Determinants of patient satisfaction in ambulatory oncology: A cross sectional study based on the OUT-PATSAT35 questionnaire

Abstract

The aim of this study was to identify factors associated with satisfaction with care in cancer patients undergoing ambulatory treatment. We investigated associations between patients' baseline clinical and socio-demographic characteristics, as well as self-reported quality of life, and satisfaction with care.
Patients undergoing ambulatory chemotherapy or radiotherapy in 2 centres in France were invited, at the beginning of their treatment, to complete the OUT-PATSAT35, a 35 item and 13 scale questionnaire evaluating perception of doctors, nurses and aspects of care organisation. Additionally, for each patient, socio-demographic variables, clinical characteristics and self-reported quality of life using the EORTC QLQ-C30 questionnaire were recorded.
Among 692 patients included between January 2005 and December 2006, only 6 were non-responders. By multivariate analysis, poor perceived global health strongly predicted dissatisfaction with care (p < 0.0001). Patients treated by radiotherapy (vs patients treated by chemotherapy) reported lower levels of satisfaction with doctors' technical and interpersonal skills, information provided by caregivers, and waiting times. Patients with primary head and neck cancer (vs other localisations), and those living alone were less satisfied with information provided by doctors, and younger patients (< 55 years) were less satisfied with doctors' availability.
A number of clinical of socio-demographic factors were significantly associated with different scales of the satisfaction questionnaire. However, the main determinant was the patient's global health status, underlining the importance of measuring and adjusting for self-perceived health status when evaluating satisfaction. Further analyses are currently ongoing to determine the responsiveness of the OUT-PATSAT35 questionnaire to changes over time.

Full text

RESEARCH ARTICLE Open Access
Determinants of patient satisfaction in
ambulatory oncology: a cross sectional study
based on the OUT-PATSAT35 questionnaire
Thanh Vân France Nguyen
1,3*
, Jean-François Bosset
1,3
, Alain Monnier
2
, Jacqueline Fournier
1
, Valérie Perrin
2
,
Cédric Baumann
4
, Anne Brédart
5
and Mariette Mercier
3,6
Abstract
Background: The aim of this study was to identify factors associated with satisfaction with care in cancer patients
undergoing ambulatory treatment. We investigated associations between patients’ baseline clinical and socio-
demographic characteristics, as well as self-reported quality of life, and satisfaction with care.
Methods: Patients undergoing ambulatory chemotherapy or radiotherapy in 2 centres in France were invited, at
the beginning of their treatment, to complete the OUT-PATSAT35, a 35 item and 13 scale questionnaire evaluating
perception of doctors, nurses and aspects of care organisation. Additionally, for each patient, socio-demographic
variables, clinical characteristics and self-reported quality of life using the EORTC QLQ-C30 questionnaire were
recorded.
Results: Among 692 patients included between January 2005 and December 2006, only 6 were non-responders.
By multivariate analysis, poor perceived global health strongly predicted dissatisfaction with care (p < 0.0001).
Patients treated by radiotherapy (vs patients treated by chemotherapy) reported lower levels of satisfaction with
doctors’ technical and interpersonal skills, information provided by caregivers, and waiting times. Patients with
primary head and neck cancer (vs other localisations), and those living alone were less satisfied with information
provided by doctors, and younger patients (< 55 years) were less satisfied with doctors’ availabi lity.
Conclusions: A number of clinical of socio-demographic factors were significantly associated with different scales
of the satisfaction questionnaire. H owever, the main determinant was the patient’s global health status, underlining
the importance of measuring and adjusting for self-perceived health status when evaluating satisfaction. Further
analyses are currently ongoing to determine the responsivene ss of the OUT-PATSAT35 questionnaire to changes
over time.
Keywords: Patient satisfaction, Ambulatory oncology, Quality of life
Background
Patient satisfaction is recognised as a key performance
indicator in assessing quality of care, increasi ngly
required by accreditation agencies in the monitoring of
quality of hospital care in order to identify c are areas i n
need of improvement. Furthermore, satisfaction with
care may influence a patient’ s adherence to medical
treatment and consequently, impact on outcome.
Cancer treatments are often long, are associated with
frequent interactions and increased dependenc y on mul-
tidisciplinary healthcare services. In this context, patient
satisfaction with th eir experience of continuity of care, as
well as their relationships and communication with care-
givers, nee d to be evaluate d with a view to dete rmining
whether the patients’ expectations are being fulfilled.
Deter mining predictors of patient satisfaction has sev-
era l objectives. Firstly, identifying patient characteristics
(socio-demographic or clinical factors, baseline quality
of life (QOL)), should aid in interpreting questionnaire
results, by adjusting for these factors, particularly for
* Correspondence: nguyen_france@yahoo.fr
1
Oncology-Radiotherapy Department, Besançon University Hospital, 3
boulevard Fleming, 25030 Besançon, Cedex, France
Full list of author information is availabl e at the end of the article
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© 2011 Nguyen et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution Licens e (http://creativecommons.org/license s/by/2.0), which pe rmits unrestricted use, distribution, an d reproduction in
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benchmarking when comparing health care services
[1-3]. Furtherm ore, patient satisfaction surveys can help
to identify patient groups who need additional attention
or even targeted interventions, and bring to light areas
of the care process (e.g. organisation, providers’ commu-
nication skills) where there is room for improv ement
[4,5]. Socio-demographic charac teristics and health sta-
tus are the most w idely studied predictors of satisfac-
tion, with older age, low education and a good state of
health commonly reported to be associated with greater
satisfaction [ 6-11]. However, conflicting results have
been observed in this regard and especi ally the relation-
ship between these two conce pts, self-perceived qua lity
of life and satisfaction with care, remains debated.
In the setting of oncology, there has been an increase in
the use of ambulatory treatments, which represent a
completely differ ent cont ext to hospitalization. While
interpersonal (i.e. communication) o r technical (i.e. drug
administration) aspects of care, and multidisciplinary
teamwork are components common to patient satisfac-
tion in both in- and o ut-patients, other factors, such a s
hospital accessibility a nd t reatment en vironment (i.e.
location, appointment waiting lists, waiting times, park-
ing facilities) are concerns that are more specific to the
ambulatory setting [12]. A number of studies evaluating
patientsatisfactionquestionnaireresponsesinanambu-
latory oncology setting have been published [12-21]
focusing mainly on organisational aspects of care and the
quality of patient-caregiver relationships. However, none
of these studies attempted to ide ntify patient groups who
may be more “at risk” of dissatisfaction with care.
