Analysis of Factors Influencing Inpatient and Outpatient Satisfaction with the Chinese Military Health Service

Background Relatively few articles have focused on exploring factors influencing soldiers’ overall satisfaction and differences between inpatients’ and outpatients’ satisfaction, particularly in the Chinese army. Elucidating factors influencing military inpatient and outpatient care separately and analyzing their differences may provide more information for the healthsystem. Methods The Revised China National Health Service Survey questionnaire was used in the survey. The questionnaire included 5 sections and 32 items concerning demographic, inpatient, and outpatient characteristics and perception variables for both inpatients and outpatients. Bivariate and multivariate techniques were used to reveal relationships between satisfaction and the variables assessed. Results Outpatients’ and inpatients’ overall satisfaction rates were 19.0% and 18.5%, respectively. The strongest determinant of outpatients’ satisfaction was satisfaction with doctor’s communication regarding therapeutic regimen followed by length of military service, level of trust in medical staff, and disease severity. Determinants of inpatients’ satisfactionincludedstaff categories, satisfaction with environment, and satisfaction with medical quality. Conclusion The factors influencing military outpatients’ satisfaction differed from those of inpatients. Exploring the causes of satisfaction and dissatisfaction with military health institutions is important in their fulfillment of their responsibility to maintain soldiers’ health.


Introduction
Patients' perception of healthcare isa critical indicator in measuring medical service quality. Medical disputes and violence against Chinese medical personnel often originate from a gap between care provision and patient expectationsconcerning ideal care. [1]Schoenfelderet al. posited thatdetermining the aspects of health services that influence satisfaction is essential in evaluating intervention effectiveness and improvingcarequality. [2]In 2009, The Chinese government started their medical and health service system reform to achieve more affordable national health care. A series of policies were enacted to improve the medical care and service system, public health system and the drug supply system. These factorscould be used to guide the healthsystem revolution. Inthe military health service, efficient improvement of medical care quality couldconsolidate soldiers' fighting capacity. Therefore,exploration of the causes of satisfaction or dissatisfaction with military health institutions is of interest to the Military Ministry of Health in China.
Many researchershaveexplored the structure and factors influencing patient satisfaction and concluded that it is a multidimensional concept containing influential factorssuch as demographic characteristics, belief in care, waiting time,and information provision. Boudreaux argued that patients' subjective experiences, rather than demographic and visit-related factors, are the most consistent determinants of satisfaction. [3] Similarly, Newsome and Wright (1999) reviewed 46 patientsatisfaction studies and found that the factors most commonly related to patient satisfaction were technical competence, interpersonal factors, convenience, costs, and facilities. [4]Bredartet al. posited that patients' judgments regarding care quality are important for satisfactionwiththe technical quality of care, providers' interpersonal skills, coordination, continuity, waiting times, availability, and physical environment. [5,6]Further, efficient doctorpatient communication was emphasized inprevious studies, while the environment was not. Predictors of satisfaction vary according tosetting,and improving key factors could advance healthcarequality and satisfaction.
Although various studieshave focused onexploring factors influencingcivilian satisfaction, relatively few have involvedmilitary personnel,particularlythose in the Chinese army. In china, military patients' options are limited to specific health institutions while the citizen can receive civilian healthcare whenever and wherever they want which is of great difference. The military Soldiers' health is directly related to troops' daily training and fighting capacity.  [11][12][13]. However,they did not focus on differences in satisfaction between inpatients and outpatients. Considerable differencesin treatment measures, standards, time,and environment remain between inpatient and outpatient care. Patientsare concerned about different issueswhen receiving these2types of care. Elucidating factors influencing inpatient and outpatient care separately and analyzing their differences may provide more information for the health system. Military healthcare delivery shouldinclude services designed to map various healthcare needs and preferences. Weaimed to identify significant factors predicting inpatient and outpatient satisfaction inChinese military personnel and their relationship.

