An unusual cause of lower gastrointestinal bleed in an
uncommon condition

Muhammad Usman Shah; Moarij Amer Qazi; Mobasser Mahmood; Ahsin Manzoor Bhatti

An unusual cause of lower gastrointestinal bleed in an uncommon condition

Muhammad Usman Shah , Moarij Amer Qazi , Mobasser Mahmood , Ahsin Manzoor Bhatti

Syed Shuja Qadri, Rambha Pathak^*, Mukhmohit Singh, SK Ahluwalia, Shveta Saini, PK Garg
Department of Community Medicine, MMIMSR Mullana, Ambala, India

Corresponding Author: Dr. Rambha Pathak; Assistant Professor, Department of Community Medicine, MM Institute of Medical Sciences & Research, Mullana Ambala, India Email: rambha_p@yahoo.com Mobile: +91-9815985227

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Abstract

We present a case of lower gastrointestinal bleeding (LGIB) in a patient with previously diagnosed aortic dissection extending to the superior mesenteric artery (SMA). Ischaemic gut due to thrombosis of SMA was considered. However, exploratory laparotomy carried out revealed healthy gut with bleeding jejunal diverticula, excision of which relieved the symptoms. Jejunal diverticula, although rare, must be considered among all the possible causes of LGIB.

Key Words

Patient satisfaction, Hospital services, Quality care

Introduction

Health care quality is a global issue. The health care industry is undergoing a rapid transformation to meet the ever-increasing needs and demands of its patient population. Hospitals are shifting from viewing patients as uneducated and with little health care choice, to recognizing that the educated consumer has many service demands and health care choices available. Respect for patient’s needs and wishes, is central to any humane health care system.1 Quality of health services was traditionally based on professional practice standards, however over the last decade; patient’s perception about healthcare has been predominantly accepted as an important indicator for measuring quality of health care and a critical component of performance improvement and clinical effectiveness.2

Patient satisfaction has been defined as the degree of congruency between a patient’s expectations of ideal care and his /her perception of the real care (s) he receives.3 It is a multidimensional aspect, represents a vital key marker for the quality of health care delivery and this is an internationally accepted factor which needs to be studied repeatedly for smooth functioning of the health care systems.4 It has been an important issue for health care managers. The client here does not technically assess their own health status after receiving care but the degree of satisfaction with the services delivered.

Various dimensions of patient satisfaction have been identified, ranging from admission to discharge services, as well as from medical care to interpersonal communication. Well recognized criteria include responsiveness, communication, attitude, clinical skill, comforting skill, amenities, food services, etc. It has also been reported that the interpersonal and technical skills of health care provider are two unique dimensions involved in patient assessment of hospital care.5 Better appreciation of the factors pertaining to client satisfaction would result in implementation of custom made programs according to the requirements of the patients, as perceived by patients and service providers.6

Following increased levels of competition and the emphasis on consumerism, patient satisfaction has become an important measurement for monitoring health care performance of health plans. Patient is the best judge since (s) he accurately assesses and provides inputs which can help in the overall improvement of quality health care provision through the rectification of the system weaknesses by the concerned authorities.7

Many previous studies have developed and applied patient satisfaction as a quality improvement tool for health care providers. Thus, patient satisfaction is an important issue both for evaluation and improvement of healthcare services.8 Keeping this in view, the present study was conducted to assess patient satisfaction with services provided in a tertiary care hospital situated in rural part of Northern India (Haryana).

Material and Methods

Setting and study design

This was a cross sectional study conducted in a tertiary care centre situated in the rural part of northern India. The hospital is a centre for undergraduate and postgraduate medical teaching and has an operational strength of 700 beds. The hospital has 17 departments and provides outpatient consultations and inpatient services to patients presenting to the hospital from other levels of care or on self referral. Patients are mainly seen in the General Outpatient Department, Specialty clinics, Emergency Pediatric Unit and Accident and Emergency unit. It receives patients from within Haryana, and the neighboring states of India (Uttar Pradesh, Himachal, Punjab, and Chandigarh). The majority of patients are indigenous Hindu, although the Muslim and Sikh ethnic groups also constitute a substantial proportion of the clientele. A mixed occupational background individuals as farmers, traders, service class and students avail the super-specialty health care facility.

