Paper

Is primary angioplasty an acceptable alternative to thrombolysis? Quantitative and qualitative study of patient and carer satisfaction

Fiona C. Sampson MSc,* Alicia O�Cathain PhD� and Steve Goodacre PhD� *Research Fellow, �Senior Research Fellow and �Professor of Emergency Medicine, ScHARR, University of Sheffield, Sheffield, UK

Correspondence

Fiona C. Sampson

ScHARR

University of Sheffield

Regent Street

Sheffield S1 4DA

UK

E-mail: [email protected]

Accepted for publication

7 October 2009

Keywords: angioplasty, myocardial

infarction, patient satisfaction

Abstract

Objective The National Infarct Angioplasty Project assessed the

feasibility of establishing a comprehensive primary angioplasty

service. We aimed to compare satisfaction at intervention hospitals

offering angioplasty-based care and control hospitals offering

thrombolysis-based care.

Design Mixed methods, with postal survey of patients and their

carers, supported by semi-structured interviews.

Setting and participants Survey of 682 patients and 486 carers, and

interviews with 33 patients and carers, in eight English hospitals.

Interventions Primary angioplasty or thrombolysis.

Main outcome measures Satisfaction with treatment.

Results Responses were received from 595 ⁄ 682 patients (87%) and 418 ⁄ 486 carers (86%). Satisfaction with overall care was high at both intervention and control sites (78% vs. 71% patients rated their

care as �excellent�, P = 0.074). Patient satisfaction was higher at intervention sites for some aspects of care such as speed of treatment

(80% vs. 67% �excellent�, P = 0.001). Convenience of visiting was rated lower at intervention sites by carers (12% vs. 1% �poor�, P = 0.001). During interviews, carers reported that they accepted

the added inconvenience of visiting primary angioplasty sites in the

context of this life-saving treatment. Patient satisfaction with

discharge and aftercare was lower in both treatment groups than

for other aspects of care.

Conclusions Reorganization of care to offer a primary angioplasty

service was acceptable to patients and their carers. Satisfaction levels

were high regardless of the type of care received, with the exception

of discharge and aftercare.

Primary angioplasty as an alternative to intra-

venous thrombolysis for patients with acute ST-

elevation myocardial infarction (STEMI) has

been shown to reduce mortality, re-infarction,

stroke and the need for coronary artery bypass

grafting. 1 Economic analyses suggest that if both

doi: 10.1111/j.1369-7625.2009.00589.x

350 � 2010 The Authors. Health Expectations � 2010 Blackwell Publishing Ltd Health Expectations, 13, pp.350–358

treatments are routinely available, primary

angioplasty is likely to be cost-effective if it can

be delivered in a timely manner. 2 In the United

Kingdom (UK), primary angioplasty is not

currently the standard treatment for patients

with STEMI, although rates are increasing rap-

idly with over one in five STEMI patients

receiving reperfusion having primary angio-

plasty in England and Wales in 2007 ⁄ 8.3 Health policy makers in England have advocated

expediting the process of making primary

angioplasty the principal treatment for STEMI

patients. 4

In 2004, the British Cardiac Society and the

Department of Health established a working

group to consider the feasibility of implement-

ing a countrywide primary angioplasty service

for patients with STEMI in England. Ten hos-

pitals offering primary angioplasty took part in

the National Infarct Angioplasty Project

(NIAP) during 2005–6 and collected data on

call and treatment times, clinical measures and

outcomes for all patients admitted to their

hospitals during the year. The sites represented

a range of potential service models, including

single centres, centres taking referrals from local

hospitals and networks of centres working

together to serve local populations. 5 Due to the

specialist facilities and staffing required, the

routine provision of primary angioplasty

required significant reorganization of services,

with patients transferring from, or bypassing,

local emergency departments to go to a primary

angioplasty centre. There are concerns that

centralization of services will adversely affect

patient satisfaction, 6–8

and in this case that

carers would be inconvenienced by having to

travel greater distances to primary angioplasty

centres.

To date there has been little consideration of

the views of patients or their carers regarding the

development of primary angioplasty services.

Existing research focuses largely upon experi-

ences of angioplasty as an elective procedure. 9

As part of an independent evaluation of the

NIAP pilot sites, we undertook a study of

patients� and carers� views of care provided at NIAP sites compared with views of patients and

carers at hospitals providing mainly thrombol-

ysis-based care.

