PEDIATRICS Vol. 121 No. 6 June 2008, pp. 1111-1118 (doi:10.1542/10.1542/peds.2007-1700)
ARTICLE |
Factors Influencing Parental Satisfaction With Neonatal Intensive Care Among the Families of Moderately Premature Infants
a Department of Society, Human Development, and Health, Harvard School of Public Health, Boston, Massachusetts
b Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
c Kaiser Permanente Medical Care Program, Division of Research, Perinatal Research Unit, Oakland, California
d Department of Pediatrics, Kaiser Permanente Medical Center, Walnut Creek, California
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONAPPENDIX. Satisfaction QuestionsREFERENCES |
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OBJECTIVE. The goal was to examine the factors influencing parental satisfaction with neonatal intensive care for moderately premature infants in 10 hospitals in Massachusetts and California.
METHODS. A total of 677 infants without major anomalies or chromosomal disorders who were born between 30 and 34 weeks of gestation in the participating hospitals and discharged alive were included. Parental satisfaction with neonatal intensive care was ascertained 3 months after discharge by using a previously developed scale of 12 Likert items (scored 1–5), addressing such issues as perceptions regarding the staff providing emotional support, information, or education. The questionnaire, which was administered by telephone, also included parental ratings of child health and reports of subsequent health care use, sociodemographic characteristics, and history of infertility treatment. Data on the prenatal, perinatal, and neonatal course were abstracted from the medical charts, and the factors associated with parental satisfaction were analyzed.
RESULTS. Parental satisfaction with neonatal intensive care varied significantly across the 10 hospitals. The major predictors of satisfaction were sociodemographic characteristics, history of infertility treatment, and especially parental ratings of child health 3 months after discharge, rather than aspects of the perinatal or neonatal course. Controlling for these factors, differences across hospitals were not statistically significant. However, the variance explained by all of the measured factors, including child health rating, was modest (19%).
CONCLUSIONS. Although we included variables across the full spectrum of neonatal intensive care, we found that the major predictor of parental satisfaction with neonatal intensive care was child health at the time of the interview, followed by sociodemographic factors and previous infertility treatment. However, the variance explained was limited, which suggests that research is needed on the factors influencing satisfaction.
Key Words: infant • newborn • infant • premature • patient satisfaction • intensive care units • neonatal
Abbreviations: KCMCP—Kaiser Permanente Medical Care Program • PNR—patient/nurse ratio • SNAP-II—Score for Neonatal Acute Physiology II
An increasingly important element in improving the quality of health care is the goal of making the care patient centered1 or, in the case of children, family centered.2 This element is 1 of the 6 aims identified by the Institute of Medicine in Crossing the Quality Chasm: A New Health System for the 21st Century1 and is incorporated in such formulations of quality health care in pediatrics as the medical home.2 Assessment of the achievement of this goal is most often performed by obtaining patient/parent perceptions of the care, especially satisfaction with care.3 Satisfaction is defined as fulfilling expectations, needs, or desires with regard to health care. Although satisfaction ratings are increasing in use, their interpretation is not straightforward. In a systematic review of the literature, Crow et al4 concluded that satisfaction implies adequate or acceptable, not superior, service and ratings may vary among individuals because individual standards regarding care may differ. In their review of factors influencing parental satisfaction with neonatal intensive care, Connor and Nelson5 argued that parental satisfaction is a function of characteristics of the infants as they enter care and the complete continuum from admission/transport through the acute and maturational phases of care to follow-up care and infant outcomes. Their evidence for the importance of various aspects of care was derived from a variety of studies, but few of those studies referred specifically to neonatal intensive care. The purpose of this study was to examine the factors associated with parental ratings of satisfaction with the health care received by their moderately premature infants treated in 10 NICUs in Massachusetts and California.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONAPPENDIX. Satisfaction QuestionsREFERENCES |
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Study Population and Sampling Strategy
To be eligible for this study, infants needed to be born between 30 and 34 weeks of gestation and discharged alive from 1 of 10 NICUs in California (5 level III nurseries, of which 4 were in the Kaiser Permanente Medical Care Program [KCMCP] and 1 was a fee-for-service hospital with both fee-for-service and KCMCP neonatology services) or Massachusetts (2 level III and 3 level II nurseries affiliated with the Division of Newborn Medicine, Department of Pediatrics, Harvard Medical School). Infants with major anomalies or chromosomal disorders were excluded, and gestational age was determined by using the best obstetrician-defined estimate. Sampling, informed consent, enrollment, and data collection procedures were described elsewhere6 and are summarized here as pertains to this report.
