Patient Satisfaction with Wait Times at an Emergency

Ophthalmology On-Call Service

Brian J. Chan, MD,* Joshua Barbosa, BHSc,*,† Prima Moinul, MD,* Nirojini Sivachandran, MD,*
Laura Donaldson, MD,* Lily Zhao, MD,* Sarah J. Mullen, MD,*
Christopher R. McLaughlin, MD,* Varun Chaudhary, MD, FRCSC*
ABSTRACT ●
Objective: To assess patient satisfaction with emergency ophthalmology care and determine the effect provision of anticipated
appointment wait time has on scores.
Design: Single-centre, randomized control trial.
Participants: Fifty patients triaged at the Hamilton Regional Eye Institute (HREI) from November 2015 to July 2016.
Methods: Fifty patients triaged for next-day appointments at the HREI were randomly assigned to receive standard-of-care
preappointment information or standard-of-care information in addition to an estimated appointment wait time. Patient satisfaction
with care was assessed postvisit using the modified Judgements of Hospital Quality Questionnaire (JHQQ). In determining how
informing patients of typical wait times influenced satisfaction, the Mann-Whitney U test was performed. As secondary study
outcomes, we sought to determine patient satisfaction with the intervention material using the Fisher exact test and the effect that
wait time, age, sex, education, mobility, and number of health care providers seen had on satisfaction scores using logistic
regression analysis.
Results: The median JHQQ response was “very good” (4/5) and between “very good” and “excellent” (4.5/5) in the intervention and
control arms, respectively. There was no difference in patient satisfaction between the cohorts (Mann-Whitney U ¼ 297.00, p ¼
0.964). Logistic regression analysis demonstrated that wait times influenced patient satisfaction (OR ¼ 0.919, 95% CI 0.864–
0.978, p ¼ 0.008). Of the intervention arm patients, 92.0% (N ¼ 23) found the preappointment information useful, whereas only
12.5% (N ¼ 3) of the control cohort patients noted the same (p o 0.001).
Conclusion: Provision of anticipated wait time information to patients in an emergency on-call ophthalmology clinic did not influence
satisfaction with care as captured by the JHQQ.

Performance-monitoring frameworks (PMFs) have
increasingly been adopted by the health service sector in
an attempt to improve efficacy and efficiency of care.1,2 In
Ontario, a prominent PMF is the quality-based procedures
(QBP) system. Here, expert advisory panels develop
practice recommendations for a given procedure and
outline indicators to monitor quality improvements in a
modified version of the Balanced Scorecard (BSC) struc-
ture initially proposed by Kaplan and Norton.3 Reim-
bursement has historically been tied to the quality
indicators in an attempt to drive systemwide
improvements.
Appropriate quality indicators and metrics that suffi-
ciently discriminate patient satisfaction are salient issues
for the QBPs. The current QBPs for ophthalmic care
emphasize patient satisfaction and strive to place “the
patient/user at the center of the care delivery” and include
“patients’ values, preferences and expressed needs in the
care they receive.”4 Patient satisfaction, however, is a
complex outcome and is influenced by a plethora of
factors. Uncertainty, cultural perceptions, and lack of
perceived control over circumstances appear to modify
satisfaction ratings.5–7 Moreover, the patient satisfaction
metric may diverge from other PMF quality indicators
because higher patient satisfaction scores have been
associated with both higher overall health care expendi-
tures and increased mortality.8 Herein, we sought to assess
the current state of patient satisfaction in an emergency
ophthalmology on-call clinic setting using the modified
Judgements of Hospital Quality Questionnaire (JHQQ)
by Ware. In addition, the effect provision of anticipated
wait times had on satisfaction ratings was evaluated.
METHODS
Study design and eligibility
Patients presenting to the Hamilton Regional Eye
Institute, Hamilton, Ont., for an emergency ophthalmol-
ogy on-call consultation from St. Joseph Hospital Emer-
gency Department and St. Joseph Hospital Urgent Care
Center in Hamilton between November 1, 2015, and July
31, 2016, were asked to participate in this study. Patients
were included in this study if they were 18 years or older at
the time of the appointment, proficient in English, and
both willing and able to give informed consent for study
participation. Potential study participants were excluded if

& 2017 Canadian Ophthalmological Society.

Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jcjo.2017.08.002
ISSN 0008-4182/17

CAN J OPHTHALMOL — VOL. ], NO. ], ] 2017 1

Patient satisfaction in emergency ophthalmology using JHQQ—Chan et al.
they had a mental or physical disability that precluded
accurate survey completion. If a patient presented with
poor vision and was willing to participate in the study, a
masked trained research assistant aided the patient in
completing study documentation. This study received
ethics approval from the local institutional review board
(REB#0498) and adhered to the tenants of the Declara-
tion of Helsinki.
Study participants were randomized to either a control
or intervention cohort. The control cohort received
preappointment information that included the visit time
and date, clinic location, and physician name if known at
the time. This was consistent with the Hamilton Regional
Eye Institute’s standard of practice at the time. The
intervention cohort received identical preappointment
information with the addition of details regarding antici-
pated wait times, a descriptor of a typical patient encoun-
ter at the clinic, and a suggested list of items patients could
bring with them to the appointment should they so
choose. A copy of study intervention material is provided
in Appendix 1. The intervention specifically addressed
uncertainty regarding wait times, explaining the reasons
behind potentially longer-than-expected wait times, and
introduced the concept of possible triaging among
patients at the eye clinic. Randomization was performed
in blocks of 4 with an allocation ratio of 1:1 between study
cohorts. The ophthalmologists evaluating study partici-
pant were blinded to cohort assignment at the time of
evaluation.
After the patient–physician encounter, study partici-
pants were given a copy of the modified JHQQ. The
questionnaire is available for reference in Appendix 2. The
JHQQ is a validated metric9 that assesses patient satisfac-
tion and has historically been applied to an English-
speaking ophthalmic population.6 The JHQQ assesses
satisfaction on using a 5-point Likert response scale, with
response options consisting of “poor,” “fair,” “good,” “very
good,” and “excellent” for most domains.
Statistical analysis
Participant demographic information is summarized as
means and standard deviations for continuous variables or
frequency with associated percentages for categorical
measures. Survey responses were scored on a 5-point
Likert scale, with 1 being the lowest or most disagreeable
score and 5 being the highest or most agreeable score. This
was true of all questions except the final question, which
assessed patient satisfaction on a 3-point scale. We treated
the survey scores as ordinal data. For ordinal data, the
preferred measures of central tendency and dispersion are
the median and interquartile range, respectively. Survey
responses were reported using this convention. To assess
the influence that informing the patient of typical wait
times for an emergency on-call ophthalmology clinic
2 CAN J OPHTHALMOL — VOL. ], NO. ], ] 2017
appointment had on perceived satisfaction as captured
by survey responses, the Mann-Whitney U test was
performed. For all questions, the exact, 2-sided p-value
was calculated, with the standard alpha error of o0.05
considered significant.
As a secondary study outcome, we sought to determine
what effect wait time to see a physician; patient age, sex,
education, and mobility; and number of health care
providers seen at the appointment had on patient satisfac-
tion. The wait time satisfaction response was dichotomized
as scores at or above the 50th percentile and scores below
the 50th percentile. A score at or above the 50th percentile
corresponded to a survey response of “excellent.” To
preserve degrees of freedom, mobility was dichotomized
as no help required or help required, and the number of
health care providers was dichotomized as one provider
seen or more than one provider seen. A forward logistic
regression model was then performed; only those variables
that achieved statistical significance were included in the
model. The odds ratios (ORs) of significant variables with
95% confidence intervals (95% CIs) were calculated and
reported. The p-value of the Hosmer-Lemeshow goodness-
of-fit test was reported for the model. Study participants
were asked to assess their satisfaction with the preappoint-
ment information as either satisfied or not satisfied. The
Fisher exact test was used to compare responses between
intervention and control cohorts.
Analysis was performed on SPSS software (IBM, version
22.0). Post hoc, a histogram of patient wait time satisfac-
tion scores by intervention, control, and all study partic-
ipants was generated on SPSS. If a given participant’s
survey was missing a response to the primary research
question, the entire survey was excluded from analysis.
However, if a response option other than the primary
endpoint was left blank, the survey was still included in
the primary analysis but was excluded in the analysis of the
missing domain.
RESULTS
From November 1, 2015, to July 31, 2016, 50 patients
consented to study participation. One of the 50 patients
failed to provide a survey response to the primary outcome
and was subsequently removed from analysis. The study
cohort consisted almost equally of male (46.9%) and
female (53.1%) participants. The mean age of study
participants was 54.4 ± 18.0 years. Total wait time to
see the doctor upon arrival at the eye clinic averaged 20.5
± 23.6 minutes. Subsequent demographic information is
provided in Table 1. The survey response to question 2,
which reads, “Compared to your expectations, the wait
was poor, fair, good, very good, or excellent,” served as the
dependent variable for the primary research question. The
median response was 4.00 for the intervention cohort and
4.50 for the control cohort, meaning that the median
 Patient satisfaction in emergency ophthalmology using JHQQ—Chan et al.

