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ORIGINAL ARTICLE

Testing a New Theory of Patient Satisfaction WithTreatment Outcome

Pamela L. Hudak, BScPT, PhD,* Sheilah Hogg-Johnson, PhD,† Claire Bombardier, MD,‡Patricia D. McKeever, RN, PhD,§ and James G. Wright, MD, MPH, FRCPC�

Objectives: Theories of patient satisfaction with treatment outcomehave not been developed and tested in healthcare settings. Theobjectives of this study were to test a new theory linking patientsatisfaction and embodiment (body–self unity) and examine it inrelation to other competing theories.Design: We conducted a prospective cohort study.Setting: This study was conducted at a tertiary care hospital.Patients: We studied 122 individuals undergoing elective handsurgery.Methods: Satisfaction with treatment outcome approximately 4months after surgery was examined against the following factors(representing 7 theories of satisfaction): 1) overall clinical outcome,2) patients’ a priori self-selected important clinical outcomes, 3)foresight expectations, 4) hindsight expectations, 5) psychologicstate, 6) psychologic state in those with poor outcomes, and 7)embodiment.Analysis: Seven hypotheses were tested first using univariateanalyses and then multivariable regression analysis.Results: Satisfaction with treatment outcome was significantlyassociated with embodiment. Three confounders—the extent towhich surgery successfully addressed patients’ most important rea-son for surgery, hindsight expectations, and workers’ compensa-tion—were also significant. The final model explained 84% of the

variance in a multidimensional measure of satisfaction with treat-ment outcome.Conclusion: This research suggests that satisfaction with treatmentoutcome could be facilitated by developing strategies to improvebody–self unity, and eliciting and addressing the patient’s mostimportant reason for undergoing treatment.

Key Words: patient satisfaction, cohort study, hand surgery,theory, embodiment

(Med Care 2004;42: 726–739)

Patient satisfaction is influential in today’s healthcare en-vironment and has recently been linked in the United

States with physician reimbursement (LA Times, July 10,2001). Although literature on patient satisfaction is extensive,relatively little attention has been given to developing ortesting theories for the healthcare setting. Expectancy–dis-confirmation theory from the consumer behavior and market-ing literature, proposing a direct relationship between satis-faction and the fulfillment of expectations, has been adominant theory in health care.1 In contrast to the generalbelief of a strong link between satisfaction and the fulfillmentof expectations,2,3 some prior research on patient satisfactionwith care found this relationship to be relatively weak.4

Clinicians generally want their patients to be satisfied,provided their healthcare needs have been appropriately met.However, the means to achieve satisfaction have been elusivein light of competing and unproven theories. For example,should clinicians focus on eliciting and meeting patients’expectations, or seek out and address aspects of personality ormental health? In prior work,5,6 we proposed a new theorylinking patient satisfaction with treatment outcome to statesof embodiment. “Embodiment,” used in place of “body,”emphasizes the body as a site of meaningful experience, andnot as a physical entity separate from the mind or self.7 Thistheory proposed that in relation to treatment outcome, satis-faction is experienced as a relative lack of tension (or dis-unity) between one’s sense of self and the affected body part.In our study of patients undergoing hand surgery, satisfaction

From *St. Michael’s Hospital, and Health Policy, Management and Evalu-ation, University of Toronto, the †Institute for Work & Health, andHealth Policy, Management and Evaluation, University of Toronto, the‡Department of Medicine, the Institute for Work & Health and Univer-sity Health Network, University of Toronto §Public Health Sciences,Family and Community Medicine, and the Joint Centre for Bioethics,University of Toronto, and �Health Policy, Management and Evaluation,and Public Health Sciences, University of Toronto, and PopulationHealth Sciences, The Hospital for Sick Children, Toronto, Ontario,Canada.

Dr. Wright was supported as an Investigator of the Canadian Institute forHealth Research. This research was supported in part by the PhysicalMedicine Rehabilitation Foundation through a Woodbridge ResearchGrant, and by the Physiotherapy Foundation of Canada through an AnnCollins Whitmore Memorial Award to P. L. Hudak.

Reprints: Pamela L. Hudak, BScPT, PhD, Department of Medicine, St.Michael’s Hospital, 4-036, Queen Wing, 30 Bond Street, Toronto,Ontario M5B 1W8, Canada. E-mail: [email protected].

Copyright © 2004 by Lippincott Williams & WilkinsISSN: 0025-7079/04/4208-0726DOI: 10.1097/01.mlr.0000132394.09032.81

Medical Care • Volume 42, Number 8, August 2004726

with treatment outcome meant having a hand that could belived with unself-consciously.

Because studies comparing theories of patient satisfac-tion in a prospective, quantitative fashion are lacking, thisstudy was designed to test a new theory linking patientsatisfaction with treatment outcome and embodiment, and toexamine this theory in relation to other theories of satisfac-tion.

METHODS

Overview of StudyWe began by constructing 7 hypotheses based on 6

existing theories of satisfaction and a seventh based on ourqualitative study (Fig. 1 and Table 1).8–14 From the start, 12variables were of interest: 5 patient characteristics (age, sex,income, educational attainment, history of a workers’ com-pensation claim for their hand condition), 5 variables repre-senting the 7 theories (clinical outcome, foresight and hind-sight expectations, embodiment, psychologic state), andsatisfaction with care. Some variables (eg, expectations) canbe evaluated in several different ways. We anticipated thatwithin a particular theory, the multiple proposed measureswould be highly correlated. Thus, to minimize multicollinear-ity, the first part of the analysis involved selection of a singlemeasure for some of the original 12 variables using a range ofstatistical procedures (correlation matrices, partial correla-tions, proportions, and general linear regression models). Thesecond part of the analysis involved building a multivariablemodel of satisfaction with treatment outcome using regres-sion analysis.

