinical Science, Intervention and Technology at Karolinska Institutet, Division of Medical Imaging and Technology, Stockholm, Sweden, 2Department of Radiology, Ersta Hospital, Stockholm, Sweden, and 3Department of Radiology, Karolinska University Hospital in Solna, Stockholm, Sweden Abstract Background. Outsourcing radiological examinations from public university hospitals affects the patient, who has to attend a different clinic or hospital for the radiological examination. We currently have a limited understanding of how patients view outsourcing and their care related to MR examinations. Aim. To examine the experiences of patients who are sent to private radiology units when their referrals for MR examinations are outsourced from a university hospital, as well as to explore factors which influence patient satisfaction regarding the quality of care related to the MR examination. Methods. A group of patients (n = 160) referred for MR examinations and either examined at a university hospital or at an external private unit were interviewed. The interview was designed as a verbal questionnaire. Data were analyzed using Student’s t test, analysis of variance (ANOVA), and Pearson’s correlation. Results. Sixty-nine percent of the patients could neither choose nor influence the location at which they were examined. For those who could, aspects that influenced the patient’s choice of radiology department were: short waiting time 79% (127/160), ease of traveling to the radiology department 68% (110/160), and short distance to their home or work 58% (93/160). For 40% (60/160) of the patients, a short time in the waiting room was related to a positive experience of the MR examination. Conclusion. If patients were informed about outsourcing and could also choose where to have their examination, key factors contributing to patient satisfaction could be met even when MR examinations are outsourced. Key words: care quality, decision-making, health policy, outsourcing radiology Introduction About 60 million magnetic resonance (MR) exam- inations are performed annually worldwide (1), and numbers have increased over recent years. The ability of magnetic resonance imaging (MRI) to provide high soft-tissue contrast resolution images without ionizing radiation is important for many diagnoses, and this contributes to the modality being highly coveted (2). According to a report on the Census of the Radiology Workforce in the UK in 2008, 18% of radiology clinics outsourced a number of radiological imaging procedures, the median of the requested MR exam- inations being 49% (3). In Sweden, increased demand for MR examinations has resulted in longer waiting times for these examinations. In this setting, many public hospitals in Sweden outsource a propor- tion of their referrals for radiological examinations, including MR examinations, to external hospitals or units, usually private radiology departments. Out- sourcing radiological examinations from a university hospital to external private units affects the patient, who has to attend a different clinic or hospital for the radiological examination. We currently have a limited Correspondence: Parvin Tavakol Olofsson, Department of Clinical Science, Intervention and Technology at Karolinska Institutet, Division of Medical Imaging and Technology, Stockholm, Sweden. E-mail: Parvin.tavakol@ki.se (Received 22 April 2014; accepted 29 July 2014) ISSN 0300-9734 print/ISSN 2000-1967 online � 2014 Informa Healthcare DOI: 10.3109/03009734.2014.951133 http://informahealthcare.com/journal/ups mailto:Parvin.tavakol@ki.se understanding of how patients feel when their MR examination is outsourced and how they view the quality of their care related to these examinations. The aim of this study was to examine the patients’ reactions about being sent to private radiology units when their referrals for MR examinations are outsourced from a university hospital, as well as to explore factors which influence patient satisfaction regarding the quality of care related to the MR examination. Material and methods This study was conducted at the two private radio- logical units that received most outsourced referrals and at Karolinska University Hospital in Stockholm, Sweden. A total of 160 patients who were referred for MR examinations, either to the Karolinska University Hospital or to external private units, were interviewed over a two-month period. The interviews took place in the radiology departments just after the patients had completed their MR examination. For practical rea- sons, the interviews were scheduled on three days per week over a two-week period in each radiology department: Monday, Tuesday, and Wednesday dur- ing the first week, and Wednesday, Thursday, and Friday during the second week. Sixty patients at each private unit and 40 patients at the University Hospital were interviewed. The average duration of each inter- view was 20 min. Participation was voluntary, and all informants were free to make an independent decision about taking part in the study. Each patient gave consent verbally before the interview. All participants were verbally informed about the overall purpose of the research and its main features. All participants were ensured confidentiality about their identity and were also informed that the data from the interviews would only be used in this study for the purpose of providing knowledge through understanding their experience. Data were collected by one of the researchers (P.T.O.). The project in its entirety was approved as quality assurance by the Regional Ethical Review Board at the Karolinska Institute. The interview had a structured design which con- sisted of alternative questions and a few open-ended questions (4). The interview questions also included background