Sampling strategies were designed to achieve a sample of 100 infants at each hospital, distributed evenly across a 15-month enrollment period. Where discharges exceeded the desired number, infants were selected randomly for the study. At 4 sites, the discharge rate proved to be less than anticipated from previous experience, and enrollment was capped at 60 to 65 infants. A total of 867 infants were enrolled in the study. Of those infants, 3-month outcomes were obtained for 677 (78%).
Measures
Parental Satisfaction
Twelve questions regarding parental satisfaction were adapted from the NICU survey instrument developed by the Picker Institute and used in the Baby CareLink project at Beth Israel Deaconess Hospital.7 The questions covered the areas of availability of staff members, emotional support, information, NICU rules, and facilities (see Appendix ). Higher scores indicated greater satisfaction.
Pregnancy and Neonatal Variables
To operationalize the full spectrum of care identified by Connor and Nelson,5 we obtained information on the sociodemographic background of the parents, prenatal/perinatal factors, characteristics of the infant at birth, neonatal complications and interventions, and factors at discharge. The sociodemographic factors included maternal age (in years), race/ethnicity (white, black, Asian, or other), and educational attainment (less than high school graduate, high school graduate, some college or college graduate, or more than college), and family income ($30000 or less, $31000–74999, or $75000 or more). Prenatal/perinatal factors included infertility treatment (yes or no), prenatal steroid treatment (yes or no), delivery through cesarean section (yes or no), intrapartum antibiotic treatment (yes or no), and tocolysis (yes or no).
Infant characteristics at birth included birth weight, gestational age, gender of the child, Score for Neonatal Acute Physiology II (SNAP-II) (a measure of the severity of illness at admission),8 and singleton versus multiple gestation. Neonatal complications included surgical diagnosis, infection, patent ductus arteriosus, air leak, hematologic diagnosis, periventricular leukomalacia, intracranial hemorrhage, retinopathy of prematurity, other central nervous system diagnosis, and oxygen dependency at 36 weeks. These factors were examined singly and as a composite variable of 
1 complication versus none.
Neonatal interventions/observations included head ultrasound results, surfactant administration, hyperalimentation, duration of phototherapy, duration of intravenous administration, use of a central venous line, duration of assisted ventilation, duration of supplemental oxygen treatment, transfusion, indomethacin therapy, receipt (ever) of cardiorespiratory resuscitation, administration of cardiovascular agents, seizure medications, or viral/fungal medications, and duration of xanthine use. These variables were examined separately and in combination, weighted as in the Neonatal Therapeutic Intervention Scoring System.9 The scoring needed to be adapted for interventions for which the duration of use was not recorded; only a weight was given to those variables. In this study group, the mean score was 22 (median: 13; SD: 29; range: 0–308). The distribution of the scores was consistent with the characteristics of the study population, in that most infants required few interventions and those tended to be of low intensity. However, a few infants were quite ill and required much more intensive care.
Characteristics of the infant at discharge included postmenstrual age at discharge and average daily weight gain. The infant-specific factor characterizing the hospital of NICU care was the patient/nurse ratio (PNR). The PNR was calculated by using the census for each day of hospitalization and the number of nurses on each shift. The total PNR was the average of values for each shift over all hospital days. This ratio had a mean of 2.3 (SD: 0.6; range: 0.6–3.5).
The hospital to which the NICU care was attributed was the hospital to which the infant was admitted after birth, designated by an alphabetical letter. Sample sizes for each hospital are not provided, to protect the identity of the hospitals.
Child Outcomes at 3 Months
Parents were asked to rate their infants' health by using the 6-item general health rating index for children 0 to 4 years of age used in the National Health Insurance Experiment.10 The questions are scored such that higher scores indicate better health. In the Rand study,10 the mean rating score was 27.9 (SD: 4.6). In addition, we asked about rehospitalization and emergency department use in the period between discharge and the interview.