Theaimofthepresentstudywas,ontheonehand,to
identify patients’ clinic al and socio-demographic charac-
teristics as potential determinants of satisfaction with care
in cancer patients undergoing ambulatory chemo- or
radiotherapy. On the other hand, we investigated the influ-
ence of self-reported quality of life on satisfaction with
care, as measured by multi-dimensional questionnaires.
Methods
We conducted a multicenter, prospective cohort s tudy
of cancer outpatients from the beginning to 3 months
after the end of their treatment. The present analyses
were performed only on data collected at the beginning
of the treatment
The protocol was approved by the ethics committee of
the University Hospital of Besançon (Doubs, France),
the National French Data Protec tion Agency, and sup-
ported by a regional grant (Programme Hospitalier de
Recherche Clinique).
Patients
Patients were enrolled in two centres (one university
teaching hospital and one local (non-academic) hospital)
in eastern France between January 2005 and December
2006. Inclusion criteria were: patients aged over 18
years, able to understand written and spoken French,
able to provide written consent, able to com plete the
questionnaires, with a confirmed histological diagnosis
of cancer, and due to undergo ambulato ry treatment by
chemo- or radiotherapy,
The subsequent cancers were included in 9 treatment
groups: 2 prostate cancer groups (radiotherapy only or
surgery followed by radiotherapy), 3 breast cancer groups
(surgery plus radiotherapy, or surgery plus chemo and
radiotherapy, or chemotherapy alone), 2 head and neck
cancer groups (surgery plus radiotherapy or radiotherapy
with or without concurrent chemotherapy), 1 rectum
cancer group (radiochemotherapy plus surgery) a nd 1
lung cancer group (chemo and radiotherapy).
Study procedures and measures
Patients were invited to participate in the study at the
end of the first week of radiotherapy or at the second
cycle of chemotherapy . However, it was n ot technical ly
possible to meet all patients on a systematic basis.. Once
the patient agreed to participate and provided informed
consent, the socio-demographic questionnaire was com-
pleted with the research technician. The EORTC QLQ-
C30 and OUT- PATSAT35 questionnaires were given to
the patient to complete at home and mail back using a
pre-addressed, stamped envelope. Patients were
reminded to return the questionnaires on their next
visit, if they came back for radiotherapy treatment, or by
phone after 2 weeks, where necessary.
The EORTC IN-PATSAT32 questionnaire was devel-
oped by the EORTC QOL group in order t o assess
patient satisfaction with careinoncologyhospitals
[Additional file 1: Appendix A]. The OUT-PATSAT35
questionnai re was adapted from IN-PATSAT32, for use
among outpatients treated b y ambulatory chemotherapy
or radiotherapy [Additional file 2: Appendix B]. Ade-
quate psychometric properties have been reported in
French and Spanish language versions [22,23].
OUT-PATSAT35 contains 35 items covering 12
multi-item scales organized into three sections of fo ur
scales each: 2 sections evaluating doctors and nurses
(for chemotherapy) or radiation therapists (for radio-
therapy), as regards their technical skills (knowledge,
experience, assessment o f physical symptoms), i nterper-
sonal skills (int erest, wil ling ness to listen), provision of
information (about the disease, medical tests and treat-
ment), and a vailability (time devoted to patients); and a
third section evaluating the organization of the depart-
ment, the exchange of information between caregivers
(coherence, identification of the reference doctor), the
interpersonal skills and qua lity of infor mation pr ovided
by other hospital staff, waiting times (for consultation,
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medical tests, or treatment), the physical environment
(access, comfort, orientation), and lastly, a single-item,
overall satisfaction scale.
Items a re rated on a 5-level Likert scale as follows:
“poor” , “fair”, “good”, “ very good”, “excellent”. All scores
are linearly transformed to a 0 -100 scale, with a higher
score reflecting a higher level of satisfaction.
The EORTC QLQ-C30 (versio n 3.0) is a 30-item self-
assessment of 15 scales of quality of life: 5 functional scales
(physical, ro le, emotional, cognitive, social) , 9 sympt om
scales (fatigue, nausea or vomiting, pain, dyspnoea, insom-
nia, constipation, diarrhoea, financial difficulties) and
finally, a global health scale. All measures range from 0 to
100. High scores on the functional scales represent a heal-
thier level of functioning, whereas high scores on the
symptom scales represent a higher level of symptoms.
The following variables were collected by self-adminis-
tered questionnaire and f rom medical records: gender,
age (in years), marital status, level of education (primary,
secondary, high school diploma or highe r), number of
children, occupation (employed versus unemployed/
retired), monthly income (i n Euro), distan ce from home
to hospital (in kilometres (km)), means of transport
(personal car versus other), leisure activities (yes/no),
number of co morbidities (renal, cardiac, respiratory,
hepatic, diabetes), primary cancer site (prostate, head
and neck, breast, rectum, lung), treatment mo dality
(chemotherapy and/or radiotherapy).
Statistical methods
Thesamplesizeof520patients was calculated acc ord-
ing to Cohen’s procedure based on multiple regression
with a b risk of 20%, an a risk of 1%, a participation
rate of 90% and a ΔR
2
of 0.05 [24].
Patient characteristics were compared using Fisher’ s
exact test, or Chi square for categorical data, and the
Student t test for continuous data. Continuous data
were subsequently coded into 2 or more classes catego-
rical variables for the further analyses.
Bivariate analysis
The associations between EORTC QLQ-C30 and OUT-
PATSAT35 scores were analysed by Pearson correlation
and general linear regression. Then, we assessed the
relationship bet ween eac h categoric al vari able (cl inical
and socio-demographic data) and all OUT-PATSAT35
scores (considered as dependent variables) using analysis
of variance (MANOVA model). We investigated colli-
near r elationships between sex, chemo- or radiotherapy,
and primary cancer localization.
Multivariate analysis
Significant categorical and cont inuous variables (QLQ-
C30 scores) by bivariate analysis, were introduced into
the multivariate models using analysis of variance
(ANOVA) for each scale score of the OUT-PATSAT35
questionnaire.
The significance level for bivariate analysis was set at
a = 0.05 and for multivariate analysis at a =0.01(to
correct for multiple testing). All tests were two-sided.
For the in terpretation of the scores, we considered the
minimal difference defined as clinically meaningful by
Osoba et al as a mean change of at least 5 points [25].
Statistical analysis was performe d using Sta tistical
Analysis Software (version 9.1, SAS Institute, Cary, NC).