Table 1—Patient demographics

Variable Letter (N ¼ 25) Control (N ¼ 24) All (N ¼ 49)

Sex
Male, n (%) 12 (48.0) 11 (45.8) 23 (46.9)
Female, n (%) 13 (52.0) 13 (54.2) 26 (53.1)
First visit to clinic
Yes, n (%) 13 (52.0) 16 (66.7) 29 (59.2)
Education
Did not complete high school, n (%) 4 (16.0) 2 (8.3) 6 (12.2)
High school, n (%) 3 (12.0) 7 (29.2) 10 (20.4)
College or university, n (%) 15 (60.0) 11 (45.8) 26 (53.1)
PhD or masters, n (%) 0 (0.0) 2 (8.3) 2 (4.1)
Choose not to respond, n (%) 3 (12.0) 2 (8.3) 5 (10.2)
Severity of eye condition
Minor, n (%) 7 (28.0) 3 (12.5) 10 (20.4)
Moderate, n (%) 8 (32.0) 12 (50.0) 20 (40.8)
Serious, n (%) 10 (40.0) 8 (33.3) 18 (36.7)
Missing, n (%) 0 (0.0) 1 (4.2) 1 (2.0)
Assistance with mobility
A lot of help required, n (%) 1 (4.0) 0 (0.0) 1 (2.0)
Quite a bit of help required, n (%) 0 (0.0) 1 (4.2) 1 (2.0)
Some help required, n (%) 0 (0.0) 1 (4.2) 1 (2.0)
A little help required, n (%) 3 (12.0) 1 (4.2) 4 (8.2)
No help required, n (%) 21 (84.0) 21 (87.5) 42 (85.7)
Patient encounter with healthcare providers while at clinic visit
One doctor only, n (%) 16 (64.0) 16 (66.7) 32 (65.3)
2 or more doctors, n (%) 8 (32.0) 7 (29.2) 15 (30.6)
One doctor and a photographer, n (%) 1 (4.0) 1 (4.2) 2 (4.1)
Dilating eye drops
Not given during the appointment, n (%) 3 (12.0) 5 (20.8) 8 (16.3)
Drops given before seeing doctor, n (%) 4 (16.0) 4 (16.7) 8 (16.3)
Drops given after seeing doctor, n (%) 18 (72.0) 14 (58.3) 32 (65.3)
Missing, n (%) 0 (0.0) 1 (4.2) 1 (2.0)
Age (mean ± SD), years 58.2 ± 20.0 50.5 ± 15.2 54.4 ± 18.0
Wait time before being called into the clinic room (mean ± SD), minutes 14.7 ± 22.8 13.8 ± 16.3 14.2 ± 19.5
Wait time in clinic room waiting for the doctor (mean ± SD), minutes 8.1 ± 11.0 4.5 ± 4.8 6.3 ± 8.5
Total time waiting for the doctor (mean ± SD), minutes 22.8 ± 28.6 18.3 ± 18.1 20.5 ± 23.6

