Grogan et al report that their Patient Satisfaction Questionnaire
(PSQ) is a valid and internally reliable tool for assessing patient
satisfaction with primary care services despite the acknowledgement in
their discussion that further research is required to confirm other
aspects of reliability and validity. We feel that their conclusion is
Having recently been involved in the valida...
Having recently been involved in the validation of a postal
questionnaire to assess quality of life in dyspeptic patients we are aware
of the importance of a full evaluation. Our principal concerns with the
published study relate to the lack of information relating to
representativeness and acceptability. The need to demonstrate
acceptability is heightened when questionnaires are to be self-completed.
Response rate data were not provided because of the study design. Response
rates give not only an indication of the acceptability of the questions
used, but also provide information about the acceptability of the concept,
e.g. will patients answer questions about their doctor? Full data sets
were available for 1151/1390 returned questionnaires; 17% of patients
chose not to complete all questions, which may indicate lack of
acceptability of certain items. Acceptability is important for several
1) ethically we should not be utilising tools which may
2) financially we should not use a tool which will not be
returned or where intense effort is required to generate responses
3) in the interests of quality we should not use a tool where differential
acceptability may cause bias.
Before recommending the PSQ as a tool we
would like to see some evidence that acceptability has been demonstrated
in different patient groups.
Other evidence that would be useful before concluding that the
questionnaire should be adopted includes data on reproducibility
(consistency of response) and responsiveness over time. Before using the
questionnaire for repeated audit or to evaluate change in practice, it is
important to confirm that the questionnaire is able to reflect changes in
satisfaction over time.
Whilst the data provided indicates the PSQ to be valid and reliable,
these data must be interpreted with some caution given the lack of
information about sample selection and representativeness. Other issues
pertinent to questionnaire evaluation have not been fully explored and,
given that this is designed to be a self-completion questionnaire for use
in an area in which traditionally patients have not been consulted,
acceptability of the questionnaire and individual questions should be
assessed before concluding that the tool be adopted.
(1) Grogan S, Conner M, Norman P, Willits, Porter I. Validation of a
questionnaire measuring patient satisfaction with general practitioner
services. Quality in Health Care 2000;9:210-15
I agree that every opportunity should be taken to discuss with
patients with diabetes how they can reduce the risk of complications, and
that screening can present one such opportunity. However, because the
effectiveness of this approach has not been tested in an RCT, it was not
included in the review on which this Effective Health Care Bulletin was
The authors point out the effectiveness and need for retinopathy screening and foot care in diabetes. However, as in much of the "screening" literature, the opportunity for intervention during the screening visit is not ephasised.
We know that by achieving an HbA1c of 6% and blood pressure of 130/80 or below, not smoking, and having a hyperlipidaemia treated, most retinopathy could be avoided or delayed (U...
We know that by achieving an HbA1c of 6% and blood pressure of 130/80 or below, not smoking, and having a hyperlipidaemia treated, most retinopathy could be avoided or delayed (UKPDS and DCCT studies). But few patients are aware of this information, fewer still know their own levels, and fewer still know how to achieve such levels. By providing such information, regarding the importance of the levels and finding them out and the need for medical care to reach the required targets, patients would not only be screened but an intervention would have been carried out that would enable many patients to avoid retinopathy and other complications.
Surely it is time to consider that retinopathy screening visits provide the opportunity for vastly improved quality of care, not simply a check up. Indeed, the authors note the success of foot intervention programs in preventing amputations, whilst it is only a very small further step to prevent many diabetic complications by informing patients of the need for good control of their diabetes, and the need to check control with HbA1c and blood pressure checks.
(1) Diabetes Control and Complications Trial (DCCT) Research Group. The Effect of Intensive Treatment of Diabetes on the Development and Progression of Long Term Complication in Insulin-Dependant Diabetes Mellitus. N Engl J Med 1993;329:977-86.
(2) Adler, AI, et al, on behalf of the UK Prospective Diabetes Study Group. Association of systolic blood pressure with macrovascular and microvascular complications of type 2 diabetes (UKPDS 36). BMJ 2000;321:412-19.
(3) Stratton, IM, et al, on behalf of the UK Prospective Diabetes Study Group. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35). BMJ 2000;321:405-12.