Results
Patient characteristics
733 patients met the eligibility criteria and were invited
to participate in the study: 41 patients (5.6%) declined.
Thus, 692 patients were included. of whom 2 patients
failed to answer both questionnaires OUT-PATSAT35
and QLQ-C30 and 4 patients for the OUT-PATSAT35
(0.9% of non respondents). The characteristics of the
study population are shown in Tabl e 1. Median age var-
ied from 63 to 66 years (range 29-88), with a balanced
proportion of ma les and females. The percentage of sin-
gle patients was 18% and 21% in the local and university
teaching hospitals respectively, while monthly income
waslessthan1500Eurofor42%and41%ofpatients,
respectively. Most significant differences between the
two centres were observed for the distribution of the
primary cancer site, the number of patients treated by
radiotherapy and the distance fr om home to hospital (p
< 0.0001). All patients were treated in a curative intent
except for 5 patients who had metastases.
EORTC QLQ-C30 and OUT-PATSAT35 scores
Mean scores for the OUT-PATSAT35 sc ales ranged
from 61.7 to 71.3 for the evaluation of doctors, from
58.5 to 72.5 for nurses or radiation therapists, from 59.8
to 64.6 for the organization or physical environment,
while the mean overall satisfaction score was 72.5. Mean
scores for the EORTC QLQC30 functio nal scales ranged
from 63.6 (global health) to 82.7 (cognitive functioning)
and for symptom scales from 8.7 ( financial difficulties)
to 33.5 (fatigue) (Table 2).
Bivariate analysis
Correlation coefficients were significant between almost
all OUT-PATSAT35 scales and the QLQ-C30 functional
scales, fatigue, pain and sleep. The highest correlation
coefficients (0.20 < r < 0.30, p < 0.000 1) were observed
between global health and almost all OUT-PATSAT35
scales (the maximal correlation was between gl obal
health and the doctors ’ technical skills), between emo-
tional functioning and nurse or radiation therapist avail-
ability, and doctor’s provision of information scales.
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Table 1 Socio-demographic and clinical characteristics of the study population
Characteristics Local hospital Teaching hospital p
309 383
Sex male/female 157 (51) 198 (51.7) 0.88
Age Median [min;max] 66 [29;88] 63 [31;84] 0.06
30-55 65 (21) 87 (22.7)
56-65 72 (23.3) 114 (29.8)
66-75 118 (38.2) 138 (36)
76-88 54 (17.5) 44 (11.5)
Marital status Single or separated 55 (18.2) 81 (21.2) 0.34
Living with partner, or family 248 (81.8) 301 (78.8)
Education level primary 149 (50.5) 169 (44.6) 0.01
secondary 80 (27.1) 87 (23)
high school diploma or higher 66 (22.4) 123 (32.4)
Employment status Employed 64 (21.1) 111 (29.1) 0.02
Retired or unemployed 239 (78.9) 270 (70.9)
Children No 28 (10.3) 47 (12.5) 0.52
Yes (not dependent) 193 (70.7) 268 (71.1)
Yes (still dependent) 52 (19) 62 (16.4)
Distance home-hospital Number of km: Median [min;max] 15 [1;160] 35 [1;145] < 0.0001
≤ 20 203 (65.7) 146(38.1) < 0.0001
> 20 106 (34.3) 237(61.9)
Means of tranport Personal car 135 (48.8) 120(31.3) 0.0007
Other (taxi, ambulance, bus) 173 (56.2) 263(68.7)
Monthly income In Euro 0.03
MW or less 34 (13) 36 (9.8)
MW-1499 103 (39.3) 115(31.4)
1500-2999 96 (36.6) 152(41.5)
≥ 3000 29 (11.1) 63 (17.2)
Leisure activities Yes/no 178 (59.3) 242 (64.2) 0.20
Localization treated Prostate 76 (24.6) 52 (13.6) < 0.0001*
RT
Surgery+RT 32 (10.4) 50 (13)
Head and neck 6 (1.9) 16 (4.2)
Surgery+RT
RT+/-CT 26 (8.4) 45 (11.8)
Breast 72 (23.3) 133 (34.8)
Surgery+RT
Surgery+CT+RT 66 (21.4) 35 (9.1)
CT 5 (1.6) 0
Rectum 5 (1.6) 18 (4.7)
RT+CT+surgery
Lung 21 (6.8) 34 (8.9)
CT+RT
Chemotherapy Yes 111 (36) 111 (29) 0.048
Radiotherapy Yes 236 (77.1) 347 (90.6) < 0.0001
Number of comorbidities 0 94 (30.4) 107 (27.9) 0.24
1 132 (42.7) 142 (37.1)
2 63 (20.4) 97 (25.3)
≥ 3 20 (6.5) 37 (9.7)
RT = radiotherapy; CT = chemotherapy; MW = minimum wage.
*p for heterogeneity between primary localizations
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We identified primary localization, type of treatment,
age, sex, marita l status, leisure activities, home-hospital
distance and monthly income as variables significantly
associated with at least one OUT-PATSAT35 scale (p <
0.05, Tabl e 3) . Considering the min imal clinicall y mean-
ingful differenc e score, patients treated for head and
neck cancer appeared to be less satisfied with the tech-
nical skills, information and a vailabilit y of doctors, pro-
vision of info rmation by nurses or r adiati on therap ists,
exchange of information between caregivers, physical
environment and overall satisfaction than those treated
for prostate cancer. Patients receiving radiotherapy
reported less satisfaction with doctors’ technical s kills,
interpersonal skills, provis ion of information, nurses’ or
radiation therapists’ interpersonal skills, provision of
information, availability, and waiting times than those
treated by chemotherapy. Patients who had leisure activ-
ities reported more satisfacti on on doctors’ evaluation
scales and exchange of information between caregivers.
Patients < 55 years old were less satisfied with doctors’
availability. Patients living alone were less sati sfied with
doctors’ information than those living with family.
Multivariate analysis
The linear regression between the QLQC30 and the
OUT-PATSAT35 scales selected the following signifi-
cant scales for subsequent analyses: global health status,
emotional and social functional scales, and sleep, pain
and fatigue for symptom scales.
In mult ivariate mo dels, lo calization of the primary
cancer (breast, prostate, head and neck, rectum, or lung)
and type of treatment received (radiotherapy and/or
chemothera py) were included in two separ ate models
because a collinear relationship was observed between
these two variables. In the first model (Table 4), head
and neck cancer, compared to prostate cancer, ap peared
to be the primary localization where patients were sig-
nificantly less satisfied with doctors’ provision of infor-
mation and the physical environment (mean score
differences were 10 and 9 respectively).
