Patients’ perceptions with musculoskeletal disorders regarding their experience with healthcare providers and health services: an overview of reviews

Objectives This overview of reviews aimed to identify (1) aspects of the patient experience when seeking care for musculoskeletal disorders from healthcare providers and the healthcare system, and (2) which mechanisms are used to measure aspects of the patient experience. Data sources Four databases were searched from inception to December 20th, 2019. Review methods Systematic or scoping reviews examining patient experience in seeking care for musculoskeletal from healthcare providers and the healthcare system were included. Independent authors screened and selected studies, extracted data, and assessed the methodological quality of the reviews. Patient experience concepts were compiled into five themes from a perspective of a) relational and b) functional aspects. A list of mechanisms used to capture the patient experience was also collected. Results Thirty reviews were included (18 systematic and 12 scoping reviews). Relational aspects were reported in 29 reviews and functional aspects in 25 reviews. For relational aspects, the most prevalent themes were “information needs” (education and explanation on diseases, symptoms, and self-management strategies) and “understanding patient expectations” (respect and empathy). For functional aspects, the most prevalent themes were patient’s “physical and environmental needs,” (cleanliness, safety, and accessibility of clinics), and “trusted expertise,” (healthcare providers’ competence and clinical skills to provide holistic care). Interviews were the most frequent mechanism identified to collect patient experience. Conclusions Measuring patient experience provides direct insights about the patient’s perspectives and may help to promote better patient-centered health services and increase the quality of care. Areas of improvement identified were interpersonal skills of healthcare providers and logistics of health delivery, which may lead to a more desirable patient-perceived experience and thus better overall healthcare outcomes. Trial registration Systematic review registration: PROSPERO (CRD42019136500).


Introduction
Musculoskeletal (MSK) disorders including neck and low back pain, hip and knee osteoarthritis, and rheumatoid arthritis, are some of the most burdensome conditions in terms of disability worldwide, associated high healthcare utilization and costs [1][2][3]. Because of the high incidence of chronicity [4] of these disorders, seeking treatment from and recurring visits to healthcare services are frequent and common [5][6][7]. Efforts to optimize the overall quality of healthcare could promote better outcomes and patient satisfaction as well as minimize the burden of healthcare delivery in MSK settings [8][9][10]. Patient experience has been recognized as a significant contributing factor to the quality of healthcare and has recently drawn more research interest [5,[11][12][13][14]. A deeper understanding of patients' experience of healthcare-seeking, their perspectives while receiving medical services and, patients' perceptions of the impact of the process of care may provide a different point of view regarding healthcare delivery [15].
The context of patient experience is multi-dimensional. Any feedback provided by patients regarding their perceptions of met needs after a clinical encounter or ward rounds is considered a component of the patient experience [16,17]. Through applying patient-reported experience measures (PREMs), researchers or clinicians would be able to identify what patients value the most during patient-healthcare provider interaction and acknowledge feedback directly from patients regarding how to fine-tune provision of integrated care and improving outcomes [18]. Doyle et al. [10] outlined a framework from a cluster of terms related to the patient experience into relational and functional aspects. Relational aspects refer to the interactions between patient and healthcare provider. Empathy, respect, and building mutual trust are factors that enable providers to offer self-care interventions to patients and adequately engage them in their own decision-making. Functional aspects emphasize the logistics of healthcare delivery that entail the efficiency and effectiveness of healthcare services, smooth transition between facilities, clean and safe environment as well as physical access to healthcare services.
There is an increasing focus on capturing, measuring and analyzing the patient experience for a variety of high-volume conditions (including osteoarthritis, osteoporosis, and low back pain, and rheumatoid arthritis) [10,[19][20][21][22][23][24][25][26], as a means to drive better patient-centered care and improve the quality of healthcare delivery. There could be value in providing an overview of the patient experience when seeking care from healthcare providers and services in the healthcare system. An overview of reviews aims to appraise and summarize the evidence from multiple reviews on the same topic, which can support healthcare provider's decision-making and facilitate the development of clinical guidelines [27].
Thus, the objectives of this overview of reviews is to 1) identify aspects of the patient experience when seeking care for musculoskeletal disorders from healthcare providers and the healthcare system. 2) identify which mechanisms are used to measure aspects of the patient experience. This overview focused on adults as it was considered challenging to collect patient-reported experience outcomes from pediatric populations. It was our interest to critically appraise, summarize, and identify gaps in the current evidence about the experiences of patients when seeking care from healthcare providers and services in the healthcare system.