response was between “very good” and “excellent.” The DISCUSSION

25th and 75th percentiles for both intervention and
control cohorts were 4.00 and 5.00, respectively. As
captured in Figure 1, the response distribution was highly
skewed for all respondents, but the distributions appeared
relatively uniform across study arms. This is noteworthy
because the Mann-Whitney U test assumes a similar,
although not necessarily normal, distribution. There was
no difference in satisfaction between those individuals who
were given information on eye clinic wait times and
those who were not (Mann-Whitney U ¼ 297.00,
p ¼ 0.964); neither were there any significant differences
in satisfaction scores observed for all other survey
responses (see Table 2).
When evaluating the effect of age, sex, wait time,
education, mobility, and number of health care providers
seen at appointment on patient wait time satisfaction, only
wait time to see the physician was statistically significant
(OR ¼ 0.919, 95% CI 0.864–0.978, p ¼ 0.008). The
Hosmer-Lemeshow goodness-of-fit test of the logistic
regression was 0.089, suggesting that the model was a
good fit. Of the intervention group participants, 92.0%
(N ¼ 23) found the preappointment information regard-
ing wait times and visit details useful, whereas only 12.5%
(N ¼ 3) of the control cohort patients noted the same
(p o 0.001).
Patient-centred care and individual autonomy are
mainstays of medical practice in Canada. Concerted efforts
to involve patient feedback in clinical decision making
reflect these deeply held values. For this reason, ophthal-
mology QBPs involve assessing patient satisfaction with
care.4 To date, there has been a paucity of studies
evaluating patient satisfaction with emergency ophthal-
mology care in a Canadian cohort. This study sought to
address that knowledge gap.
The median patient satisfaction score was “very good”
(4/5) for the intervention cohort that received preappoint-
ment approximate wait time information and “very good”
to “excellent” (4.5/5) for the control cohort. Thus, the
provision of interventional information pertaining to
anticipated wait times did not influence patient satisfac-
tion as captured by the JHQQ (Mann-Whitney U ¼
297.00, p ¼ 0.964). Regression analysis demonstrated that
physical wait times influenced patient satisfaction (OR ¼
0.919, 95% CI 0.864–0.978, p ¼ 0.008). For every
additional minute spent waiting to see a doctor, the
likelihood that a patient would give a satisfaction score
in the top 50th percentile was 0.919. This means that a
given patient was less likely to score his or her satisfaction
as “excellent” as time to see the doctor increased—a

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Patient satisfaction in emergency ophthalmology using JHQQ—Chan et al.
Patient Wait-Time Satisfaction Intervention(N=25)
Patient Wait-Time Satisfaction All (N=49)
Fig. 1 — Patient Satisfaction with Wait-Times.
finding consistent with previous research.5 Despite there
being no difference in patient satisfaction between the
intervention and control cohorts, intervention patients
reported appreciating the anticipated wait time informa-
tion. Of patients in the intervention group, 92.0% (23/25)
reported that information provided regarding wait times
and visit details was useful. Meanwhile, only 12.5% (3/24)
of control patients reported the same (p o 0.001). The
overall distributions of satisfaction scores were highly
skewed to the left (Fig. 1) in both control and intervention
cohorts, with 85.7% (n ¼ 42) of all study participants
reporting a satisfaction score of either “very good” or
“excellent.”
Thus, although patients reported that having knowledge
of anticipated wait times was useful and that increases in
wait times decreased their satisfaction with care, neither
factor resulted in a statistically meaningful difference in
satisfaction scores between intervention and control
cohorts using the JHQQ. Apparent contradiction in
seemingly corollary proxies for patient satisfaction and
satisfaction with care itself is not a new phenomenon.
Donelan et al. reported high care satisfaction across
patients from 5 nations who described the health care
systems of their individual countries as having significant
4 CAN J OPHTHALMOL — VOL. ], NO. ], ] 2017
Patient Wait -Time Satisfaction control (N=24)
problems.10 Patient satisfaction scores have been demon-
strated to correlate positively with all-cause mortality and
higher health care expenditures.8 It is now known that, in
part, these contradictory findings can be explained by the
fact that the experience a patient has at a given encounter
within a given health care system accounts for only a
fraction of variation in satisfaction scores. In a study of 21
European Union countries, Bleich et al. found that
approximately 10% of all variability in patient satisfaction
scores could be accounted for by patient encounter
experience with the health care system.11 Meanwhile,
other known factors explained some 17.5% of satisfaction
variability, whereas the majority of satisfaction variability
can be attributed to as-yet-unknown determinants.11
Like many measures of patient satisfaction, the JHQQ
uses a Likert scale. These metrics suffer from ceiling and
floor effects, and their discriminatory ability has been
called into question.12,13 The divergence between patient-
reported relevance of anticipated wait time knowledge and
actual wait times satisfaction suggests that the JHQQ scale
itself had poor discriminatory ability in assessing patient
experience with an on-call ophthalmology care system.
This explanation is further corroborated by extensive left
skewing of survey scores in both study cohorts (see Fig. 1).
 Patient satisfaction in emergency ophthalmology using JHQQ—Chan et al.