Methods

Design and setting

The study was part of a wider evaluation which

included studies of the workforce and economic

implications of NIAP. The patient and carer

satisfaction component of this wider study was a

cross-sectional comparison of care provided in

four hospitals offering mainly primary angio-

plasty (intervention sites) and four hospitals

offering mainly thrombolysis-based care (control

sites) in England. A mixed methods design was

used 10

drawing on the strengths of quantitative

research to measure differences in patient and

carer satisfaction between hospitals offering

mainly primary angioplasty and those offering

mainly thrombolysis, and the strengths of qual-

itative research to understand the important

components of satisfaction and elaborate on the

findings from the quantitative research. 11

The

study was undertaken in three phases: qualita-

tive interviews with patients and carers to

understand the key aspects of their experience

and to develop a questionnaire for use in the

survey; a survey of patients and carers in both

intervention and control hospitals; and further

qualitative interviews with patients to examine

issues raised in earlier phases of the study.

Recruitment

For the �phase 1� interviews, nurses approached patients with STEMI who were admitted to

hospital at two of the intervention sites. Con-

sent was gained for a researcher to approach

both the patient and their carer for interview.

We used purposive sampling to select intervie-

wees experiencing the range of referral routes

within NIAP sites (i.e. via the emergency

department, direct to catheter lab, hospital

bypass). Based on these interviews we developed

a questionnaire for patients and a questionnaire

for carers. For the �phase 2� survey, nurses recorded the admission of all patients with

Patient and carer satisfaction with primary angioplasty, F C Sampson, A O�Cathain and S Goodacre

� 2010 The Authors. Health Expectations � 2010 Blackwell Publishing Ltd Health Expectations, 13, pp.350–358

351

STEMI at the four intervention and four con-

trol sites. To comply with ethics committee

requirements, nurses asked patients to consent

to being sent a questionnaire and to provide

details of a carer where possible. Patients who

were critically ill, unable to consent due to

cognitive impairment, or unable to understand

English were excluded. A questionnaire, and up

to two reminders, were then sent to patients and

carers at around 1 week after admission.

Recruitment took place between February and

November 2007. For the �phase 3� interviews, we followed up an issue which arose from phase 1

by selecting survey respondents who felt that

they had been �fixed� by their treatment or not,12

and also followed up an issue which arose from

phase 2 by selecting survey respondents who

reported their discharge and aftercare as

unsatisfactory.

Interview schedules and questionnaire

The phase 1 interviews followed a critical inci-

dent technique to identify key aspects of care. 13

Interviewees were asked to describe the positive

and negative aspects of their experience from

onset of symptoms to discharge home. The

development of the phase 2 questionnaire was

informed by the research brief and findings from

the phase 1 interviews. The patient questionnaire

consisted of 27 satisfaction items using a five

point scale �excellent� �very good� �good� �fair� �poor� and the extra option of �not sure� because some patients may have been unaware of events

for parts of their care. Items addressed com-

munication with staff, speed and efficiency of

care, management of pain and comfort, conve-

nience of family visiting the hospital, discharge,

post-discharge care, the different places of care,

and care overall. Other questions addressed

demographical information, experience of

transfer between hospitals and permission for an

interview at a later time. There were four open-

ended questions about good and poor aspects of

care. The carer questionnaire was similar, with a

focus on convenience of visiting the patient.

Phase 3 interviews focused on care after dis-

charge from hospital.

Analysis

Survey data was analysed using SPSS version

12.0 and STATA version 8. We dichotomized

satisfaction items into �excellent� vs. �very good to poor�, because patients who tick �excellent� tend to find no fault with a service.

14 We

undertook multilevel logistic regression

accounting for clustering by site using the

XTLOGIT function in STATA. We adjusted for

age and sex to determine whether the proportion

of patients reporting �excellent� differed in intervention and control sites. It was important

to adjust for age because older people tend to

report higher levels of satisfaction. 15

Because of

the large number of statistical tests undertaken,

the significance level was taken as P < 0.01

rather than the usual P < 0.05. Free text com-

ments at the end of the questionnaire were read

by one of the authors (FS) and key themes were

identified. 16

These indicated the strength of

feeling that respondents had about certain

aspects of their care and elucidated answers

within the structured part of the questionnaire.