Protocol and registration
The protocol of this overview of reviews is registered on the International Prospective Register of Systematic Reviews (PROSPERO: CRD42019136500). This overview of reviews was conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [28] checklist and the Cochrane Handbook of Systematic Reviews of Interventions (overview of reviews section) [29].
Search methods for identification of reviews A systematic literature search was conducted in electronic bibliographic databases: CINAHL, PubMed, EMBASE, and Scopus from their inception up to December 2019, without language restrictions. The search strategies were developed by the biomedical librarian (LL). Controlled vocabulary and keywords related to musculoskeletal disorders, patient experience, and reviews were combined for the search and were adjusted for each of the databases previously mentioned. The searches were re-run just before the final analyses and further studies retrieved for inclusion. In addition to the electronic database search, the authors conducted citation tracking on the reference list of included reviews to identify any potentially eligible reviews. Reviews meeting the inclusion criteria that were not originally included during the electronic search and citation tracking were manually selected. The full search strategy is outlined in Appendix 1. All citations were imported into Covidence Software and dual-screened by the authors.

Criteria for considering reviews for inclusion Population of interest
The population of interest were adults (≥18 years of age), with at least one type of musculoskeletal disorders (i.e., low back pain, neck pain, osteoarthritis, rheumatoid arthritis, fibromyalgia, surgical pain after joint replacement or spinal fusion, and osteoporosis). Reviews investigating participants with systemic or non-musculoskeletal pathology (e.g. tumors or infection) or pregnancy were excluded, since there would be different expectations for healthcare providers and services from these populations and other confounding factors such as life expectancy.

Study design and selection
Considering the substantial amount of existing evidence on the topic of interest, we decided to include systematic reviews (with or without meta-analysis) or scoping reviews that examined any related concepts that fall within the definition of "patient experience". If an eligible study was published in a language outside the primary or secondary languages of the authorship team (English, Portuguese, Chinese and Spanish) all possible efforts would be made to get a translation; if that was not feasible the study was excluded. Articles that investigated healthcare delivery aspects were also included.

Outcomes of interest
For this review, we considered the patient experience as "the sum of all interactions that patients have with the healthcare system, including their care from health plans, and from doctors, nurses, and staff in hospitals, physician practices, and other healthcare facilities, shaped by an organization's culture, that influence patient perceptions across the continuum of care" [30].
Doyle et al. [10] proposed compiling the patient experience into relational (interpersonal) and functional (logistics of healthcare delivery) aspects. We adopted this general framework into Table 1 in an attempt to identify patient experience for our target population.

Mechanisms used to measure relational and functional aspects of patient experience
We included several methods such as paper and electronic survey, focus group, patient journal, and interview, and patient-reported experience measures that have been utilized as instruments to measure and track changes of different aspects of patients' perceptions.

Selection of reviews
Four reviewers (working in groups of two: AC and MC, KB and BG) independently screened titles and abstracts to identify relevant studies for full texts based on the agreed eligibility criteria checklist and approved by the senior advisors (AG and CC). The same reviewers independently screened full texts for final inclusion. Any disagreement between reviewers was resolved by discussion and reaching consensus. If the initial reviewers failed to reach a consensus, a third reviewer from the other group arbitrated. Agreement between reviewers (on the independent inclusion of title/abstracts and full-text articles) were quantified using a kappa statistic [31,32].

Data extraction and management
Four reviewers (AC, MC, KB, and BG) independently extracted data from the included studies, using a standardized data extraction form. The following data were extracted: a) authors, year of publication, b) study design (systematic or scoping reviews), c) review country, d) settings of the individual studies, e) number and study designs of the individual studies, f) musculoskeletal disorder, g) relational and functional aspects of patient experience, h) data collection method, i) and main findings. Disagreement in the data extracted between reviewers was resolved by discussion and if necessary, arbitration by a third reviewer (AG).