In the second model (Table 5), patients treated by
radiotherapy were signif icantly less satisfied with doc-
tors’ technical skills, interpersonal skills, provision of
information by doctors, nurses or radi ation therapists
(mean score difference > 10 for information provision),
Table 2 Number of patients, mean score and standard deviation for each scale of the OUT-PATSAT35 and QLQC30
questionnaires
OUT-PATSAT35 QLQC30
Scale Number of patients Mean score (SD) Scale Number of patients Mean score (SD)
Overall satisfaction Functional scales
SATGEN 669 72.5 (19.7) Global health 679 63.6(19.8)
Evaluation of Doctors Physical 685 82.6 (18.6)
SATDTS 661 71.3 (20.3) Role 682 78.7 (27.6)
SATDIS 659 67 (24.1) Emotional 684 75 (23.1)
SATDIP 668 65.1 (25) Cognitive 684 82.7 (20.9)
SATDAV 671 61.7 (23.6) Social 681 80.4 (25)
Evaluation of Nurses or radiation therapists Symptom scales
SATNTS 679 72.5 (21.1) Fatigue 680 33.5 (25.6)
SATNIS 676 71.6 (20.5) Nausea 684 10 (20.7)
SATNIP 640 58.5 (26.4) Pain 685 19.4 (24.7)
SATNAV 653 66.1 (23) Dyspnoea 674 18.4 (27.9)
Organization, physical environment Sleep 679 30 (31.7)
SATEXE 609 64.6 (23.1) Appetite 671 16.5 (28)
SATOTH 634 63.7(21.9) Constipation 678 17.6 (28.8)
SATWAI 625 60.6 (20.6) Diarrhoea 670 9.50 (20.4)
SATPE 674 59.8 (20.1) Financial difficulties 675 8.74 (20.9)
SATGEN = overall satisfaction; SATDTS doc tors’ technical skills; SATDIS = doctors’ interpersonal skills; SATDIP = do ctors’ provision of information; SATDAV doctors’
availability; SATNTS = nurses’ or radiation therapists’ technical skills; SATNIS = nurses’ or radiation therapists’ interpersonal skills; SATNIP = nurses’ or radiation
therapists’ provision of information; SATNAV = nurses’ or radiation therapists’ availability; SATEXE = exchange of information between caregivers; SATOTH = other
personnel’s interpersonal skills and provision of information; SATWAI = waiting time; SATPE = physical environment. OUT-PATSAT35 scales: SATGEN = overall
satisfaction, SATDTS doctors’technical skills, SATDIS = doctors ’ interpersonal skills, SATDIP = doctors’ information provision, SATDAV doctors’availability, SATNTS =
nurses’ or technologists’ technical skills, SATNIS = nurses’ or technologists’ interpersonal skills SATNIP = nurses’ or technologists’ information provision, SATNAV =
nurses’ or technologists’ availability, SATEXE = exchange of information between caregivers, SATOTH = other personal interpersonal skills and information
provision, SATWAI = waiting-time, SATPE = physical environment
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Table 3 Univariate analysis (Manova model) between each clinical and sociodemographic variable and all OUT-PATSAT35 scales
SATGEN SATDTS SATDIS SATDIP SATDAV SATNTS SATNIS SATNIP SATNAV SATEX SATOTH SATWAI SATPE
Center 0.93 0.46 0.98 0.85 0.78 0.80 0.35 0.33 0.30 0.41 0.43 0.93 0.40
Teaching hospital 72.5 (19.8) 71.6 (20.7) 68.3 (23.9) 66.0 (24.4) 61.8 (23.9) 73.1 (20.9) 72.0 (19.9) 60.2 (25.0) 66.6 (22.1) 64.2 (22.5) 63.9 (21.4) 60.4 (20.7) 59.3 (21.1)
Local hospital 74.7 (19.7) 73.4 (19.7) 67.9 (24.0) 67.7 (24.7) 63.4 (24.3) 73.3 (21.2) 72.8 (21.1) 61.0 (26.6) 66.5 (23.6) 65.7 (23.6) 65.7 (22.5) 63.2 (20.8) 61.9 (20)
Localization 0.01 0.005 0.09 < 0.0001 0.002 0.14 0.12 0.004 0.09 0.03 0.40 0.61 < 0.0001
prostate 77.6 (18.6) 74.6 (19.6) 70.3 (23.9) 69.4 (24.6) 68.0 (22.9) 76.0 (19.9) 75.7 (20.0) 61.1 (26.3) 68.6 (22.6) 68.4 (23.7) 67.4 (22.6) 63.4 (20.8) 66.3 (20.0)
head neck 69.1 (21.6) 64.8 (22.1) 61.2 (26.3) 54.1 (29.4) 55.0 (25.4) 69.3 (22.2) 69.8 (20.7) 53.7 (27.6) 60.4 (22.9) 58.8 (23.1) 62.6 (22.1) 59.2 (21.6) 52.4 (18.9)
breast 72.1 (18.2) 73.9 (19.3) 68.9 (22.1) 70.4 (20.8) 61.6 (23.1) 73.0 (20.5) 71.4 (19.9) 64.1 (23.7) 67.8 (22.3) 65.1 (21.9) 63.5 (21.3) 60.8 (20.3) 58.9 (20)
rectum 75.0 (21.1) 72.2 (24.3) 71.1 (26.3) 61.7 (25.9) 60.0 (25.5) 75.0 (21.7) 68.9 (23.6) 51.1 (30.7) 62.5 (25.4) 65.8 (20.3) 62.2 (25.2) 62.8 (19.9) 57.8 (24.3)
lung 71.7 (25.3) 68.6 (20.4) 66.1 (27.4) 59.7 (26.5) 59.4 (26.5) 69.4 (24.5) 69.9 (21.7) 53.7 (25.3) 64.4 (23.8) 60.1 (24.6) 65.1 (20.6) 63.0 (22.9) 60.6 (22.2)
