Emergency Department Patient Satisfaction Research Articles

Navigation Support during Transitions in Care for Persons with Complex Care Needs: A Systematic Review

Persons with complex care needs that arise due to chronic health conditions, serious illness, or social vulnerability are at increased risk of adverse health outcomes during transitions in care. To inform the development of a best practice guideline, a systematic review was conducted to examine the effect that navigation support has during transitions in care on quality of life, emergency department visits, follow-up visits, patient satisfaction, and readmission rates for persons with complex care needs. Eight databases were searched from 2016 to 2023. Studies were appraised using validated tools and data were extracted and presented narratively. The GRADE approach was used to assess the certainty of the evidence. Seventeen studies were included and the majority focused on transitions from hospital to home. Navigation support was provided for one month to one year following a transition. Results weakly indicate that providing navigation support during transitions in care may increase follow-up visits, reduce readmissions within 30 days, and increase patient satisfaction for persons with complex care needs. There were no important differences for quality of life and emergency department visits within 30 days of a transition. The certainty of the evidence was very low. Providing navigation support during transitions in care may improve outcomes for persons with complex needs; however, there remains uncertainty regarding the effectiveness of this intervention and more high-quality research is needed.

The Impact of Involving a Senior Emergency Physician in the Triage Process

BACKGROUND: Emergency Department (ED) overcrowding has been demonstrated in several studies to be associated with undesirable effects such as longer waiting times, reduced patient satisfaction, and, most importantly, poor patient outcomes. Furthermore, long waiting times for walk-ins result in more complaints and patient dissatisfaction than illness management itself, with the majority of issues arising as a result of real and perceived waiting periods before being seen by the doctor. AIM: We set out to investigate whether introducing a senior emergency physician into the triage system would reduce waiting time, door-to-decision time, and door-to-doctor time, as well as increase patient satisfaction across the ED. METHOD: This was an interventional pre-post study that utilised retrospective data to evaluate the effect on ED throughput of triage by senior emergency physicians. We aimed to measure its impact on waiting time, door-to-decision time, and door-to-doctor time, along with ED patient satisfaction. RESULTS: Patient satisfaction, the overall assessment of treatment received during the visit, increased, from 74.975 to 77.425, and the likelihood of patients recommending the ED increased from 71.36 to 75.21. Operational metrics revealed a considerable drop in door-to-decision time (admit or discharge) of 46 minutes and 3 seconds, as well as a 1 minute and 21 second reduction in time from door to doctor (arrival to first provider). CONCLUSION: The mixed results hint at an effective but iterative process of enhancing patient flow and experience in the ED through senior physician triage.

Overlapping otolaryngologic surgery: Safety and efficacy

BackgroundSurgical procedures scheduled staggered between two operating rooms increase efficiency by eliminating turnover time. However, the practice might increase the surgeon's fatigue. Overlapping surgery has been assumed to be safe because no critical portions of procedures are performed simultaneously in two rooms, but there is little evidence in the literature to support that assumption for otolaryngologic surgery, and there is no evidence comparing non-overlapping and overlapping surgical outcomes for a single surgeon with all confounding factors controlled. MethodsRetrospective cohort study that included a consecutive sample of adult subjects who underwent otolaryngologic laryngeal or otologic surgery between June 2013 and March 2016. All procedures were performed by the same surgical team and surgeon who had block time with 2-rooms every other week and 1-room on alternate weeks. The incidence of surgical complications was assessed in the perioperative period. Duration of surgery and time-in-room also were evaluated, as were surgical outcomes. ResultsA total of 496 surgeries were assigned to either overlapping-surgery (n = 346) or non-overlapping-surgery (n = 150) cohorts. Overlapping-surgery was a significant predictor for increased time-in-room on multivariate analysis but was not a significant predictor for surgery duration. Rate of complications, hospital readmission, emergency department visit, reoperation, mortality, and patient satisfaction did not differ significantly between cohorts. ConclusionsOverlapping surgery does not hinder patient safety or functional outcomes in patients undergoing otolaryngologic operations such as voice or ear surgery.