Study PopulationConsecutive patients scheduled for elective hand sur-

gery from February 1999 to January 2000 in a hospital-based

program specialized in hand disorders were approached toparticipate. Ethics approval for the study was obtained and allpatients provided written informed consent. Eligible patientswere at least 18 years of age and able to complete surveys inEnglish. Excluded patients were those with malignancy or acongenital hand abnormality (because the nature and prog-nosis for these patients differs from those having electivesurgery), patients undergoing carpal tunnel release surgery(because of competing demands with a randomized trial), andthose undergoing emergency procedures (eg, digital replan-tations) or minor surgical procedures (eg, ganglion removal).Patients were interviewed within 1 month before and approx-imately 4 months after surgery.

Independent VariablesMultiple measures of some variables were included in

the baseline survey because literature supporting the choiceof any particular measurement approach was often lacking.Measures are detailed subsequently and in Tables 2 and 3.

Overall Clinical OutcomeDisease-specific health status was measured using the

qkDASH15,16 plus an additional item on acceptability of thehand’s appearance. Patients and clinicians also globally ratedclinical outcome on 5-point scales with response optionsranging from unacceptable to excellent.

Patients’ Self-Selected Important ClinicalOutcomes

Patients rated the extent to which surgery successfullyaddressed their most and second most important reasons forhaving surgery on a 5-point scale with response optionsranging from “not at all” to “completely.” These self-selectedreasons were identified by patients before surgery from a listof 18 possible reasons for having hand surgery (Appendix 1).

Foresight Expectations (Fulfillment andDiscrepancy)

Single-item measures of expectations for outcomes ofinterest (referred to here as foresight expectations whencollected a priori) were based on relevant theories, clinicaljudgment, and existing literature17–20 (Table 3). Foresightexpectations were evaluated in 2 ways: 1) according tofulfillment theory, satisfaction is the algebraic differencebetween patients’ rating of outcome after surgery and theirexpectations about outcome formed before surgery; and 2)according to discrepancy theory, the same algebraic differ-ence described for fulfillment theory is divided by expecta-tions formed before surgery. Foresight expectations calcu-lated according to fulfillment and discrepancy theoryincluded: 1) how patients expected to be after surgery withregard to each of the qkDash items; 2) to what extent patientsexpected surgery would successfully address their most and

FIGURE 1. Modification of cognitive and affect-augmentedconsumer satisfaction/dissatisfaction model.

Medical Care • Volume 42, Number 8, August 2004 A New Theory of Patient Satisfaction

© 2004 Lippincott Williams & Wilkins 727

second most important reasons for having surgery; and 3)global expectations of their hand condition after surgery, theirsurgeon, and hand therapist and, finally, of themselves interms of participating in their recovery.

Hindsight ExpectationsHindsight expectations were determined by asking after

surgery about the extent to which patients perceived theirexpectations had been met using a better-than, worse-thanheuristic. Two items were constructed to assess patients’hindsight expectations about their hand condition (Table 2).

Responses were coded as 1 � much or somewhat better thanexpected (positive disconfirmation), 2 � as expected (simpleconfirmation), and 3 � much or somewhat worse than ex-pected (negative disconfirmation).

Psychologic StatePatients completed 1) the Multidimensional Health

Locus of Control Scale,21 3 8-item scales that assesspatients’ beliefs that health-related behaviors are primarilyinternal, a matter of chance, or under the control ofpowerful others; 2) the Life Orientation Test,22 an 8-item

TABLE 1. Hypotheses and Associated Theories

Hypothesis Origin

Overall Clinical Outcome1. Satisfaction will be higher (lower) for better (worse)

clinical outcome.Performance Theory: Prior expectations do not matter; actual

performance will overwhelm any psychologic responsetendencies related to expectations (Oliver & DeSarbo 1988,Olshavsky & Miller, 1972).

Clinical Outcome: Most Important Reason2. Satisfaction will be high as long as there are favorable

evaluations for either the majority or most importantattributes.

Disjunctive Model: Not all attributes need to be considered.“Brands” are rated high only when seen as superior on 1 ormore relevant attributes (Day, 1972).

Foresight Expectations3. Satisfaction will vary positively with the extent to

which perceived outcome concurs with preoperativepredicted expectations.

Fulfillment Theory: Satisfaction is the difference between actualoutcome and some other ideal or other desired outcome(Lawler, 1971, Linder-Pelz, 1982).

Discrepancy Theory: Satisfaction is the difference between actualoutcome and some other ideal or other desired outcome, alldivided by the ideal or other desired outcome.

Hindsight Expectations4. The effect of expectations on satisfaction will be

strongest when expectations are disconfirmed;satisfaction will be highest if “better than expected”(positive disconfirmation), then “as expected” (simpleconfirmation) and finally “worse than expected”(negative disconfirmation).

Expectancy–Disconfirmation Theory: Patients form expectationsof surgical outcome before surgery. Subsequent surgery revealsactual outcome, which is then compared with expectation levelsusing a better-than, worse-than heuristic (modification of Oliver& DeSarbo, 1988).

Psychologic Measures5. Satisfaction will be highest for those with high

psychologic well-being regardless of whether outcomeis good or poor.

Blalock et al (1988) demonstrated satisfaction was stronglyrelated to psychologic well-being even after controlling forphysical impairment in patients with rheumatoid arthritis.