The interviews were transcribed verbatim. We

used the first stages of �framework analysis�17 by reading transcripts to identify themes and cod-

ing all transcripts systematically according to the

thematic framework. The way in which different

aspects of having primary angioplasty contrib-

uted to a sense of �feeling fixed� has been pub- lished elsewhere.

12 Here, we report only the

aspects of the qualitative findings which elabo-

rate on the quantitative survey results.

Presentation of results

Three types of results are presented below. First,

the survey data is used to identify differences

between intervention and control sites. Second,

the proportion of survey respondents reporting

�excellent� care is compared for the range of sat- isfaction items to identify poorly perceived

aspects of care. Finally, findings from the inter-

views, and free text comments from the survey,

are used to elaborate on issues raised in the survey

data. We have combined these results within a set

of themes addressing key aspects of care.

Patient and carer satisfaction with primary angioplasty, F C Sampson, A O�Cathain and S Goodacre

� 2010 The Authors. Health Expectations � 2010 Blackwell Publishing Ltd Health Expectations, 13, pp.350–358

352

Results

Sample characteristics

Survey

For the survey, 1165 STEMI patients were iden-

tified across all eight sites, of whom 144 did not

meet inclusion criteria (see Fig. 1). Of the 1021

eligible patients, 682 (67%) were recruited into

the study. There was no difference in recruitment

rates between intervention and control sites: 66%

(432 ⁄ 659) vs. 69% (250 ⁄ 362), P = 0.255. Rea- sons for non-recruitment included patient refusal,

patients being missed, or patients being dis-

charged or transferred before nurses could

approach them for consent. Patients who were

recruited were younger than non-recruited

patients (mean age 62 vs. 67, P = 0.001) and a

higher proportion of males was recruited than

females (60% vs. 51%, P = 0.006).

The response rate to the survey was 87%

(595 ⁄ 682) for patients and 86% (418 ⁄ 486) for carers. Questionnaires were completed on aver-

age 4 weeks after admission. There was no

difference in response rates between intervention

and control sites for patients (86% vs. 89%,

P = 0.244). The response rate was similar for

male and female patients (87% vs. 89%,

P = 0.588) but respondents were older than

non-respondents (mean age 62 vs. 59,

P = 0.033). Any statistically significant differ-

ences between patient respondents in interven-

tion and control sites were related to the

standard treatment offered within those sites

(Table 1). That is, patients in intervention sites

were more likely to have primary angioplasty

and be transferred between hospitals.

Interviews

Prior to the survey, we undertook interviews

with ten patients and six carers from interven-

tion sites on average 2 weeks post-admission.

After the survey, we interviewed a further 11

patients at intervention sites and six patients at

control sites who had responded to the survey.

Overall satisfaction

Satisfaction levels with different aspects of care

are displayed in descending order for patients

(Table 2) and carers (Table 3). Overall satisfac-

tion with care was high in both intervention and

control sites, for patients and carers. Although it

appeared that overall satisfaction was higher at

intervention than control sites for both patients

(78% vs. 71% �excellent�) and carers (63% vs. 55% �excellent�), these were not statistically sig- nificantly different (P = 0.074 and P = 0.116

respectively). This was reflected in the open

comments on the questionnaires and in the

qualitative interviews. Both patients and carers

praised the care, with almost one in ten patients

adding additional comments to the question-

naire about how excellent their treatment had

been. During interviews, patients referred to

their treatment as �exceptional� or �first class� and expressed gratitude for the service they had

received.

Recruitment of patients for the patient questionnaire

Critically ill = 57 Cognitive impairment = 13

Unable to understand English = 27

Discharged/transferred = 102 Missed = 18

Refused = 22 No reason given/other = 85

Identified n = 756

Eligible n = 659

Intervention Control

Identified n = 409

Eligible n = 362

Critically ill = 33 Cognitive impairment = 11

Unable to understand English = 3

Discharged/transferred = 25 Missed = 62 Refused = 0

No reason given/other = 25

Recruited n = 432

Responded n = 372

Did not return questionnaire = 60 Recruited n = 250

Responded n = 223

Did not return questionnaire = 27

Figure 1 Flow diagram of patients recruited for the patient questionnaire.