Study design and setting
The survey was conducted in army establishments in Guangzhou and Hainan provinces. We recruitedmilitary personnel, ranging from soldiers to retired cadre, using random sampling. Inpatientswere soldierswho had received inpatient care the last yearand spent at least 1 night in hospital, while outpatientswere those who had received outpatientcare within thepreceding fortnight and did not stay in the hospital overnight. Weendeavored to minimize time-related recall bias because of these restrictive conditions. Patients with no cognitive impairment were eligible to participate.
All participants were assured that their responses would remain anonymous, and surveys did not include participant identifiers. Patients received consent forms, and participation was voluntary. For participants who were younger than 18 years of age,we obtained verbal consent for their participation from their guardians. Because the soldiers wererecruited throughout the country, it was almost impossible to obtain written consent during interviews; therefore, we spoke to minors' guardians via telephone and recorded theirverbal consent. However,we were unable to contact the guardians of 8 soldiers who were younger than 18 years of age; therefore, we selected another 8 soldiers whose series numbers are next to them. All participants aged 18 years and older were asked to provide written informed consent prior to the initiation of the study. The study complied with all voluntary principles and was conducted in accordance with the Declaration of Helsinki. Ethical approval was granted by the ethics committee atthe Second Military Medical University. The consent procedure for the research wasalso approved by thisethics committee.

Questionnaire design
Thequestionnaire used to explore soldiers' satisfactionwas based on thatof the China National Health Service Surveyconducted by the China Ministry of Health (now the Health and Family Planning Commission) every 5 years for the past 25 years; results have beenapplied in Chinese health departments at all levels of scientific management and decisionmaking. [14,15]The questionnaire did not include insurance-related questions,asparticipantswere covered by the military healthcare system and were not required to pay for treatment. The questionnaire included5 sections and 32 items concerningdemographic,inpatient,and outpatient characteristics andperception variables for both inpatients and outpatients. In addition, the questionnaire also included a multiple-choice questionabout reasons of dissatisfaction.
Demographic characteristics. This section contained questions regarding sex,ethnicity, age,and length of military service.
Outpatient characteristics. This sectionincluded disease type,severity,illness time,number of days absent, number of treatments, and medical institution.
Inpatient characteristics. This sectionincluded operation situation,number of times hospitalized,time waited for hospitalization, time required to reach the medical institution,medical institution, hospitalization day, and discharge causes.
Perception variables. Thissectionincluded 4 questions concerning medical and service factors such as satisfaction with medical personnel's explanation of conditions,satisfaction with doctor's communication regarding therapeutic regimen, satisfaction with environment, level of trust in medical staff, and overall satisfaction. The inpatient subsection also included satisfaction with medical personnel's attitudes and medical quality, while the outpatient subsectionincluded satisfaction with healthcare information.
Following careful screening, we distributed6,238 questionnaires;6,049were returned. Only 796 questionnaires were completed by participantswho had previously received inpatient or outpatient care, and 73of these were considered invalid. Therefore, we analyzed723 questionnaires including 521 and 248 containingoutpatient and inpatient data, respectively (some participants received both types of care). The Response rate is 12.0%.

Statistical analysis
To simplify the data analysis,continuous variables were recoded into categorical variables. Descriptive statistics and frequencies were analyzed. Bivariate and multivariate techniques were used to reveal relationships between satisfaction and the variables assessed. SPSS 18.0 for windows was used for all analyses. Data regarding sex were discardedprior to analysis, as all but 7 soldiers were male. Overall satisfaction wasabinary variable;therefore,bivariate analysis involved a chi-square test. All associations were considered statistically significant at p<0.05. Due to the limited sample size,bivariate screening was performed to create sparse models with few degrees of freedom. [2]Multivariate analysis involved binarylogistic regression. Factors that were statistically significant in the bivariate analysis were analyzed usingbinary logistic regression to identify significant predictors of military soldiers' satisfactionwith inpatient and outpatient care. In the logistic regression, missing data for the 6perception variables were substituted with average ratingsfor the respective questionnaire items,to ensure the largest possible dataset for multivariate analysis. [2]

Results
The study sample consisted of 521 outpatients and 243 inpatients, all of whom completed the section concerning demographic characteristics. As shown in Table 1, in both inpatients and outpatients, Han was the most prevalent ethnicity, and most patients were aged 21-30years, while those older than 36 years comprised the smallest group. More than half of the soldiers had served in the army for less than 5 years. Most patients originated from middle and eastern regions. Regarding educational levels, in both groups,more than half of the soldiershad attended technical secondary or senior high school,andmanyhad attended university or junior college. Further,mostparticipants were sergeantsor conscripts.