Psychologic State and Poor Outcome6. The effect of psychologic well-being will be strongest

in individuals with poor outcome; satisfaction will behigher for those with high psychologic well-being/pooroutcome than low psychologic well-being pooroutcome.

Interaction between psychologic well-being and outcome. Relatedto common perception that some individuals’ psychologicprofile predisposes them to being satisfied regardless ofoutcome (and vice versa).

Body–Self Unity7. The proportion of patients who are satisfied will be

highest among patients who experience the lived body,followed by cultivated immediacy, and those movingfrom object body to cultivated immediacy. Theproportion of patients who are satisfied will be lowestamong patients who experience the object body.

Based on qualitative findings of an association between body–selfunity (Gadow, 1980) and satisfaction with the outcome of handsurgery (Hudak, 2002).

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measure of dispositional optimism; and, 3) the Self-Con-sciousness Scale,23 a 23-item measure with 3 subscales onsocial anxiety, private and public self-consciousness. De-pression was measured using the Current Health Assess-ment from the American Academy of Orthopaedic Sur-geons’ Arm, Shoulder and Hand Outcomes DataCollection Instrument.24

Psychologic State and Poor OutcomeAn interaction between psychologic state and clinical

outcome was analyzed because of the lay perception thatsome people are dissatisfied no matter what is done for orwhat happens to them.

EmbodimentPatients were asked at follow up to select 1 of the 5

groups of statements reflecting different states of embodimentwhich best described how they felt about their hand most of

the time (Appendix 2). In brief, the lived body is the experi-ence of taking the body for granted and not thinking about it(unity of body and self); the object body is the experience ofopposition or disunity between body and self, accompaniedby intense conscious awareness of the body; cultivated im-mediacy is when the altered body and self remain distinct butare no longer opposed because injury or limitation is incor-porated; the subject body is when the body or body part is nolonger perceived as problematic and is attributed with sym-bolic meaning.8,14

Other VariablesWe also considered the following: 1) sociodemographic

variables: sex, marital status, highest educational attainment,household annual income (before tax), and history of work-ers’ compensation claim for the hand condition; and 2)satisfaction with care, assessed separately from satisfaction

TABLE 2. Single-Item Measures of Expectations

Foresight Expectations,Fulfillment Theory Items

Most important reasons To what extent did your hand surgery successfully address your most important reason? MINUS To whatextent do you think having surgery will successfully help your most important reason? (1 � not at all,2 � a little, 3 � moderately, 4 � a lot, 5 � completely, 6 � not sure/no opinion)

qkDash items (eg., item“open a tight or newjar)

How would you rate your ability to “open a tight or new jar” in the last week? (after surgery) MINUSOnce you have recovered from surgery and your hand or wrist is as good as it is going to be, howmuch difficulty do you expect to have opening a tight or new jar? (1 � no difficulty, 2 � milddifficulty, 3 � moderate difficulty, 4 � severe difficulty, 5 � unable)

Hand condition To what extent has surgery been successful in treating your hand or wrist problem? MINUS To whatextent do you think surgery will be successful in treating your current hand or wrist problem? (1 � notat all, 2 � a little, 3 � moderately, 4 � a lot, 5 � completely, 6 � not sure/no opinion)

Surgeon and therapists To what extent did your surgeon provide the treatment and care you expected from him or her? MINUSTo what extent do you think your surgeon will provide the treatment and care you expect from him orher? (1 � not at all, 2 � a little, 3 � moderately, 4 � a lot, 5 � completely, 6 � not sure/no opinion)

Self To what extent do you think you were able to do what your surgeon and therapists recommended aftersurgery? MINUS To what extent do you think you will be able to do what your surgeon and therapistrecommend after surgery? This could include going for hand therapy, doing exercises, wearing a splint,resting your hand. (1 � not at all, 2 � a little, 3 � moderately, 4 � a lot, 5 � completely, 6 � notsure/no opinion)

Foresight Expectations,Discrepancy Theory

As per Foresight Expectations, Fulfillment Theory (above) but divided by the preoperative predictedexpectation

Hindsight ExpectationsHand condition Version A: “Considering how your hand was before surgery (either as a result of an accident or disease,

and your age), is your hand better or worse than you thought it actually would be?” (1 � much betterthan I expected, 2 � somewhat better than I expected, 3 � about what I expected, 4 � somewhatworse than I expected, 5 � much worse than I expected, 6 � no opinion/did not have any expectations)

Version B: “Right now, compared with before surgery, my hand/wrist is. . .1 � back to what is “normal”for me, 2 � my hand/wrist is much better, 3 � my hand/wrist is somewhat better, 4 � my hand/wristhas not changed—it is the same as it was before surgery, 5 � my hand/wrist is somewhat worse, 6 �my hand/wrist is much worse, 7 � not really sure; I feel it is too early to say, 8 � something else(please specify)



with treatment outcome using the 8-item Client SatisfactionQuestionnaire.25

Dependent VariableSatisfaction With Treatment Outcome

Satisfaction with outcome was measured using a sum-mated 9-item measure (Appendix 3). Items were scored on a7-point scale ranging from extremely satisfied to extremelydissatisfied, with higher values representing less satisfaction.This measure has good internal consistency (alpha coefficient� 0.89), a small ceiling effect (6%), a reasonable distributionof scores, and was derived from insights generated in thequalitative study. In particular, the qualitative findings high-lighted how satisfaction with treatment outcome was influ-enced by the social and symbolic meaning of the involvedbody part, aspects of satisfaction not included in other mea-sures of this construct.