Patient and carer satisfaction with primary angioplasty, F C Sampson, A O�Cathain and S Goodacre

� 2010 The Authors. Health Expectations � 2010 Blackwell Publishing Ltd Health Expectations, 13, pp.350–358

353

The way I was treated by the staff from the cleaner

to the doctors was excellent and if private care is

better then I would like to see it (patient 15, survey)

Speed and efficiency

Patients were very satisfied with the time they

waited for treatment, and the efficiency with

which they were treated, with significantly

higher satisfaction levels at intervention than

control sites for both aspects of care [see items

(a) and (d), Table 2]. Again, these high levels of

satisfaction were reflected in the open comments

on the questionnaire and in the qualitative

interviews. During the interviews at intervention

sites, patients and carers expressed amazement

at the short time period between contacting the

emergency services to the completion of treat-

ment. They perceived an efficiency and

�smoothness� in the care provided, and were impressed at the teamwork involved, often

describing how the team were awaiting their

arrival.

This for me was the NHS working at its very best.

From the 999 call to coming out of surgery took

3.5 h (patient 307, survey)

Table 1 Characteristics of respondents to patient and carer surveys

Intervention

% (n ⁄ N) Control

% (n ⁄ N) All

% (n ⁄ N) P

Patients

Male 76% (282 ⁄ 372) 74% (165 ⁄ 223) 75% (447 ⁄ 595) 0.633* Mean age (range, SD) 63.1 (25–92, 12.04) 61.34 (25–92, 12.02) 62.4 (25–92, 12.05) 0.098

�

Primary angioplasty received 92% (341 ⁄ 372) 5% (12 ⁄ 223) 59% (353 ⁄ 595) <0.001* Admission �in hours� 39% (116 ⁄ 297) 38% (78 ⁄ 203) 39% (194 ⁄ 500) 0.886* Transfer to second hospital 28% (101 ⁄ 366) 6% (13 ⁄ 215) 20% (114 ⁄ 581) <0.001*

Carers

Male 22% (59 ⁄ 263) 19% (28 ⁄ 147) 21% (87 ⁄ 410) 0.421* Mean age (range, SD) 55 (16–85, 14.06) 57 (22–90, 13.2) 56 (16–90, 13.8) 0.106

�

Living with patient 82% (216 ⁄ 262) 86% (127 ⁄ 148) 84% (343 ⁄ 410) 0.376*

*Chi-square. �Student t-test.

Table 2 Patient satisfaction with hospital treatment for a heart attack (% rating each aspect of care as �excellent�)

Intervention

% (n ⁄ N) Control

% (n ⁄ N) Adjusted odds

ratio (95% CI)* P-value

(a) Efficiency with which you were treated 83% (305 ⁄ 369) 74% (162 ⁄ 219) 1.72 (1.14, 2.59) 0.009 (b) Professional skill and ability of doctors and nurses 81% (297 ⁄ 368) 73% (161 ⁄ 221) 1.50 (1.10, 2.24) 0.052 (c) Overall experience of being treated for a heart attack 78% (287 ⁄ 367) 71% (155 ⁄ 218) 1.42 (097, 2.09) 0.074 (d) Time waited before having treatment 80% (292 ⁄ 364) 67% (148 ⁄ 219) 2.17 (1.45, 3.22) 0.001 (e) Confidence in doctors and nurses treating you 75% (278 ⁄ 369) 69% (151 ⁄ 219) 1.32 (0.86, 2.03) 0.549 (f) Confidence in the treatment received 71% (263 ⁄ 370) 61% (134 ⁄ 218) 1.52 (1.06, 2.17) 0.022 (g) Explanations given about what was wrong with you 56% (206 ⁄ 365) 50% (109 ⁄ 220) 1.18 (0.68, 2.03) 0.549 (h) Ease and convenience for friends and family to visit 54% (196 ⁄ 363) 51% (111 ⁄ 219) 1.12 (0.80, 1.58) 0.502 (i) Explanations given of risks & benefits of treatment 47% (170 ⁄ 361) 44% (96 ⁄ 216) 1.07 (0.70, 1.62) 0.750 (j) Time spent waiting to be discharged from hospital 38% (115 ⁄ 306) 46% (84 ⁄ 182) 0.77 (0.51, 1.55) 0.205 (k) Involvement in decisions about treatment 37% (133 ⁄ 357) 32% 70 ⁄ 216) 1.23 (0.75, 2.01) 0.409 (l) Information about medication & potential side-effects 34% (104 ⁄ 308) 38% (69 ⁄ 183) 0.81 (0.54, 1.23) 0.322 (m) Support and follow-up provided once left hospital 36% (108 ⁄ 300) 32% (56 ⁄ 175) 1.04 (0.62, 1.75) 0.873 (n) Information given about how to manage condition

in future

25% (78 ⁄ 311) 30% (55 ⁄ 182) 0.68 (0.47, 0.99) 0.049

*Adjusted for patient age and sex.

