|Year : 2012 | Volume
| Issue : 3 | Page : 157-162
A comparative evaluation of patients satisfaction with cataract surgical services in a public tertiary and a private secondary eye care facilities in Nigeria
Olusola Olawoye1, Adeyinka Ashaye1, Charles Bekibele1, Ademola J Ajuwon2
1 Department of Ophthalmology, University College Hospital Ibadan, Nigeria
2 Department of Health Education, University of Ibadan, Ibadan, Nigeria
|Date of Web Publication||5-Jun-2012|
Department of Ophthalmology, University College Hospital Ibadan
| Abstract|| |
Background/Purpose: This study compared the degree of patients' satisfaction with cataract surgical services at a private, semi urban secondary eye care hospital - St Mary's Catholic Eye Hospital, Ago Iwoye, (SMEH) and a public tertiary hospital-University College Hospital Ibadan (UCH) in South Western Nigeria.
Materials and Methods: A prospective, observational study of consecutive patients undergoing cataract surgery at SMEH and UCH was conducted between May and October 2007. Questionnaires were administered to a total of 366 patients preoperatively, 1 st day and 8 th week postoperatively. Results were analyzed using the SPSS statistical software.
Results: Evaluation of patients' satisfaction with preoperative care showed that patients were more satisfied with the pre-consultation time (P=0.006) and cost of surgery (P<0.001) at SMEH than in UCH. There was no statistically significant difference with respect to satisfaction of patients with vision in both hospitals (P=0.09). More patients were satisfied with overall care at SMEH than UCH and were therefore more likely to recommend the hospital.
Conclusion: This study compared patients' satisfaction with cataract surgical services in two hospitals. Patients from the private secondary eye care hospital were more satisfied than patients from the public tertiary hospital. Satisfied patients have a great role to play in increasing cataract surgical uptake.
| Abstract in French|| |
Contexte/objet: Cette étude a comparé le degré de satisfaction des patients avec des services de chirurgie de la cataracte dans un, semi urbain œil secondaire soins hôpital privé - St Mary catholique Eye Hospital, il y A Iwoye, (SMEH) et un public tertiaire hôpital-University College Hospital Ibadan (UCH) dans le sud ouest Nigeria.
Des matériaux et des procédés: a prospective, observational study of consécutifs patients subissant une chirurgie de la cataracte à SMEH et UCH a été réalisée entre mai et octobre 2007. Questionnaires ont été administrés à un total de 366 patients avant l'opération, 1er jour et 8e semaine après l'opération. Résultats ont été analysés à l'aide du logiciel de statistique de SPSS.
Résultats: Évaluation de la satisfaction des patients avec soins préopératoires ont montré que les patients étaient plus satisfaits de l'époque préconsultation (P = 0,006) et le coût de la chirurgie (P < 0,001) à SMEH que dans UCH. Il n'y n'avait aucune différence statistiquement significative à l'égard de la satisfaction des patients atteints de vision dans les deux hôpitaux (P = 0,09). Plus de patients étaient satisfaits des soins globaux à SMEH que UCH et sont donc plus susceptibles de recommander à l'hôpital.
Conclusion: Cette étude a comparé la satisfaction des patients avec des services de chirurgie de la cataracte dans deux hôpitaux. Les patients de l'hôpital de soins oculaires secondaire privée étaient plus satisfaits que les patients de l'hôpital public de tertiaire. Convaincu les patients ont un grand rôle à jouer en augmentant la cataracte chirurgicale absorption.
Mots clés: Services de chirurgie de la cataracte, la satisfaction des patients, hôpital privé, l'hôpital public
Keywords: Cataract surgical services, patient satisfaction, private hospital, public hospital
|How to cite this article:|
Olawoye O, Ashaye A, Bekibele C, Ajuwon AJ. A comparative evaluation of patients satisfaction with cataract surgical services in a public tertiary and a private secondary eye care facilities in Nigeria. Ann Afr Med 2012;11:157-62
|How to cite this URL:|
Olawoye O, Ashaye A, Bekibele C, Ajuwon AJ. A comparative evaluation of patients satisfaction with cataract surgical services in a public tertiary and a private secondary eye care facilities in Nigeria. Ann Afr Med [serial online] 2012 [cited 2013 Jun 18];11:157-62. Available from: http://www.annalsafrmed.org/text.asp?2012/11/3/157/96877
| Introduction|| |
The vast majority of cataract blind people live in the poor countries of the developing world; in communities with limited resources to care for the visually handicapped.  In Nigeria, 50% of blindness is due to cataract and 486,000 adults are in immediate need of cataract surgery.  Cataract surgical rates vary from 6,300 operations/year/million population in Australia  to 100 operations/year/million population in Nigeria.  According to the Nigerian National Survey of blindness and low vision working group,  50% of these cataract surgeries in Nigeria are carried out by traditional 'couchers' with consequent poor visual outcome. Therefore in Nigeria and in many developing countries, there is a high backlog of un-operated cataract patients due to low cataract surgical rate (CSR), increasing incidence of cataract due to an ageing population, and a high number of poor outcomes following traditional cataract couching.
