Journal of General Internal Medicine

, Volume 23, Issue 11, pp 1729–1735

The Relationship Between Measured Performance and Satisfaction with Care Among Clinically Complex Patients

Original Article



Recent work has shown that clinically complex patients are more likely to receive recommended care, but it is unknown whether higher achievement on individual performance goals results in improved care for complex patients or detracts from other important but unmeasured aspects of care, resulting in unmet needs and lower satisfaction with care.


To examine the relationship between measured performance and satisfaction with care among clinically complex patients

Design and Participants

An observational analysis of a national sample of 35,927 veterans included in the External Peer Review Program in fiscal years 2003 and 2004.


First, compliance with individual performance measures (breast cancer screening with mammography, colorectal cancer screening, influenza vaccination, pneumococcal vaccination, lipid monitoring, use of ACE inhibitor in heart failure, and diabetic eye examination), as well as overall receipt of recommended care, was estimated as a function of each patient’s clinical complexity. Second, global satisfaction with care was estimated as a function of clinical complexity and compliance with performance measures.

Main Results

Higher clinical complexity was predictive of slightly higher overall performance (OR 1.13, 95% CI 1.09 to 1.18) and higher performance on most individual performance measures, an effect that was mediated by increased visit frequency. High measured performance was associated with higher satisfaction with care among patients with high clinical complexity. In fact, as complexity increased, the effect of achieving high performance on the odds of being satisfied with care also increased


Not only was measured performance higher in clinically complex patients, but satisfaction with care was also higher among clinically complex patients with high measured performance, suggesting that compliance with performance measures in clinically complex patients does not crowd out unmeasured care.