Table 2—Survey response

Question Letter Control Difference of Medians, Mann-Whitney U, p-value

Q1. Were you given choices, asked what’s important to you, and had your questions answered?
Poor, fair, good, very good, excellent
Median 5.00 4.00 203.00 0.643
25th percentile 4.00 3.50
75th percentile 5.00 5.00
Q2. Compared to your expectations, the wait was
Poor, fair, good, very good, excellent
Median 4.00 4.50 297.00 0.964
25th percentile 4.00 4.00
75th percentile 5.00 5.00
Q3. How clear and complete were explanations about tests, treatments?
Poor, fair, good, very good, excellent
Median 5.00 5.00 268.5 0.461
25th percentile 4.00 4.00
75th percentile 5.00 5.00
Q4. How well the doctor explained how to prepare for procedures/surgery
Poor, fair, good, very good, excellent
Median 5.00 5.00 239.5 1.00
25th percentile 4.00 4.00
75th percentile 5.00 5.00
Q5. Ability of the doctor to make you comfortable and reassure you
Poor, fair, good, very good, excellent
Median 5.00 5.00 288.5 0.876
25th percentile 4.00 4.25
75th percentile 5.00 5.00
Q6. Ability to diagnose problems, thoroughness of exam, skill in treating your conditions, knowledge
Poor, fair, good, very good, excellent
Median 5.00 5.00 277.00 0.660
25th percentile 4.00 4.25
75th percentile 5.00 5.00
Q7. The amount of time doctor spent with you
Poor, fair, good, very good, excellent
Median 5.00 5.00 292.5 0.851
25th percentile 4.00 4.00
75th percentile 5.00 5.00
Q8. Importance of being seen quickly
Don’t know, not at all important, not very important, somewhat important, very important
Median 5.00 5.00 246.50 0.237
25th percentile 4.00 4.00
75th percentile 5.00 5.00
Q9. Friendliness and concern of staff
Don’t know, not at all important, not very important, somewhat important, very important
Median 5.00 5.00 250.50 0.242
25th percentile 4.00 4.00
75th percentile 5.00 5.00
Q10. Importance of comfortable, pleasant clinic
Don’t know, not at all important, not very important, somewhat important, very important
Median 5.00 5.00 278.50 0.673
25th percentile 4.00 4.00
75th percentile 5.00 5.00
Q11. Importance of being seen by specialist or senior eye doctor
Don’t know, not at all important, not very important, somewhat important, very important
Median 5.00 5.00 255.00 0.250
25th percentile 4.50 4.00
75th percentile 5.00 5.00
Q12. Importance of spending a long time with the doctor
Don’t know, not at all important, not very important, somewhat important, very important
Median 4.00 4.00 241.00 0.305
25th percentile 4.00 3.00
75th percentile 5.00 5.00
Q13. There were some things about my visit that could have been better
Strongly agree, somewhat agree, somewhat disagree, strongly disagree, don’t know
Median 4.00 4.00 239.50 0.545
25th percentile 2.00 3.00
75th percentile 4.00 4.00
Q14. The care I received at the hospital was so good I bragged to family and friends
Strongly agree, somewhat agree, somewhat disagree, strongly disagree, don’t know
Median 1.00 2.00 185.50 0.065
25th percentile 1.00 1.00
75th percentile 2.00 3.00
Q15. I was very satisfied with the quality of care provided by the doctors

