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Complaint behaviour among healthcare users: self-reported complaint experience and complaint proneness in adult men
  1. Søren Birkeland1,2,
  2. Marie Bismark3,
  3. Michael J Barry4,
  4. Sören Möller2,5
  1. 1 Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
  2. 2 Open Patient data Exploratory Network, Odense University Hospital, Odense, Denmark
  3. 3 Public Health Law, University of Melbourne, Parkville, Victoria, Australia
  4. 4 Harvard Medical School, Boston, Massachusetts, USA
  5. 5 Department of Clinical Research, University of Southern Denmark, Odense, Denmark
  1. Correspondence to Dr Søren Birkeland; sbirkeland{at}health.sdu.dk

Abstract

Aims When patients are harmed by, or dissatisfied with, healthcare, only a minority will lodge a complaint or file a claim for compensation. This survey aimed to investigate complaint behaviour and inequalities in complaints using self-reports and hypothetical case vignettes.

Methods Cross-sectional, web-based survey among 6755 Danish men aged 45–70 years (response rate=30%). Participants reported their lifetime complaint experience and the likelihood that they would complain in response to hypothetical case vignettes.

Results Overall, 4.8% of participants had complained about healthcare. Predictors were younger age (OR 2.08, 95% CI 1.32 to 3.27, p=0.002 45–50 years compared with 65–70 years), chronic illness (OR 1.49, 95% CI 1.12 to 1.98, p=0.006), rural residence (OR 2.11, 95% CI 1.20 to 3.73, p=0.010 comparing least and most populated areas), high healthcare utilisation (OR 1.55, 95% CI 1.18 to 2.03, p=0.002 primary care, and OR 1.97, 95% CI 1.52 to 2.55, p=0.000 hospital care) and decreased agreeableness on the 10-item Big Five personality inventory (OR 0.91, 95% CI 0.83 to 0.99, p=0.034). Complaint experience was associated with increased wish to complain about the treatment in the hypothetical vignettes (p=0.006).

Conclusions Roughly 1 in 20 men reported having complained about healthcare. Complaints were more common among men who were younger, living in rural areas, diagnosed with chronic illness and high users of healthcare services. Prior complaint experience may be associated with a higher proclivity for complaining about future healthcare. Findings suggest differences in the way healthcare users respond to care experiences, pointing to the importance of aligning expectations and providing clear information about treatment options.

  • health services research
  • decision making
  • health behavior
  • patient satisfaction
  • complaints
  • medical law

Data availability statement

Data are available upon reasonable request.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjoq-2023-002581

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    WHAT IS ALREADY KNOWN ON THIS TOPIC

    • Virtually all our knowledge about patient complaints arises from registers of data held by medicolegal agencies.

    WHAT THIS STUDY ADDS

    • In a web-based survey, roughly 1 in 20 men reported having complained about healthcare.

    • Complainants more commonly were younger, living in rural areas, diagnosed with chronic illness and high users of healthcare.

    • Complainants also had increased wish to complain about the treatment illustrated in hypothetical vignettes.

    HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

    • The study highlights inequalities in self-reported complaint behaviour and that a complaint may indicate a one-off event but also could signify that discontent is experienced by others.

    Introduction

    During their career, many healthcare workers will experience a complaint, investigation or malpractice claim (hereafter referred to as ‘complaints’).1 2 Most complaints are initiated by patients.3 4 Patients have a variety of reasons for contacting medicolegal agencies such as medical boards, complaint entities or compensation authorities (hereafter, referred to as ‘medicolegal agencies’): they may seek compensation, they may want a doctors’ fitness to practice reviewed or they may seek an apology or explanation.5 6 Worldwide, malpractice litigation is an increasing public health concern with rising complaint numbers and professional liability insurance premiums, and there is a perception that certain groups of patients account for a disproportionate share of complaints, while other groups are largely under-represented.7 8 A parallel factor is the inherent power dynamic that is present between patients and providers which can affect one’s desire to lodge a formal complaint. For example, in situations where access to care is difficult or scarce, one may be hesitant to complain if ongoing care from the same provider is required. But what is the prevalence of prior complaints among the population of healthcare users, and does the hypothesis have any merit that there is inequality in complaints and some citizens simply are more inclined to complain about healthcare, while other groups are less likely to complain?

