- Open Access
Patients' needs, satisfaction, and health related quality of life: Towards a comprehensive model
© Asadi-Lari et al; licensee BioMed Central Ltd. 2004
- Received: 10 May 2004
- Accepted: 29 June 2004
- Published: 29 June 2004
With the publication of its 100th paper, the new open access Journal Health and Quality of Life Outcomes (HQLO), achieves a significant milestone. Launching a journal in this field was not just a challenge with respect to nomenclature,  but also provided a forum for disseminating research which emphasises the unique contributions as well as the inter-relationships among determinants of health, provision of care, and outcomes. So far, prominence (as measured by the number of scientific manuscripts accepted for publication) has been given mainly to the unique contributions of health-related quality of life (HRQL). Other determinants like health needs and satisfaction have sporadically been considered [2–7]. A few additional papers have focused on approaches to detect ill health. In this editorial we would like to explore the relationship between needs, satisfaction and quality of life, identify gaps in the current knowledge base, and encourage future research in these areas.
The World Health Organisation (WHO) in 1948 defined health as a "a state of complete physical, mental, and social well being not merely the absence of disease or infirmity" . While this definition is comprehensive (though rather utopian and ambitious) it clearly indicates what should be the goal of health care intervention. Medical professionals however tend to focus more narrowly on a medical model of health care -a history and examination- followed by investigation and treatment, and finally clinical measures of successful outcome. This approach has been criticised for producing a paternalistic doctor-patient relationship [9, 10]. The relative success of a given health care intervention may differ significantly from a patient perspective vis-à-vis the health care provider's perspective. When this occurs we may ask ourselves; Has a health need been met? Was the care process satisfactory? Has the burden of disease on the patient's quality of life been minimised?
This traditional approach to patient assessment, using clinical and laboratory evaluation, is largely based on observer ratings by health professionals. In the 'medical model', there is an optimal level of functioning and everybody below this could be assumed to suffer ill health. However if these cases are examined carefully, physically-disabled individuals could be found with better quality of life than individuals with optimal functioning, as quality of life refers to a broader concept of health than has traditionally been defined. Modern medicine is slowly beginning to recognise the importance of the perspective of the patient in health care and more investigations are needed to understand the importance of the inter-relationships among health needs, satisfaction, and quality of life.
No consensus seems to be exist about the meaning and concept of 'need' in health, sociology and political literature [11–13]. The ambiguity of the concept of 'needs' and enormity of the task imposed upon practitioners has made the transition from service-led to needs-led much harder ; this vagueness is more apparent when a specific need fails to fall neatly into 'health care' or 'social care' domains, each of which is correlated with the other. Patients with depreciated perception of health status have more social needs , thus meeting social needs may have a direct impact on general health status, which eventually falls into the health domain, perhaps indicating the 'holistic nature' of needs . For example, cancer patients may have a need to better understand their diagnosis and the specific prognosis. However, they may feel guilty about interrupting a busy General Practitioner, and so their needs are not met. This may raise the patient's level of anxiety, which in turn may worsen their emotional health status [6, 15, 16].
Need has a broad spectrum, as the range of human experiences is quite large. The main focus in Wen and Gustafson's paper  was on emotional problems, which despite its importance in perceived HRQL, consists of just one part of the whole concept- there are more subscales. Apparently, the physical scale has been ignored in their models, as are other components of the physical and emotional domains such as quality of sleep, pain and discomfort, social contacts and overall perception of quality of life perception.
'Need' may have a direct effect on satisfaction with care but the direction of the relationship is not clear. For example, patients may have a need for more or better information on some aspect of health. If this need is unmet, it may result in dissatisfaction with services. Alternatively, the better informed patient tends to have higher expectations and so be dissatisfied with care . Both of these scenarios directly influence quality of life .
A current definition of need that has been occasionally published in the National Health Service (NHS) documents indicates that need is the 'capacity to benefit from health care services'. However this definition may be too restrictive as "legitimate" patient needs might be limited to those that can be easily addressed within existing health services and that are considered 'medically necessary', maintaining the medical model which experience suggests has proven unsatisfactory in meeting patient needs.
The pressure of political self-preservation obliges health decision makers to handle health issues with no further increase in global health budget, thus they prefer to manipulate and introduce rather strict and somewhat artificial definitions to justify shortages in resources devoted to the health sector. Unfortunately using a more restrictive definition of 'need' masks the larger amount of genuine health needs of the population. Satisfying all of these desired health needs would, most certainly, require more monetary resources.
The challenge therefore is to identify and target patients' genuine needs. Mobilising resources to meet these needs would certainly avoid further expenses, keep patients satisfied with services, and lead to better quality of life. At the moment, there is no single definition of genuine health needs precisely within the context of public health policy, yet it makes sense to describe this inherently complex issue as 'what patients – and the population as a whole- desire to receive from health care services to improve overall health'. Even this definition may leave practitioners 'open to making judgement based on implicit knowledge, rooted in professional training and values, office culture and assumptive world' .
