Eduvest ï¿½ Journal of Universal Studies Volume 4 Number 09, September, 2024 p- ISSN 2775-3735- e-ISSN 2775-3727

Factors Associated With Outpatient Loyalty In Hospital: Systematic Literature Review
Muhammad Tsany Saadi¹, Purnawan Junadi² ï¿½ï¿½ ^1,2Fakultas Kesehatan Masyarakat, Universitas Indonesia, Indonesia Email: ï¿½[email protected], [email protected]
ABSTRACT
The healthcare industry is undergoing a paradigm shift towards patient-centered care. In this competitive environment, patient satisfaction and loyalty are crucial for hospitals. While patient satisfaction is routinely measured, its precise relationship with loyalty remains unclear, as existing studies have yielded mixed results. Other determinants aside from patient satisfaction may also influence patient loyalty. By identifying these key determinants, hospitals can develop targeted strategies to enhance patient satisfaction and promoting patient loyalty, ultimately securing a competitive advantage. Objective: This systematic literature review aims to explore the current research on factors influencing outpatient loyalty to hospitals. Method: This systematic review uses Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A search strategy was used to identify relevant studies in PubMed, ProQuest, and ScienceDirect. The search timeframe encompassed publications between January 2019 and April 2024. A set of predefined inclusion and exclusion criteria were applied, resulting in the identification of 17 articles relevant for further analysis. Result: Patient satisfaction emerged as a key driver of loyalty, positively influenced by factors beyond service quality.ï¿½ These factors include trust in the hospital, word of mouth, hospital image, strong patient-physician relationships, patient convenience, patient motives, switching cost, customer relationship management, and staff kindness and consideration. Conclusion: Patient loyalty is influenced by a multitude of factors extending beyond service quality and satisfaction.ï¿½ Building trust, nurturing patient relationships, optimizing the patient experience, and offering value are crucial considerations.ï¿½ Tailoring strategies to specific patient demographics and cultural contexts are essential.
KEYWORDS	Outpatient; Loyalty; Revisit Intention; Service Quality; Satisfaction; Hospital
	*This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International*

Hospitals are healthcare facilities that provide comprehensive individual healthcare services, including inpatient, outpatient, and emergency care (Asri Rossnita Dewi et al., 2023; Sangkot et al., 2022). The hospital industry has grown rapidly in recent decades, leading to intense competition among hospitals both nationally and internationally. Currently, there is a paradigm shift in healthcare delivery. The model that was previously disease-centered is now becoming patient-centered, where patients can actively participate in the care process and their needs and preferences are involved in medical decision-making. This change in the decision-making process creates competition between healthcare institutions, forcing them to become financially sustainable. One of the strategies used is to understand and meet patient needs, similar to other commercial business models (Park et al., 2021).

In the patient-centered model, it is crucial to consider patient perceptions of the given services to evaluate the outcomes of the healthcare delivery process, so that hospitals can provide services that meet patient expectations and needs. This form of patient evaluation should be considered a priority in hospital healthcare services (Park et al., 2021). Understanding patient perceptions allows hospitals to identify areas for improvement and ultimately enhance patient experience, and high satisfaction may be an indicator for patient loyalty.

Loyalty or revisit intention is defined as the intention or desire to choose the same organization to achieve well-being in health. Loyalty is an essential indicator of service quality, although there is currently not much empirical evidence to support this claim (Pighin et al., 2022). Therefore, for a healthcare institution to survive and have a competitive advantage, a customer-oriented marketing strategy is needed that can meet customer expectations by providing quality healthcare, which can lead to repeat visits when needed (Woo & Choi, 2021). However, the relationship between patient satisfaction and revisit intention is complex and has been the subject of numerous studies with mixed results. Some studies have found no significant association between patient satisfaction and revisit intention (Rahmiati & Temesveri, 2020; Sangkot et al., 2022), while others have found positive correlations between various dimensions of patient satisfaction and revisit intention (Gozal et al., 2022; Wandebori, 2017; Yassir et al., 2023).

