Abstract
Geographical differences exist in patients being offered percutaneous coronary intervention (PCI). Whether such differences are also present in patient experiences with hospital care and treatment is not well-known. This study assesses urban and rural differences in patient-reported experiences with hospital stays, and factors related to satisfaction with care and experienced treatment benefits. A prospective observational study was conducted with patients undergoing PCI (n = 479) who responded to a standardized questionnaire at discharge and after 3 months. Urban and rural grouping was based on travel time by road to PCI-hospitals (less than or ≥1 h). There were no significant geographical differences in patient-reported experiences. Patients reported the lowest scores on information about postdischarge ailments and relapse management, involvement in treatment decisions, and collaboration between the hospital and general practitioner. Healthcare personnel competency, organization, information, admission type, delayed/incorrect diagnosis, among others, predicted satisfaction with care and perceived treatment benefits. These findings offer insight into patient perspectives, areas of improvement in specialized healthcare, and further research on follow-up and collaboration following PCI, all of which are important in ensuring equal and accessible healthcare services within large PCI-hospital catchment areas.
Keywords
Introduction
Coronary heart disease (CHD) is a common cause of death, and patients with this disease often need invasive procedures such as coronary angiography and percutaneous coronary intervention (PCI).1–4 In Norway, approximately 25 500 patients are hospitalized annually for invasive coronary assessment, resulting in approximately 11,700 PCI procedures. 5 The incidence of CHD, including myocardial infarction (MI), is higher in northern Norway than anywhere else in the country. 6 Investigating patient experiences of undergoing PCI can illuminate today's healthcare services, challenges, and potential improvements to increase equity for patients with CHD residing within geographically large hospital catchment areas.
Patient experiences arise from occurrences and events that happen independently and collectively within healthcare, influenced by a person's perception of health, a patient's experience of illness, and healthcare users’ experiences with healthcare systems.7,8 Critical elements of patient experiences include access to care, coordination and integration of care, transition and continuity, emotional support, respect, physical comfort, information, communication and education, and expectations of healthcare.9–11
Attention to patient experiences and outcomes is recommended to monitor and improve the quality of care and inform clinical decisions. 12 Patient-reported experience measures are commonly used to gain insight into patient perspectives and opinions regarding illness and treatment.
Previous Norwegian surveys suggest that patients generally have positive experiences with hospital stays, except regarding the information received and the hospitals’ collaboration with general practitioners (GPs). 13 Factors such as low socioeconomic status, poor health, low education, and low income increase dissatisfaction with healthcare services and reduce access to treatment for cardiovascular diseases. 14 Furthermore, rural Canadian PCI patients were highly satisfied with the standards of care received in the hospital. However, they experienced less quality of care due to pre- and posttreatment transportation issues and inaccessibility to formal cardiac rehabilitation (CR) programs. 15 The authors emphasize the need for innovative strategies that facilitate seamless transitions for individuals commuting to urban areas for interventional cardiology and secondary prevention.
Previous studies have revealed variations in access to PCI treatment and disparities in treatment for patients with MI in northern Norway, as well as low participation rates and geographic variations in CR in Norway.16–18 Other studies call for further research on the challenges confronting patients in rural settings where unstable weather conditions affect access to healthcare professionals and hospitals.19,20
Various definitions of rurality exist. In this study, rurality is defined as having 60 min or more of travel time by road from the place of residence to the PCI-hospital, based on previous research.19,21 The extent to which urban and rural patients differ in their experiences of satisfaction with care and the benefits of PCI treatment, as well as whether differences in access and treatment reflect differences in satisfaction and the benefits of treatment, has, to the best of our knowledge, been sparsely investigated. This study aims to assess urban and rural differences in patient-reported experiences with the hospital stay. Furthermore, this study aims to identify factors related to satisfaction with care and the benefits of treatment experienced by patients undergoing PCI.
Methods
Design and Settings
A prospective cross-sectional observational study was conducted in northern Norway, which is a geographically large Subarctic and Arctic region. In northern Norway, PCI treatment is available at one 24/7 PCI center and 1 daytime-only PCI center, resulting in travel distances of up to 468 km by air and approximately 900 km (13 h) by road for participants. The participants were grouped into urban and rural categories based on the travel time by road (using Google Maps) from their place of residence (postal code) to the PCI center where they received treatment. A 1-h travel time by road to a PCI-hospital is set as the urban–rural cut-off value, as previously mentioned. Two public collaborators contributed by advising on the recruitment strategy, items included in the questionnaire, and pretesting the survey.