The modern approach to healthcare seeks to engage the attention of both patients and the public in developing healthcare services and equity of access, but this is not easy to achieve, requiring time, commitment, political support and cultural change to overcome barriers to change [18, 19]. Improvement in selected aspects of health care delivery through quality assurance and outcome assessment has been driven by political expediency. While this is important, a 'bottom up' assessment of patient satisfaction seems preferable if service improvement is to be translated into outcomes meaningful to patients, especially improved quality of life [20, 21].
Satisfaction can be defined as the extent of an individual's experience compared with his or her expectations . Patients' satisfaction is related to the extent to which general health care needs and condition-specific needs are met. Evaluating to what extent patients are satisfied with health services is clinically relevant, as satisfied patients are more likely to comply with treatment , take an active role in their own care , to continue using medical care services and stay within a health provider (where there are some choices) and maintain with a specific system . In addition, health professionals may benefit from satisfaction surveys that identify potential areas for service improvement and health expenditure may be optimised through patient-guided planning and evaluation .
Critics draw attention to the lack of a standard approach to measuring satisfaction and of comparative studies [26, 27] and so the significance of the results of those surveys that do exist in the literature is often ignored. There is less controversy with respect to clinical outcome measures, as health-related quality of life (HRQL) is not only widely regarded as a robust measure of outcome assessment but also is extensively used in several clinical areas [28, 29].
Patient satisfaction is considered by some to be of dubious benefit in facilitating the process of clinical care, as patients have no specific clinical expertise and are -perhaps- readily influenced by non-medical factors; in addition, there are few reports on the reliability of satisfaction surveys [19, 30, 31]. Nevertheless, satisfied patients are more likely to comply with medical treatment and therefore ought to have a better outcome .
Wen and Gustafson  proposed an interesting model of the relationship between health needs, satisfaction with care and quality of life in cancer patients. Their research makes a compelling case for us to reassess the concept of needs assessment and better explore its relationship with outcome measurements, like clinical endpoints, quality of life, and satisfaction with care. The association of health needs and health-related quality of life and also satisfaction with health services have been acknowledged in cancer patients, oral health and cardiac patients in Health and Quality of Life Outcomes [3–5, 7], and a few in other journals .
A comprehensive evaluation of health care should ascertain a patient's expressed health needs . Identification of the needs of individuals (and of the local population), whether through formal needs assessment or some surrogate, is an essential first step towards optimising the use of allocated resources.
The correlation between health needs and health-related quality of life scores might have potential benefits in routine clinical investigation, too, where comprehensive care is targeted. Administration of appropriate HRQL tools in clinics, surgeries or health centres may detect areas of health care needs worthy of health professionals' closer scrutiny. For example, a patient with an impaired Short Form Physical Component Score  or physical dimension (SAQ-Phys) may perhaps be distinguished not only as being at high risk in terms of clinical end points , but also as a vulnerable patient who might have difficulty accessing health care services, for which extra care (such as after hours services or ambulance transport) may be required. Similarly where the satisfaction component in the SAQ yields a lower score, cardiac care teams must be aware of potential shortcomings in the delivery of care and investigate reasons for any dissatisfaction; even provision of information about the nature of cardiovascular disease or its treatment may improve the satisfaction score.
Health-related quality of life tools have the potential to identify specific and general health needs. First, components of disease-specific HRQL tools are more likely to be associated with specific health care needs. Second, measuring HRQL provides outstanding insight towards approaches that may lead to improved quality of care . Third, the administration of 'off-the-shelf' quality of life tools affords a rapid screening test to identify both populations and individuals who warrant a more detailed health needs assessment.
A common critique of quality of life tools in clinical research is that data are 'soft' and less reliable than traditional clinical assessment or physiological measurement. Nevertheless, both generic and disease-specific tools can detect subtle clinical changes quite precisely , especially in cardiac disease . Some are concerned that HRQL tools may not precisely identify the most important problems yet, from an economic and existential point of view, it is conceded that patients' perception has equal validity and legitimacy to that of physicians . English language-based quality of life tools have been tested in a wide range of diseases; overall in clinical practice and in health service research, they have proven so useful that both generic and disease-specific tools have been translated into a variety of other languages for wider application.
Basing health care needs on quality of life scores, however, necessarily incorporates several sources of uncertainty due to factors such as age, sex, social class and individual patient's health status. In addition, quality of life tools may fail to distinguish between health problems and the desire to get professional attention .
Despite the documented relative merits of HRQL tools in various clinical and research settings, these tools may not detect individual health needs in depth. For example, assume a coronary artery patient who has attended in a cardiac rehabilitation session with an impaired emotional score in the MacNew (Quality of Life after Myocardial Infarction) or sleep disorder in the Nottingham Health Profile (NHP) questionnaire: can we distinguish the background reason for this impairment? Is it due to (at worst) heart failure disturbing depth of sleep or simply because the patient has teen-aged grandchildren who afford little time for rest? At this stage, an in-depth needs assessment could reveal the background explanation, which may warrant changes in medical treatment or the provision of social support. Any comprehensive modelling must include both needs and outcome assessment to evaluate the whole process of care in individual and population levels. The optimum approach, perhaps, could be a combination of needs and outcome assessment, preferably at individual levels .
The authors are very grateful in particular to Neil Oldridge for reviewing the manuscript and providing constructive comments and also thankful to James T. Fitzgerald, Chris Haffer and Rosemarie Kobau for their invaluable suggestions.
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