Sample size and data collection

The study was carried out between January 2011 and June 2011. On the basis of previous studies of patient satisfaction and quality of care9 and using an appropriate statistical formula for estimating minimum sample size in descriptive health studies [n=Z pq/d], a sample size of 440 was calculated to detect level of satisfaction among the study participants. The prevalence used for sample size calculation was 80%. The sample size was inflated by 10% to take care of non-response, incomplete responses and refusals. Patients between the ages of 18 and 80 years attending the outpatient department (OPD) and admitted in various specialties of indoor patient departments (IPD) were included in the study. However, patients referred or advised for or admitted to the Intensive care unit / cardiac care unit / emergency with conditions related to psychiatry or maternity and those with severe acute or chronic illness were excluded from the study since these were considered to be exceptional circumstances.

Thus a total of 450 patients were enrolled for the study. A multistage sampling technique was used to select study population. In the first stage seven clinical departments [Surgery, Obstetrics & Gynecology, Pediatrics, Ophthalmology, Family Medicine, Medicine and Otorhinolaryngology] were selected using balloting. In the second stage, a stratified sampling technique with proportionate allocation was used to select 70, 82, 66, 56, 84, 58 and 34 patients from these respective departments. Finally, systematic sampling technique was used to select respondents from among out patients and inpatients in the sampled clinical departments. Every 5th patient attending the OPD and IPD was taken for the study purpose.

Questionnaire

A semi -structured questionnaire was designed to examine several aspect of hospital care. Questions to be included in the instrument were devised on the basis of a literature review and in depth interviews of the patients attending the hospital. The questionnaire was standardized by a small scaled pilot test on 50 patients. It is comprised of 40 items which measures seven core dimension of patient satisfaction- accessibility of health care facility, perception of waiting time, availability of basic amenities, satisfaction with cost of services, relationship between patient and health providers, availability of laboratory, radiological and pharmacy facilities, information and communication. It also contained questions on socio demographic characteristics of the respondents. The questionnaire consisted of five points Likert scale items, with 1 and 5 indicating the lowest and highest levels of satisfaction, respectively. Patients indicated their level of satisfaction by selecting responses ranging from poor=1, fair=2, good=3, very good=4 and excellent=5. Those who chose poor and fair were considered dissatisfied while those who selected good, very good and excellent were considered satisfied. Patients were also asked if they had specific complaints or recommendations regarding their encounter in the hospital. The prescribing doctor and the supporting staff were largely kept unaware of the survey, except in unavoidable circumstances, to avoid the bias in their behavior with the patient.

The questionnaire was administered by trained individuals after obtaining verbal consent from all subjects. In order to maintain complete confidentiality no names were recorded on the questionnaire. Prior approval of the ethical board was obtained before beginning the survey. Outpatients were interviewed during their exit from the clinics while inpatients were interviewed in the wards.

Analysis

The surveyed questionnaires were collected and coded in a MS Excel database and analyzed by using the SPSS statistical package, version 17.0. Descriptive statistics were performed on the sociodemographic data, and Pearson’s chi-square test was used to examine the relationship between satisfaction with health services, behavior of doctor and other staff, satisfaction with clinic services and satisfaction with pharmacy services and others. Furthermore, stepwise nominal regression model was used to identify the predictors of satisfaction with health care services.

Results

A total of 450 patients attending the various indoor and outdoor departments were included in the study. The mean age of the respondents came out to be 39 years. Out of total, 66.4% of the study population comprised of males. Over 87% of the respondents were more than 30 years old. Majority of the respondents (58.9%) were Hindus belonging to rural areas. 53.55% were employed while the rest were students, housewives, or were retired. Majority of the respondents (44%) were illiterate. Most of the respondents (87.2%) were married. A good number of respondents belonged to the lower socioeconomic status. (Table-1)

When asked about availability of doctors, 62% of the respondents attending OPDs did not report any problem related to it but 76% of them were dissatisfied with timings of the hospital as OPD was open only from 9 AM to 2 PM. Out of total, 46% reported that only junior doctors were available in the emergency department which is only option available to the patient for half of the day and whole of the night. The level of satisfaction regarding availability of doctors was lower (46%) in admitted patient.

In accord with practices in all health facilities, people coming to hospital registered and waited for their turn for consultation. The proportion of respondents indicating that waiting time was excellent, very good and good were 18%, 32% and 20% respectively. Most patients had to wait for 15-30 minute to be called into the consultation room. 32.4% of the patients said that they did not have to wait, but were called instantly.