Patient and carer satisfaction with primary angioplasty, F C Sampson, A O�Cathain and S Goodacre

� 2010 The Authors. Health Expectations � 2010 Blackwell Publishing Ltd Health Expectations, 13, pp.350–358

354

The speed ⁄ efficiency of (transfer hospital) sending me to the (intervention hospital) who, in turn,

dealt with me with such speed that I was in the

door, up the lift and straight into theatre – bril-

liant! (patient 242, survey)

Convenience of care

Carers in general had lower levels of satisfac-

tion with convenience of visiting than for other

aspects of care [see items (h) and (i), Table 3].

There was no difference between intervention

and control sites in proportions rating conve-

nience of visiting as �excellent� for either patients [see item (h), Table 2] or carers [item

(h), Table 3]. However, the distribution of

satisfaction for this variable for carers was

different than for other variables, with a large

proportion of carers rating convenience of

hospital for visiting as fair or poor. A higher

proportion of carers rated convenience of vis-

iting the hospital as �poor� at intervention than control sites (12% (30 ⁄ 257) vs. 1% (2 ⁄ 143) �poor�, P = 0.001). During the qualitative interviews with carers from intervention sites,

concerns were raised about the prohibitive cost

of parking facilities and worries about travel-

ling long distances, especially at night. How-

ever, carers also reported that they were

willing to accept this inconvenience in the

context of the life-saving nature of primary

angioplasty.

I think it�s a good thing he was brought there you know, I think if he had gone to his local hospital

then he mightn�t, you know, I wouldn�t rate his chances to be honest (carer 5, phase 1 interview)

Discharge and aftercare

Satisfaction levels with hospital discharge pro-

cedures and aftercare were notably lower than

for other aspects of care for both intervention

and control sites [see items (j), (l), (m) and (n),

Table 2]. Patient satisfaction with information

about how to manage the condition in future

was lower in intervention than control sites

although this was not statistically significant at

the 0.01 level (P = 0.049). This was explored

further in �phase 3� qualitative interviews where patients explained how they spent a long time

waiting for hospital discharge, often involving

several hours waiting for drugs from the phar-

macy. They also felt there was a lack of consis-

tency regarding follow-up care and advice.

Patients discussed how they found it difficult to

absorb information about the drugs they were

taking and future management of their condi-

tion during the hospital stay immediately fol-

lowing their heart attack. Some reported

anxiety, when they suffered side-effects from

their medication because they did not know

what was �normal� and what might be a warning sign of something more serious, particularly if

they felt that they had not received adequate

Table 3 Carer satisfaction with hospital treatment for a heart attack (% rating each aspect of care as �excellent�)

Intervention

% (n ⁄ N) Control

% (n ⁄ N) Adjusted odds

ratios (95% CI)* P-value

(a) Professional skill and ability of doctors & nurses 75% (198 ⁄ 265) 66% (98 ⁄ 149) 1.31 (0.63, 2.71) 0.468 (b) Confidence in doctors & nurses treating patient 68% (181 ⁄ 265) 65% (97 ⁄ 149) 0.99 (0.49, 2.23) 0.985 (c) Overall impression of treatment & care in hospital 63% (167 ⁄ 263) 55% (81 ⁄ 147) 1.50 (0.90, 2.49) 0.116 (d) Reassurance and support offered 60% (158 ⁄ 265) 55% (82 ⁄ 144) 1.20 (0.70, 2.06) 0.503 (e) Confidence in the treatment received 59% (157 ⁄ 265) 53% (79 ⁄ 147) 1.10 (0.55, 2.22) 0.783 (f) Information you were given about what was

happening to patient

49% (130 ⁄ 263) 43% (64 ⁄ 149) 1.23 (0.71, 2.14) 0.462

(g) Opportunity to ask doctors and nurses questions 51% (135 ⁄ 266) 37% (55 ⁄ 149) 1.79 (1.06, 3.01) 0.028 (h) Convenience of hospital for you to visit patient 28% (72 ⁄ 261) 34% (50 ⁄ 145) 0.72 (0.46, 1.12) 0.149 (i) Visiting times 30% (77 ⁄ 258) 31% (46 ⁄ 148) 0.93 (0.54, 1.60) 0.799 (j) Facilities available to visitors 28% (71 ⁄ 254) 19% (28 ⁄ 144) 1.61 (0.93, 2.78) 0.089

*Adjusted for carer age and sex.

