title: The Relationship between Patient Satisfaction with Service Quality and Survival in Non-Small Cell Lung Cancer - Is Self-Rated Health a Potential Confounder?
abstract: OBJECTIVE
  Previously we reported that higher patient satisfaction (PS) with service quality is associated with favorable survival outcomes in a variety of cancers. However, we cautioned the readers that patients with greater satisfaction might be the ones with better self-rated health (SRH), a well-established prognosticator of cancer survival. In other words, SRH could potentially confound the PS and survival relationship. We investigated this hypothesis in non-small cell lung cancer (NSCLC).
  
  
  METHODS
  778 NSCLC patients (327 males and 451 females; mean age 58.8 years) treated at 4 Cancer Treatment Centers of America hospitals between July 2011 and March 2013. PS was measured on a 7-point scale ranging from "completely dissatisfied" to "completely satisfied". SRH was measured on a 7-point scale ranging from "very poor" to "excellent". Both were dichotomized into 2 categories: top box response (7) versus all others (1-6). Patient survival was the primary end point. Cox regression was used to evaluate the association between PS and survival controlling for covariates.
  
  
  RESULTS
  74, 70, 232 and 391 patients had stage I, II, III and IV disease respectively. 631 (81.1%) patients were "completely satisfied". 184 (23.7%) patients had "excellent" SRH. There was a weak but significant correlation between overall PS and SRH (Kendall's tau b = 0.19; p<0.001). On univariate analysis, "completely satisfied" patients had a significantly lower risk of mortality (HR = 0.75; 95% CI: 0.57 to 0.99; p = 0.04). Similarly, patients with "excellent" SRH had a significantly lower risk of mortality (HR = 0.61; 95% CI: 0.46 to 0.81; p = 0.001). On multivariate analysis controlling for stage at diagnosis, treatment history and gender, SRH was found to be a significant predictor of survival (HR = 0.67; 95% CI: 0.50 to 0.89; p = 0.007) while PS was not (HR = 0.86; 95% CI: 0.64 to 1.2; p = 0.32). Among the individual PS items, the only significant independent predictor of survival was "teams communicating with each other concerning your medical condition and treatment" (HR = 0.59; 95% CI: 0.36 to 0.94; p = 0.03).
  
  
  CONCLUSIONS
  SRH appears to confound the PS-survival relationship in NSCLC. SRH should be used as a control/stratification variable in analyses involving PS as a predictor of clinical cancer outcomes.
authors.affiliation: Cancer Treatment Centers of America (CTCA), 500 Remington Road, Schaumburg, Illinois, 60173, United States of America.
authors.forename: Christopher G
authors.initials: CG
authors.lastname: Lis
authors.affiliation: Cancer Treatment Centers of America (CTCA), 500 Remington Road, Schaumburg, Illinois, 60173, United States of America.
authors.forename: Kamal
authors.initials: K
authors.lastname: Patel
authors.affiliation: Cancer Treatment Centers of America (CTCA), 500 Remington Road, Schaumburg, Illinois, 60173, United States of America.
authors.forename: Digant
authors.initials: D
authors.lastname: Gupta
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002289:Carcinoma, Non-Small-Cell Lung / Q000523:psychology / Q000628:therapy*; D015986:Confounding Factors, Epidemiologic; D005260:Female; D006801:Humans; D008175:Lung Neoplasms / Q000523:psychology / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D017060:Patient Satisfaction; D015996:Survival Rate