When assessing the respondents satisfaction with the attitude of health care providers they were asked to indicate if the physician / doctors were courteous, listened to their complains, took enough time and explained what they wanted to know and gave them good advice and treatment. In this aspect of care 66.8% of respondents were satisfied with doctors (outdoor-86.6% and indoor-46.8% respectively) whereas 33.2% of respondents were dissatisfied (more in indoor respondents -53.5%). (Table 2)

On asking the respondents about the attitude and behavior regarding other staff members, it was seen that 50.0%, 59%, 60% and 45% were satisfied regarding behaviour of registration clerk, supporting staff, pharmacist and nurses. More (55%) of patients were dissatisfied with behaviour of nurses than any other health care staff. Still, for further information on the behavior pattern regression analysis was done to compute the effect of behavior of each of the health care provider on the overall satisfaction grading by the respondents. The association between the relationship with other health care providers and overall client satisfaction also yielded statistically significant results. (Table2)

Concerning the infrastructure and basic facilities at the hospital, it was observed that the overall adequacy of these facilities was 71.7%. Most of the respondents (97.4%) were satisfied with parking facilities while 32.5% complained that water coolers were not working and areas where drinking water facility was available were not clean. This was preventing patients from using it. On assessing the availability of other parameters such as lighting, fans, seating facility and general cleanliness, it was seen that the level of satisfaction varied in respect to the services obtained (92%, 78.5%, 86.5%, 94% and 74.5% respectively).

84% of the participants identified accessibility to the hospital as the commonest problem. 45% had to walk for 1-2 kms or wait for half an hour to one hour for getting any mode of transport to reach the hospital. 68% were of the opinion that the road connecting hospital to highway was also not properly maintained. Out of the total respondents 35.5% were of view that hospital toilets were not maintained and 18.25% felt food and canteen facilities required upliftment. Also 16% respondents found it difficult to find the way to various departments owing to lack of signboards in the hospital building. Overall, the study reports that 28.1% individuals were dissatisfied with availability of basic amenities in the hospital. (Table-3)

The degree of satisfaction and dissatisfaction at the various service windows i.e. pharmacy stores, X ray/USG, laboratory and health record office of the hospital was also assessed (Table 4). Majority of the respondents (73.85%) were satisfied with pharmacy. As far as availability and quality of drugs was concerned the respondents showed a higher level of satisfaction (72%) in contrast to the cost of drugs which showed a relatively higher level of dissatisfaction (43.3%).

20.04% of the patients complained about services obtained from the Radiology Department. They were of the opinion that though hospital had most of the advanced equipments in the department but many of those were either not working or the technicians were not available to operate them. The most frequent complaint (36.1%) included cost for the radiological investigations done in the department followed by prolonged waiting time (24.4%).

Microbiological and Pathological laboratory services were somewhat satisfactory as only 15.77% were not satisfied with service level. But most of the patients were unsatisfied with biochemistry laboratory services as facilities for advanced biochemical investigations (PCR, antibody detection techniques e.t.c) were not available in the department. 46% were referred to other private facilities for investigations. 29.11% reported problem with timely delivery of investigation reports, while another 22% had complaint regarding the expenses incurred for the pathological and biochemical laboratory investigations.

On assessing the dissatisfaction regarding missing of reports only 4.44% and 9% had reported the problem from laboratory and radiology department respectively. Overall dissatisfaction level in relation to record keeping was reported to a level of 5.5%.

Overall satisfaction with services

It was seen that 80.9%, 79.3%, 70.9% and 56.8% of the respondents were satisfied with information and support, organization of care, availability of general basic facilities and doctor-patient relationship. However there was high level of dissatisfaction (84%) as far as accessibility of health care services was concerned. To assess the overall satisfaction, grades: - excellent, very good and good were pooled across and it showed a high proportion of respondents (79.1%) were satisfied with the health care services received from the hospital while only 20.9% were dissatisfied. The overall satisfaction level was higher (86%) in patients attending outdoor than indoor patients (73%). Level of satisfaction was significantly associated with background (p=.0032), level of education (p=.023) and socioeconomic status (p=.016) of the participants. Level of satisfaction was significantly higher in respondents who were illiterate, from low socioeconomic status and rural background.

Discussion

The present study attempted to assess the satisfaction of the patients with various aspects of health care in a tertiary care hospital of district Ambala. The results of the study indicate that most of the respondents interviewed were satisfied with the services they received. Very few similar studies have been done and therefore we lack the data for comparison. Yet, the findings of the survey are quite helpful if they are transformed into actions for improving the quality of health care. However, the high satisfaction must be put into the context of the tertiary care centre, being a referral hospital, which receives patients who have often being shunted around between lower health facilities and attended by auxiliaries and general practitioners.