Data Collection Methods
Parental satisfaction with NICU care and parental ratings of child health were obtained through telephone interviews at 3 months after discharge. Interviews were conducted in English, Spanish, Mandarin, and Cantonese by trained interviewers at the KCMCP Division of Research (Oakland, CA). Maternal and infant prenatal, perinatal, and neonatal information was abstracted from the medical charts by trained research assistants, directly into laptop computers. The data collection protocol was based on the Kaiser Permanente neonatal minimal data set protocol11 and previous studies.6
Analyses
Because the satisfaction score was a reduced version of that used previously, we assessed the internal consistency by using Cronbach's 
and item-total correlations. Items that seemed not to contribute significantly to the overall score were removed.
Bivariate analyses were conducted by using t statistics, Spearman's correlation coefficient, and analysis of variance. Pairwise testing in the analysis of variance relied on the Tukey-Kramer all-pairwise comparison test. Multivariate models were developed by using multivariate linear regression. All analyses were conducted by using SAS 9.1 (SAS Institute, Cary, NC).
Human Subjects
The 7 institutional review boards with jurisdiction over the 10 participating sites and investigators approved this study. We also obtained institutional review board approval from the Harvard School of Public Health and hospitals not in the study that sent transported patients to the study hospitals.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONAPPENDIX. Satisfaction QuestionsREFERENCES |
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Comparison of Respondents and Nonrespondents at 3 Months
As shown in Table 1, mothers who were not interviewed at 3 months tended to be younger and less likely to have had prenatal steroid treatment or tocolysis in the perinatal period but more likely to have received intrapartum antibiotic treatment. Nonrespondents were more likely to have had singleton births and less likely to be using breast milk at discharge. Their infants averaged greater daily weight gain, compared with those of respondents. The
2 test for differences according to site yielded P = .06, with sites C and D having slightly higher and site E somewhat lower response rate (Table 1). No differences according to birth weight, gestational age, SNAP-II, number of neonatal complications, intervention intensity, or postmenstrual age at discharge were seen. Comparisons according to sociodemographic characteristics were limited to that according to maternal age, because other characteristics were obtained through the interview.
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Parental Satisfaction
Of the 677 mothers who agreed to the 3-month interview, satisfaction scores were obtained for 621. The satisfaction scores first were examined for internal consistency of the items. Three items (questions h to j) did not correlate well with the total score and did not seem relevant to moderately premature infants (eg, such infants would not be categorically eligible for early intervention in either state, so that few parents would have been told about special programs; item i). When these items were eliminated, the overall score had a coefficient
of .89. The mean score for all respondents was 37.6 (SD: 6.4; range: 9–45). The mean value suggested that most parents were satisfied with their care.
Satisfaction According to Site of Care
As shown in Table 2, satisfaction with care varied significantly according to site. Site C had the highest average satisfaction score and site J the lowest. The ranking of sites according to satisfaction did not correlate with response rates. That is, the hospitals with the highest satisfaction scores were not more likely to have higher response rates at 3 months. To assess what factors might influence ratings of satisfaction, we examined the independent variables noted.
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Correlates of Parental Satisfaction
As shown by the distribution of subjects according to demographic factors in Table 3, the study population was largely white, well educated, and of moderate income. In general, satisfaction was slightly higher among more-educated, older, and white mothers but was lower among more-affluent mothers.
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Approximately one third of the study population had undergone previous infertility treatment, and two thirds received prenatal steroid treatment. More than one half underwent delivery through cesarean section and received intrapartum antibiotic treatment. Relatively few underwent any tocolysis. None of these factors affected parental satisfaction.
The infants were born at an average birth weight of 1948 g and gestational age of 33 weeks. The relative acuity of illness at admission was low, as indicated by an average SNAP-II of <6. Slightly less than one half of the infants were from multiple gestations. Approximately one half were male, as expected. Satisfaction was correlated positively with birth weight, the only birth characteristic associated with satisfaction.