Patient satisfaction in Emergency Department

Patient satisfaction in Emergency Department

An Evaluation on the Attitude Toward Using Patient Rights and Satisfaction Levels in Emergency Department Patients

IntroductionIn emergency health care services, patient satisfaction is one of the fundamental indicators of quality emergency care, making it essential to identify factors that can impact this component of care. This study aimed to determine emergency service patients’ attitudes toward using patient rights, their satisfaction levels with emergency service, and related factors. MethodsThe cross-sectional study was conducted with 382 patients who presented to the emergency department between November 2022 and March 2023. Data were collected using the Patient Description Form, the Emergency Department Patient Satisfaction Scale, and the Scale of Patient Rights Using Attitude. The study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist for reporting. ResultsThe mean score of the Emergency Department Patient Satisfaction Scale was 53.88 ± 6.88 (minimum score, 30; maximum score, 68), and the mean score of the Scale of Patient Rights Using Attitude was 108.89 ± 11.90 (minimum score, 73; maximum score, 135). As a result of the regression analysis, it was found that the Scale of Patient Rights Using Attitude scores and frequency of ED visits significantly contributed to the Emergency Department Patient Satisfaction Scale scores. Younger patients who had higher educational status presented to the emergency department more frequently and had chronic diseases were associated with positive attitudes about using patient rights and had higher levels of ED patient satisfaction (P < .001). DiscussionThe study has provided valuable information for assessing the attitudes of ED patients toward exercising their patient rights and their satisfaction levels. Respect for patient rights and their effective utilization by patients can enhance the quality of ED services and increase patient satisfaction.

Patients' opinion on violence against healthcare workers and their level of satisfaction in emergency department in Turkey: A cross-sectional study

BackgroundViolence, with an increasing rate of cases in the health care system which adversely affects the quality of provision of services, has become a social health issue that also has negative impacts both on healthcare workers and patients. This study was conducted to determine the opinion of patients, who had been admitted to the emergency department, towards violence against healthcare workers, and their level of satisfaction with health services. MethodsThe study employed a cross-sectional design and was conducted with 348 patients who had received healthcare services in the adult emergency department in Turkey. The Emergency Department Patient Satisfaction Survey and An eight-item questionnaire prepared by the researchers consisting of the patient's characteristics and their statements on violence were used to collect the data. ResultsAmong the patients, 26.7% stated that they had been violent toward healthcare workers. It was determined that 91.4% of the cases were verbal and 8.6% were physical. Among the patients, 82.2% had not known about the legal sanctions for violence against healthcare workers. The low level of propensity for violence in patients who were satisfied with the emergency department service was statistically significant (p < 0.05). ConclusionsAs a result of the study, it was found that one in four patients had been violent to healthcare workers, and the vast majority had a lack of information about legal sanctions. Policymakers should take deterrent measures to prevent the occurrence of violence and develop more critical sanctions.

Emergency Department Patient Satisfaction Survey in a Tertiary Care Hospital of Eastern Nepal

Background: Patient satisfaction is one of the most important indicators of the quality of emergency care. This hospital-based cross-sectional study was performed to assess patient satisfaction in the Emergency department of a tertiary care hospital and identify the factors associated. Methods: The study was performed on 785 patients visiting Emergency department. Variables under study were satisfaction level, triage score, waiting times, and socio-demographic characteristics. Satisfaction level was measured using a 5-point Likert scale, Cronbach’s alpha (α= 0.86 overall, inter-item α = 0.842-0.859). A score of 47 and above was cut off to denote satisfaction with a sensitivity of 75% and specificity of 81%. Descriptive analysis and Chi-square test was performed to see the association of variables of interests with patient satisfaction. A p-value &lt;0.05 was considered statistically significant. Results: Median age of the patients was 47 years among which 51% were male. Medical emergencies were the most common problems reported (68.7%). The median (Q1, Q3, maximum) time to first contact with the doctor was 10 (5,15, 240) minutes. The patient satisfaction rate towards the Emergency services was 69%. Behavior of doctors (54%) and nurses’ care (44%) were rated as excellent services while poorer ratings were given for toilet condition (27%) and crowd control (14%). Weekends vs weekdays had a significant association with satisfaction (p = 0.04). Conclusion: Overall acceptable patient satisfaction rate was found in the services provided by the Emergency department. Areas needing improvement were identified.