Patient and carer satisfaction with primary angioplasty, F C Sampson, A O�Cathain and S Goodacre

� 2010 The Authors. Health Expectations � 2010 Blackwell Publishing Ltd Health Expectations, 13, pp.350–358

355

follow-up. When people had received aftercare

they were happy with it, but some patients

reported not receiving aftercare, or receiving it

too late after discharge.

I felt I could have done with more [support]. There

were lots of small things that worried me, the

things that didn�t seem enough to ask my GP about really (patient 123, interview)

For the intervention sites, problems with

aftercare may have been exacerbated by speedier

discharge or transfer back to a feeder hospital

before medication and rehabilitation procedures

had been fully explained.

There was not enough time to inform me about

medication etc. as the ambulance was waiting to

take me back to (transfer hospital) (patient 321,

survey)

Discussion

Patients and carers found care at primary

angioplasty hospitals as acceptable as throm-

bolysis-based care. There were a few differences

between the two types of care, and differences

mainly favoured primary angioplasty hospitals.

A key exception was carer satisfaction with the

convenience of travelling to visit the patient.

This is a potential problem when services are

centralized and indeed appeared to be a problem

for primary angioplasty. However, qualitative

interviews with carers identified that carers were

willing to accommodate this inconvenience in

the context of the life-saving treatment of the

patient.

Another potential concern was about infor-

mation offered to patients about how to manage

the problem in the future. Shorter lengths of stay

associated with primary angioplasty may affect

the ability of staff to inform patients about after

care due to the shorter length of stay associated

with primary angioplasty. 18

As well as identify-

ing differences between patients and carers

receiving two types of care, the survey also

showed that patients and carers at both inter-

vention and control sites were highly satisfied

with many aspects of emergency treatment for

STEMI, with the exception of hospital discharge

and aftercare.

A recent Department of Health policy review

cites patient experience as the most important

lever for service improvement in the NHS and

there is a strong drive towards using outputs

from patient and public involvement activity in

influencing service planning and develop-

ment. 19,20

However, relatively little research has

been undertaken to date on patient views of

primary angioplasty which could influence ser-

vice delivery. Patient satisfaction with elective

angioplasty in the United States has been found

to be high, although the experience of elective

angioplasty is likely to be different from that of

primary angioplasty. 9 Recent studies of patient

views of primary angioplasty in the UK both

found that patients undergoing primary angio-

plasty were very positive about their experiences

and also support our concerns about the infor-

mation needs of these patients for their after-

care. 21–23

Radcliffe et al. found that experiences

of aftercare were varied and some patients still

had unanswered questions when interviewed,

being particularly disappointed with their fol-

low-up in primary care. 23

Astin et al. reported

some misconceptions around the perception of

what had happened and the seriousness of the

condition and advocate further patient educa-

tion post-discharge. 22

It is important to consider the information

needs of primary angioplasty patients because

patient satisfaction with medical treatment and

information are associated with improved

physical and mental health related quality of life

in patients with angina pectoris. 24

In particular,

advice on how to improve health is associated

with improved physical health, 24

demonstrating

the importance of adequate information and

access to cardiac rehabilitation services.