Assessment of methodological quality of included reviews
Four reviewers (AC, MC, KB, and BG) independently assessed the methodological quality of included studies using A MeaSurement Tool to Assess systematic Reviews (AMSTAR-2) [33]. AMSTAR-2 is a validated instrument that uses 16 questions to assess the quality of systematic reviews that include randomized and/or nonrandomized studies of healthcare interventions. Reviewers rated either "yes" or "no" for each question based on the extent an article met certain criteria; and "partial yes" or "not applicable" for a few questions. The reviews were rated in overall confidence into four categories: "high", "moderate", "low", and "critically low", which was calculated using the AMSTAR checklist [34]. We considered critical domains of reviews, which included 1) whether or not protocol registered before commencement of the review, 2) the adequacy of the literature search, 3) the justification for excluding individual studies, 4) the methodological quality from individual studies being included in the review, 5) consideration of methodological quality when interpreting the results of the review and 6) the assessment of presence and likely impact of publication bias. It is not mandatory for scoping reviews to have a protocol, an article appraisal risk of bias tool, or syntheses of findings from individual studies, hence, when appraising scoping reviews with AMSTAR-2, all criteria related to any of these were considered not applicable [35]. Disagreements between the reviewers were resolved by discussion with the involvement of a third reviewer (AG) when necessary.

Data synthesis
We used the PRISMA flow diagram to summarize the selection of reviews and summarized the characteristics of the included reviews in structured tables. Because the outcome data included in this review are not quantitative, the results of patient experience aspects were reported descriptively. We calculated the proportion of relational and functional aspects reported by the included reviews. Themes were identified and categorized based on the definition of aspects of patient experience outlined by Doyle et al. [10] (Table 1).

Search results
From the electronic search, 7307 potentially relevant articles were identified from four databases after the removal of duplicates based on titles and abstracts. Of these, 7080 were not relevant and 227 were retrieved in full texts. For the screening of titles and abstracts, the inter-rater agreement rate between the reviewers [(AC and MC) and (KB and BG)] resulted in a Cohen's Kappa rate of 0.32 (fair agreement) and 0.51 (moderate agreement). The full-text review resulted in 30 included reviews [10,[19][20][21][22][23][24][25][26] (Fig. 1). Of these, two [10,36] were manually included when searching for relevant studies on PubMed and met the eligibility criteria; and one [54] was included after a manual search from reference lists of the included studies. The most common reasons for exclusion at the full-text reading stage were outcomes not related to our study purpose (n = 157), study designs that were neither systematic nor scoping reviews (n = 21), and other conditions not related to musculoskeletal disorders (n = 17) (Fig. 1). We have provided a list of relevant studies read in full-text, but excluded from the review with their respective reasons for exclusion (Appendix 2).
Patient experience with healthcare providers and health services outcomes (Table 4) There was a broad range of patient experience aspects reported by the included reviews. As stated in the methods, we considered patient experience from the perspective of relational and functional aspects. All reviews except one [55] reported patient experience outcomes from the perspective of relational aspects (n = 29, 97%), 26 reviews (87%) [10, 19, 21-24, 26, 36-38, 40-55] from the perspective of functional aspects; and 25 (83%) [10, 19, 21-24, 26, 36-38, 40-54] of the reviews included both relational and functional aspects. Among the included reviews, only three [41,51,53] specifically investigated the interactions between patients and physical therapists. The majority of the included reviews stood from the patient's perspective focusing on a certain musculoskeletal diagnosis, and they reported the overall patient experience while seeking healthcare services regardless of the providers they encountered.

Discussion
The main purpose of this study was to investigate the experience of people with musculoskeletal disorders when seeking healthcare services and their perception of healthcare providers. While considering abstract concepts about the patient experience, delineation and definition of relational and functional aspects provide a useful framework to scrutinize different themes and constructs in this field of study. In this overview of reviews, we identified five key themes in both the relational and Mixed, stroke (n = 3), head and neck cancer (n = 2), mixed rehabilitation (n = 2), various speech pathologies (n = 1), low back or neck pain (n = 7), jaw pain (n = 1), chronic fatigue/ myalgic encephalomyelitis (n = 1) and older adults post hip fracture (n = 1)