Most infants experienced none of the complications listed, and satisfaction was not associated with the number of complications. Intervention intensity was correspondingly low, as noted above, and the overall score was not associated with satisfaction. With regard to specific interventions, a little less than one half of infants received assistance with ventilation, generally for <3 days, approximately one fourth received surfactant, and approximately one fourth required mechanical ventilation. Satisfaction was not associated with specific interventions, with the exception of ever being ventilated. The parents of infants who underwent ventilation were more satisfied than the parents of those who did not (data not shown). In addition, higher satisfaction scores were seen for children who had been transferred in the course of their care.
Infants were discharged at a mean postmenstrual age of 36 weeks, and most were receiving breast milk. The average daily weight gain to discharge was 9.0 ± 18.1 g/d. The average PNR was 2.1 ± 0.5. Of these variables, only average daily weight gain was associated with parental satisfaction; with greater weight gain, satisfaction was lower.
The strongest correlate of parental satisfaction proved to be how the parents rated their child's health at the follow-up interview. With better perceived health of the infant, parental satisfaction was higher. However, this effect was independent of whether the child had been rehospitalized or had had an emergency department visit, because those events did not affect satisfaction scores.
Correlates of Parental Ratings of Health
Because many practices and diagnoses have been shown to vary across hospitals and these variations might affect infant health status, we examined the predictors of the rating of infant health. Significant predictors are listed in Table 4. The maternal rating of child health was not associated with maternal age, mode of delivery, receipt of intrapartum antibiotic treatment or tocolysis, SNAP-II, child gender, transfer, discharge while receiving breast milk, or daily PNR. However, consistent with the score as a reflection of health status, the rating of child health was lower with measures of lower socioeconomic status, indicators of poorer neonatal health such as birth weight, complications and interventions, and more significant health care use after discharge. Differences were also seen among hospitals, with hospital J having the lowest average for child health ratings, compared with hospitals C, D, and I. No other pairwise comparisons among hospitals were significant.
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Multivariate models were calculated with any variable that was associated significantly with satisfaction or health score. In the first multivariate model (model 1), all of the variables except health rating score were entered (Table 5). Of the demographic variables, nonwhite race/ethnicity and lower family income were significant predictors of less satisfaction. In addition, having undergone previous infertility treatment was associated with lower satisfaction. Among the hospitals, satisfaction scores were lower for site J. When the health rating score was added (model 2), it retained its strong association with satisfaction. Lower family income, nonwhite race/ethnicity, and infertility treatment also remained as significant predictors. No hospital coefficients remained significant.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONAPPENDIX. Satisfaction QuestionsREFERENCES |
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The measurement of patient satisfaction has become an integral part of the assessment of health care in the United States. Among the forces fostering this movement are the emphasis on market-oriented health care and consumerism and the notion of patient-centered care.1 In their overview of the dimensions of patient-centered care, Sofaer and Firminger3 listed access to staff members and affordable care, communication and information, courtesy and emotional support, effective care/organization, technical quality, and aspects of the facilities. These dimensions are consistent with those identified by Connor and Nelson5 for neonatal units, with the addition of pain management and follow-up care. Sofaer and Firminger3 also noted the importance of patient expectations in the assessment of the utility of the experience.
We examined satisfaction with NICU care across the spectrum described by Connor and Nelson5 and observed significant variation in satisfaction with care among 10 hospitals, for a relatively homogeneous, low-intensity population. Unexpectedly, the major predictor of satisfaction was the health status of the child at the time of the interview and not indicators of the hospital course, in terms of complications or interventions. Although this result may seem counterintuitive, it is consistent with a body of literature that suggests that a significant predictor of patient/parent satisfaction is the degree to which expectations are met.