measured performance patient satisfaction clinically complex patients 


  1. 1.
    Berwick DM, James B, Coye MJ. Connections between quality measurement and improvement. Med Care. 2003;41:I-30–8.CrossRefGoogle Scholar
  2. 2.
    Werner RM, Asch DA. Clinical concerns about clinical performance measurement. Ann Fam Med. 2007;5:159–63.PubMedCrossRefGoogle Scholar
  3. 3.
    Werner RM, Asch DA. The unintended consequences of publicly reporting quality information. JAMA. 2005;293:1239–44.PubMedCrossRefGoogle Scholar
  4. 4.
    Casalino LP. The unintended consequences of measuring quality on the quality of medical care. N Engl J Med. 1999;341:1147–50.PubMedCrossRefGoogle Scholar
  5. 5.
    Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA. 2005;294:716–24.PubMedCrossRefGoogle Scholar
  6. 6.
    Tinetti ME, Bogardus ST Jr., Agostini JV. Potential pitfalls of disease-specific guidelines for patients with multiple conditions. N Engl J Med. 2004;351:2870–74.PubMedCrossRefGoogle Scholar
  7. 7.
    Min LC, Wenger NS, Fung C, et al. Multimorbidity is associated with better quality of care among vulnerable elders. Med Care. 2007;45:480–8.PubMedCrossRefGoogle Scholar
  8. 8.
    Higashi T, Wenger NS, Adams JL, et al. Relationship between Number of Medical Conditions and Quality of Care. N Engl J Med. 2007;356:2496–504.PubMedCrossRefGoogle Scholar
  9. 9.
    Kizer KW. The “new VA”: a national laboratory for health care quality management. Am J Med Qual. 1999;14:3–20.PubMedCrossRefGoogle Scholar
  10. 10.
    Kizer KW, Demakis JG, Feussner JR. Reinventing VA health care: systematizing quality improvement and quality innovation. Med Care. 2000;38:I-7–16.CrossRefGoogle Scholar
  11. 11.
    Jha AK, Perlin JB, Kizer KW, Dudley RA. Effect of the transformation of the Veterans Affairs health care system on the quality of care. N Engl J Med. 2003;348:2218–27.PubMedCrossRefGoogle Scholar
  12. 12.
    Doebbeling BN, Vaughn TE, Woolson RF, et al. Benchmarking Veterans Affairs Medical Centers in the delivery of preventive health services: comparison of methods. Med Care. 2002;40:540–54.PubMedCrossRefGoogle Scholar
  13. 13.
    Wright SM, Craig T, Campbell S, Schaefer J, Humble C. Patient satisfaction of female and male users of Veterans Health Administration services. J Gen Intern Med. 2006;21:S26–32.PubMedCrossRefGoogle Scholar
  14. 14.
    Centers for Medicare and Medicaid Services. Physician Quality Reporting Initiative. 2007; Available at: Accessed June 11, 2008.
  15. 15.
    Joint Commission on Accreditation of Healthcare Organizations. HEDIS & Quality Measurement. 2006; Available at: Accessed 6/11/2008.
  16. 16.
    Jencks SF, Cuerdon T, Burwen DR, et al. Quality of medical care delivered to Medicare beneficiaries: a profile at state and national levels. JAMA. 2000;284:1670–6.PubMedCrossRefGoogle Scholar
  17. 17.
    Min LC, Reuben DB, MacLean CH, et al. Predictors of overall quality of care provided to vulnerable older people. J Am Geriatr Soc. 2005;53:1705–11.PubMedCrossRefGoogle Scholar
  18. 18.
    Ellis RP, Pope GC, Iezzoni LI, et al. Diagnosis-based risk adjustment for Medicare capitation payments. Health Care Financ Rev. 1996;17:101–28.PubMedGoogle Scholar
  19. 19.
    DxCG. DxCG RiskSmart Stand Alone V2.1.1 User Guide. Boston, MA 2006.Google Scholar
  20. 20.
    Rosen AK, Loveland S, Anderson JJ, et al. Evaluating diagnosis-based case-mix measures: how well do they apply to the VA population? Med Care. 2001;39:692–704.PubMedCrossRefGoogle Scholar
  21. 21.
    Petersen LA, Pietz K, Woodard LD, Byrne M. Comparison of the predictive validity of diagnosis-based risk adjusters for clinical outcomes. Med Care. 2005;43:61–7.PubMedGoogle Scholar
  22. 22.
    Werner RM, Greenfield S, Fung C, Turner BJ. Measuring quality of care in patients with multiple clinical conditions: summary of a conference conducted by the Society of General Internal Medicine. J Gen Intern Med. 2007;22:1206–11.PubMedCrossRefGoogle Scholar
  23. 23.
    Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40:373–83.PubMedCrossRefGoogle Scholar
  24. 24.
    Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol. 1992;45:613–9.PubMedCrossRefGoogle Scholar
  25. 25.
    Weeks WB, Bott DM, Bazos DA, et al. Veterans Health Administration patients’ use of the private sector for coronary revascularization in New York: opportunities to improve outcomes by directing care to high-performance hospitals. Med Care. 2006;44:519–26.PubMedCrossRefGoogle Scholar