Strengths and limitations

Recent UK Department of Health policy advo-

cates finding new ways to measure patient

experience. 25

The use of both qualitative and

quantitative methods allowed us to achieve a

more comprehensive understanding of patient

and carer views than one method alone. The

qualitative component allowed us to explore

Patient and carer satisfaction with primary angioplasty, F C Sampson, A O�Cathain and S Goodacre

� 2010 The Authors. Health Expectations � 2010 Blackwell Publishing Ltd Health Expectations, 13, pp.350–358

356

issues that were salient to participants, whilst the

survey allowed us to identify differences between

intervention and control sites. A recent editorial

highlights the dangers of reporting �superficial assessments of service users� opinions�, as overall positive experiences can mask important con-

cerns with aspects of service provision. 26

In our

phase one interviews, we indeed found that

patients were initially reluctant to criticize the

service due to their generally excellent experience

and gratitude at receiving life-saving treatment,

although some negative aspects were very briefly

mentioned. We then undertook a survey using a

specific, wide ranging list of items and indeed

identified some aspects of care that patients and

carers were unhappy with, whilst being generally

very satisfied with care. The second set of

interviews then allowed us to probe further into

these negative aspects.

Whilst our study supported that of other

studies looking at the patient experience of

primary angioplasty, we were able to attribute

some of the findings to the new service itself,

rather than solely the experience of having being

treated for a heart attack as we included patients

from a �control� group who had received mainly thrombolysis. The survey was based on a large

sample of patients from four intervention and

four control sites with a high response rate

(87%), suggesting little effect of any non-

response bias. However, although recruitment

rates for the survey were reasonable (67%),

nearly two-fifths of patients who were not

recruited were missed because they were trans-

ferred or discharged early. We may therefore

have underrepresented the views of transfer

patients who were repatriated back to their

original hospital within the intervention group.

Also, a large number of comparisons have been

tested statistically and at least one may have

occurred by chance. Further, this was an

observational study, and sites were not ran-

domized to be intervention or control. Therefore

differences found between sites may be related to

characteristics of the sites other than the main

type of care offered. Finally, intervention sites

were self-selected and therefore keen to provide

an innovative service. It is possible that patients

at sites offering primary angioplasty in the future

may have a less positive experience than those at

these �early implementer� sites.

Implications for practice

Hospitals can offer primary angioplasty without

being concerned about adversely affecting

patient or carer satisfaction. However, they will

need to ease the added burden of travel for

carers by informing them of travel reimburse-

ment schemes and the availability of overnight

accommodation. Additionally, the information

needs of primary angioplasty patients need to be

taken more seriously. In fact the last stages of

care need attention regardless of the type of

treatment offered in a hospital, particularly

given the drive to reduce length of stay and

expedite discharge for patients post-STEMI.

The discharge and aftercare of STEMI patients

requires considerable attention to increase

satisfaction levels to those with earlier parts of

care.

Conclusions

Reorganization of care to offer a primary

angioplasty service was acceptable to patients

and their carers with the exception of conve-

nience of visiting the hospital for carers, and

information needs of patients about how to

manage their condition in the future. Satisfac-

tion levels were high regardless of the type of

care received, with the exception of discharge

and aftercare.

Acknowledgements

We would like to thank all of the patients and

their carers who took part in interviews and

completed questionnaires as well as the hospital

staff who helped to recruit them. We would also

like to thank Kathryn Paulucy for clerical

assistance.

Conflicts of interest

No conflicts of interest have been declared.

Patient and carer satisfaction with primary angioplasty, F C Sampson, A O�Cathain and S Goodacre

� 2010 The Authors. Health Expectations � 2010 Blackwell Publishing Ltd Health Expectations, 13, pp.350–358

357

Source of funding

This article presents independent research com-

missioned by the UK National Institute for

Health Research Service Delivery and Organi-

zation Programme. The views expressed in this

publication are those of the authors and not

necessarily those of the NHS, the NIHR or the

Department of Health.

References

1 Keeley EC, Boura JA, Grines CL. Primary angio-

plasty versus intravenous thrombolytic therapy for

acute myocardial infarction: a quantitative review of

23 randomised trials. Lancet, 2003; 361: 13–20.

2 Bravo Vergel Y, Palmer S, Asseburg C et al. Is pri-

mary angioplasty cost effective in the UK? Results of

a comprehensive decision analysis. Heart, 2007; 93:

1238–1243.

3 Myocardial Ischaemia National Audit Project. How

the NHS manages heart attacks. Seventh Public

Report. London: Royal College of Physicians, 2008.

4 Department of Health. Our NHS, our Future: NHS

Next Stage Review Interim Report. London: DH,

2007.

5 British Cardiovascular Society. National Infarct

Angioplasty Project (NIAP). Available at: http://

www.bcs.com/pages/news_full.asp?NewsID=2154

2005, accessed 31 July 2008.