    Virtually all our knowledge about patient complaints arises from registers of data held by medicolegal agencies.2 9 10 Studies using these registries suggest some groups of patients are under-represented among complainants, including patients who are older and poorer.9 11 But dark figures and under-reporting are a well-known problem associated with studying complaint statistics.2 10 Registries provide a reasonable overview from the perspective of medicolegal agencies. However, valuable information may be missing due to variation in complaint registration thresholds (eg, excluding complaints that were quickly dismissed) or a focus on more formal complaint routes (not including verbal complaints or those that were made directly to the healthcare provider). Hence, existing studies may not accurately mirror healthcare users’ real experience with complaining about unsafe or unsatisfactory care.10 This national survey aimed to investigate inequalities in the lifetime experience of complaining about healthcare in men and complaint proneness using self-reports and hypothetical vignettes.

    Methods

    Study design, setting and participants

    This study is part of a larger research project investigating male healthcare users’ perceptions of healthcare and patient involvement in decision-making about having a prostate-specific antigen (PSA) screening test using hypothetical scenarios. Among other things, we previously demonstrated associations between greater patient involvement illustrated in hypothetical scenarios and less wish to complain about healthcare illustrated.12 A cross-sectional survey was developed with public and patient involvement.13 A random sample of men aged 45–70 years was drawn from the Danish health authorities’ national register of all Danish citizens. As previously reported, the sample was reasonably representative of men aged 45–70 years with regard to sociodemographic and personality characteristics, compared with samples previously reported from the USA, Australia, New Zealand and Europe.14 15 We used Research Electronic Data Capture and survey distribution through the authorities’ secure, digital mailbox. The latter is provided by the Danish authorities for safe communication with citizens and all adult Danish citizens are registered to use the digital mailbox per default.16 The digital mailbox is encrypted making security higher than for usual emails and mail sent by common postal service.16 We also measured participants’ personality using the 10-item Big Five Inventory-10 (BFI-10).17

    Participants received an introduction letter by email and a link to the web-based questionnaire. By the beginning of the questionnaire, each participant was randomly allocated to one among different case vignette scenarios illustrating decision-making about PSA screening in men. Scenarios are described in detail elsewhere (please see online supplemental material and13 18). Some scenarios illustrated poor doctor communication and/or a poor outcome, but the scenarios did not describe clinical negligence.12 In brief, scenarios had an identical core structure but differed with respect to (1) the style of decision-making about having or not having a PSA (five levels from no information to shared decision-making with the use of decision aid), (2) the decision made (if a PSA test was decided on) and (3) three outcome scenarios (a ‘favourable’ outcome without prostate cancer; an ‘unfortunate’ outcome with advanced, eventually lethal prostate cancer; and an ‘intermediate’ outcome with successfully treated prostate cancer) with combinations adding up to 30 different vignette scenarios. Vignettes reflected situations encountered in clinical practice and drew on scenarios reported in the literature.19 For example, in one scenario, the patient chose not to have a test done after slight nudging against the PSA test (‘the doctor would suggest himself not to have a PSA test done …’) and afterwards was diagnosed with an advanced, eventually lethal prostate cancer. In another scenario, the illustrated patient chose to have a test and afterwards was diagnosed with treatable prostate cancer.

    Supplemental material

    Invitations with information letters were sent out to 12 000 men aged 45–70 years on 24 January 2019. Potential participants who did not respond to the invitation received a reminder following 14 days with similar information. After this reminder, it appeared that sending out a new wave of 12 000 invitation letters was required to obtain a reasonable sample size (for sample size requirements, please see14). Invitation letters were sent out on 7 March 2019, and following another 14 days, a reminder again was sent out. Following the two waves, 6755 people completed the survey (response rate of 30%).

    Outcomes, measures, and statistical analyses

    Regarding the hypothetical set-up, supposing they received the care in the vignettes, participants rated their degree of satisfaction, the likelihood that they would use the doctor described again, the likelihood that they would recommend the doctor described and the likelihood that they would complain about healthcare (using 5-point Likert scales; please see table 2 for exact wording of items). As is the case in many other countries, in Denmark, healthcare users may claim monetary compensation (through a patient injury compensation organisation or through the courts), or they may seek non-monetary forms of accountability through complaining to a state disciplinary board, or they may choose to do both.20 Participants responded to two items: ‘How likely is it that you would claim compensation?’ and ‘How likely is it that you would complain about the doctor’s care?’.