Patient evaluation of medical care (satisfaction) reflects the degree to which it meets implicit or explicit requests for specific elements of care. Unmet expectations may occur in the context of perceived vulnerability, direct or vicarious previous experience with the health care system, knowledge derived from a variety of sources, and perceived seriousness of symptoms.12–14 More-positive expectations can drive satisfaction even when outcomes are similar, and patient-reported outcomes and satisfaction may be influenced by physicians' predictions of recovery.14 Satisfaction may not be associated with characteristics of the illness, including concerns or worries about the health problem, but may reflect knowledge about the problem derived from a variety of sources.15
It is not clear what aspect of parental rating of health at 3 months is influencing satisfaction. The idea that this scale is reflecting child health is suggested by the associations with lower socioeconomic status of the parents and indications of physical health, such as birth weight, gestational age, neonatal complications, intensity of neonatal interventions, average daily weight gain, oxygen dependency at 36 weeks, and postdischarge rehospitalization and/or emergency department use. However, we speculate that factors in premature infant behavior other than the health issues we observed may influence parental perceptions. Even late preterm infants may have feeding problems, other regulatory problems, and higher rates of health problems than term infants.6,16,17 It may be the disparity between expectations about their infants and their current experience18,19 that leads parents to be dissatisfied with hospital care. Dissatisfaction with the hospital, even controlling for health status, may indicate a greater communication disjunction concerning appropriate expectations.
The interpretation of our results must take into account certain limitations. A major limitation is the lack of data on the hospitals and their practices. Although a survey of the directors of the NICUs was conducted as part of this project, the focus was primarily on procedures and practices that would lead to variations in clinical management and not on procedures and policies for families. The single measure PNR is an inadequate measure of such procedures and policies. However, the questions in the satisfaction questionnaire addressed these procedures very directly and concretely; therefore, responses seem to reflect parents' experiences.
Although the data are limited, the characteristics of those who did not respond to the survey suggest that they might have been more dissatisfied than those who did. Unless they differed in characteristics from those who did respond to the survey and were less satisfied, however, the cohort attrition should not affect the results. Also, the timing of the assessment might not have been optimal. The 3-month window was selected to provide an opportunity to observe health events that might have occurred as a result of variations in neonatal practices. However, previous studies varied in the effect of timing on satisfaction ratings and found that the timing affected the response rate but not the satisfaction score.20,21 Finally, the homogeneity of the study population might have reduced the variation in satisfaction that might have been seen if the full scope of NICU care was assessed.
In this study, we have assessed parental satisfaction with NICU care for moderately premature infants across the full continuum of care posited by Connor and Nelson.5 We found that outcomes (as measured by parental ratings of the health of the infant at 3 months) made the greatest contribution to parental satisfaction. In contrast to what many clinicians might think, the degree of illness of the infant and the medical response in terms of services had far less impact. However, the amount of variance explained by the variables in this study was quite modest. It should be noted, however, that the relatively limited amount of variance explained is similar to that in other studies14 and a recent study examining the effect of personal and institutional variables, in which the maximum explained in any dimension was 25%,21 and in the same range as estimates for other outcomes such as cost and length of stay.22 These results underscore the importance of assessing parental expectations when using satisfaction to compare the quality of care across different units. They also suggest a needed research agenda. A better understanding of the factors and experiences that lead to an association between parental satisfaction and ratings of child health might guide parental education in the NICU and discharge procedures to ensure better parental adjustment to premature infants.
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APPENDIX. Satisfaction Questions |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONAPPENDIX. Satisfaction QuestionsREFERENCES |
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- The availability of the staff to answer your questions or concerns. By "staff," I mean doctors, nurses, social workers, and other support staff in the NICU.
- The staff's ability to give you answers you could understand when you had important questions about your baby.
- The amount of information you were given about your baby's condition or treatment.
- The emotional support the staff provided.
- The rules about visiting your baby.
- The amount of privacy you and your family had when visiting your baby.
- The teaching you received about caring for your baby at home.
- The help you received in selecting a doctor for your baby to go to after she or he was discharged.
- The information you were given about special programs for premature infants.
- The follow-up telephone call you received from the NICU staff after your baby left the NICU.
- Overall, the way the NICU staff worked together to care for your baby.
- Overall, the health care your baby received in the NICU.
Possible responses were poor, fair, good, very good, excellent, not applicable or not given, or do not know. Parents also were asked whether they would recommend the NICU to other parents, with the possible responses of yes, no, do not know, or refused.
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ACKNOWLEDGMENTS |
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This work was funded by the Agency for Healthcare Research and Quality (grant R01 HS 10131).