questions, which sought to obtain patient socio-demographic data, such as age, education level, occupation, and physical and psychological well- being. The remaining questions were divided into a number of domains concerning patients’ expectations of care such as: the caring attitude of the staff, waiting time, availability, and the patient’s freedom of choice regarding selection of radiology clinic. These ques- tions were based on two criteria: comprehensiveness and importance, e.g. each question regarding health care experiences and related to the MR examination was followed by a question about the importance of the question (5). The interview consisted of 34 ques- tions of which 10 questions were follow-up questions. In these follow-up questions patients were asked to indicate on a five-point scale (a = 5, of greatest importance; b = 4, of great importance; c = 3, of little importance; d = 2, of no importance; e = 1, cannot take a position on the issue) how important they considered the subject. Degree of perceived satisfac- tion was measured on a five-point scale: E = 1, very bad; D = 2, bad; C = 3, neither good nor bad; B = 4, good; and A = 5, very good. Degree of information quality was also measured on a similar five-point scale. Degree of access, including waiting times for radiological examinations, was measured on a five- point scale: E = 1, do not know; D = 2, three months or more; C = 3, one to two months; B = 4, one to four weeks; and A = 5, less than a week. Degree of satisfaction regarding the staff at the radiology depart- ment where the patients had their MR examinations was assessed on a three-point scale: 1 = do not know; 2 = no; and 3 = yes. In total, 20 of the items about patient experiences had a five-point response scale, three had a four-point scale, and seven questions hade a three-point scale (see Appendix). Analysis Statistical analyses were carried out using SPSS soft- ware, version 20. The patients’ satisfaction with their care was calculated by the mean satisfaction scores in each dimension, compared with patient characteris- tics using Student’s t test and ANOVA to compare differences between independent and dependent variables, as appropriate. Correlations were analyzed by Pearson’s test, where satisfaction was defined for p < 0.05. Analysis of the text from open-ended questions proceeded as follows. In order to pick up relevant information, only those sentences in the responses that were clear and created context were transcribed. The data were organized in a commonly used spread- sheet format with Microsoft Office Excel 2010 11.6560.6568 SP3 software by Microsoft� and Micro- soft Word 2010 (6,7). Two questions guided analysis of these responses. First, what specific aspects of care or outsourcing MR examinations are the interview texts discussing? Second, what are the issues regarding care or outsourcing MR examinations that are of concerntothepatients interviewed?Inorder toidentify common themes each response was read carefully. The second step was to develop coding categories for each response. Data were organized through coding 344 P. T. Olofsson et al. http://informahealthcare.com/doi/suppl/10.3109/03009734.2014.951133/suppl_file/10.3109/03009734.2014.951133_suppl.doc categories so that text providing similar context on a given theme could be separated from the other data. The third step was labeling each response with one or several coding categories. The final step was to find out what categories were related to each other and to identify the common theme. The most common types of coding categories that emerged in this study were: codes of situation (which define a setting: for example, patients’ views on the staff’s work) and codes of activity (related to commonly occurring varieties of behavior: for example, patients’ visits to the radiology department). A total of four themes emerged: Quality ofpatient care,Office waiting time, Choice ofradiology department, and Improvement of the patient’s satisfaction. Results Of the 160 patients who participated in this study, 67 were men and 93 were women, between 18 and 81 years old (median age for men was 43, and for women 61). Table I also shows the other character- istics of the socio-demographic background of the patients interviewed, such as education and occupa- tional status. Thirty-three patients (20.6%) considered their physical health to be very good; 71 (44.4%) good; 28 (17.5%) neither good nor bad; 27 (17%) bad; and 1 (0.6%) very bad. Sixty-four patients (40%) judged their psychological health to be very good; 72 (45%) good; 10 (6.3%) neither good nor bad; 9 (5.6%) bad; and 5 (3.1%) very bad. The most common MR examinations the patients had undergone were those of the knee or spine, which together constituted 58% of the examinations (Figure 1). Two different groups of patients were separated in the analysis: those who had previously had an MR examination (Group A, n = 105; 66%) and those who had not (Group B, n = 55; 34%). Group A consisted of two smaller subgroups, namely patients who had both their current and previous MR exam- inations in the same radiology department (Subgroup a1, n = 23; 14%) and patients who had their previous and current MR examinations in different radiology departments (Subgroup a2, n = 82; 51%) (Figure 2). Patients’ satisfaction and the caring attitude of the staff Based on the result of this study, patients’ satisfaction levels with the four dimensions of care quality (infor- mation given by radiology staff, communication between the staff and patients, level of expertise, and caring attitude of the staff) are presented in Table II. The majority of the patients were very satisfied with the amount of information given by the radiology staff. This included both written and