Patient satisfaction after Elective Major Gynaecological Surgery in 2 reference hospitals in Yaounde: A cross-sectional study

Patient satisfaction is a quality of care measure and reveals patients’ appreciation of healthcare delivery. We sought to measure patient satisfaction following major gynaecological surgeries in 2 University Teaching Hospitals in Yaounde, Cameroon. Ours was a cross-sectional, prospective study over 9 months (October 1 st 2018, to June 30 th 2018) at the Yaounde Gynaeco-Obstetric and Paediatric Hospital (YGOPH) and the Yaounde Central Hospital (YCH). By administering a modified Surgical Satisfaction Questionnaire (SSQ-8) via phone call 6 months after surgery we appreciated and scored key aspects linked to patient satisfaction, and obtained information on post-operative complications. Data was analysed using Microsoft Excel 18 and SPSS 21 setting significance at p<0.05. We recruited 72 patients aged 24 to 68 years. Our participants had a mean satisfaction score of 26 ± 7.854 (59.7% satisfied and 40.3% dissatisfied). All aspects tested on the SSQ-8 questionnaire influenced patient satisfaction. Patients who said they were satisfied with pain control after surgery (OR=0.207 CI=0.070– 0.609, P=0,003), and with surgical results in the SSQ-8 questionnaire (OR=0.053, CI=0.011–0.254, P<0.001) achieved statistically significant post-operative satisfaction. Contrarily, patients who were dissatisfied with surgery results (OR=132.000, CI=15.256-114.131, P< and those who developed complications (OR=7.922, CI=2.241 – 28.004, P<0.001) were significantly dissatisfied with surgery. Additionally, 47.2% declared a poor post-operative current 52.8% who a good status. Following multivariate analysis, satisfaction with the results of surgery (aOR= 0.071, CI=0.008–0.657, P= 0.020) and the occurrence of complications (aOR=7.284, CI=1.146 – 46.273, P=0.035) were the main determinants of patient Patient status to patient with to resume (aOR=0.039, CI=0.004-0.398, P=0.006) and pre-operative exercise routine (aOR=0.038, CI=0.002–0.678, P-value=0026).


Introduction
Worldwide, the use of patient-reported outcome measures (PROMs) as part of a holistic approach to determine the adequacy of care, as against the traditional methods based uniquely on clinical outcomes is gaining grounds (1,2). Defined as "any aspect of a patient's health status that come directly from the patient without the interpretation of the patient's responses by a physician or anyone else" (3), these PROMs can be combined into 3 main areas namely; quality of life, current health state, and patient satisfaction (4). Unlike the previous two, satisfaction is an entirely subjective and complex concept with no consensual definition, that reveals varying considerations such as lifestyle, past experiences, future expectations, and individual or societal values (5)(6)(7)(8). It however is best revealed as a measure of the extent to which a patient is contented with the health care which they received from their health care provider (9), or the degree to which a patient feels they have received high-quality health care (10). Donabedian (11) in 1966 while describing the quality of care, made reference to three tangible aspects namely structure, process and outcome. In describing outcome, his focus was on the final result of health care hence the terms morbidity and mortality. Since then, there has been an implied association between outcome statistics and quality of care (10,12). Thus we are faced with the contrasting reality of the healthcare provider's perspective based on objective post-operative clinical outcomes, and the perspective of the patient based solely on the more complex, subjective and multi-dimensional perspective of the patient, independent of the course of clinical events. This subjectivity has strengthened many paternalistic physicians who question the validity of patient satisfaction as a measure of the quality of surgical care. Nonetheless, many authorities today agree that patient satisfaction is a performance indicator and a quality of care measure for medical and surgical services (10,13,14).
Many studies worldwide, have evaluated the determinants of PROMs in general and satisfaction particularly following surgical care. In the clinical review by Chow et al. describing the determinants of patient satisfaction with surgical care, "outcome expectations" defined as the outcome of the health care interaction and whether it corresponds with the patient's desires such as symptom relief or the occurrence of complications were identified as key to satisfaction (10). Like others, they advised strongly that to improve on the measurability of what seems to be a very subjective variable, the tools used must respond to a number of criteria including appropriateness, reliability, validity, responsiveness, precision, interpretability, acceptability, and feasibility of the instruments (10,15). Other determinants of   satisfaction with surgical care described by different authors include: patient preoperative knowledge levels, meeting patients' pre-operative expectations,   satisfactory pain relief, satisfactory hospital experiences and surgical technique especially minimally-invasive surgery (6,(16)(17)(18).
In Cameroon, Fouogue et al in 2017 described high levels of post-operative satisfaction in patients who underwent laparoscopic fertility-enhancing pelvic surgery (19). Yet studies evaluating patient satisfaction following elective major gynaecologic surgery, or following major surgery in general remain rare in our setting. We view patient satisfaction as a measure of consumer satisfaction with healthcare services, and that its integration into the evaluation of the quality of care could positively impact healthcare policy and surgical practice in our setting.
We therefore sought to measure patient satisfaction following major gynaecological surgeries in 2 University Teaching Hospitals in Yaounde, Cameroon.