    Participants responded to questions about sociodemographic characteristics. The latter was supplemented with municipality-level information from national registries about municipality-level population density, tax per citizen and proportion of citizens with non-Western origin.21 We measured participants’ personality using the BFI-10, a valid and reliable measure of personality for contexts in which participant time is limited.17 This instrument uses short phrases to assess the most prototypical traits associated with the Big Five personality dimensions.17 In brief, the five-factor personality model encompasses different trait dimensions, including ‘extraversion’, ‘agreeableness’, ‘conscientiousness’, ‘neuroticism’, and ‘openness’. Finally, participants responded to a question about their own experience with complaining about real-life healthcare (‘Have you ever complained or claimed compensation due to your own healthcare provision?’; response options, ‘Yes’ or ‘No’).

    We applied logistic regression to investigate associations between prior experience with complaining and participant characteristics. We conducted crude analyses, only adjusted for the 30 vignette groups and age group, and then conducted analyses adjusted for all factors including education, employment, chronic disease and all five BFI-10 subscales. To investigate differences in satisfaction and complaint wish, we grouped participants according to satisfication with the care described (including their wish to use the same doctor in the future and to share positive recommendations about the doctor), and then used linear regression. CIs and p values for the linear regressions were computed by bootstrapping with 1000 repetitions. We set the level of statistical significance at p<0.05.

    Results

    Roughly 1 in 20 adult men (327 out of 6755, 4.8%) reported a real-world experience with complaining about a healthcare service. Table 1 shows the predictors for having ever complained about their own healthcare.

    View this table:
    Table 1

    Predictors of having real-life experience with complaining about healthcare

    As seen in table 1, in our adjusted analyses, several sociodemographic characteristics were associated with increased real-world experience of having complained about healthcare. There was a stepwise reduction in complaint experience with older age, with those aged over 65 years being the least likely to have complained about healthcare. Having a personality with high agreeableness on the Big Five Inventory was also associated with less real-world complaint experience. Having complained about healthcare was statistically significantly associated with more often using general practice-level or hospital level healthcare, with the association being even stronger among those who frequently used hospital. Similarly, those with chronic illness had more complaint experience. Among those without chronic illness, 3% had experience with complaining about healthcare, compared with 6% of those with one chronic illness and 12% of those with two or more chronic illnesses (not shown in table 1). Having complained about healthcare was also associated with living in areas with low population density.

    Respondents who had real-life complaint experience were more inclined to indicate in their response to hypothetical scenarios that they would complain (mean difference in combined complaint proclivity of 0.16 on Likert scale ranging from 1 to 5; 95% CI: 0.04 to 0.27, p=0.006; adjusted for all variables in the model; not shown in the table).

    When rating satisfaction with the doctor’s care illustrated in the hypothetical vignettes, 78% (5300 out of 6755) of respondents were ‘satisfied’ or ‘very satisfied’. 15% were ‘neutral’ (1015 out of 6755). 13% (903 out of 6,755) of respondents found it ‘unlikely’ or ‘very unlikely’ that they would tell others that they had had a good experience with the doctor illustrated in the vignette, and 7% declared themselves to be ‘dissatisfied’ or ‘very dissatisfied’ with the doctor’s care (440 out of 6755). When considering overlapping among responses, 16% (1081 out of 6755) of participants were dissatisfied (or very dissatisfied) with the care described, would not use the doctor again (rated ‘unlikely’ or ‘very unlikely’) or would not recommend the doctor to others (‘unlikely’ or ‘very unlikely’). Among respondents giving any of these answers, 25% (271 out of 1081) expressed a wish to complain (complaint ‘likely’ or ‘very likely’). Further responses with indicators of clear-cut discontent are shown in table 2.

    View this table:
    Table 2

    Sample responses to hypothetical scenarios

    Supplemental material

    One per cent of respondents expressed that they were very dissatisfied with healthcare, and a similar proportion expressed great reluctance to use the same doctor again. Two per cent expressed great reluctance to recommend the doctor to others, and a similar proportion responded that they would very likely complain about the care described in the scenario (figure 1).

    Figure 1
    Figure 1

    Participant responses to hypothetical clinical case scenarios.