oral information in 64/160 (40%), radiographers’ communication skills in 94/160 (58.8%), perceived level of expertise in 142/160 (88.8%), and the staff’s caring attitude 145/160 (90.6%). Fifty-nine percent (94/160) of the patients answered that the attitude of the staff was of major importance, 40% (64/160) of great importance, and 1% (2/160) of no importance. In general, the Table I. Socio-demographic characteristic background of the patients interviewed. Background n % Age groups 18–39 y 44 27.5 40–65 y 74 46.25 66–81 y 42 26.25 Gender Female 93 58.1 Male 67 41.9 Education Primary school 15 9.4 Polytechnic school/high school 64 40 College education 77 48.1 Other degree 4 2.5 Occupational status Student 6 3.8 Employed 78 48.8 Employer 25 15.6 Unemployed 1 0.6 Retired 50 31.2 0 5 10 15 20 25 30 35 40 45 50 Number and types of radiological examinations Ab do m en C he st He ad & n ec k Kn ee Lo we r e xt re m itie s Up pe r e xt re m itie s W ho le s pi ne & s pi ne Figure 1. MR examinations: number of examinations of different anatomic regions. Outsourcing and care related to magnetic resonance examinations 345 majority of patients, 146/160 (91%), were very satis- fied with their care during their visit to a radiology department, while others, 14/160 (9%), were quite satisfied. Fifty-three percent (84/160) believed this point was of major importance, 44% (70/160) of great importance, 2% (4/160) of no importance, and 1% (2/160) could not take a position. Sixty-six patients (41.2%) who were dissatisfied with radiographers’ communication skills were of the opinion that radiographers’ communication during the performance of MR examinations is very important and necessary in order to increase the patient’s sense of security. Patient satisfaction regarding the staff’s ability to provide care, the quality and amount of information, and patient age were inversely related. Radiographers’ communication skills were significantly lower accord- ing to reports from patients between 18 and 58 years old (mean age = 34.8) than from patients between 45 and 81 years old (mean age = 68) (Figure 3). Patients in both groups (A and B) reported high satisfaction relative to their MR examination. No significant correlations were found between satisfac- tion and patient age or gender. Waiting time including office waiting time Twenty-nine percent (46/160) of the patients had waited less than one week between their referral and the MR examination; 60% (96/160) between one and four weeks; 6% (10/160) between one and two months; 2% (3/160) had waited three months or more; and 3% (5/160) did not know their waiting time. When patients were asked what an acceptable waiting time for an MR examination would be, 23.1% (37/160) answered less than one week; 64.4% (103/ 160) one to four weeks; 9.4% (15/160) one to two months; and 3.1% (5/160) did not have an opinion. The reported acceptable waiting time was signifi- cantly (p < 0.001) lower among the patients between 18 and 38 years old than among the patients between 48 and 81 years old who specified that an acceptable waiting time was between one and four weeks. The age of the 15 patients who reported that it was Group B, n = 55 Patients with no previous experience Group A, n = 105 Patients with previous experience Patients who had their current and previous examinations in the same radiology department Subgroup ±1, n = 23 Subgroup ±2, n = 82 Patients who had their current and previous examinations in different radiology departments The patients interviewed, n = 160 Figure 2. Number of patients interviewed, stratified according to previous experience and radiology department. Table II. Patients’ level of satisfaction within four dimensions of assessment of care quality. Very good Good Neither good nor bad Bad Cannot judge Level of satisfaction Freq. % Freq. % Freq. % Freq. % Freq. % Information given by radiology staff 64 40 54 33.7 4 2.5 19 11.9 19 11.9 Radiographers’ communication skills 94 58.8 66 41.2 Level of expertise 142 88.8 6 3.8 1 0.63 2 1.3 9 5.6 Caring attitude of the staff 145 90.6 15 9.4 346 P. T. Olofsson et al. acceptable to wait one to two months for an MR examination was between 69 and 81 years old. For 40% (64/160) of the patients, a short time in the waiting room was related to a positive response regarding returning for a further MR examination. Choice of radiology department and patients’ freedom of choice When patients were asked whether they could choose or influence where their MR examination would be performed, 27.5% (44/160) of the patients answered yes; 69.4% (111/160) answered no; and 3.1% (5/160) replied partly. When patients were asked how important this freedom of choice was, 23.1% (37/160) replied that it was of major impor- tance; 30% (48/160) of great importance; 24.3% (39/ 160) of little importance; 11.3% (18/160) of no importance; and 11.3% (18/160) had no opinion on the issue. Ninety of the patients in this study (56.3%) believed that it was their physician who decided where their MR examination should be performed. Aspects that influenced the patient’s choice of radiology department were: short waiting time 79.4% (127/160); ease of traveling to the radiology department 68.8% (110/160); and short distance to their home or work 58% (93/160). Improvement of the patients’ satisfaction Forty-eight percent (77/160) of the patients suggested that better information about the examination would increase their satisfaction related to the MR exami- nation, and 52% (83/160) desired more instructions during the procedure. Discussion The main finding of this study is that the majority of patients referred for an MR examination (140/160; 91%) were satisfied with the level of care that they received in the radiology department, whether it was the one in the