Patient satisfaction is a critical consideration of patient-centred care1 in physical therapy as satisfied patients are more likely to be active participants in their care and adhere to treatment recommendations.2 Increasing patient involvement in their care is particularly important for individuals with musculoskeletal disorders as the burden of musculoskeletal disorders such as low back and neck pain is increasing, and is now the leading cause of years lived with disability in high income countries such as Australia, the United Kingdom, and France.3 Patients with musculoskeletal pain or disorders typically attend musculoskeletal physical therapy services delivered in private physical therapy clinics, or in emergency and outpatient departments within hospitals.4 In a fee for service setting, such as private musculoskeletal physical therapy clinics, ensuring patients are satisfied with the quality of their care has implications for business sustainability as satisfied patients are more likely to recommend the clinic or service to another individual.5 As has been shown in other industries,6 a high percentage of customers who actively “recommend” a product or service is strongly correlated with business growth which may be an important consideration for private physical therapy practice.

An important consideration with studies of patient satisfaction is determining how satisfaction is defined and measured - 'patient satisfaction with physical therapy experience/care' or 'patient satisfaction with treatment outcome'.7 Many of the parameters linked to 'patient satisfaction with physical therapy experience/care' can be directly modified, while ‘satisfaction with treatment outcome’ is typically related to resolution of pain or improvements in identified impairments8 which may be influenced by factors that are not easily modifiable such as (but not limited to) the type of condition/injury or the chronicity of the condition or responses to previous treatment.9 A recent systematic review identified that five out of six themes that contributed to patient satisfaction with musculoskeletal physical therapy related to the physical therapy experience/care rather than treatment outcome.10

While higher levels of patient satisfaction are associated with patients being more actively involved in their management, adhering to recommendations, and recommending the service to others, the individual factors that best delineate between satisfied and dissatisfied patients in private practice physical therapy are not clearly established. Most studies of patient satisfaction with musculoskeletal physical therapy have been conducted in outpatient settings9,11-13 or those that have been conducted in private practice settings were published at least 10 years ago with small (n<300) sample sizes.14,15 Consequently, key contributors to patient satisfaction in private practice (fee for service) settings requires further investigation. Understanding which factors most influence patient satisfaction in private practice can help clinicians and managers to identify which areas of the physical therapy experience should be prioritised or improved.

Therefore, the primary aim of this study was to identify which aspects of the private practice musculoskeletal physical therapy experience best delineated “completely satisfied” and “dissatisfied patients,” and those who were likely to or unlikely to recommend the service to others.

A total of 1712 responses were received out of 7320 survey recipients for a response rate of 23%. Most (86%) of the responses were completed online. 86% of respondents were classified as “completely satisfied” and 87% were “likely to recommend” (Table 1).

Table 1 shows that 63% of respondents identified as female and the most common decades for the age of participants were between 55 and 64 years and 45–54 years. Table 1 also shows the distribution of areas of symptoms and the number of sessions attended by respondents. Mean values for individual questionnaire items are presented in Table 2.

Overall satisfaction, likely to recommend, and total MRPS score were higher for females than males (p<0.001). There were no differences in the mean score of overall satisfaction, likely to recommend, or total MRPS score by age group. Higher scores were reported by respondents who attended a greater number of sessions for overall satisfaction, likely to recommend, and total MRPS score (p<0.05). Satisfaction or likely to recommend scores were not different for area/condition treated (Table 1).

All individual items were significantly correlated with each of the two global items (Table 2). Most correlations were low to moderate, with the highest correlation (0.59) identified for “My therapist listened to my concerns” and “My therapist answered all my questions.”

The AUC for ROC analyses are shown in Tables 3 and 4. For satisfaction, all individual items except two (“My therapist treated me respectfully” and “This office provided convenient parking”) scored above 0.7, indicating at least “fair” classification ability. Three individual items scored above 0.8, indicating “good” classification ability. Only the total score of 18 items, scored above 0.9, indicating “excellent” classification ability. For likely to recommend, all individual items except two (“My therapist treated me respectfully” and “This office provided convenient parking”) scored above 0.7, indicating at least “fair” classification ability. Two individual items scored above 0.8, indicating “good” classification ability, and the total score of 18 items scored above 0.9, indicating “excellent” classification ability.

For the free-form question “Is there anything we can do to improve your experience at this clinic?”, most respondents (n = 1384) listed no/nothing. The most common feedback related to clinic setting/organisation (n = 128) such as parking and uncomfortable seating in reception areas, and therapist specific concerns (n = 105) such as poor communication, lack of skill or time spent with the therapist. Price (n = 49), privacy (n = 23) and reception staff concerns (n = 19) were less commonly reported.