Outpatients' and inpatients' overall satisfaction rateswere 19.0% and 18.5%, respectively. Reasonsfor soldiers' dissatisfactionwere examined in the survey. The main reason for outpatient dissatisfaction was lack of medicine (33.4%), followed by poor service attitude (30.1%) and poor equipment (25.9%). In contrast, the main reason for inpatients' dissatisfaction waspoor service attitude (40.3%), followed by lack of medicine (33.7%) and poor medical technology (32.9%). Table 1 shows the relationship between overall satisfaction and soldiers'demographic characteristics. Age, length of military service, educational level, marital status, and staff category were related to outpatients' overall satisfaction in the bivariate analyses. However,in inpatients, only marital status and staff category were related to overall satisfaction. In outpatients, soldiers aged 16-20years and those with 1-5 years of military service reported highersatisfaction levelsrelative tothose of other groups. Outpatientswith high educational levelswereless satisfied relative to other groups. Regarding staff category,the cadetshipcategory in outpatients and the division level or above cadrecategory in inpatientsshowed higher overall satisfactionlevels relative to those of other groups. Interestingly,in both outpatients and inpatients,married soldiers were less satisfied relative to unmarriedsoldiers. Table 2 summarizes the relationships between soldiers' satisfaction andillness status,outpatient care, and perception variables. Influenza, physical pain,disease severity,illness duration, medical institution, and subjective feeling influenced overall satisfaction. Suffering physical painreduced overall satisfaction, while patients with influenza reported higher satisfaction levels. Patients withmild diseasesor illnesses that had lasted for less than a fortnight reported higher satisfaction levels relative to those of other groups. "Receiving clinical care" is related to higher patient satisfaction rate. Patientswho responded"yes"or "very good"toperception items, such assatisfaction with healthcare information,satisfaction with doctor's communication regarding therapeutic regimen, satisfaction with environment,and level of trust in medical staff,reported higher satisfaction levels relative to those of soldiers who responded "no." Table 3 shows the relationships between inpatientsatisfaction and hospitalization-related factors andperception variables. None of the hospitalization-relatedfactorswere relatedto overall satisfaction. All of the items concerning patients' subjective views of medical care influenced overall satisfaction. Table 4 shows the results of the logistic regression analysis. The strongest determinant of outpatients' overall satisfaction was satisfaction with doctor's communication regarding therapeutic regimen, followed by length of military service, level of trust in medical staff,and disease severity. The determinants of inpatients' overall satisfactionincludedstaff category,satisfaction with environment, and satisfaction with medical quality.

Discussion
Inpatient and outpatient services differed with respect to treatment measures, standards, time, and environment. Outpatient care is a short-term medical service that does not require an overnight stay in hospital or a medical facility. In contrast, inpatient care involvescontinuity of care between patients and medical staff,in which inpatients' perception of the environment and service process is valued. Outpatients' and inpatients' overall satisfaction rateswere19.0% and 18.5%, respectively. The overall satisfaction ratewas lower relative to those reported in other studies, suggesting that the care provided by the Chinese army does not fulfillsoldiers' health needs. The literature review showed that soldiers' overall satisfaction rates in previous studieswereapproximately 90% [16,17],while civilians' satisfaction varied according to setting. Our survey showed that outpatientscomplainedmost about medicine shortages,while inpatients complainedabout the attitudes of medical staff. . From the clinic to the tertiary hospital, the medical resource and Diagnosis and treatment level growth greatly. Clinic means primary medical institutions without meeting the standard of hospital. The primary hospital is the hospitals focuses on the community or the grass-roots units providing the most basic medical service. The secondary hospital is the regional medical centre. The tertiary hospital is a kind of trans-regional hospital which has more medical resource and can provide advanced medical service. The local hospital and others means the hospitals beyond the military medical institutions.