    Associations between participant responses to the hypothetical scenarios are shown in table 3.

    View this table:
    Table 3

    Associations between healthcare user reactions to hypothetical scenarios

    For example, those who responded that it was ‘very likely’, ‘likely’ or there was an ‘even chance’ that they would ‘Use the doctor again’, on average, responded 4.00 with regard to complaint likelihood on the 1–5-point Likert scale, indicating that it was ‘unlikely’ that they would ‘Complain about the doctor’s care’. Those who responded that it was ‘unlikely’ or ‘very unlikely’ that they would ‘Use the doctor again’, on average, responded 2.83 on the scale (almost ‘even chance’ that they would ‘Complain about the doctor’s care’), and that difference is significant (p<0.001). Unsurprisingly, participants who expressed satisfaction with care were significantly less likely to want to complain. Likewise, those who would use the doctor again were more satisfied with the care described and less likely to want to complain. Similar results were observed for recommending the doctor.

    Discussion

    Statement of principal findings

    In this survey, investigating real-life complaint behaviour and responses to hypothetical healthcare scenarios in Danish men, we found roughly 1 in 20 respondents had real-life experience of making a complaint about healthcare. Those who had complained about healthcare were more likely to be younger, to live in a rural area, to have a chronic illness and to go to the doctor or hospital often, while those with agreeable personality traits were less likely to have made a real-life complaint. When asked to reflect on hypothetical scenarios, most participants were very satisfied with the care described. Only a small proportion expressed high levels of dissatisfaction. Unsurprisingly, those expressing dissatisfaction with healthcare were more likely to wish to complain. Those participants with real-life experience of complaining about healthcare were more inclined to express a wish to complain in response to hypothetical healthcare scenarios.

    Interpretation within the context of the wider literature

    We found that around 5% of adult men had, at any point in time, complained about their healthcare. To our knowledge, this is the first report of this kind. Although one would expect lifetime complaint experience to accumulate with age, the oldest participants in our study were the least likely to have ever complained. Previous analyses have also found a negative association between complaints and higher age.9–11 22 23 One ‘driver’ for the lower occurrence of complaints with increasing age may be that even if accessibility of complaint systems has improved, the systems may be still easy to use for younger patients. An alternative explanation is that older patients come from the so-called ‘grateful generation’ and were raised with a belief that healthcare providers should be respected and trusted, making it difficult for them to raise concerns about healthcare.

    Furthermore, respondents with a chronic illness and those with frequent use of general practitioners or hospitals were more likely to have real-world experience of making a complaint about healthcare. Likewise, Dolinsky et al previously found that higher healthcare utilisation was statistically significantly associated with complaints.24 This finding could simply be explained by greater exposure to healthcare, with a risk of unsafe or unsatisfactory care attached to each encounter. It is also possible that people with chronic illness and high healthcare utilisation are more likely to have complex and challenging health needs which may increase the risk of an adverse event. Our finding that complaints are more common in rural areas challenges a common perception within the healthcare services, as well as previous study findings, that citizens in urban areas are more prone to complaining.25 It would be helpful for future studies to try and control for the quality of healthcare provided, as there is good evidence that people living in rural areas find it more difficult to access high-quality care, so this finding may reflect care quality rather than the underlying propensity to complain.26 Regarding personality and complaint behaviour, evidence has been anecdotal at best.18 27–29 Some empirical knowledge, however, exists from studies of patient satisfaction. In particular, studies using the Five-Factor Personality Inventory have found agreeableness to predict patient satisfaction.18 30–32 Conversely, patients with low agreeableness have negative views of others and low trust, which may be associated with a tendency to blame others for poor outcomes and a wish to complain.18

    More generally, we found that most healthcare users were satisfied with the care described in a wide range of hypothetical scenarios, even in situations where the doctors’ communication was poor or the outcome was negative. Consistent with Dolinsky et al’s research, high satisfaction with care was inversely associated with complaint proclivity.24 One in six healthcare users in our study said that they were dissatisfied (or very dissatisfied) with the care described in survey vignettes, would not want to use a similar doctor again or would not recommend the doctor to others. Yet, only about one in four in this group expressed a wish to complain. This is consistent with the ‘iceberg’ pattern of healthcare users’ evaluations of healthcare in standardised illustrations of healthcare20 23 33 34 and confirms that for every person who complains about healthcare, a greater number are unhappy with care but do not complain. Complaining about healthcare can be an uncomfortable and resource-intensive process for healthcare users,22 35 particularly at a time when their health is poor. Howard et al in their interview study from 2013 found 15 of 16 participants did not voice their complaint at the time of the event but after the event stated that they wished that they had reacted differently and complained at the point in time that they were dissatisfied.36

