Review for 10.1186/1471-230X-8-25 (2008)

Reviewer's report
Title:Quality of health care and patient satisfaction in liver disease: the
development of the QUOTE-Liver questionnaire
Version: 1Date:5 November 2007
Reviewer: Andrew M Garratt
Reviewer's report:
General
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Major Compulsory Revisions (that the author must respond to before a decision
on publication can be reached)
1. The final sentence in the Background makes a rather strong claim for the new
QUOTE instrument “and deals with all aforementioned methodological issues”. I
would like to see a more detailed description of how the new instrument will
achieve this picking up on each of the methodological issues in turn. However I
take issue with some of the points which follow below.
2. The authors should provide more information relating to data collection within
the Methods section:
(a) Exactly how many patients were asked to take part and how many did take
part in each of the three aspects of data collection?
(b) Were they given the information at the clinic or was it sent to their homes?
(c) When it says that they were invited to take part in just one part of the study
does this mean the focus group, item ranking or selection of items? This needs
clarification.
(d) Were patients given any incentive to take part?
(e) Where did the data collection take place?
(f) What was the role of any researchers that were present in each aspect of data
collection? How many researchers were involved?
3. The levels of missing data should be reported and possibly be included within
a table.
4. Did the authors not consider using factor analysis or principal component
analysis to assess the scale structure of the questionnaire? Perhaps it assesses
more than one aspect of experiences.
5. The QUOTE comprises importance and performance. To what aspects of the
instrument do the tests of internal consistency apply? Why was item-total
correlation not used?
6. The correlation with one item relating to the extent to which the patient would
recommend the same care does not relate that closely to what the QUOTE
purports to measure and happens to be just one test. This requires discussion.
Where there no other variables available for assessing validity including health
status, age, sex? Such comparisons would have to refer to the literature reviews
and large empirical studies that are available as a means of hypothesis
generation.
7. I do not see the value of this type of importance rating and would like to see
some discussion as to how their validity or usefulness might be assessed or
indeed whether such work has been done before. There has been some work
within patient-reported outcomes and quality of life measurement that has found
that such items add little or nothing to the information obtained. Most patients
give quite high rankings of importance to all of the items/areas. It has implications
for response burden and hence there is a need for a study assessing usefulness
in relation to patient experiences/satisfaction measurement. Economists would
prefer to give combinations of responses to items or scales preference or
valuation weightings derived from studies specifically designed to address this
issue. Such weightings reflect preferences for states that have been proposed for
use in cost-utility analysis.
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Minor Essential Revisions (such as missing labels on figures, or the wrong use of
a term, which the author can be trusted to correct)
1. The Background states that there has been “a lack of disease-specific items”.
Disease- or care specific- questionnaires might be a better description. But what
are the advantages and disadvantages of generic and disease-specific
questionnaires. It might be argued that for many patients and aspects of care
delivery, the same aspects of patient experiences are important including for
example, access, information, communication. The QUOTE items selected by
patients are all fairly general questions relating to the consultation.
2. The third paragraph in the Background talks about sub-optimal questionnaires.
This is rather vague and should be changed to “proliferation of questionnaires
with inadequate measurement properties”.
3. The Results states that two disease-specific items were included in the
QUOTE-Liver. There was just one ‘indirect’ disease-specific item within the
questionnaire before these two were included. Why were these two items
included?
4. Is there any support for the guideline of 10% in relation to aspects of care
needing improvement?
5. The first sentence of the Discussion is rather strong for reasons given above. It
is not correct to conclude that the QUOTE is valid after one comparison with
responses to a single item. The sentence should be changed to
“self-administered questionnaire that has evidence for…”.
6. Discussion, paragraph 3. Is there evidence that there is a high standard of
care within the liver centre? If not then something along the lines of “possible
high standards of care” should be inserted. Such a comparison of care that is
referred to in the same paragraph would not be considered ethical. An
opportunistic study comparing a new facility with more advanced care or a before
and after study including some change in care delivery known to improve quality,
might be more feasible.
7. The second paragraph of the Background refers to problems with VAS scales
and single items. Such scales are rarely used as stand alone measures of patient
satisfaction with care. A more important point would be to describe the
differences between measures of patient satisfaction and experiences which ask
more about more concrete experiences of care including for example whether
patients received adequate information or not. It has been argued that such
questions produce data that is not as skewed towards positive ratings.
8. The Results states that the mean importance scores ranged from 4.65 to 1.38.
I could not see these values in Table 2.
9. The footnote to Table 2 which mentions repetition should be included in the
main text with some further clarification.
10. “Satisfying” should be replaced for “satisfactory” in the second sentence of
the Abstract Results.
11. The last sentence of the Abstract Results should read “The reliability of the
QUOTE-…”
12. QUOTE is misspelt in places.
13. “Subjects” and “patients” are used within the article. Please stick with one to
avoid confusion.
14. At the top of page 5 “…like their validity” should be changed to “including
their validity…”.
15. Page 7, paragraph 2. “chose” should be replaced by “aimed”.
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Discretionary Revisions (which the author can choose to ignore)
What next?: Unable to decide on acceptance or rejection until the authors have
responded to the major compulsory revisions
Level of interest: An article of importance in its field
Quality of written English: Acceptable
Statistical review: No, the manuscript does not need to be seen by a
statistician.
Declaration of competing interests:
I declare that I have no competint interests.