doi:10.1371/journal.pone.0151234.t002 As shown in the logistic regression analysis results,in both outpatients and inpatients,most demographic characteristics, such assex, age,ethnicity, home address, educational level, marital status, and workplace, did not remain significant in the logistic regression analysis. This result is consistent with those of previous studies, which showed that the influence of sociodemographic characteristics on patients' satisfaction wasinconsistent. For example,with respect to education levels,Szycaet al. argued that more highly educated patientsdemonstrated lower expectations and greater satisfaction relative to those who had received less education [18], while Schulmeister et al. held the opposite view [19][20][21][22][23]. However,multivariate analysis identified an association between length of military service and outpatients' overall satisfaction, while staff category influenced inpatients' overall satisfaction. Specifically,soldiers in the regimental or below cadre and sergeant categories reported lower satisfaction levels relative to those of other groups. This phenomenon may have resulted from the considerable gap between soldiers' expectations and the care that they received. Expectation has repeatedly emerged as a fundamental factor in satisfaction expression. [24][25][26][27] Patient satisfaction is related to perception of the benefits of care and the extent to which they meet patients' expectations. Unlike the conscript and cadetship categories,these 2 groups represent military officials who shouldreceivesuperior and more comprehensive healthcare and insurance protection. However,relative to that of other officials, those in the cadre category received healthcare that was only marginally superior to that of soldiers, and grassroots medical institutions cannot meet their needs, causing embarrassment. Consequently, the healthcare and insurance protection received did not meet their expectations, which led to low satisfaction levels. The influence of length of military servicewas similar to that of staff category, which influenced soldiers' perceptions ofmilitary health services. Soldiers achieved higher rank and received more advanced and comprehensive care with longer military service,which also led to higher expectations. Imbalanced health resource allocation is inappropriate and unsustainable and cannot maintain soldiers' health. Additional health resources should be allocated to the grassroots army to improve soldiers' perceptions of the health service. Disease severity wasan influential factorinoverall patient satisfaction. Bredartet al. posited that patients' judgments regarding care quality depend on theirphysical conditions. [5,6]Soldiers with serious diseases were constantlyunhappy, which mayhave led to pain and distrust of medical personnel. In contrast, patients are more familiar with mild diseases, such as influenza, and they demonstrate reasonable expectationsconcerning the disease and optimistic attitudes towards their treatment. These factors are all vital to overall satisfaction. It is worth noting that the medical institution factor was removed from the multivariate analysis. In China, hospitals were categorizedaccording to their functions, equipment, and technology levels. From clinics to tertiary hospitals, medical resources and diagnosis and treatment levelsincreasedconsiderably. Thereare strict medical service rules in place for treatment provided to soldiers, which stipulatethat theyare supposed to receive medical servicesfirst from primary military medical institutionsand then to advanced military hospitals. In some situations, they receive local,rather than military, medical services. The evaluation of medical services is always based on service quality, environment, and equipment. A numberof important factors that influence patient satisfaction, such as surroundings and medical service quality, have been analyzed individually. Therefore, the medical institution factor was eliminated from the multivariate analysis.