6 Black A. Reconfiguration of surgical, emergency, and

trauma services in the United Kingdom. Centralisa-

tion of services is politically impossible. BMJ, 2004;

328: 178–179.

7 Trust P. Reconfiguration of surgical, emergency and

trauma services: patient power may be the way for-

ward. BMJ, 2004; 328: 522–523.

8 Senate of Surgery of Great Britain and Ireland.

Reconfiguration of Surgical, Accident and Emergency

and Trauma Services in the UK. Glasgow: RCSENG-

Professional Standards and Regulation, 2004. Avail-

able at: http://www.rcseng.ac.uk/publications/docs/

reconfiguration.html, accessed 24 July 2008.

9 Gulanick M, Bliley A, Perino B et al. Patients� responses to the angioplasty experience: a qualitative

study. American Journal of Critical Care, 1997; 6: 25–

32.

10 Creswell JW, Plano-Clark V. Designing and Con-

ducting Mixed Methods Research. Thousand Oaks,

CA: Sage Publications, 2007.

11 O�Cathain A, Murphy E, Nicholl J. Integration and publications as indicators of �yield� from mixed methods studies. Journal of Mixed Methods Research,

2007; 1: 147–163.

12 Sampson FC, O�Cathain A, Goodacre S. Feeling fixed and its contribution to patient satisfaction with

primary angioplasty: a qualitative study. European

Journal of Cardiovascular Nursing, 2009; 8: 85–90.

13 Flanagan JC. The critical incident technique.

Psychological Bulletin, 1954; 51: 327–358.

14 Collins K, O�Cathain A. The continuum of patient satisfaction – from satisfied to very satisfied. Social

Science & Medicine, 2003; 57: 2265–2470.

15 Crow R, Gage H, Hampson S et al. The measurement

of satisfaction with healthcare: implications for

practice from a systematic review of the literature.

Health Technology Assessment, 2002; 6: 45–51.

16 O�Cathain A, Thomas KJ. �Any other comments?� Open questions on questionnaires – a bane or a bonus

to research? BMC Medical Research Methodology,

2004; 4: 25.

17 Ritchie J, Spencer L. Qualitative data analysis for

applied policy research. In: Bryman A, Burgess RG

(eds) Analysing Qualitative Data. London: Routledge,

1994: 173–194.

18 MINAP steering group. How the NHS Manages

Heart Attacks. Sixth Public Report on the Myocardial

Infarction National Audit Project (MINAP). London:

Royal College of Physicians, 2007.

19 Darzi A. High Quality Care for all: NHS Next Stage

Review Final Report. London: Department of Health,

2008.

20 Department of Health. Getting Over the Wall. How

the NHS is Improving the Patient�s Experience. London: Department of Health, 2004.

21 Astin F, Closs SJ, McLenachan J et al. The infor-

mation needs of patients treated with primary

angioplasty for heart attack: an exploratory study.

Patient Education and Counselling, 2008; 73: 325–

332.

22 Astin F, Closs SJ, McLenachan J, Hunter S, Priestley

C. Primary angioplasty for heart attack: mismatch

between expectations and reality? Journal of Advanced

Nursing, 2009; 65: 72–83.

23 Radcliffe EL, Harding G, Rothman MT, Feder GS.

�It got right to the spot�. The patient experience of primary angioplasty: a qualitative study. European

Journal of Cardiovascular Nursing. 2009. Online first.

DOI:10.1016/j.ejcnurse.2009.02.001.

24 Guldvog B. Can patient satisfaction improve health

among patients with angina pectoris? International

Journal of Quality in Health Care, 1999; 11: 233–

240.

25 Darzi A. High Quality Care for all: Our Journey so

far. London: Department of Health, 2009.

26 Entwistle VA. When service users�support obscures problems with care: the need for rigorous research

into patients� experiences. Health Expectations, 2009; 12: 117–119.

Patient and carer satisfaction with primary angioplasty, F C Sampson, A O�Cathain and S Goodacre

� 2010 The Authors. Health Expectations � 2010 Blackwell Publishing Ltd Health Expectations, 13, pp.350–358

358

Copyright of Health Expectations is the property of Wiley-Blackwell and its content may not be copied or

emailed to multiple sites or posted to a listserv without the copyright holder's express written permission.

However, users may print, download, or email articles for individual use.