In order to increase cataract surgical uptake, it is important to give patient-centred care which is health care that is responsive to patients' wants, needs, and preferences. This reflects the reality that the choice and success of many treatment options are based on subjective patient-defined criteria  and that patient satisfaction is an element of health status itself.  Satisfied patients report greater compliance and better surgical outcomes.  As health care is becoming increasingly privatized and economically competitive, it is important to produce satisfied patients who will both remain with and recommend their health provider to other potential clients. This will increase the CSR and reduce avoidable blindness in Nigeria and other developing countries.
This study compared the degree of patients' satisfaction with cataract surgical services at a private eye care hospital and a public tertiary hospital in Nigeria.
| Materials and Methods|| |
The study sites were SMEH and UCH. They both have a drive to increase CSR, and vibrant cataract surgical outreaches programs. SMEH is a privately owned 36 bed secondary eye care facility located in a semi-urban town of Ago Iwoye, south-western Nigeria. It has one consultant ophthalmologist, one ophthalmic nurse, 10 ophthalmic assistants, one optometrist and one optician. The pre-consultation waiting time (PWT) is 1-3 h and all patients are seen in the order of arrival to the hospital. An average of 70 patients is seen daily. They operate on an average of 25 cataract patients per operation day. Cataract surgery costs N19,000 (127USD).
UCH, however, is an 840 bed, government tertiary hospital with 28 (3.3%) of its beds allocated to the Ophthalmology department. It is located in the urban city of Ibadan south-western Nigeria. There are 6 consultant ophthalmologists, 11 resident doctors, 20 trained general nurses on the eye ward, 8 ophthalmic theatre nurses, and 15 trained nurses who work on shift basis in the clinic. An average of eight cataract surgeries is done per operation day. The PWT is 3-7 h and patients are not seen in order of arrival to hospital. An average of 90 patients is seen daily. Cataract surgery costs N12,000 (80USD). The WHO cataract outcome monitoring form is used in this hospital to monitor outcome of surgery.
Two focus group discussions, each consisting of six respondents, were done at UCH six months before commencement of the study. This helped in developing the questionnaire used in this study. A pilot study, to test the adequacy of patient's comprehension of the questions, was done three months before the onset of the study at UCH. Adjustments were made as required. The questionnaire was translated to the local language (Yoruba) and back translated to English by a Yoruba translator to ensure original meanings were maintained.
A total sampling of all patients who met the inclusion criteria and presented with operable cataract to both hospitals between May and October 2007 were studied. The inclusion criteria were patients coming for the first eye cataract surgery to prevent bias from earlier experiences and patients who were 40 years and above. Patients were excluded if they had other ocular co-morbidities such as those with complicated cataracts or those who had cosmetic cataract surgeries. Individual verbal informed consent was obtained from each participant.
The study protocol was approved by the Ethical Review Board of the University College Hospital. A total of 366 patients who presented to the two hospitals were recruited for the study (184 patients at UCH, and 182 at SMEH). Data was collected in three stages.
The team that carried out this study comprised of the principal investigator, and two assistants with Ordinary National Diploma qualifications. The two assistants were trained for two days by the investigator on how to assess visual acuity of the patients by the standard method of using the Snellen or illiterate E chart. They were trained on the use of the pinhole in assessing for improvement in visual acuity of the patients (one assistant worked in each hospital). These assistants were also trained on how to administer the semi structured pre-operative and immediate post-operative questionnaire. The investigator administered the section of the questionnaire on patient satisfaction in the pre-operative, immediate and eight weeks postoperative period at both hospitals.
In the pre-operative assessment, the socio-demographic data of each patient, and the presenting pre-operative visual acuity (V/A) unaided and with pinhole in both eyes were recorded. Visual outcome was categorized using the World Health Organization (W.H.O) standard  where good vision is 6/6 to 6/18, borderline vision is ≤ 6/18 - 6/60 and poor vision is <6/60. Patient satisfaction with the preoperative services was assessed using four factor analysis: courtesy of health staff; pre-consultation waiting time; education/counselling; and cost of surgery. Each of these were assessed on a 4 score scale which ranged from 1(very dissatisfied), to 4 (very satisfied). Other categories were 2 (dissatisfied), and 3 (satisfied).