Radiotherapy 0.64 0.0004 0.009 < 0.0001 0.17 0.05 0.04 0.0002 0.02 0.03 0.23 0.003 0.63
No 74.4 (16.8) 79.4 (16.9) 74.2 (18.1) 76.6 (17.6) 65.7 (20.3) 77.1 (19.3) 76.5 (18.4) 69.8 (20.7) 71.6 (20.5) 69.6 (20.5) 67.3 (17.8) 67.6 (19.7) 59.6 (19.9)
yes 73.4 (20.3) 71.1 (20.6) 67 (24.8) 64.7 (25.4) 61.8 (24.7) 72.4 (21.3) 71.6 (20.6) 58.8 (26.2) 65.7 (23.1) 63.9 (23.4) 64.2 (22.6) 60.5 (20.9) 60.7 (20.8)
Sex 0.07 0.56 0.99 0.05 0.17 0.33 0.10 0.02 0.72 0.56 0.27 0.45 0.19
female 71.8 (19.1) 72.9 (20.1) 68.1 (23.2) 68.9 (22.5) 61.0 (23.2) 72.2 (21.2) 70.8 (20.4) 63.2 (24.8) 67.0 (23.1) 64.2 (22.7) 63.6 (21.4) 60.9 (20.3) 59.2 (20)
male 74.9 (20.2) 71.9 (20.5) 68.1 (24.6) 64.8 (26.2) 63.8 (24.7) 74.0 (20.9) 73.7 (20.3) 58.1 (26.3) 66.3 (22.6) 65.4 (23.3) 65.7 (22.3) 62.3 (21.2) 61.5 (21.1)
Age 0.09 0.06 0.06 0.06 0.0002 0.04 0.03 0.07 0.01 0.20 0.07 0.21 0.001
[30;55] 70.4 (19.7) 72.0 (21.3) 64.7 (25.5) 64.4 (25.3) 54.0 (23.4) 74.3 (21.5) 71.9 (20.4) 60.9 (25.0) 65.5 (21.9) 63 (22.8) 61 (22.3) 59.1 (22) 55.7 (21.3)
[55;65] 75.7 (19.3) 75.5 (20.3) 71.5 (23.1) 71.3 (24.1) 64.9 (24.2) 75.7 (19.3) 75.0 (19.2) 64.4 (24.5) 70.0 (21.9) 68 (23.5) 67.5 (20.3) 63.5 (20.2) 59.5 (19.6)
[65;75] 72.8 (20.1) 69.6 (20.0) 66.7 (23.9) 64.9 (23.7) 65.0 (23.1) 69.7 (22.0) 69.3 (21.4) 56.9 (26.5) 63.0 (23.6) 63.2 (23) 63.9 (22.6) 60.8 (20.6) 61.6 (20.3)
[75;88] 76.1 (19.1) 74.1 (18.3) 70.9 (22.0) 66.1 (25.6) 65.1 (24.4) 75.2 (20.2) 75.5 (19.0) 61.5 (26.5) 70.8 (22.6) 65.9 (21.8) 67.3 (21.6) 64.3 (20) 67.5 (20.5)
Marital status 0.03 0.79 0.54 < 0.05 0.76 0.11 0.18 0.07 0.16 0.27 0.37 0.89 0.93
Living with partner/family 74.4 (19.4) 72.6 (20.2) 68.6 (24) 67.8 (24.0) 62.7 (24.4) 73.9 (20.4) 72.9 (20.0) 61.5 (24.9) 67.2 (22.2) 65.4 (22.6) 65.1 (21.5) 61.8 (20.5) 60.4 (20.4)
Single/separated 69.7 (20.9) 72.0 (20.4) 66.9 (23.5) 62.3 (28.5) 61.9 (22.2) 70.1 (23.6) 69.8 (22.2) 56.3 (28.8) 63.6 (25.0) 62.6 (24.5) 62.9 (23.4) 61.5 (22.1) 60.6 (21.9)
Distance 0.73 0.03 0.19 0.09 0.16 0.52 0.37 0.07 0.23 0.14 0.58 0.05 0.04
[1; 20] 73.7 (20.7) 74.2 (20.6) 69.4 (25.1) 68.5 (25.6) 63.9 (24.6) 73.7 (23.0) 73.1 (21.7) 62.4 (26.3) 67.7 (24.0) 66.3 (24.1) 65.2 (22.5) 63.3 (21) 58.7 (21.2)
[20; 145] 73.1 (18.7) 70.4 (19.7) 66.7 (22.5) 64.9 (23.3) 60.9 (23.3) 72.5 (18.7) 71.5 (18.8) 58.5 (25.0) 65.3 (21.4) 63.3 (21.6) 64.1 (21.2) 59.8 (20.5) 62.3 (19.8)
Leisure activities 0.20 0.007 0.004 0.0001 0.006 0.01 0.09 0.14 0.04 0.009 0.22 0.82 0.25
no 71.9 (20.8) 69.3 (21) 64.2 |(24.9) 61.4 (26.3) 58.7 (24.8) 69.9 (22.0) 70.3 (20.8) 58.2 (26.1) 63.7 (22.7) 61.4 (24.3) 63.1 (22.6) 61.4 (21.7) 59.1 (21.4)
yes 74.2 (19.2) 74.3 (19.5) 70.4 (22.7) 69.8 (22.8) 64.7 (23.1) 74.8 (20.3) 73.4 (20.0) 61.7 (25.4) 68.1 (22.8) 66.8 (22) 65.5 (21.3) 61.8 (20.4) 61.3 (20.2)
Monthly income 0.32 0.06 0.60 0.10 0.64 0.05 0.37 0.15 0.33 0.16 0.65 0.94 0.37
MW or less 75.0 (21.8) 67.5 (23.2) 64.5 (28.2) 62.4 (29.3) 60.5 (24.9) 74.8 (20.6) 73.2 (21.4) 62.1 (25.0) 64.7 (24.6) 61.9 (26.8) 64.1 (26.6) 60.1 (24) 63.4 (21.6)
MW-1499 71.8 (19.3) 70.9 (19.6) 67.7 (21.7) 64.9 (23.8) 61.1 (24.8) 69.8 (21.4) 70.9 (19.8) 58.3 (26.0) 64.5 (21.9) 62.7 (21.3) 63.9 (21.1) 61.6 (21.9) 58.5 (21.2)
1500-2999 75.1 (19.0) 73.6 (20.5) 68.5 (23.9) 68.5 (23) 63.4 (23.0) 75.6 (20.8) 74.4 (20.5) 63.7 (26.0) 68.5 (22.7) 66 (22.7) 66.4 (21.5) 61.8 (19.2) 61.5 (18.7)
?3000 71.9 (18.6) 76.1 (18.6) 70.1 (25.2) 71.5 (25.8) 64.4 (24.1) 75.0 (20.3) 71.2 (20.9) 57.5 (25.7) 68.2 (22.9) 69 (23.6) 63.3 (21) 60.7 (20.1) 60.5 (22.9)
SATGEN = overall satisfaction; SATDTS doctors’ technical skills; SATDIS = doctors’ interpersonal skills; SATDIP = doctors’ provision of information; SATDAV doctors’ availability; SATNTS = nurses’ or radiation therapists’
technical skills; SATNIS = nurses’ or radiation therapists’ interpersonal skills; SATNIP = nurses’ or radiation therapists’ provision of information; SATNAV = nurses’ or radiation therapists’ availability; SATEXE = exchange
of information between caregivers; SATOTH = other personnel’s interpersonal skills and provision of information; SATWAI = waiting time; SATPE = physical environment. MW = minimum wage.
