We found that self-reported continuity of care was strongly associated with patients' satisfaction with their provider and with their health care. This association persisted after extensive adjustments for characteristics of patients, providers, and practice setting. Continuity of care was found to account for a substantial proportion of the variance that could be explained by the final model, along with health status and clinic site. This is supported by the fact that the addition of continuity to a model containing all other determinants of satisfaction explained an additional 5% of the variance in both humanistic and organizational satisfaction scores.
Further supporting the strength of the association between self-reported continuity and patient satisfaction is the incremental improvement in satisfaction with increasing continuity of care. The magnitude of the effect of continuity for each category of continuity is large, with the average SOSQ humanistic score 16.8 points higher for patients who always saw their provider compared to those who rarely saw their provider. Patients who mostly saw the same provider had average scores 10 to 11 points higher. This is a larger effect on satisfaction scores than patient gender, socioeconomic status, or utilization variables.
These results are consistent with a prior study in which personal continuity with the provider as well as the length of the doctor-patient relationship were associated with general satisfaction after a specific outpatient encounter.47
A sustained patient-clinician relationship over time is an essential component of primary care.16,48
With recent changes in the organization and delivery of health care, continuity has been difficult to preserve in many settings.23,24,49
There is evidence, however, that continuity with a provider is associated with several benefits such as increased trust of patients in their physician,30
improved physician-patient communication,46
and improved outcomes, including better glycemic control among diabetics21
and less frequent hospitalizations.20,31
In addition to having a doctor who listens and sorts out problems, patients value continuity of care50
and are more likely to think that continuity is important for serious medical problems.51
Patients prefer their own practitioner who is familiar with their unique medical condition and background.51
As described by Hjortdahl and Laerum, the relationship between continuity and satisfaction is complex.47
Patients who have continuity with a provider they like tend to be more satisfied, and satisfaction with a provider helps to determine whether or not they stay with the same provider in the future. We found that continuity was associated with both satisfaction with the provider's humanistic skills and with satisfaction with the organization of, and access to, health care within the one health care system. This suggests that personal continuity with a provider also helps to ensure that the patient is able to interact with the health system more effectively.
The relationship between continuity and satisfaction that we observed did not change significantly after adjusting for other factors including provider characteristics such as gender, type of training, or panel size. Characteristics of the provider were associated with SOSQ humanistic scores, but not organizational scores. This type of survey study precluded the ability to measure individual provider factors such communication skills, which likely would contribute to patient satisfaction with their provider.
Continuity of care may be related to the clinic structure. Within the VA system, all general internal medicine clinics are organized similarly: providers are organized into practice groups, and patients are assigned to individual providers within a group. Patients are permitted to change providers if requested, and may see another provider within the group if they are unable to see their usual primary care provider. Interestingly, even though the clinic structure is the same, there were significant differences in satisfaction among clinic sites, suggesting that there are unmeasured factors within each site that contribute significantly to patient satisfaction. These may include clinic variables such as waiting times to get an appointment with their primary care provider or referral to a specialist, unmeasured differences in patient coexisting illness or health status, or provider characteristics that may have impacted the interaction between patients and their providers.
Consistent with a prior study of dual users of VA and non-VA primary care clinics, we found that patients who obtain some of their care at non-VA clinics were less satisfied with their care.9
Although we adjusted for distance, a factor known to be associated with use of VA facilities, we could not assess other potential reasons for dual use, such as patients who seek primary care from the VA due to generous VA pharmacy benefits but obtain the majority of their care at non-VA clinics.
As seen in prior studies,10–13
we found that health status is an important factor associated with patient satisfaction regarding the humanistic and organizational aspects of their care. Because patients place more importance on continuity of care for more serious illness,51
changing the health care structure to improve continuity of care for the patients with the greatest impairment in functional status due to chronic disease may significantly improve patient satisfaction.
In the final model, only 19% of the total variance could be explained by all potential explanatory variables. This is consistent with several other studies that found that less than 20% of the variance in satisfaction scores can be explained by factors such as patient expectations, health status, demographics, clinic structure, disease severity, or physician specialty.7,11,52,53
This suggests that there are a number of factors that contribute to patient satisfaction that are not routinely measured, and that future research will be needed to elucidate other important determinants of satisfaction.54
In the validation portion of this study, we found that both SOSQ scales have a high internal consistency, were strongly predictive of patient intent to refer a friend or family member to their provider, and were able to discriminate adequately between those who would refer and those who would not. These scales, therefore, appear to be valid instruments to measure patient satisfaction with providers and access to care.
There are several potential limitations to this study. Generally, satisfaction surveys are obtained via mail with varying response rates. Because the surveys in the ACQUIP study were sent sequentially to patients, we were able to assess the difference in satisfaction between responders and nonrespondents based on 2 individual items included in the initial health checklist. We found that general satisfaction, measured with these 2 items, was greater for responders than for nonrespondents. Although statistically significant, the differences in the percentage of patients who were very satisfied were small and may not suggest a clinical difference. Others have found that responders to mailed satisfaction surveys are less satisfied than those who answered onsite.55
Therefore, the method of questionnaire administration and the response rate appear to influence the results of patient satisfaction studies. Because the response rate was approximately 60% to each mailing, there were a large number of patients in ACQUIP for which the SOSQ was unavailable for analysis. Nonrespondents were less likely to be satisfied with their care, and the results of this analysis may not be generalizable to these patients.
In addition, patient continuity of care with their provider was obtained by self-report, which may be affected by recall bias. Patients who are more satisfied with their care may be more likely to report a high degree of continuity. We also had limited information on provider characteristics within the administrative database, and could not assess factors such as age of the provider, years in practice, or communication skills. We used proxies for practitioner experience such as panel size or type of training, but residual confounding may still have been present. Patients were also asked to rate their care from their primary care provider in the clinic; however, we could not confirm whether patients could correctly identify their provider or whether the provider was recently assigned. In addition, it is possible that interactions with providers outside of the GIMC may have affected satisfaction scores. These factors may have accounted for some of the differences in satisfaction seen between sites.
Finally, participants were restricted to a single health care system, the Department of Veteran Affairs, and were predominately male, less affluent, and had poorer overall health than the general U.S. population.56
The variability in satisfaction between VA clinic sites suggests that there are unmeasured factors unique to the VA and may limit generalizability to the non-VA clinic setting. Furthermore, because these VA clinic sites were affiliated with academic institutions and approximately 40% of the providers were physicians in training, these results may not apply to patients seen in other health settings. Strengths of this study include the fact that patients were sampled from a large outpatient clinic population with extensive information regarding nonrespondents, health care utilization, and patient health status.
We found that continuity of health care was strongly associated with higher satisfaction of patients with the humanistic skills of their primary care provider, and with the organization and access to care. Structuring the delivery of care to enable patients to maintain continuity of care with their provider, if desired by the patient, may improve patient satisfaction with health care.