Statistical AnalysesData were entered and analyzed using SPSS, version

9.0. Hypotheses were tested first using univariate analyseswith global satisfaction (All things considered, how satisfiedare you with the results of your hand surgery?) as thedependent variable. We first selected a single measure forthose variables that could be measured in different ways.Multivariable linear models were then constructed to examinethe relationship between satisfaction with treatment outcome

and embodiment, a 5-level categorical variable. Because ageand education have been associated with satisfaction withcare,26,27 all models included these as covariates. Potentialconfounders considered included demographics (sex and ed-ucation), satisfaction with care, workers’ compensation, andmeasures related to the competing theories (success of sur-gery in addressing patients’ important reasons, foresight andhindsight expectations, and psychologic state). First, correla-tion coefficients were computed between all the potentialindependent variables using Spearman rank correlation. Ad-justment was made for confounders that changed any regres-sion coefficients associated with embodiment by �10%.Because the study was planned around 12 variables, between100 and 120 patients were sought.28 Finally, the marginal andpartial contributions of the main theories of satisfaction wereconsidered by calculating 3 R2 values for each: 1) the mar-ginal R2 (reflecting that theory alone); 2) the R2 value for eachindividual theory with adjustment for age, education, andworkers’ compensation; and 3) the partial R2 (reflecting theunique contribution of each theory once all covariates andcompeting theories have been accounted for).

RESULTS

Response RatesOf 201 eligible patients, 138 (69%) returned completed

baseline questionnaires. Of the 63 nonrespondents, 35 ini-

TABLE 3. Multi-item Measures

Title Construct Source Population Scoring Response OptionsNumber of

Items Reliability Validity

qkDASH (shortversion ofDisabilities ofthe Arm,Shoulder &Hand OutcomeMeasure)

Upper extremitydisability andsymptoms

Beaton et.al., 2001

Adults withupperextremitymusculoskeletaldisorders

12–60 1 � no difficulty; 5� unable

11 (plus 1item onappearanceof handfor thisstudy)

Cronbach’s alpha �0.94; Test–retest(twice before (3–5-day interval)and twice aftertreatment (@ 4and 12 weeks) �0.94

Construct andresponsiveness(standardizedresponse mean �0.96)

Generalizedoutcomeexpectancies

Dispositionaloptimism

Scheier &Carver,1985

Male andfemaleuniversityundergraduates

0–32 4-point ordinal; 4� stronglyagree; 0 �strongly disagree

8 items, 4fillers

Cronbach’s alpha �0.76; Test–retest(4-week interval)� 0.79

Structure supportedby factoranalysis;convergent,discriminant andconstruct validity

MultidimensionalHealth Locusof ControlScales

Beliefs aboutsource ofreinforcementfor health-relatedbehaviors:internal,chance, andpowerful others

Wallston,Wallston,andDeVellis,1978

Persons �16yrs. waitingat ametropolitanairport

18–108(6–36for eachsubscale)

6-point Likert-type;1 � stronglydisagree; 6 �strongly agree

3–6-itemsubscales;2 forms

Cronbach’s alpha:0.67–0.77

Convergent,divergent andconstruct

Self-ConsciousnessScale

Public and privateself-consciousness,and socialanxiety

Fenigstein,Scheierand Bus,1975

Male andfemaleuniversityundergraduates

0–92 4-point ordinal; 0� extremelyuncharacteristic;4 � extremelycharacteristic

23 Test–retest (2-weekinterval) � 0.80for total score

Structure supportedby factoranalysis; someconstruct

Client SatisfactionQuestionnaire-8 (CSQ-8)

Satisfaction withservices

Larsen etal.,1979;Tuan etal., 1983

Outpatientmentalhealthclients in 5settings

8–32 4-point ordinal;anchors varywith item (eg., 1� poor, 4 �excellent)

8 Coefficient alpha �0.93

Structure supportedby factoranalysis; someconstruct



tially declined and 28 agreed but subsequently did not par-ticipate because of lack of time, forgetfulness, or a change ofmind. Of the 138, 122 (87%) completed the follow-up ques-tionnaire. Clinician global ratings of clinical outcome wereavailable for 88 (72%) of the 122. Sociodemographic char-acteristics of the sample are shown in Table 4.

Hypothesis 1: Satisfaction will be higher for betteroverall clinical outcome.

All measures of clinical outcome were significantlycorrelated with each other (r � 0.58–0.86, P �0.01,2-tailed). The highest correlation with patients’ global satis-faction was with patients’ global rating of clinical outcome(0.86). The strong association between satisfaction and allclinical outcomes provided support for Hypothesis 1.

Hypothesis 2: Satisfaction will be high as long asthere are favorable evaluations for either themajority or most important attributes.

To operationalize this hypothesis, we used patients’self-selected most and second most important reasons forhaving surgery. Success for the most and second most im-portant reasons was highly correlated (0.86). Patients’ globalsatisfaction was also correlated with the success of surgery ataddressing patients’ most and second most important reasons(0.81 and 0.72, respectively). The correlation between globalsatisfaction and patients’ second most important reason, con-trolling for most important reason (partial correlation test),drops to 0.22 (P � 0.02) indicating that although the firstmost important reason was overwhelming in its ability toexplain satisfaction, a small amount of variance was ex-plained by the second most important reason. Thus, there wassupport for Hypothesis 2.