The Correlation between Service Quality and Patient Satisfaction in the Maternal Emergency Department in “Anyar Community Health Center” 2023 A Cross Sectional Study

Overall, it is estimated that 15% of pregnant women experience serious obstetric complications and require treatment in the maternal emergency department (IGD Maternal) at the community health center (Puskesmas). However, sometimes in health services, especially in government basic service centers in Indonesia, there is interaction or delivery of information between health workers and patients or families that is not good enough to reduce patient satisfaction. The purpose of this study was to analyze the relationship between the level of patient satisfaction and the quality of maternal emergency department services. A cross-sectional study design was carried out in April 2023 at the maternal emergency department at the Community health center, Serang-Banten. The research sample consisted of 33 pregnant women who attended and had taken care of the maternal emergency department. Satisfaction and service quality were measured using a questionnaire that had been tested for validity and reliability. Chi-square bivariate analysis was performed using SPSS. Most of the patients were quite satisfied with the service (51.5%). However, assessing the quality of service is still lacking (54.5%). Statistical analysis concluded that there is a significant relationship between service quality and patient satisfaction (OR: 10.4; 95% CI (2.03 – 53.2); p value: 0.003). Good service quality will increase patient satisfaction 10 times compared to poor service quality.

Waiting time and patients' satisfaction in the emergency department in Taif city, Saudi Arabia

Background: Patients' satisfaction in emergency departments (EDs) could be improved by providing estimates of the expected waiting time. Aim: The aim of this study was to determine waiting time and assess patients' satisfaction in EDs. Setting and Design: A descriptive, cross-sectional study was carried out in Taif city included patients who come to EDs of three main hospitals throughout the period from mid-August to mid-September 2022 if they aged from 18 to 65 years. Materials and Methods: Data were collected through a pretested Arabic version of the Brief Emergency Department Patient Satisfaction Scale questionnaire. Statistical Analysis: Data were entered into the Statistical Package for the Social Sciences (SPSS) software version 26 for Windows. Results: The study included 612 patients. Almost a quarter (23%) aged 25–34 years. Regarding satisfaction of patients with ED, the highest score was observed concerning physicians' care (4.31 ± 0.88) whereas the lowest satisfaction score was reported regarding arrival in reception (AIR) (3.57 ± 1.08). The highest score was observed among those who attended King Faisal Medical Complex (4.19 ± 0.74), whereas the lowest score was observed among those who attended Alhada Armed Forces Hospital (3.75 ± 0.91), P &lt; 0.001. The highest score of satisfaction was observed among patients aged 65 years/above (4.08 ± 0.76), P = 0.041. Non-Saudi patients were more likely to be satisfied compared to Saudi patients (4.33 ± 0.77 vs. 3.89 ± 0.87), P &lt; 0.001. Patients who did not read/write were more likely to be satisfied compared to educated patients (4.23 ± 0.83 vs. 3.89 ± 0.87), P = 0.001. The waiting time exceeded 2 h among 13.9% of patients. With decreasing the waiting time, the patients' satisfaction with ED was increasing, P &lt; 0.001. Conclusion: The overall patients' satisfaction with ED was high; it was lowest regarding AIR. In addition, longer waiting time was associated with patients' dissatisfaction.

The Effect of A ‘Covid Tent’ On Emergency Department Efficiency and Patient Satisfaction: A Single Site Retrospective Study

Background:Overcrowding in Emergency Departments is associated with poor patient outcomes and low patient satisfaction; overcrowding has been exacerbated by the ongoing Covid-19 pandemic. One intervention used in both the H1N1 pandemic and the current Covid-19 pandemic is the deployment of temporary structures such as surge tents. Data on the effectiveness of such interventions is currently lacking. Methods:In this retrospective study, we assess ED length of stay (LOS), percent of patients leaving without being seen, and 72-hour return rate in the time period during tent operation with equivalent time periods before and after tent use. Differences in outcomes were modeled and tested using Generalized Estimating Equations (GEEs) methodology and controlled for emergency severity index (ESI). Results:Deployment of a Covid tent was associated with reduced LOS (227.5 vs. 214.5 min, ESI-adjusted p = 0.02). Additionally, we observed a significantly reduced rate of patients leaving without being seen (0.8% vs. 0.2%, ESI-adjusted p &lt; 0.001) without any increase in the 72-hour return rate (4.2% vs 4.2%, ESI-adjusted p = 0.98) during the period of Covid tent operations. Conclusion:This data suggests that the deployment of temporary structures such as tents is an effective means of decompressing EDs in the setting of the Covid-19 pandemic.