Given the inconsistencies in the literature, this systematic review aims to synthesize and evaluate the existing evidence on the factors associated with outpatient loyalty to hospitals. By identifying the key determinants of patient loyalty, hospitals can develop targeted strategies to fulfill patient satisfaction and therefore achieving patient loyalty.

RESEARCH METHOD

This systematic review employed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to identify and synthesize relevant literature on factors associated with outpatient revisit intention in hospitals. Research sources were obtained from scholarly journals that examined this topic. The search and selection of journals were conducted through several online databases, including PubMed, ProQuest, and ScienceDirect. The search terms used were ("outpatient" OR "out-patient" OR "ambulatory care") AND ("revisit intention" OR "loyalty") AND "hospital" with filters applied for research published between January 2019 and April 2024, original research, written in English, and open-access articles. Subsequently, inclusion criteria were established as follows: (1) studies investigating factors associated with hospital outpatient patient loyalty or revisit intention, and (2) studies published in journal articles. Excluded articles were those conducted only on inpatients, clinics, and literature reviews or systematic reviews.

RESULT AND DISCUSSION

Search Result

ProQuest (n=482)

Pubmed (n=7)

ScienceDirect (n=41)

Records after duplicates removed (n=528)

Full text article eligible (n=22)

(n=12) What matters to patients? A timely question for value-based care

Studies include in qualitative synthesis (n=17)

Records excluded

(n=506)

Studies do not match the inclusion criteria, Literature/Systematic Review

Total (n=530)

Full Text Articles excluded

(n=5)

Studies including health facilities other than hospital

A comprehensive search was conducted using the predetermined keywords across three scholarly databases: ProQuest, PubMed, and ScienceDirect. The initial search yielded a total of 530 articles (ProQuest = 482 articles, PubMed = 7 articles, and ScienceDirect = 41 articles). Duplicate entries were removed, and a screening process was applied to assess the relevance of titles and abstracts. This process resulted in the identification of 24 articles that met the inclusion criteria for further analysis. The selection process documented using a PRISMA flowchart diagram, as illustrated in Figure 1.

Figure 1. PRISMA Flow Diagram

This systematic literature review analyzed 17 papers with studies conducted in various countries, including Egypt, India, Thailand, Saudi Arabia, Indonesia, China, Turkey, Syria, UAE, Jordan, South Korea, Malaysia, and Ghana. All analyzed studies were cross-sectional studies, with respondents being outpatients in hospitals. Of the 17 papers, 16 used quantitative methods, while one paper used a mixed method. The results of study extraction can be seen in Table 1.