Study design and setting
We carried out a prospective cross-sectional study over 9 months (October 1st 2018, to June 30th 2018), in patients undergoing major elective gynaecological surgery at the Yaounde Gynaeco-Obstetric and Paediatric Hospital (YGOPH), and the Yaounde Central Hospital (YCH), two university teaching hospitals in Yaounde, Cameroon.
These hospitals each provide reproductive healthcare services to over a thousand women per month and employ the services of 11 and 10 Obstetrician-Gynaecologists respectively. The YCH at its famed Principal Maternity has 2 operating rooms reserved for obstetrical and gynaecological surgical procedures.
Conversely, Obstetricians/Gynaecologists share 4 operating rooms with the other surgical specialties at the YGOPH. Unlike the YCH, the YGOPH provides minimallyinvasive laparoscopic surgery and oncological breast surgery services.

Inclusion criteria
Patients seen 48hours after elective gynaecological surgery and who consented to our study.

Exclusion criteria
Patients operated upon in emergency, those with known cognitive or consciousness disorders, those who could neither communicate in English nor French and patients who withheld consent were excluded from the study.

Sample size and sampling
We carried out a facility-based convenience, consecutive and exhaustive sampling of all patients who met the inclusion criteria for the study from October 1st 2018 to December 31st 2018. During this period, we made first contact with the participants 48hours post-operatively either in the gynaecological wards or the intensive care units. Using patients' files, we confirmed their eligibility for the study following which we presented our study to them and obtained their signed consent to administer to them a surgical satisfaction questionnaire via phone call 6 months after the date of surgery. Figure 1 reveals the participants flow chart from our obtaining consent 48hours after surgery, to each participant's final inclusion in the study 6 months after surgery.

Study procedure and data collection
To evaluate participants' satisfaction with surgery, we administered a pre-tested modified version of the Surgical Satisfaction Questionnaire-8 (SSQ-8) via phone call, which questionnaire had been validated previously for use in pelvic surgeries as well as general medical care (20,21). Prior to initiating the study, the original questionnaire was reviewed by 2 senior faculty members and their suggestions were used to revise the questionnaire. Next the revised questionnaire was pretested in September 2018 on 15 patients operated upon in March 2018, and identified from the surgical registers at the YGOPH to reassess for validity and reliability. Their responses enabled us to further revise our questionnaire, and clarify identified ambiguities. We did not include the pretested patients in our study. During administration of the questionnaire, all unclear questions were explained to the patients.
For all patients who granted consent 48hours post-operatively, we filled the first part of the interviewer-administered questionnaire which included; sociodemographic data (age, sex, marital status, educational level and address), the date of surgery, type of surgery and the indication for surgery. Following up to this, we called them 6 months after surgery and administered the SSQ-8 questionnaire to them via phone call.
The questions focused on patients' appreciation of pain control after surgery both in the hospital and at home; their satisfaction with how much time they needed to resume social activities, work, and their pre-surgical exercise routine; their appreciation of the results of their surgery; their willingness to return to their caregiver if given a choice and/or recommend their surgery to someone else with a similar ailment, and finally we asked them to auto-evaluate their post-operative current health state.