It is noteworthy that perception variables exerted a strong influence on overall satisfactionin both inpatients and outpatients. In the literature review, patient satisfaction was associated with decisionmaking, [28] clinicians' communication, [29,30] treatment outcomes, patients' expectations and therapeutic listening. In the present study, military outpatient valued trust and communication with medical staff. Previous studieshave emphasized the importance of communication. [22,29,31]This is congruent with our findings. To some extent, medical treatment is both a product provided by health institutions and a service enjoyed by patients. Consequently, patients valued both care quality and their perceptions regarding outpatient care. Efficient communication between medical personnel and patients increasestheir positivityregardingcare and establishes doctor-patient relationships, which can reduce patients' anxiety. [32][33][34]This relationship was the foundation of patients'trust in medical staff, which couldhave influenced their satisfaction levels. In contrast, patients obtained information concerningtheir diseases and treatment via communication with medical staff, particularly in outpatient care. These results indicated that efficient communication improved patients' perceptions of care andled to high satisfaction ratings. Unfortunately,this communication is neglected inhealthcare settings, evokingviolence and conflictbetween doctors and patients. In addition, patients' trust in medical staff was also a factor influencing outpatients' overall satisfaction. As mentioned previously, patients' trust in medical staff and facilitiesaffects their attitudes and cooperation during treatment. All of these factors could promote patients' recoveryand increase their satisfaction. Medical personnel should enhance communication with soldiers and provide clear treatment information. Most injured soldiers are young and far from their parents. Contact with doctors and nurses is more than a simple medical relationshipand constitutes a spiritual refuge for soldiers who have experienced intensive training and suffered emotional loneliness.
Hospitalization is highly stressful,and the relatedhealth service useconstitutesa long-term experience rather thansingle,short-term event. Multivariate analysis showed that environment and medical treatment quality strongly influencedinpatients' overall satisfaction, which differedsignificantly from that of outpatients. Soldiers are inpatients only when seriously injured, which affects their training and faith. Undoubtedly,healthcare quality is important in patients' perceptionsof care,particularlythose usinginpatient medical services. Traditionally,clinicians' technical competence and mechanical precision are important factors in overall satisfaction assessment. [35]Unlike that of inpatient care, the quality of outpatient care is not observed immediately subsequent totreatment. However,inpatients are discharged only after they have receivedappropriate care and substantial symptom relief. Consequently, inpatient medical treatment quality was a primary factor when patientsappraised themedical services received. Furthermore, environment is also an important factor in soldiers' overall satisfaction. To some extent,the hospital is type of hotel in which patients reside when they are ill. The comfort of their surroundingscould exert a strong influence on patients' emotion and satisfaction, particularly for soldiers. In addition, the health institution's environment reflectsthe scale and capacity of the department, which affects soldiers' perceptionsofhospitalization. Clinics and primary hospitalsshould provide comfortableenvironments, which could offset nervousness and uneasiness in soldiers who are alone in hospital.
The study was subject tosome limitations. Because data werecollected from soldiersinHainan and Guangdong provinces,the representativeness of the findings is limited. Future research should include largersample sizes and armies from different military regions. Moreover,participantswererecruited from troops. If the studyhad been conducted in the hospital immediately following treatment, the sample could have been larger and recall bias minimized. Further, the data source was a self-report questionnaire. An objective scale and diagnosis or treatment information from hospitals' patient databaseswould have been more precise. Despite these limitations,the study provided important information regarding inpatient and outpatient satisfaction in the Chinese army. It was the first study to explore factors influencing Chinese soldiers' satisfaction with care,which couldcontribute to health system reform in China. Soldiers' health was directly related to troops' daily training and fighting capacity. Exploring the causes of satisfaction and dissatisfaction with military health institutions is important in thefulfillmentof their responsibility tomaintain soldiers' health.

Conclusion
Soldiers' health status is directly related to troops' daily training and fighting capacity. Exploring the causes of satisfaction or dissatisfaction with military health institutions is important in ensuring that military health institutions fulfill their responsibility to maintain soldiers' health. Bivariate and multivariate techniques were used to reveal the relationship between satisfaction and assessed variables. Outpatient satisfaction was related to doctor-patient communication concerning the therapeutic regimen, length of military service, levels of trust in medical staff, and the severity of disease. In contrast, inpatient satisfaction was associated with staff category, satisfaction with the environment, and satisfaction with medical quality. Health resource location reform, communication enhancement, and environment improvement are essential in increasing satisfaction.