university hospital or the external caregiver, indicating that the patients’ perception was that they received the same level of care at either public or private radiology departments. Fifty-six percent of the patients (90/160) believed that it was their referring physician who decided where the MR examination should be performed. It is natural that the patients, being unaware of the hospital’s policies, generally expect the referring phy- sician to take on the role of decision-maker (8). In reality, this decision is made in the radiology depart- ment and depends mostly on the inflow of referrals. The physician is the closest link between the patient and radiology. Although radiologists play a crucial role in patients’ health, they are invisible to patients (9) and are not perceived as decision-makers in the health care process. Sixty percent of the patients in this study waited between one and four weeks from when their referrals were written until the MR examinations were per- formed, and 65% of the patients regarded that as acceptable. This indicates that radiology departments within university hospitals and private radiology units are, together, meeting the patients’ expectations fairly well. Results showed that older patients were generally more satisfied with the staff’s ability to communicate, including the quality and amount of information they received. It is important to note that the nature of expectations could be different between older and younger patients, as well as between those patients who had previously had an MR examination versus R2 = 0.5721 Age Satisfaction level regarding radiographers¢ communication skills L e v e l o f s a ti s fa c ti o n 4 3.5 3 2.5 2 1.5 1 0.5 0 1 21 41 61 81 Figure 3. Satisfaction with the radiographers’ communication skills and patient age was correlated at the level of about r = 0.76 and R2 = 0.57. Outsourcing and care related to magnetic resonance examinations 347 those undergoing one for the first time (10). Satis- faction with care usually arises when there is no discrepancy between patients’ expectations and the care received (11). According to the results of this study, more instruc- tions during MR examinations and better information about the examination itself would increase patients’ satisfaction relative to the MR examination. One definite way to increase patient satisfaction is to focus on the patients’ views about the care they receive and their expectations of it (12). The advantage of using structured interviews, i.e. the verbal questionnaire, was that the questions could be clarified for the informants if necessary. This diminished the risk of collecting an incorrect response or partial non-response. We believe that a written questionnaire would have been of limited use in this study, because of the chance that patients would fail to recall situations. Both alternative questions and open-ended ques- tions were used in the interview. The goal was to attract the strengths and minimize the limitations of the quantitative and qualitative analyses (13). We believe that the combination of quantitative and analytical open-ended questions followed by text analyses provides a better understanding of patients’ expectations, satisfaction, and communication about outsourcing their MR examination, because the expe- rience of satisfaction cannot be measured fully by statistical methods alone. But this study also has several limitations to consider. The interviews may result in a biased sample by attracting respondents who could or were willing to participate. The result showed high satisfaction with the patient care, which could be caused by the fact that displeased patients did not participate (14). For this reason, we may not be able to generalize the results. Despite this, we believe that this study could be of interest to other public hospitals which choose outsourcing as one solution for making their radiology departments more efficient. Another limitation in this study is that we studied those dimensions of care quality during MR examinations that were most related to patient nursing. However, the quality of care related to MR examinations involves other factors, such as the radiologist’s level of expertise, work experience, knowledge, work-load pressure, as well as work sat- isfaction, all of which may have a major impact on the quality of the interpretation. Indeed these factors should be studied further. Patients undergoing MR examinations usually come into contact with radio- graphers but they seldom have direct contact with radiologists (15). In conclusion, the patients interviewed in this study were unaware of the university hospital’s policy regarding the outsourcing of MR referrals. When considering outsourcing, the patients’ desires and requirements regarding information must be consid- ered. 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Outsourcing and care related to magnetic resonance examinations 349 http://www.ncbi.nlm.nih.gov/pubmed/20671001?dopt=Abstract http://www.ncbi.nlm.nih.gov/pubmed/20671001?dopt=Abstract http://www.ncbi.nlm.nih.gov/pubmed/20671001?dopt=Abstract http://www.ncbi.nlm.nih.gov/pubmed/17411745?dopt=Abstract http://www.ncbi.nlm.nih.gov/pubmed/17411745?dopt=Abstract http://www.ncbi.nlm.nih.gov/pubmed/17411745?dopt=Abstract http://www.ncbi.nlm.nih.gov/pubmed/17411745?dopt=Abstract http://informahealthcare.com/doi/suppl/10.3109/03009734.2014.951133/suppl_file/10.3109/03009734.2014.951133_suppl.doc Abstract Introduction Material and methods Analysis Results Patients’ satisfaction and the caring attitude of the staff Waiting time including office waiting time Choice of radiology department and patients’ freedom of choice Improvement of the patients’ satisfaction Discussion Declaration of interest References