In Massachusetts, the Beth Israel Deaconess Medical Center, Brigham and Women's Hospital, Lowell General Hospital, Newton-Wellesley Hospital, and Winchester Hospital participated in the study. The California sites were the Kaiser Foundation hospitals in Hayward, Santa Clara, San Francisco, and Walnut Creek and the Alta Bates Medical Center in Berkeley. We are very grateful for the assistance we received from Dr DeWayne Pursley and Jane Smallcomb, RN, at Beth Israel Deaconess Medical Center; Dr Steven Ringer and Marianne Cummings, RN, at Brigham and Women's Hospital; Dr Mary Blackwell, Dr Kim Chatson, and Mary Beth Foley, RN, at Lowell General Hospital; Dr Richard Wilker and Karen Mueller, RN, at Newton-Wellesley Hospital; and Dr Karen McAlmon and Suzanne Murphy, RN, at Winchester Hospital. We thank Rebecca Roberts, BS, and Chris Morgan, BS, for project support. We thank Drs Gilbert Duritz and Lee Reuben at Alta Bates Medical Center; Dr Jocelyn Alcantara at Kaiser Permanente Hayward Medical Center; Drs James Kantor and Carlos Botas at Kaiser Permanente Medical Center, San Francisco; Dr Stephen Fernbach at Kaiser Permanente Medical Center, Santa Clara; and Dr Allen Fischer at Kaiser Permanente Medical Center, Walnut Creek; for their support and assistance. We are also grateful for the assistance we received from Pamela Bigbee, RN, and Rebecca Mitchell, RN, at the Kaiser Permanente Hayward Medical Center; Pat Keightley, RN, and Nancy Taquino, RN, at the Kaiser Permanente Medical Center, San Francisco; Lisette Santos, RN, and Bernadette Custodio at the Kaiser Permanente Medical Center, Santa Clara; Shirley Dostal, RN, Marilyn Taylor, RN, Josie Franck, RN, Christine Retta, RN, and Noni Ettle, LCSW, at the Kaiser Permanente Medical Center, Walnut Creek; and Katie Tobin, RN, Dr Amarjit Sandhu, Peggy Lindsley, RN, Alison Brooks, RN, MS, Ann Frost, RN, Sue Wittstock, RN, Dr Gail Levine, and Deborah Wilson, RN, NNP. We thank Kim Coleman-Phox, MA, Rachel Warder, Diane Lott-Garcia, Jeanne Holbrook, RN, and Christina Olguin at the Division of Research. We also acknowledge the comments and suggestions from Dr Jochen Profit on an early version of the manuscript.
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FOOTNOTES |
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Accepted Oct 23, 2007.
Address correspondence to Marie C. McCormick, MD, ScD, Department of Society, Human Development, and Health, Harvard School of Public Health, 677 Huntington Ave, Boston, MA 02115. E-mail: mmccormi{at}hsph.harvard.edu
The authors have indicated they have no financial relationships relevant to this article to disclose.
Deceased. 
| What's Known on This Subject Ratings of patient/parent satisfaction with care are used to rate quality. For NICU care, satisfaction is considered to reflect infant characteristics, the full spectrum of care, and infant outcomes.
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| What This Study Adds This report examines the factors predicting parental satisfaction with NICU care for moderately preterm infants from 10 hospitals and finds that few infant characteristics predict satisfaction. The most important predictor is outcome.
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REFERENCES |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONAPPENDIX. Satisfaction QuestionsREFERENCES |
|---|
- Institute of Medicine, Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001
- American Academy of Pediatrics, Medical Home Initiatives for Children With Special Needs Project Advisory Committee. The medical home.
Pediatrics. 2002;110
(1):184
–186
[Abstract/Free Full Text] - Sofaer S, Firminger K. Patient perceptions of the quality of health services. Annu Rev Public Health. 2005;26 :513 –559[CrossRef][Web of Science][Medline]
- Crow R, Gage H, Hampson J, et al. The measurement of satisfaction with healthcare: implications for practice from a systematic review of the literature. Health Technol Assess. 2002;6 (32):1 –244[Medline]
- Conner JM, Nelson EC. Neonatal intensive care: satisfaction measured from a parent's perspective. Pediatrics. 1999;103 (1 suppl E):336 –349[Medline]
- Escobar GJ, McCormick MC, Zupancic JAF, et al. Unstudied infants: outcomes of moderately premature infants in the neonatal intensive care unit.