The 2 nd phase of data collection was on the 1 st post-operative day. The information collected were the 1 st day post-operative distant V/A unaided and with pinhole using the Snellen's chart, and patient satisfaction with vision post-operation assessed on the 4 score scale as described above.
The third phase of data collection was eight weeks post-surgery. Patient's satisfaction at this stage was assessed using 2 factor analysis - overall satisfaction with care and overall satisfaction with vision. These were assessed on a scale of 1 to 10 where 1 was very dissatisfied, and 10 was very satisfied. Satisfaction was based on a scoring system where 1-4 is dissatisfied; 5-7 is moderately satisfied while 8-10 is very satisfied.
Data collected was collated, entered, cleaned and analyzed using SPSS version 12 (SPSS, Inc, Chicago, USA). Frequencies and means were generated to observe patterns of variable distribution among the patients. A P value < 0.05 was considered as significant.
| Results|| |
A total of 184 patients met the inclusion criteria and were enrolled for the study at UCH. At eight weeks postoperatively, 165 patients were studied (attrition rate of 10.3%). At SMEH, a total of 182 patients met the inclusion criteria and were enrolled for the study. At eight weeks postoperatively, 170 patients were studied (attrition rate of 6.6%).
At UCH, the mean age of patients was 67.21 years ± 11.72 while at SMEH it was 66.5 ± 10.46. [Table 1] shows the demographic characteristics of the patients.
|Table 1: Demographic characteristics of patients studied at UCH and SMEH|
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[Table 2] shows the presenting unaided and pinhole VA in the operated eye in the two hospitals. There was no statistically significant difference in the preoperative presenting visual acuity of patients in both hospitals (P=0.29, df=3, Pearson Chi Square=3.74).
|Table 2: Pre-operative presenting and aided visual acuity in the operated eye|
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Subjective satisfaction with preoperative services
Pre-consultation waiting time
At UCH, 91 patients (49.5%) were satisfied with the PWT (mean score 2.59 ± 0.75) while 116 patients (63.7%) were satisfied with the PWT at SMEH (mean score 2.78 ± 0.67). There was a statistically significant difference in patient satisfaction with PWT (P=0.006, OR=2.0, CI=0.36-0.84), with patients being more satisfied at SMEH than at UCH. At UCH, 93 patients (50.5%) were dissatisfied because they felt they waited too long and were not seen in order of arrival at the clinic, whereas 66 patients (36.3%) at SMEH were dissatisfied because they felt their waiting time could still be reduced by employing more doctors [Figure 1].
|Figure 1: Patients' dissatisfaction with cataract surgical services at St Mary's Catholic Eye Hospital Ago Iwoye and University College Hospital, Ibadan|
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Courtesy of health staff at both hospitals
At UCH, 160 patients (87.0%) were satisfied with courtesy of the health staff (mean score 3.14 ±0.54) while 166 patients (91.2%) were satisfied at SMEH (mean score 3.19 ± 0.64), (P=0.192, OR=0.643, CI=0.329-1.254). Dissatisfied patients at UCH [Figure 1] complained about the support staff that did not treat them respectfully.
Preoperative education and counselling
At SMEH, 176 patients (96.7%) were satisfied while at UCH 179 patients (97.2%) were satisfied with the education and counselling received (P=0.349, OR= 0.55, CI=0.518 - 6.257). Dissatisfied patients in both hospitals [Figure 1] felt "they had not been told everything they needed to know" especially concerning their expectations during the surgery.
Cost of surgery
At UCH, 141 patients (76.6%) were satisfied with the cost of surgery (mean score 3.04 ±0.73) while 176 patients (96.7%) were satisfied at SMEH (3.43 ± 0.56) (P<0.001, OR=8.928, CI=0.04- 0.27). At SMEH, 33.5% felt that the cost of surgery was very less when compared with what obtained in some other private hospitals. Dissatisfied patients at UCH felt that "surgery should be free", while at only SMEH few patients (3.3%) felt cost of surgery could still be lower [Figure 1].
1 st day postoperative assessment
At UCH 142 patients (77.2%) were satisfied with their vision 1 st day postoperatively (mean score 3.00 ± 0.69) while at SMEH 121 patients (66.5%) were satisfied (mean score 2.85 ± 0.70). (P=0.023, OR=1.704, CI=1.074 - 2.705).