CAN J OPHTHALMOL — VOL. ], NO. ], ] 2017 5

Patient satisfaction in emergency ophthalmology using JHQQ—Chan et al.
Table 2 (continued )
Question Letter
Don’t know, strongly disagree, somewhat disagree, somewhat agree, strongly agree
Median 5.00
25th percentile 5.00
75th percentile 5.00
Q16. Were you completely satisfied, somewhat satisfied, or not at all satisfied with the hospital visit overall?*
Not at all satisfied, somewhat satisfied, completely satisfied
Median 3.00
25th percentile 3.00
75th percentile 3.00
*Graded on a scale of 3 instead of 5
The high satisfaction of study participants may be
attributable to Bleich’s as-yet-unknown factors. Instead
of factors salient to the provision of care modulating
satisfaction scores, factors innate to the individual may be
responsible.
Study findings should also be interpreted in light of wait
time experienced by the population under investigation
and sample size. Average wait time for study participants
was 20.5 ± 23.6 minutes. Given that this wait time is
consistent with those of other services,14 wait times
experienced by patients in the present study may be
consistent with their preconceived notions of what con-
stitutes a reasonable wait. The study sample size was 50. In
light of the post hoc findings that the JHQQ had limited
discriminatory ability in our ophthalmic population, a
larger sample size is required to establish equivalence of
satisfaction scores between study arms.
Future research exploring patient satisfaction in an
emergency ophthalmology on-call service clinic should
seek to evaluate the discriminatory ability of the scale
under investigation. Other disciplines have found that
scales with a lower number of response categories have
poorer validity, reliability, and discrimination power than
scales with more response categories.15 A wider scale may,
in part, overcome the poor discriminatory ability of the
JHQQ scale in this investigation. As patient satisfaction
metrics increasingly play a relevant role in the provision of
care and systemic changes on an administrative level, it is
paramount that outcome indicators reflect the intended
construct they are designed to measure in a valid and
discriminatory manner.
Limitations
This was a single-centre study at an academic ophthal-
mology clinic. Results may not be generalizable to non-
teaching sites.
CONCLUSIONS
No study to date has sought to determine the extent to
which providing a Canadian cohort of patients with
expected wait times a priori influences emergency oph-
thalmology care satisfaction. Our study found that 85.7%
6 CAN J OPHTHALMOL — VOL. ], NO. ], ] 2017
Control Difference of Medians, Mann-Whitney U, p-value
5.00 267.0 0.616
5.00
5.00
3.00 163.50 0.858
3.00
3.00
(n ¼ 42) of survey respondents scored their satisfaction
with wait times as “very good” or “excellent.” There was
no detected difference in satisfaction with care between
patients who received anticipated wait time information
and those who did not, despite there being a difference in
the proportion of patients who found the preappointment
information useful. This may be explained, in part, by the
fact that the patient satisfaction metric used has limited
discriminatory ability in our population. Although pre-
appointment information on estimated appointment wait
time had little effect on patient satisfaction with the
ophthalmic visit, 92.0% of patients reported that the
information was useful, suggesting that the material may
have some utility in improving the overall patient experi-
ence. Patient satisfaction with care has many determinants,
and accurately assessing the construct is influenced by
numerous parameters, some of which are intrinsic to the
individual. For this reason, using patient satisfaction
measures in guiding health care system reform needs to
be done with caution.
APPENDIX
Supplementary data
Supplementary data associated with this article can be
found in the online version at http://dx.doi.org/10.1016/j.
jcjo.2017.08.002.
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Footnotes and Disclosure:
The authors have no proprietary or commercial interest in any
materials discussed in this article.This article includes online-only
material. Appendices 1 and 2 can be found on the CJO web site
at http://pubs.nrc-cnrc.gc.ca/cjo/cjo.html. They are linked to this
article in the online contents of the xxx 20xx issue.
From the *Hamilton Regional Eye Institute, Research Unit,
Division of Ophthalmology, Department of Surgery, McMaster
University, Hamilton, Ont; †Wayne State School of Medicine,
Detroit, MI.
Originally received Feb. 20, 2017. Final revision Jul. 8, 2017.
Accepted Aug. 8, 2017.
Correspondence to Joshua Barbosa, BHSc, Division of Oph-
thalmology, Department of Surgery, Hamilton Regional Eye
Institute, 2757 King Street East, Hamilton, Ont. L8G 5E4;
joshuawilliambarbosa@gmail.com
CAN J OPHTHALMOL — VOL. ], NO. ], ] 2017 7