    Finally, our study found that men with previous real-world complaint experience were more inclined to complain in response to hypothetical healthcare scenarios. It is unclear whether this reflects, for example, an underlying propensity to complain, greater confidence navigating complaint processes or experience of positive outcomes from having complained in the past.

    Strengths and limitations

    The study has several limitations. It must be remembered that the sample was constituted by adult men and the healthcare issue in question was PSA testing. It remains unknown to what extent results may generalise to other groups of healthcare users and other healthcare issues. Additionally, it is a single-country study with uncertain generalisability to other countries with different complaint systems. Furthermore, participant characteristics were recorded at the time of survey participation, in some instances perhaps many years after having complained about healthcare. Thus, sociodemographic information may not accurately characterise the participant at the time of complaining. In addition, while healthcare complaints usually involve quite a bit of effort and would usually be something that one remembers, there is a risk of recall bias. Likewise, we did not collect information about participants’ exact complaint experiences (eg, state board complaint vs compensation claim). Finally, the hypothetical case vignettes did not describe clinical negligence—it would be interesting to know whether rates of complaint intention would increase for such scenarios.

    Implications for policy, practice and research

    The study highlights patient complaints as an imperfect measure of patient discontent. Healthcare providers, institutions, quality improvement staff, etc should be aware that a patient complaint may indicate a one-off event but also could signify that various degrees of discontent with the care standards are experienced by others. Furthermore, the study confirms differences in complaint behaviour between different groups of patients, points to the need for other mechanisms for identifying poor care among elderly populations, the value of understanding and meeting the needs of patients with chronic illness and high healthcare utilisation, and the importance of aligning expectations and providing clear information about treatment options.

    Conclusion

    In this national survey, investigating real-world complaint behaviour and responses to hypothetical healthcare scenarios, we found roughly 1 in 20 adult men self-reported experience with complaining about healthcare. Findings suggest inequalities in the use of healthcare complaint measures. Healthcare users with more complaint experience were more likely to be younger and living in rural areas, to have chronic illnesses and to have higher utilisation of healthcare services. Men with more agreeable personalities were less likely to have made a real-world complaint about healthcare. Those with experience of complaining about healthcare were more likely to express a wish to complain in response to hypothetical case vignettes. Otherwise, participants’ responses to hypothetical vignettes demonstrated an ‘iceberg’ pattern with most healthcare users being satisfied with a ‘standardised’ course of healthcare, a modest number being neutral, a smaller number expressing dissatisfaction or a reluctance to reuse or recommend the health provider and a very small group expressing an intent to complain.

    Data availability statement

    Data are available upon reasonable request.

    Ethics statements

    Patient consent for publication

    Ethics approval

    This study involves human participants. Participation required an electronic, informed consent before completing the survey. According to Danish law, research using questionnaires is exempted from ethical approval (Act on Research Ethics Review of Health Research Projects, Para 14; Ethics Board Review n. 20182000-99). The launching of the survey required compliance with EU Regulation 2016/679 and Directive 95/46/EC, General Data Protection Regulation as well as Danish Health Data Agency authorisation (Case Review n. FSEID-00003692). Participants gave informed consent to participate in the study before taking part.

    Acknowledgments

    We would like to thank survey participants for their invaluable contributions to the study.

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    Supplementary materials

    • Supplementary Data

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    Footnotes

    • Contributors SB collected, analysed and interpreted the data used in this study and was a major contributor to writing the manuscript. SM assisted in analysing the data and writing the manuscript. MB and MJB assisted in interpreting the data and writing the manuscript. All authors read, commented and approved the final manuscript.

    • Funding The project was funded by a grant of €40 000 from the Danish Sickness Insurance Fund and €5700 from the Lilly & Herbert Hansen’s Foundation. The funding bodies have had no influence on the design of the study. The funding bodies have had no influence on the collection, analysis and interpretation of data or on the writing of the manuscript.

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.