Because all measures of clinical outcomes—patient andsurgeon global ratings of clinical outcome, qkDASH score,and success of surgery at addressing patients’ most andsecond most important reasons—were significantly highlycorrelated (r � 0.58–0.86), we needed to choose 1 for themultivariable regression analysis. We choose patients’ ratingof the success of surgery in addressing their most importantreason because this measurement approach was individual-ized and explicit.29

Hypothesis 3: Satisfaction will vary positively withthe extent to which perceived outcome concurswith preoperative predicted expectations.

Fulfillment variables (outcome minus preoperative ex-pectations) for the most and second most important reasonswere highly correlated with each other (0.78) and, among the6 fulfillment variables, had the highest correlations withglobal satisfaction with outcome (0.69 and 0.64).

For all discrepancy variables, the correlations withglobal satisfaction with outcome were slightly lower than for

the fulfillment variable (eg, for the most important reason,fulfillment variable � 0.69 and discrepancy variable � 0.67).Thus, there was support for Hypothesis 3 using either fulfill-ment or discrepancy theory.

The differences between fulfillment and discrepancytheory variables were small, and thus there was no clearindication that 1 theory was superior. Because the calculation

TABLE 4. Frequency Distribution of SociodemographicCharacteristics

VariablesFrequency

(percentage of total)

Age group (yr)�20 3 (2.2%)20–39 52 (37.6%)40–59 57 (41.3%)60� 26 (18.8%)Total 138 (100%)

SexMen 72 (52.2%)Women 66 (47.8%)

Marital statusSingle 27 (19.75)Married/common law 88 (64.2%)Separated/divorced 15 (10.9%)Widowed 7 (5.1%)

Household income ($)No income 5 (4.0%)�19,999 20 (15.9%)20,000–39,000 36 (28.6%)40,000–59,000 25 (19.8%)60,000–79,000 15 (11.9%)80,000� 25 (19.8%)

EducationHigh school not completed 26 (19.4%)High school 27 (20.1%)Some postsecondary 27 (20.1%)Postsecondary 54 (40.3%)

Employment statusWorking 47 (34.3%)On disability 46 (33.6%)Not working 13 (9.5%)Other 31 (22.6%)

Previous hand surgeryYes 80 (61.5%)No 50 (38.5%)

History of Workers’ CompensationBoard claim

Yes 52 (40.0%)No 78 (60.0%)



of fulfillment variables is computationally simpler, the ful-fillment variable for the most important reason for havingsurgery was used in the multivariable regression analysis.

Hypothesis 4: The effect of expectations onsatisfaction will be strongest when expectations aredisconfirmed; satisfaction will be highest if ‘betterthan expected’ (positive disconfirmation), then ‘asexpected’ (simple confirmation), and finally ‘worsethan expected’ (negative disconfirmation).

The interaction between hindsight expectations andglobal satisfaction with outcome was tested using the ques-tion “Considering how your hand was before surgery, is yourhand better or worse than you thought it would be?” A 1-wayanalysis of variance test showed a significant difference (F �50.7, df � 2,117, P �0.01) on global satisfaction between the3 groups: positive disconfirmation (mean � 1.67, standarddeviation �SD� � 0.79), simple confirmation (mean � 2.29,SD � 0.94), and negative disconfirmation (mean � 4.29, SD� 1.67), with the gradient as anticipated. Thus, there wassupport for Hypothesis 4.

There was only a moderate correlation (r � 0.53)between the hindsight expectation and a parallel foresightfulfillment expectation approach, suggesting these questionsmight tap somewhat different phenomena. Thus, a variablerepresenting each approach was included in the multivariableregression analysis.

Hypothesis 5: Satisfaction will be highest for thosewith positive psychologic states regardless ofwhether outcome is good or poor.

Correlations between global satisfaction and all mea-sures of psychologic state (comorbidity scale, presence ofdepression, generalized outcome expectancies, subscales ofthe health–belief locus of control measure and self-con-sciousness scale) were very low (r � -.067–.108) and notstatistically significant. Thus, there was no support for Hy-pothesis 5.

Hypothesis 6: The effect of psychologic state willbe strongest in individuals with poor outcome.

TABLE 5. Spearman Correlation Coefficients and P-Value Between All Independent Variables

EmbodimentAge(yrs) Income Sex Education

Successof

SurgeryForesight

Expectations*Hindsight

Expectations†

InternalHealthLocus

ofControl

SatisfactionWith Care

Workers’Compensation

Status

Embodiment —Age (yrs) �0.16 —

0.09Income �0.13 0.22 —

0.2 0.01Sex 0.03 0.14 0.07 —

0.7 0.11 0.5Education �0.09 �0.16 0.27 0.04 —

0.3 0.07 0.002 0.7Success of �0.65 0.29 0.03 0.02 �0.02 —

surgery �0.0001 0.002 0.7 0.8 0.8Foresight �0.44 0.18 �0.06 0.05 �0.14 0.80 —

expectations �0.0001 0.05 0.6 0.6 0.14 �0.0001Hindsight 0.53 �0.10 0.18 �0.12 �0.05 �0.61 �0.56 —

expectations �0.0001 0.27 0.06 0.20 0.6 �0.0001 �0.0001Internal health �0.06 �0.06 �0.05 �0.33 �0.018 �0.09 �0.07 0.11 —

locus ofcontrol

0.5 0.5 0.6 �0.0001 0.8 0.3 0.5 0.2

Satisfaction �0.54 0.06 �0.02 �0.015 �0.13 0.45 0.36 �0.40 0.12 —with care �0.0001 0.5 0.8 0.87 0.2 �0.0001 �0.0001 �0.0001 0.2

Workers’ 0.41 �0.23 �0.29 �0.15 �0.29 �0.38 �0.21 0.21 0.04 �0.09 —Compensationstatus

�0.0001 0.01 0.002 0.09 0.001 �0.0001 0.02 0.02 0.7 0.3

Note: All tests of statistical significance are 2-tailed. P values are shown below the correlation coefficients.*Foresight expectation (A) � “To what extent did your hand surgery successfully address your most important reason?” (postop) — “To what extent do

you think having surgery will successfully help your most important reason?” (preop) (1 � not at all; 5 � completely).†Hindsight Expectation (A) � “Considering how your hand was before surgery (either as a result of an accident or a disease, and your age), is your hand

better or worse than you thought it actually would be?” (1 � much better than I expected; 5 � much worse than I expected).