Systematic reviews
Verbeek, 2004 [50] Systematic reviews with meta-analysis A MeaSurement Tool to Assess systematic Reviews (AMSTAR-2) tool. b calculated by AMSTAR-2 checklist [36] Y yes, N no, PY partial yes, NA not applicable. c Q2, Q9, Q13 are not applicable for scoping reviews, and Q11, Q12, and Q15 are only applicable for studies with meta-analysis Q1. Did the research questions and inclusion criteria for the review include the components of PICO? Q2. Did the report of the review contain an explicit statement that the review methods were established prior to the conduct of the review and did the report justify any significant deviations from the protocol? Q3. Did the review authors explain their selection of the study designs for inclusion in the review? Q4. Did the review authors use a comprehensive literature search strategy? Q5. Did the review authors perform study selection in duplicate? Q6. Did the review authors perform data extraction in duplicate? Q7. Did the review authors provide a list of excluded studies and justify the exclusions? Q8. Did the review authors describe the included studies in adequate detail? Q9. Did the review authors use a satisfactory technique for assessing the risk of bias in individual studies that were included in the review? Q10. Did the review authors report on the sources of funding for the studies included in the review? Q11. If meta-analysis was performed did the review authors use appropriate methods for statistical combination of results? RCTs Q12. If meta-analysis was performed, did the review authors assess the potential impact of RoB in individual studies on the results of the meta-analysis or other evidence synthesis? Q13. Did the review authors account for RoB in individual studies when interpreting/ discussing the results of the review? Q14. Did the review authors provide a satisfactory explanation for, and discussion of, any heterogeneity observed in the results of the review? Q15. If they performed quantitative synthesis did the review authors carry out an adequate investigation of publication bias (small study bias) and discuss its likely impact on the results of the review? Q16. Did the review authors report any potential sources of conflict of interest, including any funding they received for conducting the review? No. of reviews (%)

Patient Experience Outcomes
Measure (data collection method) No. of reviews (%)

Relational aspects of patient experience
The patients' understanding of their health condition and appropriate management highly depends on their health literacy [57]. Education about the natural course of certain diagnoses, multiple domains that drive pain and disability, as well as the psychosocial aspect of the pain experience, is recommended during patient-healthcare provider encounters [58]. It is also reported that delivering clear information with good communication skills would help patients cope with their health conditions and prognoses, which would facilitate establishing a trustworthy patienthealthcare provider relationship [47,59]. Effective communication helps healthcare providers develop a clearer idea of patients' feelings and their needs [53]. Meanwhile, patients would have an increased understanding of the scope and impact of their musculoskeletal disorder(s) and possible treatment options [54]. Such processes facilitate shared decision-making models whereby patients are empowered to participate in their medical management [26,60]. Furthermore, psychological support can be influential, especially for those suffering from chronic pain, in diminishing possible fear-avoidance of initiating movement as well as compliance with their exercises throughout healthcare-seeking [61]. Therefore, to better promote quality and outcomes in healthcare, providers should consider improving their interpersonal skills to address the relational aspects of patient experience.  [19,37,41,44,47,50], Osteoarthritis [22], Rheumatoid arthritis [26,42], Others [10,46,51,55] Feasibility and availability of healthcare service [37,44], coordination and continuity of care; smooth transitions from one setting to another (patients and their caregivers may experience a lack of clarity about where clinical responsibilities ended and caregiver responsibilities began) [10,19,46,47,50,55], the need for collaboration between different HCPs, confusion about the role of different healthcare providers [19,55], time length of consultations and flexibility with patient appointments and care [26,41,50], barriers to meeting health information needs were around timely access [42], preferences for follow-up care [26,51], timing and accessibility of appropriate care and in times of need [26], need for allied health and CAM [26], disorganized discharge planning (a focus on rapid discharge, absence of patient and caregiver involvement during discharge planning and a lack of standardized patient assessment during care transitions) [55], lack of information sharing with patients and caregivers included an absence of the following: healthcare providersinitiated conversations about treatment plans, accurate information about the recovery and information from hospital staff during discharge and admission [55].
Privacy Survey, questionnaire 3 (10%) Non-specific low back pain [23], Others [48,51] Respect for patient privacy [23,48], lack of privacy will lead to less patient satisfaction [51] Functional aspects of patient experience First, the application of individualized, tailored treatment has been proposed in the management of musculoskeletal disorders, with emphasis on customizing interventions for any given individual pathological, functional, and psychosocial variations [62][63][64]. In a shared decision-making model, patient's diagnoses, clinical manifestations, severity of symptoms, cognitive and mental status as well as their needs should all be taken into consideration to formulate holistic, personalized plans of care [65]. Second, continuity during transitions among different healthcare settings, and physical access to healthcare should also be addressed in integrated care [66]. Providing downstream transfer services after discharging patients from acute or subacute hospitals to rehabilitation facilities, nursing homes, or outpatient clinics is recommended to ensure that patients receive required medical attention and care without disruptions. Third, physical accessibility of healthcare sites influences the patient experience. Environmental factors including commute distance [51], cleanliness, and barrierfree designs in clinics need to be considered. The flexibility of scheduling [23] and the complexity of paperwork also impact patients' overall impression of healthcare facilities. Fourth, patients perceive the professional role [40,54] of healthcare providers based on their qualifications, competence, technical skills [19,22,23,46,53], attitudes, and beliefs [45]. Patient's trust in expertise is built upon the foundation of the knowledge and training [24,41] of a healthcare provider as well as the validation by multidisciplinary healthcare team [38]. Finally, patients expect that their privacy should be fully respected before, during and after receiving health services [23,48].

