Journal of General Internal Medicine

, Volume 20, Issue 3, pp 226–233 | Cite as

Continuity of care and other determinants of patient satisfaction with primary care

  • Vincent S. FanEmail author
  • Marcia Burman
  • Mary B. McDonell
  • Stephan D. Fihn
Original Articles


OBJECTIVE: The patient-clinician relationship is a central feature of primary care, and recent developments in the delivery of health care have tended to limit continuity of care. The objective of this study was to evaluate the extent to which continuity of care and other factors are related to patient satisfaction.

DESIGN: Cross-sectional, mailed questionnaire study.

SETTING: Primary care clinics at 7 Veterans Affairs medical centers.

PATIENTS/PARTICIPANTS: Patients (N=21,689) participating in the Ambulatory Care Quality Improvement Project who returned the baseline Seattle Outpatient Satisfaction Questionnaire (SOSQ).

MEASUREMENTS AND MAIN RESULTS: We evaluated the association between self-reported continuity and satisfaction, after adjusting for characteristics of patients, clinics, and providers. The humanistic scale of the SOSQ measures patient satisfaction with communication skills and humanistic qualities of providers, whereas the organizational scale measures satisfaction with delivery of health care services. The mean adjusted humanistic score for patients who reported always seeing the same provider was 17.3 (95% confidence interval [CI], 15.5 to 19.1) points higher than for those who rarely saw the same provider. Similarly, the mean adjusted organizational score was 16.3 (95% CI, 14.5 to 18.1) points higher for patients who always saw the same provider compared to rarely. Demographic factors, socioeconomic status, health status, clinic site, and patient utilization of services were all associated with both the adjusted humanistic and organizational scores of the SOSQ.

CONCLUSIONS: Self-reported continuity of care is strongly associated with higher patient satisfaction. This suggests that improving continuity of care may improve patient satisfaction with providers as well as with their health care organization.