Table 1. Study Extraction

Author(s), year	Title	Country	Method	Result
(Garem et al., 2024)	Factors associated with patient loyalty in private healthcare sector Factors associated with patient loyalty in private healthcare sector in Egypt	Egypt	Cross-sectional, the data were gathered from 462 outpatients in 62 Egyptian private hospitals in Greater Cairo using structured questionnaire, and analyzed using structural equation modelingï¿½	Service quality has significant impacts on satisfaction. Perceived service quality has a nonsignificant relationship with patient loyalty. Trust has a significant impact on patient satisfaction and loyalty. Patient satisfaction positively and significantly affects patient loyalty. Patient satisfaction fully mediates the relationship between perceived service quality and the patient loyalty. Age is found to be a major moderating variable to the relationship between satisfaction and loyalty. Patient satisfaction fully mediates the relationship between perceived service quality and patient loyalty.
(Nahima et al., 2024)	A cross-sectional study on exploring the antecedents of patientï¿½s revisit intention: Mediating role of trust in the hospital among patients in India	India	Cross-sectional, the data were gathered from 242 outpatients in three multispecialty hospitals in Bangalore Urban and one in Mysore. The data is collected using structured questionnaire and analyzed using PLS-SEM.	Patient who is satisfied with the healthcare services received will develop trust and intention to revisit the same hospital in the future. There is a partial mediation relationship between perceived service quality and trust, and between patient satisfaction and behavioral intention.
(George & Sahadevan, 2024)	What determines behavioural intention in health services? A four-stage loyalty model	India	Cross-sectional, the data were gathered from 420 respondents admitted to government hospitals in Kerala using convenience sampling method. The data were analyzed using PLS-SEM.	Physical environment, personnel quality, and technical quality have significant impact on patient satisfaction.ï¿½ Service quality dimensions play a crucial part in developing patient loyalty by instigating patient satisfaction. Patient satisfaction has a significant positive effect on trust, commitment, and behavioral intention. Trust and commitment also have a significant positive effect on behavioral intention.
(Ongpattanakit, 2024)	Examining the Factors Impacting Satisfaction and Loyalty in Innovative Personal Health Assistant Services for Hypertension Patients of a Private Hospital in Thailand	Thailand	Cross-sectional, data were obtained from questionnaire distributed to patients with hypertension symptoms at a private hospital, with 500 respondents. The data were analyzed using Confirmatory Factor Analysis (CFA) and Structural Equation Modeling (SEM).	Loyalty was driven by satisfaction. Service quality, hospital image, and trustworthiness significantly impact satisfaction. Service quality played critical role for hypertension patient as it directly impacts satisfaction and hospital image, and indirectly impact loyalty.
(Sharka et al., 2024)	Measuring the impact of dental service quality on revisit intention using an extended SERVQUAL model	Saudi Arabia	Cross-sectional, data were collected using extended SERVQUAL questionnaire. The response obtained from 355 patients in Al-Qura University Dental Teaching Hospital then analyzed using hierarchical linear regression analysis	Male and female respondents did not differ in their revisit intention. Age and level of education have a significant impact on revisit intention. In the regression model with service quality added, age and level of education were no longer significant. Responsiveness, cost-effectiveness, and staff-related factors had a significant and positive impact on revisit intention. Extended SERVQUAL model could predict the revisit intention.
(Sediawan et al., 2023)	The Patient Experiential Quality Model Scale Development and Validation	Indonesia	Cross-sectional, mixed method using qualitative and quantitative study. The qualitative study was employed through content analysis and focus group discussion with 28 health professionals. The quantitative study was conducted using explanatory factor analysis and confirmatory factor analysis, with SEM. The data were obtained from 153 respondents from maternity and paediatric clinic at Malang Region.	Perceived service quality, interpersonal quality, technical quality, environmental quality, and administrative quality are important factors that affect patient satisfaction, trust, and loyalty. There is a mediating role of patient satisfaction and trust in relationships experience of service quality with patient loyalty.
(Luo, 2023)	Determinants of Patientsï¿½ Behavioral Intention and Loyalty in Private Hospitals in Chengdu, China	China	Cross-sectional, using online questionnaire to 500 patients who use the medical service of private hospitals in Chengdu. The data was analyzed using Confirmatory Factor Analysis (CFA) and Structural Equation Modeling (SEM).	Service quality has the strongest significant influence on patient satisfaction. Patient satisfaction significantly influences patient loyalty and behavioral intention. Medical costs, reasonableness, healthcare technicality, and interpersonal behavior significantly influence service quality.
(Yıldırım et al., 2022)	Effect of relationship marketing ï¿½on hospital loyalty: the mediating ï¿½role of patient satisfaction	Turkey	Cross-sectional, the data were gathered from 401 respondents in private hospitals using purposive sampling method. Correlation analysis and statistical package for the social sciences Process Macro were used to analyze the data.	Patient satisfaction has an effect on hospital loyalty. Relationship marketing has an impact on hospital loyalty, and this effect is further enhanced by patient satisfaction. Patient satisfaction has a mediating role in the impact of relationship marketing on hospital loyalty. Relationship marketing plays an important role in creating hospital loyalty and patient satisfaction.