Study Population
Specially trained nurses identified and included patients at the 2 hospitals from August 2020 to January 2022, by consecutive sampling. The inclusion criteria were men and women of 18 years or older with a Norwegian social security number who received PCI during admission, with the ability to communicate orally and in written Norwegian and provided informed written consent to participate. The exclusion criteria included other severe diseases, cognitive impairment, and postal codes outside the health region. Elective patients received written information via postal services, along with an invitation to participate, 3 weeks prior to their hospital stay. Acute patients received written and oral information at the hospital after PCI. All participants were registered with an ID in REDCap® upon inclusion to facilitate follow-up procedures. Among the 538 patients who consented to participate, 479 responded to the baseline questionnaire at discharge, and 418 responded at the 3-month follow-up.
Data Collection
Baseline clinical and procedure-related data were retrieved from the hospital's electronic medical records at the time of inclusion. Sociodemographic characteristics were assessed via self-report questionnaires distributed to participants at their home addresses or mailed to them via a secure link from REDCap®, as they preferred. The participants received up to 2 questionnaire reminders to minimize loss to follow-up.
Patient-Reported Experience Measures
Patient experiences were assessed using items from the Patient Experience Questionnaire (PEQ).22–24 The PEQ questionnaires have been described in detail and used on somatically hospitalized patients in general in several Norwegian studies, satisfying the requirements for validity and reliability. Similarly, the overall internal consistency, as measured by Cronbach's alpha, was 0.777. The final questionnaire included the following number of items (in parentheses): overall satisfaction and treatment benefit (2), clinician services (4), user involvement (3), incorrect treatment (7), information (3), collaboration (1), organization (2), and accessibility/waiting time (1). The items’ responses had a 3-, 5-, 6-, or 7-point Likert scale.
Data Management and Statistical Analysis
Scoring and data management, including the recoding of all nonapplicable responses to missing values, were performed according to the guidance of the PEQ authors. 22 Data material was checked for its assumptions, and in the statistical analysis, cases were excluded listwise. 25 Descriptive statistics are presented as frequencies for categorical variables and means and standard deviations (SDs) for continuous variables. To analyze for geographical differences in urban and rural patients, the chi-square test was used for categorical and nominal data, and Student's t-test for means after controlling for normality. 25 Standard multiple linear regression analysis was used to analyze to what extent clinical-, sociodemographic-, and geographical factors, as well as patient experiences, were related to overall satisfaction and experienced treatment benefit. Unadjusted and adjusted analyses were conducted, which ultimately resulted in a final model. The independent variables were age, sex, education, living arrangement, smoking habits, working status, rurality, type of admission, delayed transfer or transport to PCI-hospital, previous cardiac events (MI, PCI, and coronary artery bypass graft), other comorbidities, length of hospital stay, referral to, information about and participation in learning and mastery courses (LMCs) or CR, and other follow-up as well as relevant PEQ items. LMCs are learning and coping skills services offered to patients, users, and next-of-kin following PCI treatment to provide insight into their situation and life after health changes in Norway. 26 The duration of these courses varies between hospitals, ranging from 2 days to longer. The statistical analysis was conducted using IBM SPSS version 29 as statistical software (SPSS Institute, Inc., Chicago, IL, USA).
Ethical Issues
This study conformed to the principles outlined in the Declaration of Helsinki 27 and was approved by the local data protection authorities at the hospitals (2020/1759, 2020/4161). The regional ethics committee assessed the study protocol; however, approving data was not within their mandate. Written informed consent was obtained from the patients for their anonymized information to be published in this article. All participants were informed about the possibility of withdrawing from the study at any time without providing a reason. The study is reported in accordance with the STROBE guidelines (Supplemental 1). 28
Results
The sociodemographic and clinical characteristics of the 479 patients who responded at baseline are presented in Table 1. The typical participant was a 66-year-old male, retired, living with others, and a former smoker with no previous history of CHD or other comorbidities affecting daily life. The urban patient group had higher educational levels, were more often retired, were less unemployed, and had fewer current smokers than the rural group. Most participants experienced acute admission with acute coronary syndrome. There were statistically significant differences between the groups in indications for PCI. Most rural patients had unstable angina or MI, while most urban patients had stable angina.
Baseline Sociodemographic, Clinical, and Event Characteristics and Post-PCI Follow-up at Three-Months.
Abbreviations: MI, myocardial infarction; PCI, percutaneous coronary intervention; CABG, coronary artery bypass graft; NSTEMI, non-ST-elevation myocardial infarction; STEMI, ST-elevation myocardial infarction; LMC, learning and mastery course; CR, cardiac rehabilitation.
Several responses possible.