The Antecedence and Consequences of Patient Satisfaction in Emergency Department of XYZ Hospital

Data on patient visits to the emergency room from all visits to public hospitals in Indonesia are always increasing from year to year. In line with this fact, the Community Satisfaction Index survey data conducted by the Ministry of Health of the Republic of Indonesia (2017) reported that hospital services have not met patient expectations or in other words the level of patient satisfaction is still low. This study aims to determine the influence of service quality factors consisting of responsiveness, tangible, empathy, assurance, and reliability in influencing customer satisfaction and to analyze customer satisfaction as a mediating variable on revisit intention in the Emergency Room (ER) at XYZ Hospital. This study used quantitative research and data collection was carried out using a questionnaire. The target population of this study were all patients undergoing treatment in the emergency room at XYZ Hospital. Based on data for August 2022 there were 2,564 outpatients. The number of samples was determined as many as 200 samples. The sampling technique used was purposive sampling. Partial Least Square-Structural Equation Modeling (SEM-PLS) was applied in this study. The results showed that revisit intention was positively influenced by patient satisfaction in the emergency room at XYZ Hospital, and service quality had a positive effect on patient satisfaction. The practical implications of this research show that to maintain revisit intention in the XYZ Hospital Emergency Room, one must always listen to the voice of consumers, and have the ability to respond to every wish, expectation and demand of service users of health care facilities.

Measuring patient satisfaction in emergency department: An empirical test using structural equation modeling

ABSTRACT Background Patient satisfaction is gaining an attention as an important quality indicator tracked closely by healthcare providers and emergency departments (EDs). Unfortunately, the primary factors driving patient satisfaction remain poorly studied in literature at developing countries. Objectives The aim of the study is to determine the association of latent construct with patient satisfaction in emergency department (ED) using structural equation modeling (SEM). Methods A total of 219 ED patients from 9 different healthcare facilities were employed to measure the patient satisfaction via PSQ-18. An exploratory factor analysis was used to group items and SEM were applied to identify the factors. Results Time and access to care had a significant influence on general satisfaction. Interpersonal communication had positive and significant impact on general satisfaction. Financial aspects had negative and significant influence on general satisfaction. Technical quality was failed to influence general satisfaction of patients of emergency department. Conclusions To enhance the level of patient satisfaction and to deliver better experience by improving the quality of healthcare services, the care provider shall increase their attention to the influencing factor such as time, access to care, and financial aspects.

Intra-Articular Lidocaine versus Procedural Sedation for Shoulder Dislocation Reduction: A Randomized Trial.

Two common ways of providing anesthesia for shoulder dislocation reductions in the emergency department (ED) are intra-articular lidocaine (IAL) injections and procedural sedation (PS). We sought to compare PS with propofol or etomidate to IAL for shoulder dislocation reductions in the ED. This was an open-label, randomized controlled trial of patients aged 18-70 years with anterior shoulder dislocations who presented to a single ED. We randomized patients to either PS or IAL for their shoulder dislocation reduction. The primary outcome measure was ED length of stay (LOS). Secondarily, we assessed patient satisfaction and the number of attempts required for successful reduction. We identified 60 patients who met the criteria for enrollment, and were able to enroll 43. We randomized 23 patients to IAL and 20 to PS. In the IAL group, the mean ED LOS was 133 min as compared to 124 min for the PS group (difference 9 min [95% confidence interval (CI)-22-41], P = 0.54). Patients in the IAL group required an average of 1.9 reduction attempts as compared to 1.2 in the PS group (difference of 0.7 [95% CI 0.2-1.2]). The mean patient satisfaction scores were similar at 9.7 and 9.8 for the IAL and PS groups, respectively. This study lacked a sufficient sample size to detect small differences but found no statistically significant difference in mean ED LOS or patient satisfaction for patients who received IAL as compared to PS. Patients in the PS group required fewer attempts for successful reduction.