  26. 26.
    Zhang J, Yu KF. What’s the relative risk? A method of correcting the odds ratio in cohort studies of common outcomes. Am Med Assoc. 1998;280:1690–1.CrossRefGoogle Scholar
  27. 27.
    Anderson G, Horvarth J. Chronic Conditions: Making the Case for Ongoing Care. Baltimore: Johns Hopkins Press; 2002.Google Scholar
  28. 28.
    Breen A, Breen R. Back pain and satisfaction with chiropractic treatment: what role does the physical outcome play? Clin J Pain. 2003;19:263–8.PubMedCrossRefGoogle Scholar
  29. 29.
    Edlund MJ, Young AS, Kung FY, Sherbourne CD, Wells KB. Does satisfaction reflect the technical quality of mental health care? Health Serv Res. 2003;38:631–45.PubMedCrossRefGoogle Scholar
  30. 30.
    Gross R, Tabenkin H, Porath A, et al. The relationship between primary care physicians’ adherence to guidelines for the treatment of diabetes and patient satisfaction: findings from a pilot study. Fam Pract. 2003;20:563–9.PubMedCrossRefGoogle Scholar
  31. 31.
    Orlando M, Meredith LS. Understanding the causal relationship between patient-reported interpersonal and technical quality of care for depression. Med Care. 2002;40:696–704.PubMedCrossRefGoogle Scholar
  32. 32.
    Meredith LS, Orlando M, Humphrey N, Camp P, Sherbourne CD. Are better ratings of the patient-provider relationship associated with higher quality care for depression? Med Care. 2001;39:349–60.PubMedCrossRefGoogle Scholar
  33. 33.
    Druss BG, Rosenheck RA, Stolar M. Patient satisfaction and administrative measures as indicators of the quality of mental health care. Psychiatr Serv. 1999;50:1053–8.PubMedGoogle Scholar
  34. 34.
    Cleary PD, McNeil BJ. Patient satisfaction as an indicator of quality care. Inquiry. 1988;25:25–36.PubMedGoogle Scholar
  35. 35.
    Chang JT, Hays RD, Shekelle PG, et al. Patients’ global ratings of their health care are not associated with the technical quality of their care. Ann Intern Med. 2006;144:665–72.PubMedGoogle Scholar
  36. 36.
    Jackson JL, Chamberlin J, Kroenke K. Predictors of patient satisfaction. Soc Sci Med. 2001;52:609–20.PubMedCrossRefGoogle Scholar
  37. 37.
    Regehr G, MacRae H, Reznick RK, Szalay D. Comparing the psychometric properties of checklists and global rating scales for assessing performance on an OSCE-format examination. Acad Med. 1998;73:993–7.PubMedCrossRefGoogle Scholar
  38. 38.
    Cohen DS, Colliver JA, Marcy MS, Fried ED, Swartz MH. Psychometric properties of a standardized-patient checklist and rating-scale form used to assess interpersonal and communication skills. Acad Med. 1996;71:S87–9.PubMedCrossRefGoogle Scholar
  39. 39.
    Hays RD, Shaul JA, Williams VS, et al. Psychometric properties of the CAHPS 1.0 survey measures. Consumer Assessment of Health Plans Study. Med Care. 1999;37:22–31.CrossRefGoogle Scholar
  40. 40.
    Shea JA, Guerra CE, Ravenell KL, McDonald VJ, Henry CA, Asch DA. Health literacy weakly but consistently predicts primary care patient dissatisfaction. Int J Qual Health Care. 2007;19:45–9.PubMedCrossRefGoogle Scholar
  41. 41.
    Mah JK, Tough S, Fung T, Douglas-England K, Verhoef M. Parents’ global rating of mental health correlates with SF-36 scores and health services satisfaction. Qual Life Res. 2006;15:1395–401.PubMedCrossRefGoogle Scholar
  42. 42.
    Weech-Maldonado R, Morales LS, Elliott M, Spritzer K, Marshall G, Hays RD. Race/ethnicity, language, and patients’ assessments of care in Medicaid managed care. Health Serv Res. 2003;38:789–808.PubMedCrossRefGoogle Scholar
  43. 43.
    Shea JA, Guerra CE, Weiner J, Aguirre AC, Ravenell KL, Asch DA. Adapting a patient satisfaction instrument for low literate and Spanish-speaking populations: Comparison of three formats. Patient Educ Couns. 2008;in press.Google Scholar

Copyright information

© Society of General Internal Medicine 2008

Authors and Affiliations

  1. 1.Center for Health Equity Research and PromotionPhiladelphia Veterans Affairs Medical CenterPhiladelphiaUSA
  2. 2.Division of General Internal MedicineUniversity of Pennsylvania School of MedicinePhiladelphiaUSA
  3. 3.Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaUSA
  4. 4.Department of SociologyUniversity of PennsylvaniaPhiladelphiaUSA

Personalised recommendations