(AlOmari et al., 2022)	Strategies to improve patient loyalty and medication adherence in Syrian healthcare setting: The mediating role of patient satisfaction	Syria	Cross-sectional, the data were obtained from six hospitals in Damascus, with respondents of 321 patients. The data were collected using questionnaires and analyzed using Structural Equation Modeling.	Four dimensions of service quality (tangibility, assurance, reliability, and financial aspects) had a positive influence on the satisfaction of the Syrian patients. Reliability and responsiveness had a positive impact on patient loyalty. However, tangibility, empathy, assurance, and financial aspect had no influence on patient loyalty. Patient satisfaction mediated the relationship between service quality dimensions (assurance, reliability, and financial aspect) and patient loyalty.
(Indiraswari et al., 2022)	Government Hospital Service Convenience Model to Increase Patient Satisfaction and Loyalty in The Internal Medicine Polyclinic of Haji Hospital, Surabaya East Java Indonesia	Indonesia	Cross-sectional, data were obtained from questionnaire distributed to outpatients in internal medicine polyclinic of Haji Hospital, involving 95 respondents. The data were analyzed using SEM-PLS	Patient satisfaction had a moderate influence on patient loyalty. There is a strong direct significant effect between service convenience on patient satisfaction, and a moderate indirect influence on patient loyalty.
(Dayan et al., 2022)	Factors influencing patient loyalty to outpatient medical services: an empirical analysis of the UAEï¿½s government healthcare system	United Arab Emirates	Cross-sectional, questionnaires were provided to 418 participants using methods such as short message service, e-mail, and face-to-face delivery. The data were analyzed through the application of SmartPLS 3.0	Service quality, word of mouth, and outpatient-physician relationship positively impact outpatient satisfaction and indirectly affect outpatient loyalty. Hospital Image positively impacts outpatient satisfaction and loyalty and has a partially mediating effect on loyalty. Waiting time satisfaction has no effect on outpatient satisfaction and no moderating effect on the outpatient satisfaction-loyalty relationship. Switching cost has a positive effect on loyalty but no moderating effect on the outpatient satisfaction-loyalty relationship.
(Almomani et al., 2022)	Factors influencing patient loyalty in Jordanian public hospitals	Jordan	Cross-sectional, data were obtained using a close-structured questionnaire. The number of responses collected was 400 patients who has visited a public hospital in Jordan. The data were analyzed using structural equation modelling technique.	Patient convenience has a positive direct effect on patient loyalty and satisfaction. Patient satisfaction has a positive direct effect on patient loyalty. Patient satisfaction mediated the relationship between patient convenience and patient loyalty.
(Tuncay et al., 2022)	Do Patient Experiences Have Mediating Roles on Patient Loyalty?	Turkey	Cross-sectional, data were obtained using electronic questionnaire regarding feedback from 5,732 outpatients. The data were analyzed using correlation test, unpaired-T test, and mediation analysis	This research was using Net Promoter Score (NPS₁₁) to measure loyalty. Patients give higher score for the NPS₁₁ in Day shift compared to those on the Night shift. The NPS₁₁ score is significantly associated with physician experience and nursing care experience. In females, the NPS11 score was affected by the waiting time experience.
(Woo & Choi, 2021)	Medical service quality, patient satisfaction and intent to revisit: Case study of public hub hospitals in the Republic of Korea	South Korea	The data of 2,951 outpatients were collected using the "2018 Regional Hub Public Hospital Operational Evaluation". The data were analyzed using structural equation modelling technique.	Physician's practice service, hospital's physical environment, and patient satisfaction directly affected intention to revisit. Physician's practice service, hospital's physical environment, and medical staffï¿½s kindness and consideration had a significant effect on patient satisfaction. Among healthcare quality factors, medical staffï¿½s kindness and consideration had the most substantial effect in outpatient revisit intention.
(Morissan & Gan, 2021)	Motivation and loyalty of Indonesian medical tourists toward Malaysian health services	Indonesia - Malaysia	Cross-sectional, questionnaires were distributed to medical tourists in Malaysia from Indonesia (n=152) who have visited hospitals in Malaysia at least once. The data were analyzed using multivariate test, multiple linear regression, and simple linear regression.	Satisfaction is a significant predictor for loyalty. Push and pull motives are significantly associated with patient satisfaction.
(Abekah-Nkrumah et al., 2021)	Customer relationship management and patient satisfaction and loyalty in selected hospitals in Ghana	Ghana	Cross-sectional, data were obtained using a two-stage sampling process and using structured questionnaires to collect data from 788 patients from three hospitals in Greater Accra, Ghana. The data were analyzed using regression via partial least squares-based structural equation model.	Customer relationship management (CRM) is significantly positively correlated with patient satisfaction and patient loyalty. Patient satisfaction is significantly correlated with patient loyalty. The introduction of education, health facility ownership, health insurance status, and gender neither impact significantly on the relationship between CRM and satisfaction/loyalty, nor influenced patient satisfaction and loyalty directly.
(Lai et al., 2020)	The effects of service quality and ï¿½perceived price on revisit intention of patients: the Malaysian context	Malaysia	Cross-sectional, data were obtained from questionnaire distributed to outpatients in three major cities in Malaysia. The response obtained from 400 patients were analyzed using structural equation modelling technique.	Behavioral price mediates the relationship between monetary price and revisit intention. Service quality has a causal relationship with revisit intention. Monetary price has been found to affect revisit intention in a positive direction, but behavioral price weaken revisit intention. Monetary price has mediating effects on the relationship between service quality and revisit intention. Behavioral price has significant mediation effects on the service quality-revisit intention and monetary price-revisit intention.