Arch Dis Child Fetal Neonatal Ed. 2006;91
(4):F238
–F244
[Abstract/Free Full Text] - Gray JE, Safran C, Davis RB, et al. Baby CareLink: using the Internet and telemedicine to improve care for high-risk infants.
Pediatrics. 2000;106
(6):1318
–1324
[Abstract/Free Full Text] - Richardson DK, Corcoran JD, Escobar GJ, Lee SK. SNAP-II and SNAPPE-II: simplified newborn illness severity and mortality risk scores. J Pediatr. 2001;138 (1):92 –100[CrossRef][Web of Science][Medline]
- Gray JE, Richardson DK, McCormick MC, Workman-Daniels K, Goldmann DA. Neonatal Therapeutic Intervention Scoring System: a therapy-based severity-of-illness index.
Pediatrics. 1992;90
(4):561
–567
[Abstract/Free Full Text] - Eisen M, Donald CA, Ware JE, Brook RH. Conceptualization and Measurement of Health for Children in the Health Insurance Study. Santa Monica, CA: Rand Corp; 1980. Publication R-2313-HEW
- Escobar GJ, Fischer A, Kremers R, Usatin MS, Macedo AM, Gardner MN. Rapid retrieval of neonatal outcomes data: the Kaiser Permanente neonatal minimum data set. Qual Manag Health Care. 1997;5 (4):19 –33[Medline]
- Kravitz RL. Measuring patients' expectations and requests.
Ann Intern Med. 2001;134
(9):881
–888
[Abstract/Free Full Text] - Lutz GK, Butzlaff ME, Atlas SJ, Keller RB, Singer DE, Deyo RA. The relation between expectations and outcomes in surgery for sciatica. J Gen Intern Med. 1999;14 (12):740 –744[CrossRef][Web of Science][Medline]
- Like R, Zyzanski SJ. Patient satisfaction with the clinical encounter: social psychological determinants. Soc Sci Med. 1987;24 (4):351 –357[CrossRef][Web of Science][Medline]
- Wang ML, Dorer DJ, Fleming MP, Catlin EA. Clinical outcomes of near-term infants.
Pediatrics. 2004;114
(2):372
–376
[Abstract/Free Full Text] - Tomashek KM, Shapiro-Mendoza CK, Weiss J, et al. Early discharge among late preterm and term infants and risk of neonatal morbidity. Semin Perinatol. 2006;30 (2):61 –68[CrossRef][Web of Science][Medline]
- Escobar GJ, Clark RH, Greene JD. Short-term outcomes of infants born at 35 and 36 weeks of gestation: we need to ask more questions. Semin Perinatol. 2006;30 (1):28 –33[CrossRef][Web of Science][Medline]
- Linder-Pelz S. Toward a theory of patient satisfaction. Soc Sci Med. 1982;16 (5):577 –582[CrossRef][Web of Science][Medline]
- Quintana JM, Gonzalez N, Bilbao A, et al. Predictors of patient satisfaction with hospital health care. BMC Health Serv Res. 2006;6 :102[CrossRef][Medline]
- Saal D, Nuebling M, Husemann Y, Heidegger T. Effect of timing on the response to postal questionnaires concerning satisfaction with anaesthesia care.
Br J Anaesth. 2005;94
(2):206
–210
[Abstract/Free Full Text] - Safran DG, Karp M, Coltin K, et al. Measuring patients' experiences with individual primary care physicians: results of a statewide demonstration project. J Gen Intern Med. 2006;21 (1):13 –21[CrossRef][Web of Science][Medline]
- Shwartz M, Ash AS. Evaluating risk-adjustment models empirically. In: Iezzoni LI, ed. Risk Adjustment for Measuring Health Care Outcomes. 3rd ed. Chicago, IL: Health Administration Press; 2003:231 –273
PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics
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