Key words

patient satisfaction health services research quality of care questionnaire design linear models 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Rubin HR, Gandek B, Rogers WH, Kosinski M, McHorney CA, Ware JE Jr. Patients’ ratings of outpatient visits in different practice settings. Results from the Medical Outcomes Study. JAMA. 1993;270:835–40.PubMedCrossRefGoogle Scholar
  2. 2.
    Ware JE Jr, Davies AR. Behavioral consequences of consumer dissatisfaction with medical care. Eval Program Plann. 1983;6:291–7.PubMedCrossRefGoogle Scholar
  3. 3.
    Hulka BS, Cassel JC, Kupper LL, Burdette JA. Communication, compliance, and concordance between physicians and patients with prescribed medications. Am J Public Health. 1976;66:847–53.PubMedGoogle Scholar
  4. 4.
    Uhlmann RF, Inui TS, Carter WB. Patient requests and expectations. Definitions and clinical applications. Med Care. 1984;22:681–5.PubMedCrossRefGoogle Scholar
  5. 5.
    Alazri MH, Neal RD. The association between satisfaction with services provided in primary care and outcomes in Type 2 diabetes mellitus. Diabet Med. 2003;20:486–90.PubMedCrossRefGoogle Scholar
  6. 6.
    Linn MW, Linn BS, Stein SR. Satisfaction with ambulatory care and compliance in older patients. Med Care. 1982;20:606–14.PubMedCrossRefGoogle Scholar
  7. 7.
    Kerr EA, Hays RD, Mitchinson A, Lee M, Siu AL. The influence of gate-keeping and utilization review on patient satisfaction. J Gen Intern Med. 1999;14:287–96.PubMedCrossRefGoogle Scholar
  8. 8.
    Schauffler HH, Rodriguez T. Availability and utilization of health promotion programs and satisfaction with health plan. Med Care. 1994;32:1182–96.PubMedCrossRefGoogle Scholar
  9. 9.
    Borowsky SJ, Cowper DC. Dual use of VA and non-VA primary care. J Gen Intern Med. 1999;14:274–80.PubMedCrossRefGoogle Scholar
  10. 10.
    Covinsky KE, Rosenthal GE, Chren MM, et al. The relation between health status changes and patient satisfaction in older hospitalized medical patients. J Gen Intern Med. 1998;13:223–9.PubMedCrossRefGoogle Scholar
  11. 11.
    Bidaut-Russell M, Gabriel SE, Scott CG, Zinsmeister AR, Luthra HS, Yawn B. Determinants of patient satisfaction in chronic illness. Arthritis Rheum. 2002;47:494–500.PubMedCrossRefGoogle Scholar
  12. 12.
    Hall JA, Feldstein M, Fretwell MD, Rowe JW, Epstein AM. Older patients’ health status and satisfaction with medical care in an HMO population. Med Care. 1990;28:261–70.PubMedCrossRefGoogle Scholar
  13. 13.
    Hall JA, Milburn MA, Epstein AM. A causal model of health status and satisfaction with medical care. Med Care. 1993;31:84–94.PubMedCrossRefGoogle Scholar
  14. 14.
    Hall JA, Dornan MC. What patients like about their medical care and how often they are asked: a meta-analysis of the satisfaction literature. Soc Sci Med. 1988;27:935–9.PubMedCrossRefGoogle Scholar
  15. 15.
    Hall JA, Irish JT, Roter DL, Ehrlich CM, Miller LH. Satisfaction, gender, and communication in medical visits. Med Care. 1994;32:1216–31.PubMedCrossRefGoogle Scholar
  16. 16.
    Donaldson MS, Yordy KD, Lohr KN, Vanselow NA. Primary Care: America’s Health in a New Era. Washington, DC: Institute of Medicine; 1996.Google Scholar
  17. 17.
    Saultz JW. Defining and measuring interpersonal continuity of care. Ann Fam Med. 2003;1:134–43.PubMedCrossRefGoogle Scholar
  18. 18.
    Christakis DA, Mell L, Koepsell TD, Zimmerman FJ, Connell FA. Association of lower continuity of care with greater risk of emergency department use and hospitalization in children. Pediatrics. 2001;107:524–9.PubMedCrossRefGoogle Scholar
  19. 19.
    Gill JM, Mainous AG III, Nsereko M. The effect of continuity of care on emergency department use. Arch Fam Med. 2000;9:333–8.PubMedCrossRefGoogle Scholar
  20. 20.
    Mainous AG III, Gill JM. The importance of continuity of care in the likelihood of future hospitalization: is site of care equivalent to a primary clinician? Am J Public Health. 1998;88:1539–41.PubMedGoogle Scholar
  21. 21.
    Parchman ML, Pugh JA, Noel PH, Larme AC. Continuity of care, self-management behaviors, and glucose control in patients with type 2 diabetes. Med Care. 2002;40:137–44.PubMedCrossRefGoogle Scholar
  22. 22.
    O’Malley AS, Mandelblatt J, Gold K, Cagney KA, Kerner J. Continuity of care and the use of breast and cervical cancer screening services in a multiethnic community. Arch Intern Med. 1997;157:1462–70.PubMedCrossRefGoogle Scholar
  23. 23.
    Manian FA. Whither continuity of care? N Engl J Med. 1999;340:1362–3.PubMedCrossRefGoogle Scholar
  24. 24.
    Hjortdahl P. Continuity of care—going out of style? Br J Gen Pract. 2001;51:699–700.PubMedGoogle Scholar
  25. 25.
    Safran DG, Tarlov AR, Rogers WH. Primary care performance in fee-for-service and prepaid health care systems. Results from the Medical Outcomes Study. JAMA. 1994;271:1579–86.PubMedCrossRefGoogle Scholar
  26. 26.
    Flocke SA, Stange KC, Zyzanski SJ. The impact of insurance type and forced discontinuity on the delivery of primary care. J Fam Pract. 1997;45:129–35.PubMedGoogle Scholar
  27. 27.
    Kletke PR, Emmons DW, Gillis KD. Current trends in physicians’ practice arrangements. From owners to employees. JAMA. 1996;276:555–60.PubMedCrossRefGoogle Scholar
  28. 28.
    Love MM, Mainous AG III. Commitment to a regular physician: how long will patients wait to see their own physician for acute illness? J Fam Pract. 1999;48:202–7.PubMedGoogle Scholar
  29. 29.
    Nutting PA, Goodwin MA, Flocke SA, Zyzanski SJ, Stange KC. Continuity of primary care: to whom does it matter and when? Ann Fam Med. 2003;1:149–55.PubMedCrossRefGoogle Scholar