Measuring patient satisfaction has many purposes, but there are three prominent reasons to do so. Such interviews help to evaluate health care services from the patient’s point of view, facilitate the identification of problem areas and help generate ideas towards resolving these problems. Despite a pretty good level of patient satisfaction, a small, but by no means insignificant, proportion of patients expressed dissatisfaction. The fact that patients expressed dissatisfaction with the services indicates that hospital administration needs to do more in the drive towards improving services.

The overall satisfaction of patients with services received from this tertiary care institute came out to be (79.3%) which is similar to the figures reported by SA Deva et al.10 in Kashmir (80%), Kumari et al.9 in lucknow, (81.6%) and Qureshi et al.11 in Kashmir (72%) whereas it is lower than as reported by Bhattacharya et al (88%)12, SK Jawhar et al.13 in India (90-95%) and Ofili and colleagues (83%)14 in Benin city but higher than those reported from Mahapatra et al.15 in Andra Pradesh (63%). Apart from variations in the way services are delivered, differences in study population and hence patient’s expectations could affect satisfaction levels. The later could also be affected by socio cultural differences and variations in levels of literacy. The cultural milieu and relatively lower level of literacy of our catchment population could have altered the level of satisfaction. In addition, variation in methodology and timing of the study could explain some of the differences. This calls for caution for comparing our findings with previous studies.

The satisfaction regarding listening of complaints and behavior of doctor and paramedical staff was around 60% which is similar than as reported by kersnik et al.16, 2002 (55.3%) whereas it was less as reported by Kumari et al.9, 2009 (73%). The dis-satisfied percentage had different view of doctors and health care providers. 80% of them felt that doctors have no time to discuss with patients or listen to them patiently. The fact for this dissatisfaction could be attributed to the increasing loads of the patients.

The present study found 35.5% of the respondents were dissatisfied by the toilet facilities in the hospital building and the similar results were found in a study by Srilata17 and Persak et al.18 2004, who showed lowest level of satisfaction regarding toilets (3.52%).In another study by Aleena et al.19 reported a higher level of dissatisfaction (80%).

A high proportion of patients were dissatisfied with accessibility of the hospital. This is in concordance with findings from other studies where fewer patients were satisfied with ease of accessing care as exemplified by 56% in Benin City by Ofili and colleagues.14

In the current study it was seen that 66.8%, 50.0%, 59%, 60% and 45% were satisfied regarding behaviour of the doctor, registration clerk, supporting staff, pharmacist and nurses and the results were less than in a study by Sultana et al.20, Pakistan, 2010 (95.5%, 94.5% and 93.3%). On the other hand a study conducted by Ariba et al.21 in 2007 in a Nigerian teaching hospital, found that most of the respondents (38.8%) were displeased with the overall quality and attitude of the health care providers.

Our study shows a high level of dissatisfaction (18.25%) regarding canteen/food facilities, the results of which were also found to be consistent with a study by Aleena et al (18%).19 This could be explainable by the fact that increasing modern era demands and awareness of the health care seekers push the medical care providers to deliver quality medical care in package with quality hospitality and related facilities to solace them.

Limitations

The responses of patients depend upon their socio-economic profile, personality and their perceptions; some may be satisfied with average services, while other may be dissatisfied even with the best. In the present study, most of the respondents belonged to rural areas and middle or low socioeconomic class. Henceforth, it implies caution while comparing results from such a survey wherein the outcome is largely associated with the socio-demographic profile of the study population. The study was conducted at a tertiary care centre only but the level of patient satisfaction with different types of health providers could have given more insight into various aspects of factors related to patient satisfaction. This could not be done due to paucity of the resources.

Conclusion

Overall the study showed a moderate level of satisfaction of patients with services obtained from this tertiary care centre. We have discovered a number of potential barriers and facilitators that may influence in patient satisfaction in the northern India. Accessibility could be improved by running buses on paid basis. Cleanliness should be given top priority and areas with drinking water facility should be specifically maintained properly. Certain improvements are also needed in the waiting area by making it informative and comfortable Hospital administration should ensure that all the equipments are working properly and well maintained. The fact that some patients expressed dissatisfaction with the services indicates that health care providers need to do more in the drive towards improving service windows in order to improve efficiency, minimize patient waiting times and provide for patient comfort. Periodic patient satisfaction survey should be institutionalized to provide feedback for continuous quality improvement.

Conflict of Interest

None declared

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