STEMI, STEMI >24 h, STEMI/RESCUE PCI, and risk assessment after successful thrombolysis.
Preoperative coronary angiography, without suspicion of coronary disease.
Other types of transport: planned admission: walked or driven by family member/neighbor; acute admission: private car (drove by themselves/spouse), taxi, health bus, public or ambulance boat, or used wheelchair.
*P-value from comparing urban and rural groups by independent t-test1 and chi-square test2; confidence interval (CI) on a 95% level.
Statistically significant differences were also found between urban and rural acute patients reporting delays in transport or transfer to PCI-hospitals. Rural patients experienced delays due to weather conditions, reduced air ambulance capacity or resources, or other unknown factors. Three months after discharge, 37% of participants had received postdischarge follow-ups: 64% by a GP, 28% by a hospital physician, and 8% by a nurse. Rural patients received less information about CR or LMC than urban patients.
In patient-reported experiences, there were no statistically significant differences between the urban and rural groups (Table 2 and Supplemental 2: Table 2b). The participants generally reported high scores (mean: 4.2-4.7 out of 5) on satisfaction with the hospital stay and slightly lower scores (mean: 3.1-3.3 out of 5) on information received on what ailments to expect after discharge and how to manage relapses, involvement in decision-making, and hospital collaboration with the GP.
Patient-Reported Experiences With Healthcare Services at Three-Month Follow-Up.
All results are presented as mean (SD).
Response scales: 1 = Not at all; 2 = To a small extent; 3 = To some extent; 4 = To a large extent; 5 = To a very large extent.
Response scale: 1 = No benefit; 2 = Small benefit; 3 = Some benefit; 4 = Large benefit; 5 = Very large benefit.
*P-value from comparing urban and rural groups based on independent t-test; confidence interval (CI) on a 95% level.
The final regression model predicting overall patient satisfaction with care and treatment at the hospital explained 59% of the variance (R2 0.591, F(10, 376) = 54.22, P < .001) (Table 3). Perceived benefit of treatment, sufficient information on diagnosis, how well the institution's work was organized, how good the condition of the equipment was, trust in healthcare personnel competency, whether treatment was adapted to the situation and comorbidities affecting daily life positively predicted satisfaction, and unnecessary damage because of treatment and incorrect or delayed diagnosis negatively predicted satisfaction.
Multiple Regression Analysis of Patients’ Experience of Overall Satisfaction With Care and Treatment.
Abbreviations: CI, confidence interval; PCI, percutaneous coronary intervention; LMC, learning and mastery course; CR, cardiac rehabilitation.
The final regression model predicting patients’ perception of overall benefit from treatment explained 25% of the variance (R2 0.246, F(4, 387) = 31.29, P < .001). Significant predictors included whether treatment was adapted to the situation, admission type, sufficient information on diagnosis, and comorbidities affecting daily life (Table 4).
Multiple Regression Analysis of Patients’ Experience of Overall Benefit of Treatment.
Abbreviations: CI, confidence interval; PCI, percutaneous coronary intervention; LMC, learning and mastery course; CR, cardiac rehabilitation.
Discussion
This study aims to assess differences in patient-reported experiences between urban and rural patients regarding hospital stays, and to identify factors related to satisfaction with care, and the benefits of treatment experienced by patients undergoing PCI. The results reveal that urban and rural patients generally have positive experiences with hospital stays and experience similar benefits from treatment.
Urban and Rural Aspects of Patient Experiences
Despite statistically significant differences in various sociodemographic factors and event characteristics, as well as transport delays to PCI-hospitals and information about LMC/CR, there are no significant differences in patient-reported experiences between urban and rural patients. Moreover, geographical differences do not influence overall patient satisfaction or the benefits of treatment. The fact that rural and urban patients experience equal satisfaction and treatment benefits can indicate that both groups have similar expectations of hospital services and that these expectations are positively met, even though rural patients face longer travel times to PCI-hospitals. 7
Age, gender, and fulfilment of patient expectations are reported to be associated with patient satisfaction; for instance, elderly patients and men tend to be more positive about hospital stays than younger patients and women.9,11 Additionally, patients’ expectations are shaped by multiple social structures and relationships at a given point in time, and influenced by experiences from past and current interactions within healthcare. 11 Positive previous experiences may be a factor contributing to the lack of significant urban–rural differences observed in this study.