Mechanisms of collecting patient experience
While efforts have been made to collect and measure information about the patient experience using qualitative studies or surveys, actions and strategies on systematically improving quality of care and promoting patient-centered care according to patientreported experience measures have not yet been fully undertaken [67]. Considering the positive correlation between the patient experience and clinical outcomes, it needs to be considered as a tool to refine the quality of care and enhance the implementation of the concept of patient-centeredness [18,64,68]. In a recent study evaluating key drivers of the patient experience in pediatric population with heart disorders, cheerfulness during practice, the cohesiveness of staff, and explanation of problems and conditions from the providers were identified as predictive of overall satisfaction [69]. Furthermore, it has also been reported in a study evaluating interview narratives who had been hospitalized that, medication management, physical comfort, and emotional security were what matter most [70].

Strengths and weaknesses of the study
One of the strengths of this overview of reviews is that a comprehensive search was conducted for studies relating to the patient experience. We provided evidence from different perspectives of the patient-healthcare provider relationship and summarized ten themes about the patient experience. Providers working in healthcare settings treating patients with musculoskeletal disorders may find this overview of reviews beneficial to better understand patients' perceptions when using healthcare services, value of effective interpersonal skills, and need to simplify the process of access to quality healthcare. A few limitations of this overview of reviews included the unfeasibility of performing a meta-analysis (due to the heterogeneity among the study designs and population of included reviews) and lack of analysis of overlapping between the reviews. This means that one original study might have been included in more than one review. As we did not review all different musculoskeletal disorders, it may not necessarily be applicable to all health settings.

Unanswered questions and future research
Further investigation of the patient experience should focus on patients with neurological disorders or other chronic conditions that require intensive healthcare services. It is also worth discussing issues on cultural differences/impacts that are relevant/different in various countries or geographical regions. To bridge the evidence to clinical practice, it is healthcare providers' responsibility to try to understand the patient experience when delivering services. When acknowledging the relational and functional aspects of patient experience, healthcare providers would value the importance of communication and strive to comprehend what truly matters to their patients, which could be their individual information needs, preferences of treatment, or expectations of a supportive healthcare environment. Collecting patients' feedbacks will assist healthcare providers better evaluate their services and ensure the voices of service users are heard [71].

Conclusion
Patient experience alongside safety and clinical effectiveness serve as the three pillars that enhance quality of healthcare and influence patients' perspectives when receiving healthcare services. In healthcare settings, which currently treat musculoskeletal conditions, efforts on measuring and capturing patient experience could help guide improvement in healthcare providers' interpersonal aspects, and patient's expectations on how healthcare should be delivered. This overview of reviews identified constructs regarding patient experience of healthcare providers and health services and proposed ways to enhance healthcare experience of patients with musculoskeletal disorders. By adjusting healthcare providers' professional attitudes and behaviors when interacting with patients, as well as changing environmental factors in healthcare facilities, an improvement in patient adherence to medical advice and regimens promoting health and well-being would be reasonably expected. Our findings suggested that healthcare providers understand the importance of patient information needs and expectations via effective communication. It is also recommended that patients be treated individually with personalized intervention plans in a supportive, comforting environment.