Patients attending Australian private practice physical therapy clinics were highly satisfied and were likely to recommend the service to their friends or family. The mean overall patient satisfaction score of 4.8 is higher than previously reported in private practice settings in Australia and the United States,14,29 and similar to findings from Brazil.17 These findings are based on more than 1700 responses, to our knowledge making our study the largest conducted exclusively within private musculoskeletal physical therapy settings. Satisfaction levels were higher for females than males which aligns with previous studies14 and may relate partly to males having higher expectations of care.9

The findings from this study indicate that together with the overall 18-item score, the individual items that most accurately classified patient satisfaction and likelihood to recommend were “My therapist advised me on how to avoid future problems” and “I feel I am involved in the decisions related to my care.” Our results align with previous findings from Australian and American outpatient settings that found items relating to patient-therapist interactions most strongly contributed to overall satisfaction,12,14 but these contributing factors appear to differ slightly between countries and settings. For example, while patient-therapist interactions and patient education were most strongly associated with overall satisfaction in Brazilian musculoskeletal settings17 and in Spanish-speaking American patients,30 extrinsic factors such as respectful office staff and office cleanliness were also strongly correlated with overall satisfaction. Extrinsic factors such as convenient location, parking availability, and courteous reception staff were only fair or poor predictors of patient satisfaction and likelihood to recommend in our study, further highlighting the importance of interpersonal attributes of therapists in contributing to patient satisfaction in an Australian private practice context.

In their systematic qualitative meta-summary, Rossettini et al.10 reported that therapist-patient relationship features such as tailored communication, and treatment features such as shared decision making and patient education, were some of the best strategies to increase patient satisfaction in musculoskeletal physical therapy. Our results affirm the findings from Rossettini et al.,10 and suggest that musculoskeletal physical therapists should focus on developing effective patient-centred communication and education skills to enhance the therapeutic alliance with their patients.31 A therapeutic alliance emphasizes building rapport to enhance patient motivation and a sense of ownership over the treatment plan.32 Of course, developing this therapeutic alliance requires adequate time spent with a patient and specific interpersonal communication skills such as empathy, confidence, and encouragement.10,33 As the item “My therapist spent enough time with me” was one of the items associated with satisfaction (AUC 0.801), ensuring that therapists spend enough time with patients to allow them to be listened to, promote shared decision making and, to provide education/advice33 is important for satisfaction. This is often perceived to be difficult in a fee-for-service setting where the number of patients seen is directly linked to revenue and is particularly challenging for inexperienced therapists,34 who are still in the early phases of developing their clinical reasoning, communication skills, and independence.35 Therefore, physical therapy programs, clinical placement opportunities, and senior clinicians should focus on developing students’/graduates’ ability to form strong therapeutic alliances and to facilitate shared decision making with their patients.36 To better understand how patients were involved in shared-decision making, future satisfaction studies should include a validated shared-decision making questionnaire such as collaboRATE.37

This study had some limitations including a low response rate (23%) which may have contributed to a positive response (1712 responses were received out of 7320 survey recipients). Most participants had attended at least 10 sessions of physical therapy and although other research has suggested patient satisfaction is high in Australian musculoskeletal physical therapy settings and compares favourably to international data,14 it is likely those patients who were dissatisfied would cease care and would be less likely to complete the survey. Therefore, the data from this study capture information on largely satisfied patients and does not encapsulate factors that led to dissatisfaction in musculoskeletal physical therapy. Additionally, we modified the wording of question 20 to better capture “promoters” without validating the modified question, which may impact the validity of the relationships identified for question 20. Another limitation of this study is that participants were all at different timepoints of care. Given the large sample size it would not have been pragmatic to administer region specific patient reported outcome measures, however a global rating of change scale could be included in future studies. Satisfaction of treatment outcomes was also not explored in this study, and while treatment outcomes are infrequently and inconsistently associated with patient satisfaction across musculoskeletal settings,17,29 identifying the association between 'patient satisfaction with physical therapy experience/care' and 'patient satisfaction with treatment outcome' may have provided additional insights. Finally, while the data were collected from 18 clinics, all the clinics were from one private musculoskeletal physical therapy group in Australia, predominantly in metropolitan areas. Therefore, these results may only be generalizable to Australian private practice musculoskeletal physical therapy settings.

Most patients who completed the survey were highly satisfied with their physical therapy experience. The factors that most contributed to being satisfied and likely to recommend the service to others related to appropriate education/advice and shared decision making. Whilst often perceived to be difficult to implement in fee-for-service settings, the findings support previous studies that have highlighted the importance of adopting strategies that promote patient-centred care and therapeutic alliance. Clinicians and clinic owners can use these results to target professional development at improving these aspects of the physical therapy experience within the context of a private practice setting. Additionally, physical therapy educators should ensure that physical therapy programs and clinical placement opportunities adequately prepare graduates to facilitate shared decision making with their patients and deliver patient specific advice and education.