Evaluation of Patient Satisfaction and Outcomes After Assessment for Acute Ankle Injuries DEBORAH E. WILSON, MN,*† THOMAS W. NOSEWORTHY, MD, MSc, MPH,† BRIAN H. ROWE, MD, MSc,† AND BRIAN R. HOLROYD, MD‡ Physicians argue that patient preferences influence their test ordering and their potential for compliance with clinical practice guidelines (CPG). This study was conducted to evaluate patient satisfaction with clinical practice in emergency department (ED) settings using a validated and widely publicised set of CPGs. Patients presenting to 4 hospital EDs were eligible if they had sustained acute ankle or foot injuries. All sites were involved with the dissemination of radiography CPG, and use of radiography was determined by treating physicians. Telephone fol- low-up was attempted for all patients who did not receive ankle or foot radiography (Group 1). A random sample of 25% of patients who had a normal radiograph interpretation (Group 2) was also chosen for follow- up. Structured telephone interviews were administered and included information on postencounter health care utilization, subsequent radi- ography, and patient satisfaction. A structured questionnaire was admin- istered to all ED physicians (N  60) to elicit their perspectives on the clinical practice guidelines. In Group 1, 342 (69%) of 494 nonradio- graphed patients were successfully contacted. In Group 2, 623 (77%) of 812 patients with normal ED radiographs, were successfully contacted. After ED discharge, 86 (25%) Group 1 and 191 (31%) Group 2 patients had visited another physician within 2 weeks of the initial ED encounter (P  .07). Subsequent ankle radiography was similar between the groups (38 [11%] in Group 1 vs. 59 [10%] in Group 2; P  .38). Patients appeared to be similarly highly satisfied with physician care (P  .58) and with discharge instructions (P  .12) in both groups. Overall, 76% of physi- cians supported the use of CPGs; however, 78% reported that patient expectations influenced their application of the Ottawa Ankle Rules. This study suggests that patients are equally satisfied with care, access additional health care services similarly and obtain the same percentage of radiographs irrespective of the initial ED ankle/foot radiograph order- ing. These results may help physicians in re-evaluating their perceptions that patient expectation influence utilization and have important implica- tions in guideline development. (Am J Emerg Med 2002;20:18-22. Copyright © 2002 by W.B. Saunders Company) Understanding patients’ expectations for medical care is an area of increasing importance to clinicians, managers, and researchers. For clinicians, understanding patient ex- pectations and attempting to meet these is central to the provider/patient relationship and a determinant of patient satisfaction. For managers, patients’ expectations warrant attention because of their potential influence on health care utilization. Furthermore, fulfilling public expectations is one measure of the quality of health care systems. 1 The assess- ment of patients’ satisfaction with physicians and medical care is also an important method of identifying potential areas for improving aspects of patient management pro- vided by physicians. The purpose of this study was to examine post-ED med- ical encounters and radiography, and satisfaction in 2 groups of patients, those who received and those who did not receive radiography for ankle/foot injuries seen in the ED. METHODS Setting The study was conducted in Edmonton, a northern Al- berta city with a population of 820,000 (1996 Census, Statistics Canada). At the time of the study, the city was served by 5 acute care hospitals, with a combined emer- gency census of approximately 280,000 patient visits per year (1998 Capital Health Authority data). See Table 1 for details of the hospitals. Sample All patients with foot/ankle injuries presenting to any of the 4 study EDs were eligible for this study if they presented with ankle injuries. The study sites consisted of 2 urban teaching hospitals and 2 community hospitals, and enroll- ment occurred between December 1995 and October 1997. Telephone follow-up was attempted for all patients who did not undergo ankle radiography during the initial encounter. From the remaining patients whom had ankle and/or foot radiography, a 25% random sample of patients with a neg- ative radiograph interpretation were contacted (Group 2). Inclusion and exclusion criteria for this study were con- sistent with those used in the validation studies for the Ottawa Ankle Rules (OARs). 2-5 Patients presenting to the study hospital EDs after sustaining blunt injuries of the ankle and/or foot were eligible. Exclusion criteria consisted of patients who were under the age of 18 years, pregnancy, paraplegia, isolated injuries of the skin without soft tissue or bone involvement, patients referred from outside the hospi- tal with previous radiography, or if more than 10 days had From the *Alberta Clinical Practice Guidelines Program, and †De- partment of Public Health Sciences, University of Alberta, and ‡Di- vision of Emergency Medicine, Edmonton, Alberta, Canada. Presented in part at the 7th International Conference of Emer- gency Medicine, Vancouver, BC, March 1998 and the Annual Soci- ety for Academic Emergency Medicine Annual Meeting, Chicago, IL, May, 1998. Supported in part by Capital Health, Edmonton, Alberta, Canada. Manuscript received May 21, 2001, accepted August 1, 2001. Address reprint requests to Deborah Wilson, MN, Program Direc- tor, Alberta Clinical Practice Guidelines, Alberta Medical Associa- tion, 12230-106 Avenue NW, Edmonton, Alberta, Canada T5N 3Z1. E-mail: dew@amda.ab.ca Key Words: Injuries, Ottawa Ankle Rules, preference, and evi- dence-based clinical practice guidelines. Copyright © 2002 by W.B. Saunders Company 0735-6757/02/2001-0005$35.00/0 doi:10.1053/ajem.2002.30105 18