Data analysis
We obtained our data using either the English or French versions of our validated structured questionnaires. Throughout the study period, we screened our data to rule out wrong information and ensure coherence between different fields. Double occurrences and incomplete information were constantly refined.
In order to measure patients' satisfaction with surgery, we scored participants' satisfaction with different aspects of surgery evaluated on a scale of 1 to 5 as per a Likert scale. The scores attributed for the various responses were: "Very unsatisfied" or "Never" = 1; "Unsatisfied" or "Don't think so" = 2; "Neutral" = 3; "Satisfied" or "I guess yes" = 4; "Very satisfied" or "Absolute yes" = 5. We then summed up these scores to obtain each participant's satisfaction score on 40, representing the 8 aspects of the SSQ-8 that we evaluated. With this score, we categorised our participants into 2 groups of either "Satisfied" or "Unsatisfied" patients. Additionally, we chose to investigate the patients' perception of their current health state by asking them to attribute a score on a scale of 0 to 20 to their current health status. We explained to them that 0 represents the worst possible health state they could imagine, while 20 will mean they could not wish for better health. We predetermined, that all scores above and equal to 14 represented a good post-operative health state appreciation, whereas scores below 14 represented a poor current health state.
We carried out data analysis using the SPSS version 21 software. The data were described statistically and the findings evaluated for normality. The Chi-squared and Fischer tests served to compare proportions and the Students t-test for differences in means. Data were then presented as proportions, means and standard deviations.
The Odds ratio (OR) and confidence interval were calculated to measure the association between variables. Multivariate analysis was used to eliminate confounding factors in our analysis. We considered as statistically significant differences with P-value < 0.05.

Operational definitions
For the purposes of our study, we used the following definitions and predetermined the following cut-off points for scores relating to participants' post-operative satisfaction and current health state:

1.
Patient satisfaction is a measure of the extent to which a patient is contented with the health care, which they received from their health care provider (9).

2.
Major gynaecological surgery: Gynaecological surgery (upon an organ on the chest wall or within the abdomen or pelvic cavity) involving a risk to the life of the patient (22 Table 5 we demonstrate patients' satisfaction in relation to their clinical characteristics with laparoscopic surgery and the occurrence of complications predicting patient satisfaction. Additionally, in Table 6 we discover the relationship between key aspects evaluated in the SSQ-8 and overall patient satisfaction.   Table 6 Post-operative satisfaction in relation to key aspects of the SSQ-8 questionnaire  As regards the current health state score, 47.2% of our cohort thought they had a poor post-operative health state after 6 months while 52.8% of them laid claim to a good post-operative health quality. Socio-demographic variables did not significantly influence patients' reported post-operative health state, whereas as seen in Table 7, patients who developed complications post-operatively significantly reported lower scores for their current health state. 0.008-0.657, P-value: 0.020) was the most significant determinant of patients' postoperative satisfaction in our cohort as seen in Table 8   significantly better scores for their current health state as revealed in Table 9.  Although not a primary goal of our study, we found out that patient satisfaction and patient-reported current health state shared a number of common predictors.
Similarly to mean satisfaction scores in our cohort, the mean self-reported current health status score indicated that a significant proportion thought their health status 6 months after elective gynaecological surgery was poor. Also, the occurrence of post-operative complications significantly smeared patients' perception of their health status. Finally, with respect to key parameters of the SSQ-8 questionnaire, satisfaction with the time taken to return to work, and with the time taken to resume normal exercise routine were the best predictors of a good health status score 6 months after elective gynaecological surgery in our cohort.

Conclusions
In conclusion, patient satisfaction levels with elective gynaecological surgery are low and are dependent on the surgical technique, the occurrence of complications and their post-operative experience especially as regards pain control and the recovery of physical and functional capacity. Also, patient-reported current health state is influenced by similar predictors as satisfaction and tends to vary similarly with satisfaction.

Competing interests
The authors declare that there are no conflicts of interest regarding the publication of this paper.

Author's contributions
The data used to support the findings of this study are included within the article.

Acknowledgments
We heartily acknowledge the administrative staff, and the staff of the Gynaecological services of the Yaounde Gynaeco-Obstetric and Paediatric Hospital, and the Yaounde Central Hospital for facilitating our access to their facilities as well as their support during the data collection phase. We also acknowledge the personal contributions of each author for this work.

Data Availability Statement
The data used to support the findings of this study are included within the article.

Funding Statement
This article was not funded.