The only significant interaction between clinical outcomeand psychologic state in a linear regression analysis was be-tween global outcome and the internal subscale of the healthlocus of control scale (IHLC; P � 0.02). This interaction,however, was significant only for the midrange, with IHLCplaying no role for ratings of either very successful or pooroutcome. Surprisingly, in the midrange, those with high IHLCwere generally less satisfied. Thus, there was no support forHypothesis 6.

Hypothesis 7: The proportion of individuals whoare satisfied will be highest for those describingcultivated immediacy (harmony between bodyand self) and lived body states, and lowest forthe object body state (disunity between body andself).

The 7-point satisfaction scale was dichotomized for thistest, with those patients who were somewhat, very, or ex-

TABLE 6. Multiple Regression Results for Satisfaction With Treatment Outcome and Its Relationship to Embodiment

Variable

Adjusted Only for Covariates Age andEducation

Adjusted for Covariates � Success ofSurgery, Hindsight Expectations, and

Workers’ Compensation Claim History

�Standard

Error P Value �Standard

Error P Value

Intercept 2.79 0.38 �0.0001 4.30 0.35 �0.0001Embodiment overall P value for embodiment �0.0001 overall P value for embodiment �0.0001

Lived body �0.77 0.29 0.01 �0.39 0.21 0.06Subject body 0.0 — — 0.0 — —Cultivated immediacy 0.05 0.35 0.9 �0.02 0.25 0.9OB to CI* 0.90 0.28 0.002 0.31 0.21 0.1Object body 2.23 0.35 �0.0001 1.29 0.26 �0.0001

Age �0.015 0.006 0.01 �0.004 0.004 0.4Education overall P value for education 0.1 overall P value for education 0.3

High School not completed 0.51 0.24 0.04 0.28 0.17 0.1High School 0.40 0.24 0.09 0.22 0.17 0.2Some postsecondary 0.13 0.21 0.5 0.08 0.15 0.6Postsecondary 0.0 — — 0.00 — —

Success, most important reason �0.44 0.07 �0.0001Hindsight expectations overall P value for expectations �0.0001

Better than expected �0.52 0.19 0.0063As expected �0.60 0.15 0.0001Worse than expected 0.0 — —

Workers’ Compensation claimhistory

0.36 0.14 0.01

*OB to CI, transition from Object Body to Cultivated Immediacy state

TABLE 7. Marginal and Partial R2 Values Explained by Various Theories of Satisfaction

Main Theories Marginal

Covariates (age, education,Workers’ Compensation

status) Plus Theory

Partial Contribution (afteraccounting for covariates

and all other theories)

Embodiment 61.3 67.1 8.9Success, most important reason 63.9 69.2 4.8Foresight expectations 34.4 53.3 0.2Hindsight expectations 44.2 60.8 3.0Psychologic state (internal health

locus of control)0.4 31.7 0.0



tremely satisfied categorized as “satisfied” and all others as“dissatisfied.” The proportion of satisfied patients was 97%for the lived body, 83% for cultivated immediacy, 63% forthose in transition from the object body state to cultivatedimmediacy, and 36% for the object body. Thus, these findingsprovide support for Hypothesis 7.

Multivariable ModelVariables eligible for the multivariable model included

embodiment (the main explanatory variable), age and educa-tion (as covariates) and sex, income, success of surgery inmeeting patient’s most important reason, foresight and hind-sight expectations, health locus of control (internal subscale),satisfaction with care, and workers’ compensation (as poten-tial confounders). The correlation matrices for these variablesare shown in Table 5. Of note, embodiment, success ofsurgery, foresight and hindsight expectations, and satisfactionwith care all correlated at least moderately with pairwiseSpearman correlations of 0.40 and above. The final regressionresults are shown in Table 6. Success of surgery in addressingpatients’ most important reason, hindsight expectations, andworkers’ compensation were identified as confounders be-cause they altered at least 1 regression coefficient by at least10%. Controlling for confounders attenuated the coefficientsfor embodiment to some extent, although the general trendremained the same after adjustment. The coefficients forembodiment indicated that patients in the object body statewere least satisfied (� � 1.29; 95% confidence interval �CI�,0.78–1.80). That group is followed by, in order from least tomost satisfied, patients in transition from object body tocultivated immediacy (� � 0.31; 95% CI, �0.10–0.72),cultivated immediacy (� � �0.02; 95% CI, �0.51–0.47),subject body (reference group, � � 0.00), and lastly livedbody (� � �0.39; 95% CI, �0.80–0.02). This order matchesHypothesis 7. In the final model, 3 confounders—success ofsurgery, hindsight expectations, and workers’ compensa-tion—were also significantly associated with the outcome.The more surgery successfully addressed a patient’s mostimportant reason, the higher their satisfaction with outcome(� � �0.44; 95% CI, �0.58–�0.30). People whose out-comes were better than expected (� � �0.52; 95% CI,�0.89–�0.15) or as they expected (� � �0.60; 95% CI,�0.89–�0.31) expressed greater satisfaction than thosewhose outcomes were less than expected (reference group, �� 0.00). Lastly, those with a history of workers’ compensa-tion expressed less satisfaction (� � 0.36; 95% CI, 0.09–0.63). In summary, the model explained 84% of the variancein satisfaction with treatment outcome.