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Table 4 OUT-PATSAT35 scales’ mean score, mean difference and p values for clinical, socio-demographic factors and QLQC30 scales by multivariate analysis:
model with primary localization *
$
SATGEN SATDTS SATDIS SATDIP SATDAV SATNTS SATNIS SATNIP SATNAV SATEX SATOTH SATWAI SATPE
Monthly income (euros) 0.17 0.43 0.59 0.44 0.17 0.02 0.1 0.008 0.45 0.56 0.28 0.92 0.07
MW or less
a
73.3 68.6 67.9 62.8 60.8 76.1 72.9 57.7 64.9 62.5 65.5 60.2 64.7
MW-1499 -4.8 0.1 -4.5 -5.3 -5.3 -8.1 -4.7 -6.9 -3.4 -0.9 -3.5 -0.2 -7.6
1500-2999 -2.2 2.4 -3.4 -3.3 -1.1 -3.3 -1.2 -2.7 0 2 -1.4 1 -5.4
? 3000 -5.4 3.9 -2.3 -3.6 -1.3 -5 -5.6 -12.5 -1.3 2.8 -6 1.5 -4.5
Age 0.33 0.19 0.05 0.02 0.001 0.11 0.14 0.02 0.11 0.42 0.14 0.44 0.03
30-55
a
67.9 69.4 61.4 58.5 51.9 73.6 70.6 53 63.1 62.5 59.7 58.7 56
56-65 4.1 3.3 7.5 6.5 9.2 0.4 2.1 3.95 3.3 3 5.7 4 3.7
66-75 2.9 -1 4.3 0 10 -4.6 -2.7 -4.6 -2.4 -0.9 2.5 1.8 4.6
76-88 2.3 0.9 3.8 -1.5 8.8 -2.3 -1.7 -2.8 1.6 1.8 4.1 2.5 8.9
Marital status 0.04 0.96 0.28 0.003 0.36 0.20 0.37 0.01 0.11 0.29 0.23 0.94 0.89
Living with partner or family
a
72.3 70.3 66.7 63.4 60 73.4 71 55.6 65.6 64.8 64.2 60.7 60.5
Single or separated -4.2 -0.2 -2.7 -7.3 -2.2 -2.8 -1.9 -6.9 -3.8 -2.6 -2.8 0.2 -0.3
Localization
Prostate
a
74.2 73.5 66.7 64.2 64.5 75.8 74.5 57.5 66.9 66.1 64 62 65.5
Head and neck 0.03 0.03 0.13 0.002 0.02 0.04 0.11 0.02 0.09 0.04 0.47 0.46 0.002
-6 -6.3 -5.1 -10.4 -7.9 -6 -4.5 -9.1 -5.6 -6.9 -2.3 -2.3 -9.2
Breast 0.06 0.54 0.82 0.37 0.1 0.02 0.02 0.53 0.67 0.43 0.61 0.51 0.01
-3.7 -1.2 0.6 2.2 -4 -4.9 -4.8 1.8 -1.1 -1.9 -1.2 -1.5 -5.1
Rectum 0.23 0.19 0.67 0.11 0.04 0.43 0.03 0.04 0.23 0.69 0.34 0.67 0.22
-5.7 -6.3 -2.4 -9.1 -11.1 -4 -10.7 -13.8 -6.9 -2.2 -5.1 -2.3 -5.9
Lung 0.20 0.44 0.98 0.24 0.23 0.26 0.52 0.26 0.59 0.61 0.50 0.998 0.11
-4.5 -2.7 0.1 -4.9 -5 -4.2 -2.3 -5.55 -2.2 -2.1 2.7 0 -5.7
QLQC30 scales
Global health status < 0.0001 < 0.0001 < 0.0001 < 0.0001 0.004 0.0004 < 0.0001 < 0.0001 < 0.0001 < 0.0001 0.0001 0.001 0.003
*adjusted for center, leisure activities, distance from home to hospital and QLQC30 scales (emotional, social, sleep, pain, fatigue). $numbers in bold correspond to p values, numbers in italic correspond to mean
scores, otherwise numbers correspond to mean difference compared to the reference class. a: reference class. SATGEN = overall satisfaction; SATDTS doctors’ technical skills; SATDIS = doctors’ interpersonal skills;
SATDIP = doctors’ provision of information; SATDAV doctors’ availability; SATNTS = nurses’ or radiation therapists’ technical skills; SATNIS = nurses’ or radiation therapists’ interpersonal skills; SATNIP = nurses’ or
radiation therapists’ provision of information; SATNAV = nurses’ or radiation therapists’ availability; SATEXE = exchange of information between caregivers; SATOTH = other personnel’ s interpersonal skills and
provision of information; SATWAI = waiting time; SATPE = physical environment. MW = minimum wage.