HUBUNGAN IDENTIFIKASI PASIEN SECARA BENAR DENGAN KEPUASAN PASIEN DI INSTALASI GAWAT DARURAT UPTD RUMAH SAKIT MENEMBO-NEMBO BITUNG

The hospital is a health service institution that provides comprehensive health services that have a high risk of patient safety, patient companions, visitors, and human resources. The purpose of this study was to determine the relationship between correct patient identification and patient satisfaction in the uptd emergency department at the Menbo-nembo Bitung Hospital. Methods The design of this study used a descriptive analytic design with a cross sectional approach. The population is 998 respondents, the sample in this study is 99 respondents using a questionnaire measuring instrument. Then the data collected was analyzed using the Chi-Square test. With a significant value (a) 0.05. The results of the Chi-Square test showed that there were 0 cells that had an expected count value of less than 5, then the reading of the results was continued on the Fischer exact test with a p value = .000 where if the value was smaller than the value = 0.05. The conclusion in this study is that there is a relationship between correct patient identification and patient satisfaction in the uptd emergency department at the Menbo-nembo Bitung Hospital.&#x0D;

Turkish validity and reliability study of the Brief Emergency Department Patient Satisfaction Scale

IntroductionPatient satisfaction is affected by many factors, as the emergency department are units that provide rapid examination and treatment. Patient satisfaction should be evaluated differently from other clinics. MethodThis study was a descriptive, psychometric analysis using cross-sectional data collection. The study was conducted in the emergency department of a training and research hospital with 400 patients between July and September 2018. Data were collected using “Descriptive Characteristics Form” and “Brief Emergency Department Patient Satisfaction Scale (BEPSS)”. SPSS 21.0 and AMOS 24.0 package programs were used in the analysis of the data. Language equivalence, content validity, exploratory factor analysis, and confirmatory factor analysis of the scale were performed. Cronbach's alpha coefficient and item-total score correlation were evaluated to determine the reliability of the scale. ResultsThe factor structure of the scale was found to be different from the factor structure of the original scale. Scale items were collected under different factors. The factor loads of the scale items ranged from 0.642 to 0.986. Goodness of fit values were sufficient in confirmatory factor analysis. Test-retest reliability was found sufficient. The Cronbach’s alpha reliability coefficient (α = 0.940) was high and the item total score correlation varied between 0.577 and 0.832. ConclusionThe BEPSS is a valid and reliable scale and can be used in the Turkish population.

The Safe Discharge Checklist: A Standardized Discharge Planning Curriculum for Medicine Trainees.

Hospital discharge is a challenging time for residents, requiring the completion of many tasks to ensure safe transitions for patients. Despite recognition of the importance of hospital discharge planning, formal curricula are lacking. We sought to improve medicine residents' comfort and skills with discharge planning and enhance the quality of care by introducing a standardized approach to discharge on the medicine wards. The intervention included a didactic, a bedside rounds component, and a discharge checklist. Interns were surveyed at the end of rotations to measure confidence, attitudes, and frequency of completing discharge planning tasks. Results were compared with a control group of experienced interns from the previous academic year. Clinical outcomes included hospital readmission and emergency department return rates and patient satisfaction scores in discharge-related domains. Study interns reported similar confidence to control group interns with discharge planning and endorsed completing four of five discharge tasks more frequently than control interns. There were no differences in clinical outcomes. We did not identify changes in clinical outcomes, although this finding likely reflects the multifactorial nature of hospital readmissions. Interns exposed to the curriculum early in the academic year had a higher reported frequency of completing key discharge tasks and similar confidence around discharge, when compared with end-of-the-year interns. These improvements suggest that the curriculum led to a change in culture surrounding discharge planning and perhaps accelerated learning of skills associated with discharge best practices.

Effect of Queue Management System on Patient Satisfaction in Emergency Department; a Randomized Controlled Trial.

