HOW do anesthesiologists create value in health care? Although the providers of anesthesia care themselves may see the answers to this question as plainly evident, recent initiatives to reform the delivery of health care in the United States have made engaging in this and similar questions an increasingly important endeavor for those who provide, consume, and pay for medical services. Because value in this context is determined by the outcomes of health care relative to its costs,1defining those outcomes that will constitute the numerator of anesthesiology's value equation carries major potential policy implications, offering a basis for the systematic assessment and improvement of value in anesthesia care. In this issue of Anesthesiology, Mui et al.  2offer timely insights into the measurement of patient-reported outcomes that carry particular relevance to current efforts to assess the value of anesthesia services.

Increasing awareness that the value of health care services is most appropriately determined from the perspective of the individual patient3has made patient-reported outcomes, including assessments of the experience of health care, a key basis of comparison for services delivered by physicians, health plans, and hospital systems.4Although anesthesiologists have worked for at least 40 yr to develop objective measures of patient satisfaction with anesthesia care,5the lack of uniformly accepted methods for the assessment of patient experience in the perioperative setting leaves important gaps in knowledge as to how anesthesia care may be improved. Mui et al.  2help to fill in some of these gaps through their report on a new measure of patient satisfaction.

Mui et al.  2derived and validated a 30-item questionnaire to assess patient satisfaction with anesthesia care after elective inpatient and outpatient surgical procedures at one large hospital in Taiwan, People's Republic of China. This work builds on important previous efforts at measurement of patient satisfaction with perioperative services6–9and takes as its starting point a 32-item pilot questionnaire developed through literature review and in-depth semistructured interviews with 95 patients after surgery and anesthesia.10The investigators refined this pilot questionnaire in a sample of 320 patients in the 6–48 h after procedures requiring general anesthesia, using exploratory factor analysis to identify internally correlated groupings of items (factors) and to yield a final 30-item questionnaire. Although exploratory factor analysis and related techniques have been previously used to develop measures of satisfaction with anesthesia,7–9the scale of Mui et al.  goes a step further by using an additional advanced psychometric technique, confirmatory factor analysis, to validate the questionnaire into two separate samples of patients after general and regional anesthesia.

The report of Mui et al.  2makes several contributions to the measurement of patient satisfaction with anesthesia care. The researchers present a scale that is specifically focused on the anesthesia care experience, distinguishing it from several previous efforts8,9that examine perioperative care more broadly. They describe a rigorous process of pilot questionnaire development, incorporating detailed qualitative data from patient interviews, and refine this questionnaire using established exploratory factor analysis techniques. Their use of confirmatory factor analysis goes beyond past efforts at scale validation in this context, offering evidence of their instrument's validity in subsets of patients receiving differing types of anesthesia. Last, they present convincing arguments that their overall approach to the measurement of patient satisfaction makes sense in the context of other measures of patient experiences with care.

Despite its strengths, their work also has important limitations. On the most basic level, it offers no insight into the validity of this scale outside of Taiwan, an issue of particular relevance given the inclusion in the pilot questionnaire of items related directly to cultural and health care experiences that may be specific to Taiwan.10Similarly, we cannot know to what extent the translated version of the scale of Mui et al. ,2as presented herein, preserves the psychometric properties of the original instrument. The seven factors that the researchers identify account for 57% of total item variation; although this value is within the range of previous efforts to quantify satisfaction with anesthesia care,7–9it nevertheless leaves room for improvement in future work.11The researchers do not examine satisfaction among patients undergoing monitored anesthesia care or those receiving regional and general techniques in combination. Although their 30-item instrument required 5–6 min on average to complete, more succinct instruments may be required if such assessments are to be effectively implemented in practice.

Despite these shortcomings, the work of Mui et al.  2should be seen as an important step forward in efforts to assess the experiences of individual patients after anesthesia care. The researchers take a new approach to methodological and conceptual challenges in measuring an outcome of growing importance to health care policy. Thus, this work offers insights as to how clinicians and researchers in the United States and other nations may critically evaluate new measures of patient satisfaction with anesthesia and surgery, such as those recently introduced by the US Agency for Healthcare Research and Quality in collaboration with the American College of Surgeons and the Surgical Quality Alliance.*Ultimately, as efforts to improve the delivery of health care call for more objective data regarding the outcomes of care to which anesthesiologists may contribute, such measures hold the potential to offer insights into the myriad ways in which anesthesiologists create value in health care and the yet unidentified areas in which still further value may be added.

Department of Anesthesiology and Critical Care and Leonard Davis Institute of Health Original Investigations, University of Pennsylvania, Philadelphia, Pennsylvania.

Porter ME, Teisberg EO: How physicians can change the future of health care. JAMA 2007; 297:1103–11
Mui W-C, Chang C-M, Cheng K-F, Ng K-O, Tsao K-R, Hwang F-M: Development and validation of the questionnaire of satisfaction with perioperative anesthetic care for general and regional anesthesia in Taiwanese patients. Anesthesiology 2011; 114:1064–75
Porter ME: What is value in health care? N Engl J Med 2010; 363:2477–81
Wu AW, Snyder C, Clancy CM, Steinwachs DM: Adding the patient perspective to comparative effectiveness research. Health Aff (Millwood) 2010; 29:1863–71
Fung D, Cohen MM: Measuring patient satisfaction with anesthesia care: A review of current methodology. Anesth Analg 1998; 87:1089–98
Dexter F, Aker J, Wright WA: Development of a measure of patient satisfaction with monitored anesthesia care: The Iowa Satisfaction with Anesthesia Scale. Anesthesiology 1997; 87:865–73
Heidegger T, Husemann Y, Nuebling M, Morf D, Sieber T, Huth A, Germann R, Innerhofer P, Faserl A, Schubert C, Geibinger C, Flückiger K, Coi T, Kreienbühl G: Patient satisfaction with anaesthesia care: Development of a psychometric questionnaire and benchmarking among six hospitals in Switzerland and Austria. Br J Anaesth 2002; 89:863–72
Caljouw MA, van Beuzekom M, Boer F: Patient's satisfaction with perioperative care: Development, validation, and application of a questionnaire. Br J Anaesth 2008; 100:637–44
Auquier P, Pernoud N, Bruder N, Simeoni MC, Auffray JP, Colavolpe C, François G, Gouin F, Manelli JC, Martin C, Sapin C, Blache JL: Development and validation of a perioperative satisfaction questionnaire. Anesthesiology 2005; 102:1116–23
Mui WC, Chang CM, Cheng KF, Lee TY, Lui PW, Hwang FM: Patient satisfaction with anesthesia care in Taiwan: Development and validation of a pilot version of a psychometric questionnaire. Acta Anaesthesiol Taiwan 2009; 47:180–8
Streiner DL, Norman GR: Health Measurement Scales: A Practical Guide to their Development and Use. New York, Oxford University Press, 2003
New York
Oxford University Press