Table 7 shows the marginal and partial R2 analysis.Marginally, success of surgery in addressing patients’ mostimportant reason demonstrated the strongest relationship withsatisfaction, but the partial R2 values indicate high correla-tions between measures of the competing theories. Neverthe-

less, embodiment demonstrated the highest partial R2 value,indicating a small unique contribution from this theory overand above the others.

DISCUSSIONThis study is unique because it tested multiple theories

underlying patient satisfaction with treatment outcome usinga prospective cohort of patients undergoing elective handsurgery. The finding of our prior qualitative study of arelationship between perceived states of embodiment andsatisfaction with treatment outcome was confirmed. Under-standing satisfaction in this way provides a potential expla-nation for occasions when the relationship between satisfac-tion with treatment outcome and clinical outcome isparadoxical (ie, clinical outcome is judged by health provid-ers to be poor, but the patient is satisfied and alternatively,when clinical outcome is considered excellent, but the patientis dissatisfied). If body–self unity (ie, cultivated immediacy)can be achieved after surgery independent of a good clinicaloutcome, a patient could be satisfied even when their out-come is poor. This study not only provides evidence of a rolefor embodiment in explaining patient satisfaction with treat-ment outcome, but also suggests that interventions facilitatingembodiment could be usefully pursued.

The relationship between satisfaction with treatmentoutcome and embodiment remains significant but is some-what attenuated by 3 confounding variables: clinical out-come, hindsight expectations, and workers’ compensation.These confounders, which by definition are related to bothsatisfaction with treatment outcome and embodiment, makeclinical sense. First, the relationship to clinical outcome isintuitive and consistent with performance theory from themarketing literature, which proposes a link between attributeperformance (analogous to clinical outcome) and customersatisfaction.eg 30 This finding is supported by a study of 1761episodes of acute primary care,31 where a strong positiverelationship was demonstrated between patient satisfactionand functional outcome. Kane et al.32 also demonstrated thatboth absolute and relative outcomes individually explainedmuch of the relationship between outcomes and satisfaction,but that satisfaction was more closely associated with abso-lute outcomes. Our findings confirm that patients’ absoluteoutcomes play a major role in explaining satisfaction withtreatment outcome. Furthermore, it is not surprising thatclinical outcome could confound the relationship betweenembodiment and satisfaction because we might expect some-one with a good clinical outcome to more readily experiencecultivated immediacy, whereas someone with a poor clinicaloutcome could more readily experience the object body state.

Although the multiple measures of clinical outcomewere highly correlated, we used success of surgery in ad-dressing patients’ most important reason for surgery, which isconsistent with the disjunctive model in the consumer satis-



faction literature.11 In keeping with this perspective, clini-cians should spend time exploring patients’ individual con-cerns, particularly their reasons for pursuing treatment.29

Individual concerns could be useful in choosing or tailoringtreatment. For example, if patients’ most important reasonsfor having treatment are unlikely to be improved, patientscould be counseled appropriately. Furthermore, once identi-fied, these individual concerns could be measured pre- andposttreatment as a measure of treatment effectiveness mostrelevant to patients.29

The significance of hindsight expectations and its roleas a confounder of embodiment also provides support forexpectancy–disconfirmation theory.9 Although it is not clearhow hindsight expectations relate to embodiment, this studydemonstrates that embodiment continues to make an inde-pendent contribution to the model even after accounting forhindsight expectations and offers a potential explanation forpatients who are satisfied with treatment outcome despiteless-than-expected outcomes.

Workers’ compensation was the final confounding vari-able. Evidence of a relationship between workers’ compen-sation and satisfaction with treatment outcome in a handsurgery population was reported by Katz et al., who demon-strated that involvement of an attorney was significantlyassociated with lower satisfaction in patients undergoingcarpal tunnel release.33 An association between workers’compensation and worse outcome after surgery has also beenreported after carpal tunnel release.34,35

This work demonstrates how the generation and testingof theory can be facilitated by the combined use of bothtextual and numeric data. This combination led us to considersatisfaction from different perspectives and generated in-sights that might otherwise have been missed. The qualitativestudy suggested a new conceptualization for patient satisfac-tion with treatment outcome linked to embodiment. Thisconcept had not previously been considered in patient satis-faction research and would not have been identified had it notbeen for the textual data derived from patient interviews. Thecohort study allowed us to subsequently test and confirm thatembodiment was helpful for understanding patients’ expres-sions of satisfaction. The multivariable analysis yielded amore precise estimate of the influence of embodiment onsatisfaction than was available from the patient interviewsalone, and also permitted us to test the influence of embod-iment in the presence of other competing theories, therebyarriving at a sense of its relative strength, which was notavailable from the textual data alone.36,37 Although the find-ings arising from the textual and numeric data can justifiablystand alone, the combined message and consistency of theassociation between satisfaction with treatment outcome andthe view of patients as embodied is exciting.