The differences between urban and rural acute patients in terms of transport or transfer delays to PCI-hospitals align with previous data showing geographical differences in transport times between hospital admission areas for the most acute patients. 5 Additionally, research indicates unequal access to treatment and care due to disparities in air ambulance capacity during certain periods of the day. 16 Despite limited access to cardiac care facilities, research shows that rural patients with acute MI have high transfer rates to specialized services, indicating that rural regions rely on effective transfer networks. 29 This study's findings that delays due to distance are not associated with overall satisfaction with care and the experience of treatment benefits might suggest that some people residing in rural areas have come to accept that distance may impact their health, as discussed in previous research. 30 Additionally, distances and limited healthcare services are part of rural life and are not exclusively negative. 19 This contrasts with our previous findings, where rural patients with acute myocardial infarction (AMI) in northern Norway felt unsafe if they experienced a delay to treatment. 31 Nevertheless, cultural acceptance of geographic barriers may have an impact on why no significant urban–rural differences were observed in this study.
Patient Involvement and Information Gaps
Although geographical factors are found not to be related to satisfaction with hospital stays or the experienced treatment benefits, other patient-reported factors are. For instance, communicating information regarding diagnosis or ailments and adapting treatment to the patient's circumstances are positive predictors of overall treatment benefits, whereas delayed or incorrect diagnosis are negative predictors of overall satisfaction. Patients reported the lowest scores on information on postdischarge ailments and relapse management, involvement in treatment decisions, and collaboration between the hospital and GP. The findings confirm previous research indicating low scores on receiving information about what to do if they relapse and which ailments they could expect following the hospital stay. 13 This shows that information and education for CHD patients still require improvement in today's healthcare service.
Previous research on patients with acute MI shows that the more information patients receive, the more satisfactory they consider the information to be in terms of their ability to cope with the disease after discharge. 32 Importantly, patients’ need for information and follow-up decreases over time, suggesting that structured follow-up should be provided early, when patients are still motivated. 33
Sufficient information during the hospital stay can increase patients’ health literacy levels, enhance their knowledge of how to react in the event of problems, and improve their ability to manage lifestyle changes to prevent new cardiac events, as recommended in guidelines. 4 Furthermore, health literacy is associated with knowledge, self-care maintenance, self-care confidence, and mental health, and should be assessed when planning patient education and tailoring it to specific needs.3,34
Coordination of Follow-Up Care
This study shows that few patients receive follow-up care within the first 3 months after discharge, and that patients’ perception of how well the work is organized at the hospital is associated with patient satisfaction. This might indicate potential deficiencies in work organization at the PCI-hospitals, including collaboration and discharge, as shown in previous surveys. 13 Furthermore, not all patients are referred to lifestyle management or CR programs, and a lower proportion of rural than urban patients are referred to or have participated in LMS or CR. Still, low participation rates in rehabilitation services for patients with CHD remain a significant challenge.17,18 Furthermore, the accessibility of secondary prevention and rehabilitation is a critical area that requires more focus in healthcare delivery.15,35
Previous research emphasizes the importance of effective collaboration in enhancing access to follow-up care after discharge from PCI-hospitals and ensuring continuity during the transition from specialized to primary care.31,36 Low scores on hospital collaboration with the GP can indicate a need for improvement to meet patients’ needs, enhance access to healthcare providers, and improve overall patient satisfaction.
Patients in this study were highly satisfied with the competencies of doctors and nurses, and trust in the healthcare personnel's competency was positively related to satisfaction, confirming previous findings.9,37 Nevertheless, patients report lower scores on their experiences of involvement in decision-making than on other items. Previous research shows that patient experiences are linked to patient- and family-centered care principles and practices. 7 In addition, better patient involvement and shared decision-making are central to future patient care to improve health outcomes.4,38 Thus, patients’ voices and preferences should be integrated into decisions about treatment. Furthermore, individualized guidance to patients with MI, along with a different approach to communication at discharge, can help patients cope. 39
Patient satisfaction might also be influenced by the ease and convenience of accessing healthcare services, digital connectivity, and access to healthcare providers. 38 Telemedicine and telehealth platforms can transform healthcare delivery and cardiovascular care by overcoming geographical barriers, reducing disparities in health outcomes among rural communities, and serving as transformative tools in chronic disease management, thereby improving patient outcomes, access, and satisfaction.40,41
Actionable Insights
Based on these findings, hospitals could implement structured discharge protocols that emphasize postdischarge ailment management and ensure systematic collaboration with GPs, especially for rural patients. Furthermore, public information on CHD symptoms, timely referral of patients to planned coronary angiography, and well-developed prehospital services to acute coronary syndrome (ACS) patients can facilitate access to healthcare resources and diminish barriers to healthcare in this specific sociogeographical context. Additionally, systematic referral to GPs, LMCs, and CR following discharge can facilitate access and diminish barriers to healthcare. A summary of actionable insights and recommendations is presented in the Supplemental materials (Supplementary 3).