  30. 30.
    Kao AC, Green DC, Davis NA, Koplan JP, Cleary PD. Patients’ trust in their physicians: effects of choice, continuity, and payment method. J Gen Intern Med. 1998;13:681–6.PubMedCrossRefGoogle Scholar
  31. 31.
    Wasson JH, Sauvigne AE, Mogielnicki RP, et al. Continuity of outpatient medical care in elderly men. A randomized trial. JAMA. 1984;252:2413–7.PubMedCrossRefGoogle Scholar
  32. 32.
    Hjortdahl P, Borchgrevink CF. Continuity of care: influence of general practitioners’ knowledge about their patients on use of resources in consultations. BMJ. 1991;303:1181–4.PubMedGoogle Scholar
  33. 33.
    Fihn SD, McDonell MB, Diehr P, et al. Effects of sustained audit/feedback on self-reported health status of primary care patients. Am J Med. 2004;116:241–8.PubMedCrossRefGoogle Scholar
  34. 34.
    Ware JE Jr, Gandek B. Overview of the SF-36 Health Survey and the International Quality of Life Assessment (IQOLA) Project. J Clin Epidemiol. 1998;51:903–12.PubMedCrossRefGoogle Scholar
  35. 35.
    Hall JA, Dornan MC. Meta-analysis of satisfaction with medical care: description of research domain and analysis of overall satisfaction levels. Soc Sci Med. 1988;27:637–44.PubMedCrossRefGoogle Scholar
  36. 36.
    Webster G. Final Report on the Patient Satisfaction Questionnaire Project. Philadelphia, PA: American Board of Internal Medicine Committee on Evaluation of Clinical Competence; 1989.Google Scholar
  37. 37.
    Stump TE, Dexter PR, Tierney WM, Wolinsky FD. Measuring patient satisfaction with physicians among older and diseased adults in a primary care municipal outpatient setting. An examination of three instruments. Med Care. 1995;33:958–72.PubMedCrossRefGoogle Scholar
  38. 38.
    Harris LE, Swindle RW, Mungai SM, Weinberger M, Tierney WM. Measuring patient satisfaction for quality improvement. Med Care. 1999;37:1207–13.PubMedCrossRefGoogle Scholar
  39. 39.
    Davies A, Ware J. GHAA’s Consumer Satisfaction Survey and User’s Manual. 2nd ed. Washington, DC: Group Health Association of America; 1991.Google Scholar
  40. 40.
    Jatulis DE, Bundek NI, Legorreta AP. Identifying predictors of satisfaction with access to medical care and quality of care. Am J Med Qual. 1997;12:11–8.PubMedGoogle Scholar
  41. 41.
    Jackson JL, Chamberlin J, Kroenke K. Predictors of patient satisfaction. Soc Sci Med. 2001;52:609–20.PubMedCrossRefGoogle Scholar
  42. 42.
    Ware JE Jr, Kosinski M, Bayliss MS, McHorney CA, Rogers WH, Raczek A. Comparison of methods for the scoring and statistical analysis of SF-36 health profile and summary measures: summary of results from the Medical Outcomes Study. Med Care. 1995;33:AS264-AS279.PubMedCrossRefGoogle Scholar
  43. 43.
    Burgess JF Jr, DeFiore DA. The effect of distance to VA facilities on the choice and level of utilization of VA outpatient services. Soc Sci Med. 1994;39:95–104.PubMedCrossRefGoogle Scholar
  44. 44.
    Phibbs CS, Luft HS. Correlation of travel time on roads versus straight line distance. Med Care Res Rev. 1995;52:532–42.PubMedCrossRefGoogle Scholar
  45. 45.
    Lurie N. Studying access to care in managed care environments. Health Serv Res. 1997;32:691–701.PubMedGoogle Scholar
  46. 46.
    Love MM, Mainous AG III, Talbert JC, Hager GL. Continuity of care and the physician-patient relationship: the importance of continuity for adult patients with asthma. J Fam Pract. 2000;49:998–1004.PubMedGoogle Scholar
  47. 47.
    Hjortdahl P, Laerum E. Continuity of care in general practice: effect on patient satisfaction. BMJ. 1992;304:1287–90.PubMedCrossRefGoogle Scholar
  48. 48.
    Freeman G, Hjortdahl P. What future for continuity of care in general practice? BMJ. 1997;314:1870–3.PubMedGoogle Scholar
  49. 49.
    Moore G, Showstack J. Primary care medicine in crisis: toward reconstruction and renewal. Ann Intern Med. 2003;138:244–7.PubMedGoogle Scholar
  50. 50.
    Lewis JR. Patient views on quality care in general practice: literature review. Soc Sci Med. 1994;39:655–70.PubMedCrossRefGoogle Scholar
  51. 51.
    Schers H, Webster S, van den Hoogen H, Avery A, Grol R, van den Bosch W. Continuity of care in general practice: a survey of patients’ views. Br J Gen Pract. 2002;52:459–62.PubMedGoogle Scholar
  52. 52.
    Linder-Pelz S. Social psychological determinants of patient satisfaction: a test of five hypotheses. Soc Sci Med. 1982;16:583–9.PubMedCrossRefGoogle Scholar
  53. 53.
    Linder-Pelz SU. Toward a theory of patient satisfaction. Soc Sci Med. 1982;16:577–82.PubMedCrossRefGoogle Scholar
  54. 54.
    Jackson JL, Kroenke K. Patient satisfaction and quality of care. Mil Med. 1997;162:273–7.PubMedGoogle Scholar
  55. 55.
    Harpole LH, Orav EJ, Hickey M, Posther KE, Brennan TA. Patient satisfaction in the ambulatory setting. Influence of data collection methods and sociodemographic factors. J Gen Intern Med. 1996;11:431–4.PubMedCrossRefGoogle Scholar
  56. 56.
    Kazis LE, Miller DR, Clark J, et al. Health-related quality of life in patients served by the Department of Veterans Affairs: results from the Veterans Health Study. Arch Intern Med. 1998;158:626–32.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2005

Authors and Affiliations

  • Vincent S. Fan
    • 1
    • 2
    Email author
  • Marcia Burman
    • 1
    • 2
  • Mary B. McDonell
    • 1
  • Stephan D. Fihn
    • 1
    • 2
  1. 1.Health Services Research and Development Center of ExcellenceVA Puget Sound Health Care SystemSeattleUSA
  2. 2.Department of MedicineUniversity of WashingtonSeattleUSA

Personalised recommendations