Introduction:Patients’ experience in hospitals affects their satisfaction. The purpose of the present study was to assess the effect of applying a queue management system on patient satisfaction in emergency department waiting rooms.Methods:The present prospective randomized single-blinded interventional study was performed from July to August 2020 and involved 236 patients that were divided into one intervention group and one control group, each consisting of 118 patients. The mentioned patients’ perception of the waiting time and satisfaction before being visited by an emergency medicine doctor was evaluated with and without applying the queue management system.Results:The mean actual waiting time (15.5 ± 7.5 minutes) as well as the mean perceived waiting time (11.9 ± 7.4 minutes) for the intervention group were significantly lower than those of the control group with the values of 27.03 ± 8.5 and 32.8 ± 8.7 minutes, respectively (p < 0.001). The mean perceived waiting time was significantly less than the mean actual waiting time (11.9 min vs 15.5 minutes) for the intervention group (p <0.001); however, the mean perceived waiting time was significantly higher than the mean actual waiting time (32.8 vs 27.03 minutes) for the control group (p < 0.001). The level of satisfaction in the intervention group was significantly higher than that of the control group (p <0.001). There was an inverse relationship between the actual waiting time (Intervention group: r=-0.463; Control group: r= -0.567) and the perceived waiting time (Intervention group: r= -0.439; Control group: r= -0.568) with the satisfaction level in both groups (p < 0.001). Conclusion:It can be proposed that the application of a queue management system in the emergency department waiting rooms can reduce the actual and perceived waiting times and increase the patient satisfaction.

Brief emergency department patient satisfaction scale (BEPSS): Turkish validity and reliability study

Brief emergency department patient satisfaction scale (BEPSS): Turkish validity and reliability study

Multivariable Analysis of Patient Satisfaction in the Pediatric Emergency Department.

Published data on predictive factors associated with parent satisfaction from care in a pediatric emergency department (ED) visit are limited to be descriptive and obtained from small data sets. Accordingly, the purpose of this study was to determine both modifiable and nonmodifiable demographic and operational factors that influence parental satisfaction using a large and ethnically diverse site data set. Data consist of responses to the National Research Council (NRC) survey questionnaires and electronic medical records of 15,895 pediatric patients seen in a pediatric ED between the ages of 0 and 17 years discharged from May 2018 to September 2019. Bivariate, χ2, and multivariable logistic regression analyses were carried out using the NRC item on rating the ED between 0 and 10 as the primary outcome. Responses were coded using a top-box approach, a response of "9" or "10" represented satisfaction with the facility, and every other response was indicated as undesirable. Demographic data and NRC questionnaire were used as potential predictors. Multivariable regression analysis found the following variables as independent predictors for positive parental rating of the ED: Hispanic race/ethnicity (odds ratio [OR], 1.285), primary language Spanish (OR, 2.399), and patients who had government-sponsored insurance (OR, 1.470). Those survey items with the largest effect size were timeliness of care (OR, 0.188) and managing discomfort (OR, 0.412). Parental rating of an ED is associated with nonmodifiable variables such as ethnicity and modifiable variables such as timeliness of care and managing discomfort.

Operational factors associated with emergency department patient satisfaction: Analysis of the Academy of Administrators of Emergency Medicine/Association of Academic Chairs of Emergency Medicine national survey.

Patient satisfaction is a focus for emergency department (ED) and hospital administrators. ED patient satisfaction studies have tended to be single site and focused on patient and clinician factors. Inclusion of satisfaction scores in a large, national operations database provided an opportunity to conduct an investigation that included diverse operational factors. We performed a retrospective analysis of the 2019 Academy of Administrators in Academic Emergency Medicine/Association of Academic Chairs of Emergency Medicine (AAAEM/AACEM) benchmarking survey to identify associations between operational factors and patient satisfaction. We identified 59 database variables as potential predictors of Press Ganey likelihood-to-recommend and physician overall scores. Using random forest modeling, we identified the top eight predictors in the models and described their associations. Forty-three (57.3%) academic departments responding to the AAAEM/AACEM survey reported patient satisfaction scores for 78 EDs. Likelihood to recommend ranged from 30.0 to 93.0 (median= 74.8) and was associated with ED length of stay, boarding, use of hallway spaces, hospital annual admissions, faculty base clinical hours, proportion of patients leaving before treatment complete (LBTC), and provider in triage hours per day. Physician overall score ranged from 53.3 to 93.4 (median= 81.9) and was associated with faculty base clinical hours, x-ray utilization, annual ED arrivals, LBTC, use of hallway spaces, arrivals per attending hour, and CT utilization. ED patient satisfaction was associated with intrinsic and extrinsic factors, some being potentially manageable within the ED but others being relatively fixed or outside the control of ED operations. For likelihood to recommend, patient flow was dominant, with erosion of satisfaction observed with increased boarding and longer LOS. Factors associated with physician overall score were more varied. The use of hallway spaces and base clinical hours greater than 1,500 per year were associated with both lower likelihood-to-recommend and lower physician overall scores.