Limitations
First, there are various definitions of “rurality,” such as travel time or distance to service functions, populated areas, among others. The item intended to compare urban and rural groups was self-reported travel time to the PCI-hospital, based on the transportation method used. However, due to missing data on this item, travel time by road to PCI-hospitals was manually grouped by the participants’ postal codes. The postal code variable was compared to the national index of centrality, and it was found to be in good alignment. 21
Second, the types of transportation modes or treatment centers were not adjusted for. Patients were either treated at a 24/7 or a daytime-only PCI-hospital. It was not within the aim of this study to compare treatment centers, and whether adjusting for these variables would affect the results is unknown.
Third, the linear regression model shown in Table 4 should be considered carefully to avoid overstating the findings as too positive, as it explained only 25% of the variance in treatment benefit.
Conclusions
This study emphasizes the value of measuring patient experiences with healthcare services during PCI treatment, offering insights to enhance healthcare services and identify areas of significance from patients’ perspectives. Urban and rural patients within geographically large PCI-hospital catchment areas report positive and similar experiences regarding care and treatment related to their hospital stays. Overall satisfaction and experienced treatment benefits are mainly associated with organizational factors, healthcare personnel competency, and event-related aspects, rather than geographical factors.
This study provides clinicians, policymakers, and patient organizations with practical, actionable recommendations for delivering, organizing, and influencing healthcare services to patients undergoing PCI. Achieving quality and equitable services across the healthcare system should focus on patient involvement, customizing information, and coordination of follow-up services post-PCI treatment. Future research on optimizing patient trajectories, postdischarge management, and collaboration may enhance services for patients undergoing PCI in geographically dispersed healthcare catchment areas.
Supplemental Material
sj-docx-1-jpx-10.1177_23743735251415062 - Supplemental material for Percutaneous Coronary Intervention: Urban and Rural Patients’ Experience With Care and Treatment During the Hospital Stay
Supplemental material, sj-docx-1-jpx-10.1177_23743735251415062 for Percutaneous Coronary Intervention: Urban and Rural Patients’ Experience With Care and Treatment During the Hospital Stay by Anette Krane, Knut Tore Lappegård, Gunn Pettersen, Laurent O. Trichet and Tove Aminda Hanssen in Journal of Patient Experience
Supplemental Material
sj-docx-2-jpx-10.1177_23743735251415062 - Supplemental material for Percutaneous Coronary Intervention: Urban and Rural Patients’ Experience With Care and Treatment During the Hospital Stay
Supplemental material, sj-docx-2-jpx-10.1177_23743735251415062 for Percutaneous Coronary Intervention: Urban and Rural Patients’ Experience With Care and Treatment During the Hospital Stay by Anette Krane, Knut Tore Lappegård, Gunn Pettersen, Laurent O. Trichet and Tove Aminda Hanssen in Journal of Patient Experience
Supplemental Material
sj-docx-3-jpx-10.1177_23743735251415062 - Supplemental material for Percutaneous Coronary Intervention: Urban and Rural Patients’ Experience With Care and Treatment During the Hospital Stay
Supplemental material, sj-docx-3-jpx-10.1177_23743735251415062 for Percutaneous Coronary Intervention: Urban and Rural Patients’ Experience With Care and Treatment During the Hospital Stay by Anette Krane, Knut Tore Lappegård, Gunn Pettersen, Laurent O. Trichet and Tove Aminda Hanssen in Journal of Patient Experience
Footnotes
Acknowledgments
We would like to acknowledge the hospitals and healthcare professionals who contributed to the data collection, as well as the patients who participated in this research and shared their experiences.
Author Contributions
AK, TAH, and KTL were responsible for planning this study.
AK and TAH conducted the data collection.
AK performed the primary analysis, and LOT, TAH, and KTL contributed to the analysis validation.
AK, TAH, KTL, GP, and LOT contributed to the writing of the manuscript, gave final approval, and agreed to be accountable for all aspects of this work, ensuring integrity and accuracy.
Availability of Data Materials
The datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Ethical Approval
The study was approved by the local data protection authorities at the 2 hospitals where the participants underwent PCI (reference numbers 2020/1759 and 2020/4161).
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the Northern Norway Regional Health Authority (grant number 2019/359-56).
Statement of Human and Animal Rights
This article does not contain any studies with human or animal subjects.
Statement of Informed Consent
Written informed consent was obtained from the patients for their anonymized information to be published in this article.
Supplemental Material
Supplemental material for this article is available online.
References
Supplementary Material
Please find the following supplemental material available below.
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