The objective visual acuity is summarized in [Table 3]. There was no statistically significant difference in the eight week post-operative vision between the hospitals. (P=0.09, df=3, Pearson Chi square= 6.32)
|Table 3: Visual acuity on the 1st day and 8 weeks post cataract surgery SMEH and UCH|
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At eight weeks post-operation, 120 patients (70.6%) were very satisfied with their vision at SMEH while at UCH, 117 patients (71%) were very satisfied (P=0.14) [Figure 2].
|Figure 2: Overall patients' satisfaction with care at St Mary's Catholic Eye Hospital Ago Iwoye and University College Hospital Ibadan|
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At UCH, 86 patients (52.1%) were very satisfied (mean score 7.19±1.75) while 136 patients (80%) were very satisfied (mean score 8.36±1.79) at SMEH (P< 0.001). Patients at SMEH were more satisfied with respect to overall care than patients at UCH.
Predictors of overall satisfaction with care
Multiple logistic regression analysis showed that overall satisfaction with care was strongly predicted by PWT (Pearson Chi-Square=59.46, P<0.001), courtesy of health staff (Pearson Chi square=18.232, OR=2.512, 95% CI=1.157-5.453, P=0.025), and fulfilment of expectation (Pearson Chi square=17.443, P<0.001) [Figure 3].
At UCH, 149 patients (90%) would rather recommend the hospital only to potential patients who would be ready to wait for long hours in the hospital. In contrast, as many as 167 patients (98.2%) at SMEH would readily recommend the hospital to all potential users.
| Discussion|| |
This is most likely the first study in Nigeria to compare patients' satisfaction with cataract surgical services in a tertiary hospital and in a secondary eye care center. Previous studies have focused on objective visual outcome post cataract surgery. ,,
The presenting visual acuity in both hospitals were similar and comparable to those in other African studies. ,,, This shows that majority were operated when they were already blind or severely visually impaired. Thus, treatment was more of sight restoration than blindness prevention, a situation which is more likely to be associated with a large backlog of cataract blind patients requiring surgery. Therefore, more cataract surgeries are still needed to be done at an earlier stage in order to clear this backlog. The eighth week post-operative visual acuity at both hospitals is similar to that obtained in other studies in Nigeria, , but better than the report of Bekibele  in SMEH in 1999. This may be due to improvement in surgical skills as well as availability of facilities for biometric measurements over the years.
Most patients in both hospitals felt the staffs were courteous. Although the difference in both hospitals was not statistically significant, it is still relevant to note that more patients were satisfied with the courtesy of health staff at SMEH. This may be attributed to the private ownership of SMEH and the relatively smaller staff strength of the hospital which are subject to closer monitoring. Many of the patients who were dissatisfied at the UCH complained about the support staff that did not treat them with courtesy. These groups of staff do not fully understand the role of satisfied patients in increasing the output and outcome of cataract surgery. Excellent eye careservice can only be achieved when all cadres of staff work as a team and as stakeholders. There should be routine stakeholders training workshops where eye care workers are trained and re-trained on ways of improving quality of services. Awobem et al.,  found that unfriendly eye care workers was one of the barriers to effective use of hospital eye services.
Patients at SMEH were more satisfied with PWT than at UCH because their waiting time was shorter and they were seen in the order of their arrival to hospital. However at UCH, patients were not necessarily seen in turns and waiting time was much longer. Oftentimes in tertiary hospitals, patients are sorted out and complicated cases are reserved for more senior doctors to manage. Patients waiting times can however still be reduced by ensuring that these groups of patients are seen in turns and subsequently reviewed with the most senior medical personnel in the outpatient clinic. Ayeni et al.,  in a study on "service uptake in UCH" also found that long PWT was a major barrier to effective use of eye care services. This factor in the preoperative care was very important to patients and it was a strong deciding factor in determining patients' satisfaction with care.
More patients had good vision at eight weeks post refraction at UCH compared to SMEH possibly as a result of regular outcome monitoring of individual surgeons. However an earlier study  carried out in UCH in 2004 before the onset of biometry for patients and cataract outcome monitoring reported good visual outcome in 67.8% of patients after refraction.
Despite slightly better visual outcomes, cheaper surgery and greater staff strength in UCH, the CSR could still not be compared with SMEH. One major difference between these two hospitals is the care received by the patients. This may account for the higher rate of recommendation by patients at SMEH compared with UCH.
In Nigeria where 50% of cataract surgeries are still being done by traditional "couchers",  it is imperative to produce satisfied patients. This may contribute to an increase in the cataract surgical uptake and a reduction in the number of people with avoidable blindness.
Although these two centers have a drive to increase CSR, and therefore had vibrant cataract outreaches programs, SMEH was more successful than UCH in harvesting cataract patients. This is probably because patients were more satisfied in this hospital than those at UCH. Satisfaction of patients with services contributes in no small measure to the overall increase in the CSR, which will lead to improvement in surgical skills, improved training, and ultimately reduce the burden of cataract blindness in Nigeria.
Only patients who were having their first eye surgeries were included to reduce bias. Further studies are needed to address patient satisfaction with general eye care services in Nigeria.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]