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Table 5 OUT-PATSAT35 scales ’ mean score. mean difference and p values for clinical. socio-demographic factors and QLQC30 scales by multivariate analysis:
model with treatment*$
SATGEN SATDTS SATDIS SATDIP SATDAV SATNTS SATNIS SATNIP SATNAV SATEX SATOTH SATWAI SATPE
Monthly income 0.22 0.28 0.49 0.28 0.13 0.02 0.16 0.01 0.40 0.40 0.30 0.89 0.08
MW or less
a
74.9 72.3 71.5 69.9 64.6 77.5 75.7 66 68.7 64.7 67.2 62.5 65.8
MW-1499 -4.6 0.2 -4.6 -5.9 -5.4 -7.7 -4.5 -7 -3.4 -0.7 -3.8 -0.1 -7.3
1500-2999 -1.9 2.7 -3.1 -2.9 -0.9 -2.9 -1.5 -2.5 0.1 2.5 -1.9 1 -4.8
? 3000 -4.8 4.7 -1.5 -2.5 -0.6 -4.2 -5.2 -11.4 -0.8 3.8 -6 2 -3.5
Age 0.11 0.23 0.02 0.08 < 0.0001 0.41 0.31 0.1 0.15 0.43 0.07 0.22 0.001
30-55
a
68.5 72.1 64 64.9 54.2 73.6 71.6 60.5 65.8 63.8 60.2 59.9 56.1
56-65 4.9 4.1 8.3 6.3 10.2 1.7 3.5 4 4 3.7 6.5 4.9 4.8
66-75 4.9 1 6.2 1.7 12.8 -1.8 0.1 -2.8 -0.5 1.2 4 3.7 7.1
76-88 4.4 3.3 6.1 0.7 11.8 0.9 1.6 -0.1 4 4.3 5.8 4.8 11.3
Marital status 0.03 0.84 0.22 0.004 0.26 0.12 0.21 0.01 0.07 0.24 0.16 0.89 0.74
Living with partner or family
a
74.3 74.4 70.7 70.7 64.2 75.5 74.2 64.2 69.8 67.6 65.9 63.4 62.3
Single or separated -4.5 -0.4 -3 -7.2 -2.7 -3.4 -2.6 -6.9 -4.2 -3 -3.2 -0.3 -0.8
Radio-therapy 0.25 0.003 0.003 0.0001 0.03 0.06 0.03 < 0.0001 0.01 0.03 0.20 0.007 0.44
no
a
73.4 77.8 73.4 72.6 65.9 76.1 75.5 67 71.2 69.1 66 66.7 62.8
yes -2.7 -7.1 -8.4 -11 -6 -4.6 -5.2 -12.4 -7 -6 -3.4 -6.9 -1.8
QLQC30 scales
Global health status < 0.0001 < 0.0001 < 0.0001 < 0.0001 0.002 0.0002 < 0.0001 < 0.0001 < 0.0001 < 0.0001 0.0002 0.001 0.0009
*adjusted for center. leisure activities. distance from home to hospital. and QLQC30 scales (emotional. social. sleep. fatigue. pain) $numbers in bold correspond to p values, numbers in italic correspond to mean
scores, otherwise numbers correspond to mean difference compared to the reference class. a: reference class SATGEN = overall satisfaction; SATDTS doctors’ technical skills; SATDIS = doctors’ interpersonal skills;
SATDIP = doctors’ provision of information; SATDAV doctors’ availability; SATNTS = nurses’ or radiation therapists’ technical skills; SATNIS = nurses’ or radiation therapists’ interpersonal skills; SATNIP = nurses’ or
radiation therapists’ provision of information; SATNAV = nurses’ or radiation therapists’ availability; SATEXE = exchange of information between caregivers; SATOTH = other personnel’s interpersonal skills and
provision of information; SATWAI = waiting time; SATPE = physical environment. MW = minimum wage.
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and waiting times (the first questionnaire was often
delivered during the first week of treatment).
Socio-demographic determinants significantly linked to
dissatisfaction with care, in both models, were marital
status (living alone) associated with doctors’ information
provision, and young age (< 55 years) with doctors’ avail-
ability. A monthly income > 3000 Euro was associated
with less satisfaction with nurses’ or radiation therapists’
information provision, but this was only significant in the
model with primary cancer (Tables 4 and 5).
The centre was not found to be a significant determi-
nant of patient satisfaction.
Poorer perceived global health status, in both models,
was significantly associated with lower levels on OUT-
PATSAT35 scales: regression coefficient ranged from
0.17 to 0.34 (p < 0.0001, Tables 4 and 5).
Discussion
Using the OUT-PATSAT35 questionnaire, we identified
clinical (global health sta tus, primary cancer, tre atment
modalities) and socio-demographic factors (marital sta-
tus, age) significantly associated with different domains
of satisfaction with care among cancer outpatients at
the beginning of their ambulatory treatment.
None of the OUT-PATSAT35 scales correlated highly
with the EORTC QLQ-C30 (all r < 0.30; p < 0.0001).
The same findings were observed in t he French and
Spanish [22,23] validation studies of the OUT-PAT-
SAT35 questionnaire, underlining the fact that these
two questionnaires probably assess complementary
concepts.
Using the EORTC IN- PATSAT32 and QLQ-C30
questionnaires, Avery et al investigated associations
between patient satisfa ction with care and surgical mor-
bidity among inpatients undergoing surgery for oesopha-
geal or gastric cancer [ 26]. Among the 181 patients
included, r esults showed that patient satisfaction scores
remained high and were not associated with the pre-
sence of major postoperative complications. These latter
were, however, related to worse quality of life. Unfortu-
nately, the authors did not directly assess relationships
between QOL and satisfaction scores.
Indeed, the relationship between QOL and satisfaction
with care remains unclear [10,27]. Previous studies have
reported contradictory results, depending on whether
functional or symptom scales were considered (global
health, physical functioning or pain), underlining the
complexity of patient satisfaction interpretation. Despite
the multidimensional co ncept of QOL, in our study,
poor global health status was the main determinant of
low levels of satisfaction with care. Similar findings were
observed by Bredart et al among cancer inpatients
[6,28]. Our methodology su ggests that health status may
influence patient satisfaction, and not the other way
around. Different explanations have been proposed for
this relationship; for example, poorer health may nega-
tively influence one’s attitude towards medical care, or
caregivers may respond less positively to patients with
poor health, thus resulting in lower satisfaction levels
[18]. In any case, this effect has not been confirmed in
longitudinal studies with repeated measures of global
health, in order to assess whether higher levels of satis-
faction can result from interventions aimed at improving
quality of life.
Patients treated for a head and neck cancer reported
less satisfaction with the level of information provided
by doctors. Patients who start radiotherapy for head and
neck cancer are those who e xperience the most symp-
toms associated with their illness (such as pain, dyspha-
gia, dysphonia), or may have complications linked to
previous treatment (such as mutilating surgery). This
can lead to aesthetic or functional problems and co nse-
quently, difficulties in patient-doctor communication.
Moreover, because this type of cancer is usually related
to an addiction to tobacco and alcohol, it may be
hypothesised that this negatively influences care provi-
ders’ att itude toward thes e patie nts com pared t o those
treated for other cancer sites.