Based on the 17 literatures included in this systematic review, patient satisfaction is positively and significantly associated with patient loyalty. Satisfaction can be influenced by many factors, such as service quality (AlOmari et al., 2022; Dayan et al., 2022; Garem et al., 2024; George & Sahadevan, 2024; Luo, 2023; Ongpattanakit, 2024; Sediawan et al., 2023; Woo & Choi, 2021), trust (Garem et al., 2024; Ongpattanakit, 2024), hospital image (Ongpattanakit, 2024), word of mouth (Dayan et al., 2022), outpatient-physician relationship (Dayan et al., 2022), switching cost (Dayan et al., 2022), patient convenience (Almomani et al., 2022), push and pull motives (Morissan & Gan, 2021), medical staffï¿½s kindness and consideration (Woo & Choi, 2021), and customer relationship management (Abekah-Nkrumah et al., 2021).ï¿½ While service quality had a positive influence on satisfaction, one study in Syria showed that only four dimensions of service quality (tangibility, assurance, reliability, and financial aspects) had a positive influence on the satisfaction of the Syrian patients (AlOmari et al., 2022).

Trust is found to be a significant factor that influence loyalty (Garem et al., 2024; George & Sahadevan, 2024) or as a mediating factor between service quality and loyalty (Sediawan et al., 2023). Commitment (George & Sahadevan, 2024), relationship marketing (Yıldırım et al., 2022), patient convenience (Almomani et al., 2022), time of admission (Tuncay et al., 2022), physician experience and nursing care experience (Tuncay et al., 2022), waiting time experience in female (Tuncay et al., 2022), medical staffï¿½s kindness and consideration (Woo & Choi, 2021), monetary price and behavioral price (Lai et al., 2020), and customer relationship management (Abekah-Nkrumah et al., 2021).

Association between demographic factors and loyalty are inconsistent among studies. In one study, age is found to be a major moderating variable to the relationship between satisfaction and loyalty (Garem et al., 2024). In another study, age is found to have significant impact on revisit intention on its own, but not significant in the regression model with service quality added (Sharka et al., 2024). Gender does not impact loyalty in two studies (Abekah-Nkrumah et al., 2021; Sharka et al., 2024), but longer waiting time is associated with lower loyalty score in female (Tuncay et al., 2022). Level of education is found to have significant impact on revisit intention on its own, but no longer significant in the regression model with service quality added (Sharka et al., 2024). In another study, education, the ownership of health facility, and health insurance status does not influence patient loyalty (Abekah-Nkrumah et al., 2021).