This study has potential limitations. First, we did notdescribe or account for time-varying changes in satisfaction,

expectations, or embodiment. Time has been highlighted byother researchers.38,39 Longitudinal, prospective studies withrepeated measures are necessary to address time-related is-sues. Second, this work included patients having electivehand surgery. Future work should determine whether thesefindings are generalizable to other clinical populations receiv-ing different treatment interventions to different parts of thebody. Although we suspect that these findings will persistacross populations because many of the same theoreticalissues apply, this should be explored. Measures of satisfac-tion with treatment outcome specifically tailored to particularparts/systems of the body will be required. Finally, we useda standard statistical approach, multivariable regression anal-ysis. An alternative strategy that would be useful in a largercohort is structural equation modeling (SEM). SEM wouldallow the relationship between embodiment and the con-founders identified in this analysis (clinical outcome, hind-sight expectations, and workers’ compensation) to be furtherdeconstructed and causal pathways established.

CONCLUSIONA reconceptualization of patient satisfaction with treat-

ment outcome is suggested by its association with embodi-ment. Also contributing to satisfaction with treatment out-come in this analysis are the extent to which surgerysuccessfully addressed a patient’s most important reason forsurgery, hindsight expectations, and workers’ compensation.Consideration of patients’ embodiment as an important aspectof treatment outcome and individualized approaches to eval-uating patients’ reasons for having surgery should be consid-ered in future satisfaction research.

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Appendix 1 Reasons for Having Hand Surgery

Below are listed possible reasons for having hand surgery.Why are you having your upcoming hand surgery? Please circle

all that apply.I am having surgery because of:1. Pain or discomfort2. Weakness/lack of strength3. Loss of movement/mobility4. Difficulty using my hand(s) in everyday activities5. Difficulty doing my usual job/work6. Difficulty doing household chores (e.g., wash walls, wash

floors)7. Difficulty with hobbies and leisure activities8. Difficulty taking care of my family, children, grandchildren9. Amount of medication that I am taking

10. Lack of confidence using my arm/hand11. How my hand looks12. Possibility of problems with my arm or hand in the future13. To keep my hand problem from getting worse14. Problems with feeling or sensation15. My doctor or surgeon said I should have surgery16. My family or other significant person(s) wanted me to have

surgery17. Other people stare at me and my hand18. Workers Compensation Board recommended that I have

surgery19. Some other reason (please specify)



Appendix 2 Embodiment Profile

Below are a number of statements. These statements are divided into 5 groups.First, please read through all the statements.Then, put a check mark (� ) beside the one group of statements that is closest

to how you feel about your hand most of the time.Group 1 �

“I don’t even know my hand is there”.“My hand is back to normal as far as I’m concerned”.“I rarely or never think about my hand”.

Group 2 �

“I’m very aware of this hand”.“My hand feels like an alien part”.“My hand (or hands or finger) has a mind of its own”.“I hide or cover my hand”.“I still feel as if it’s not like my old hand”.“It seems that my hand(s) are not part of me”.

Group 3 �

“I’ve got to accept my hand the way it is”.“I’m learning how to use my hand more, and just trying to really notconcentrate on the injury itself, but try to adapt my hand to different ways of life”.“I’m going to have to learn to live with my hand the way it is now”.

Group 4 �

“I never realized I could do so many things (either with my injured hand orwith my other hand).”“I’m used to my hand now; it is part of me”.“It’s amazing what you can learn to do”

Group 5 �

“This hand injury (or condition) has led me to personal growth in my life”.“The injury/problem with my hand seemed to be my body’s way of tellingmy something about myself or my life which was, in the end, positive”



Appendix 3 9-item Satisfaction With Treatment Outcome MeasureHow do you feel about your hand surgery and how it turned out? We are interested in your comments, favorable and critical,regarding how satisfied or dissatisfied you are with the result. If you have had more than 1 surgery that involved your arm/wrist or hand, please comment on the most recent surgery only.Please comment in the space below on the result of your hand surgery and your satisfaction or dissatisfaction with the result.Circle 1 answer for each question listed below.

ExtremelySatisfied

VerySatisfied

SomewhatSatisfied

Mixed, AboutEqually Satisfiedand Dissatisfied

SomewhatDissatisfied

VeryDissatisfied

ExtremelyDissatisfied

Part 11. Considering how your

hand was beforesurgery (either becauseof an accident or adisease, and because ofyour age), howsatisfied are you withyour hand’s responseto surgery?

1 2 3 4 5 6 7

2. Considering the wayyour body heals, howsatisfied are you withyour hand now aftersurgery?

1 2 3 4 5 6 7

3. How satisfied are younow, after surgery,with the way yourhand(s) look?

1 2 3 4 5 6 7

Part 21. How satisfied are you

with the effort that youput into your treatmentand therapy after yourhand surgery?

1 2 3 4 5 6 7

2. How satisfied are youwith what you tried todo for yourself andyour hand?

1 2 3 4 5 6 7

Part 31. How satisfied are you

now, after surgery,with the ways in whichyour hand affects yourrelationships with otherpeople (e.g. withpartners, children,workmates, friends)?

1 2 3 4 5 6 7

2. How satisfied are younow with your level ofcomfort with shakinghands, waving,pointing, clapping, orgesturing with yourhands?

1 2 3 4 5 6 7

3. How satisfied are younow with your abilityto take part inactivities that areimportant to you (thiscould be your job,your hobbies, takingcare of your children,socializing easily withfriends and family)?

1 2 3 4 5 6 7

4. How satisfied are youthat you can carry onwith your life (even ifit is different thanbefore your handproblem started)?

1 2 3 4 5 6 7



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