Radiotherapy, as compared to chemotherapy, was sig-
nificantly linked to lower satisfaction scores in most
scales. These results should be interpreted with caution
because the few patients receiving chemotherapy were
those treated for breast cancer and these two variables
(namely treatment modality and cancer localization),
were not entered into the same model. The first ques-
tionnaire was co mpleted during the first week of radio-
therapy treatme nt, when mo st patients had experie nced
very few side effects, and thus, treatment related toxicity
cannot be the reason behind their dissatisfaction. Radia-
tion therapists, as opposed to nurses in ambulatory che-
motherapy, spend less time with patients during each
radiation session, and the care pathway in a radiother-
apy department is co mplex, requiring sever al appoint-
ments for preparation, and the time to the definitive
start of treatment may be long. Moreover, radiation
treatment is stressful in itself: patients have reported
fears about the size and possible fall of the machine, the
delivery of co rrect radiation doses, their ability to stay
unmoved in uncomfortable positions and being shut up
alone during the radiation session. Thus, the dissatisfac-
tion with care observed among radiotherapy patients
could be explained by a discrepancy between care
expectations and the perception of care received, high-
lighting the importance of delivering adequate informa-
tion [29].
Patients living alone seem to be less satisfied with doc-
tors’ information provision. Cancer patients’ understand-
ing is often affected by anxiety or denial then the
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presence of relatives, ab le to repeat and to discuss the
information given during the consultation, should facili-
tate the doctor-patient communication.
Age was a minor determinant of satisfaction, with
patients < 55 years old less satisfied with doctors’ avail-
ability. Other studies using similar questionnaires did
not find any relationship between age and satisfaction
scores [6,23,26]. Poinsot et al suggest a cultural evolu-
tion in French cancer patients to wards increased knowl-
edge of the medical aspects of their disease, and thus, a
greater homogeneity in their care expectation [23].
Level of education was not associated with satisfaction
scores, in our s tudy. Poinsot et al observ ed similar find-
ings to ours [23], although other reports have shown
that a higher level of education was associated with
higher expectations as regards quality of care [6,14].
It is like ly that our study is not representative of all
patients seen in oncology practice, since we did not
include some common primary localizations such as
uterine or upper gastrointestinal tract cancer, and meta-
static patients.
Nevertheless, our results confirm the acceptability of
the OUT-PATSAT35 questionnaire in a large outpatient
sample. A number of clinical (primary site, radiotherapy)
and socio-demographic factors (marital status, age) were
significantly associated with different scales of the satis-
faction questionnaire. However, t he major determinant
of satisfaction was patients’ global health status, suggest-
ing that self-reported quality of life is a key element in
understanding cancer patient satisfaction.
Conclusions
Our findings brought to light a number of patient charac-
teristics that are associated with dissatisfaction with care,
as well as concerns about specific aspects of care. Health-
care providers should use such results to target these
patient groups, who ar e at risk of experiencing less satis-
faction with their pathway of care (in particular, head and
neck cancer patients, patients treated by radiotherapy).
Our o bservations also highlight some aspects of health
professionals’ behaviour that may leave room for improve-
ment (e.g. providing adequate information to patients).
Lastly, our results underscore the importance of mea-
suring and adjusting for self-perceived health status
when comparing patient satisfaction with care between
hospitals or assessing variations in patient satisfaction
over time.
Further analyses are currently ongoing to determine
the responsiveness of this questionnaire to changes over
time, and to evaluate whether improvements in patients’
quality of life c ould lead to impro ved satisfaction with
car e. Indeed, if this relationship is confirmed, initiatives
targeting patients with poorer health status should gen-
erate greater returns in patient satisfaction.
Additional material
Additional file 1: Appendix A. EORTC IN-PATSAT32.
Additional file 2: Appendix B. OUT-PATSAT35.
Acknowledgements
The authors are grateful to Fiona ECARNOT and Marc PUYRAVEAU.
This publication was supported by Programme Hospitalier de Recherche
Clinique (PHRC 2004 - France).
Part of this work was presented in poster presentation of ESMO in Berlin,
september 2009: Nguyen TV, Bosset JF, Monnier A, Perrin V, Fournier J.
Determinants of patient satisfaction in ambulatory oncology: a prospective
study based on the EORTC OUT-PATSAT 35 questionnaire. Eur J Cancer
Suppl 2009;7:241; in oral presentation of 10
th
Biennal ESTRO in Maastricht,
September 2009: Nguyen TV, Bosset JF, Monnier A, Mercier M. Determinants
of satisfaction with care in cancer outpatients: a prospective study based on
the EORTC OUT-PATSAT35 questionnaire. Radiother Oncol 2009;92:S106; In
oral presentation of 16
th
ISOQOL in New Orleans, October 2009: Nguyen TV,
Bosset JF, Monnier A, Mercier M: Determinants of patient satisfaction in
ambulatory oncology: a prospective study based on the EORTC OUT-
PATSAT35 questionnaire. In ISOQOL conference Abstracts Issue. Qual Life Res
2009;A-38
Author details
1
Oncology-Radiotherapy Department, Besançon University Hospital, 3
boulevard Fleming, 25030 Besançon, Cedex, France.
2
Radiotherapy
Department, Montbéliard Hospital, 25200 Montbéliard, France.
3
Clinical
Research Department, EA 3181, Université de Franche Comté, 25030
Besançon, France.
4
Nancy University, Paul Verlaine Metz University, Paris
Descartes University, EA 4360 Apemac, Nancy, France - INSERM, CIC-EC CIE6,
Nancy, France.
5
Psycho-Oncolog Unit, Institut Curie, 75 231 Paris cedex,
France.
6
Health-Related Quality of Life in Oncology Platform, Nancy
University, Cancéropole Grand Est, France.
Authors’ contributions
TVFN participated to the coordination of the study, performed the statistical
analysis, the interpretation of data and drafted the manuscript. JFB and AM
participated in the conception and design of the study. JF and VP
contributed to the acquisition of data. CB and AB revised the manuscript
critically for important intellectual content. MM participated in the
conception and coordination of the study, and helped to the statistical
analysis and the interpretation of data. All authors read and approved the
final manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 7 June 2011 Accepted: 28 December 2011
Published: 28 December 2011
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Pre-publication history
The pre-publication history for this paper can be accessed here:
http://www.biomedcentral.com/1471-2407/11/526/prepub
doi:10.1186/1471-2407-11-526
Cite this article as: Nguyen et al.: Determinants of patient satisfaction in
ambulatory oncology: a cross sectional study based on the OUT-
PATSAT35 questionnaire. BMC Cancer 2011 11:526.
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