Discussion

This systematic review confirms a positive and significant association between patient satisfaction and loyalty. Service quality is linked to satisfaction, supported by multiple studies (Dayan et al., 2022; Garem et al., 2024; George & Sahadevan, 2024; Luo, 2023; Ongpattanakit, 2024; Sediawan et al., 2023). Service quality is the strongest predictor of satisfaction, and is a fundamental component of healthcare service that can predict patient satisfaction, leading to competitive advantages and higher business performance (Luo, 2023; Ongpattanakit, 2024). However, AlOmari et al. (2022) highlight that not all dimensions of service quality are equally important.

Their study suggests that for Syrian patients, aspects like tangibility, assurance, reliability, and financial considerations hold greater weight than others. Another study found that only reliability and responsiveness impact patientsï¿½ satisfaction, while empathy, tangibility, and assurance did not impact patientsï¿½ satisfaction. This finding is presumably due to the fact that in developing country, patients are more dependent on the treating physicianï¿½s recommendation (Meesala & Paul, 2018). This mixed findings might be the result of differences in cultural values, highlighting the importance to acknowledge the important service quality parameters that matter the most based on the patientï¿½s characteristics. This would allow hospitals to tailor their service offerings to better meet the specific needs and expectations of patients according to their patients backgrounds.

The link between service quality and loyalty varied between studies. Several studies showed that service quality is directly linked to loyalty (Almomani et al., 2022; AlOmari et al., 2022; Lai et al., 2020; Sharka et al., 2024; Woo & Choi, 2021), while others found that service indirectly impacting loyalty (Dayan et al., 2022; Garem et al., 2024; Indiraswari et al., 2022; Ongpattanakit, 2024). It is important to note that the measurement method of service quality and sample characteristics varied between studies, which may result in different research outcome. Indirect relationship between service quality and loyalty is mediated by factors such as patient satisfaction, trust, hospital image, monetary price, and behavioral price (Almomani et al., 2022; AlOmari et al., 2022; Dayan et al., 2022; Garem et al., 2024; Lai et al., 2020; Sediawan et al., 2023). This heterogeneity in findings highlights the need for further research that employs standardized service quality measurement and considers the moderating effect of sample characteristics on the service quality-loyalty relationship.

While service quality remains a cornerstone, building trust, fostering patient relationships, and optimizing the patient experience are crucial.ï¿½ Hospitals should consider implementing strategies that increase patientï¿½s trust. Investing in relationship marketing initiatives and staff training that emphasize patient-centered care can strengthen patient-hospital bonds. Additionally, streamlining processes, reducing wait times, and ensuring patient convenience can enhance the overall patient experience.ï¿½ Understanding gender-specific needs and tailoring service delivery accordingly might further improve loyalty scores, particularly among female patients. Hospitals should strive to deliver value by offering competitive pricing models and minimizing the behavioral price associated with seeking care.

CONCLUSION

This systematic review identified a multitude of factors that contribute to patient loyalty, extending beyond the well-established concept of service quality and patient satisfaction. While service quality is undeniably important, another factors such as trust, hospital image, word of mouth, outpatient-physician relationship, switching cost, patient convenience, push and pull motives, medical staffï¿½s kindness and consideration, and customer relationship management are crucial in order to create patient loyalty. Cultural values may also influence these factors. This underscores the need for hospitals to tailor their service offerings to their specific patient population. Hospitals that implement strategies addressing these diverse factors are more likely to create a patient-centric environment that encourages loyalty and repeat visits.

Further research could explore the relative weight of these factors across different patient demographics and healthcare systems. Additionally, investigating the effectiveness of specific interventions aimed at improving trust, patient relationships, and perceived value would be valuable for hospitals seeking to enhance patient loyalty.

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