Visit-specific expectations and patient-centered outcomes: a literature review

BACKGROUND: Primary care patients often have certain expectations when visiting physicians, many of which may be undetected. These unmet expectations can affect outcomes such as satisfaction with care. We performed a formal literature review to examine the effect of fulfillment of patients' visit-specific expectations on their satisfaction as well as on health status and compliance. PATIENTS AND METHODS: Included studies were conducted in primary care settings, systematically recruited patients, elicited previsit and/or postvisit expectations relative to specific visits, and measured patient-centered outcomes. Two reviewers abstracted information on study characteristics; types, timing, and method of expectation ascertainment; and outcomes. Disagreements were resolved by consensus. RESULTS: Twenty-three studies were reviewed including 7 trials, 4 cohort studies, and 12 cross-sectional studies. Patients frequently expected information rather than specific physician actions, but physicians often did not accurately perceive patients' visit-specific expectations. In 19 studies that assessed postvisit patient satisfaction, a positive association between meeting patient expectations and overall satisfaction was demonstrated in 11 studies, inconclusive in 3, and not established in 5. In 2 studies assessing physician satisfaction, physicians with access to patients' expectations were more satisfied than those without access. Other outcomes (symptom or disease improvement, health status, test ordering, health care costs, psychological symptoms) were measured in only a few studies, and the results were inconclusive. CONCLUSIONS: Addressing patients' visit-specific expectations appears to affect satisfaction to a modest degree. Future studies should evaluate methods that efficiently elicit, prioritize, and provide patients' previsit expectations for physicians and should examine the longitudinal effect of expectation fulfillment on patient outcomes. Arch Fam Med. 2000;9:1148-1155     

Effect of race on patient expectations regarding their primary care physicians

BACKGROUND: Fulfilment of patients' expectations has been associated with greater patient satisfaction with care and greater adherence to medical advice. However, little is know about how race influences patient expectations. OBJECTIVE: To determine the association between patient race and patient expectations of their primary care physician. METHODS: The design was a cross-sectional study. Setting and participants were sample of 709 primary care patients from four clinic sites at the Philadelphia Veterans Affairs Medical Center and the University of Pennsylvania Health System. The measures were an expectations instrument asking patients to rate the necessity of the physician performing 13 activities during the index visit, self-reported race, demographics, the Rapid Estimate of Adult Literacy in Medicine, the Charlson Comorbidity Index and SF-12. RESULTS: After adjusting for age, sex, education, clinic site, comorbidity, health literacy and health status, African Americans were more likely to report it was absolutely necessary for the physician to refer them to a specialist [AOR 1.55 (95% confidence interval, CI, 1.09-2.21), P = 0.01], order tests [AOR 1.59 (95% CI 1.11-2.27), P = 0.01] and conduct each of the six physical exam components. CONCLUSIONS: African American race is associated with greater expectations of the primary care physicians. More research is needed to confirm the differential expectations by race and determine the reasons for the differential expectations.     

Affective and Instrumental Communication in Primary Care Interactions: Predicting the Satisfaction of Nursing Staff and Patients

Verbal and nonverbal communication between nursing staff and patients has received scant research attention. This study examined patients' and nursing staff members' global affective and instrumental communication, mutual influence, and relationship to postvisit satisfaction. This study employed ratings of videotaped primary care visits of 81 nursing staff members with 235 patients, and assessed communication in 2 channels: nonverbal visual and speech including vocal tone. Communication channel differences and prediction of patient satisfaction were examined. The visual and vocal communication of nursing staff members and patients robustly predicted each other's satisfaction and reflected their own satisfaction with the dyadic visit. Affect was communicated more clearly through the speech with vocal tone channel, whereas instrumental communication was stronger in visual nonverbal behavior. Patients' and nursing staff members' behaviors of pleasantness and involvement frequently co-occurred.     

Meeting patient's expectations in primary care consultations in Lithuania.

OBJECTIVE: Patient satisfaction with health care services is considered an important factor of health care. Although research on patient satisfaction has become standard in Western Europe, in countries such as Lithuania the concept of patient satisfaction is still a relatively new one. This study aimed to investigate how the meeting of patients' expectations is related to increased satisfaction with medical consultation. STUDY DESIGN: The methodology used by Williams et al. in the UK was applied to the Lithuanian health care setting. Forty physicians from 22 primary health care centres attending courses on general practice at Vilnius University were recruited for the study. Every third adult patient coming to a practice during a 5-day period was invited to participate in the study. In all, 609 patients coming to meet their physician regarding health problems were included in the study sample. The patients were asked to complete three standardized questionnaires: the Patient Intentions Questionnaire prior to the consultation, and the Expectations Met Questionnaire and Medical Interview Satisfaction Scale after the consultation. Cronbach's alpha statistic was used for the validation of the questionnaires and principal components analysis was used to determine the factors of patient expectations. RESULTS: The response rate was 78%. ANALYSIS: of 460 sets of questionnaires revealed that satisfaction with medical consultation is higher among patients who have a greater number of expectations met. Physicians' success in meeting different types of patient expectations also had different influences on patient satisfaction. The most important expectations to be met were "understanding and explanation", followed by expectations of "emotional support", while "getting information" was less important. CONCLUSIONS: The most frequently reported expectations on the Patient Intentions Questionnaire were for "getting information" and "understanding and explanation" of the patients' health problem items, and the least mentioned were for emotional support items. Patients with more expectations met were found to have significantly higher scores on the satisfaction index. Satisfaction with the consultation is best predicted by meeting the patient's expectations for understanding and explanation, and for emotional support. Providing desired information to the patient as well as meeting the patient's expectations for diagnostic procedures and treatment is less associated with patient satisfaction.     

Predictors of patient satisfaction

Correlates of patient satisfaction at varying points in time were assessed using a survey with 2-week and 3-month follow-up in a general medicine walk-in clinic, in USA. Five hundred adults presenting with a physical symptom, seen by one of 38 participating clinicians were surveyed and the following measurements were taken into account: patient symptom characteristics, symptom-related expectations, functional status (Medical Outcomes Study Short-Form Health Survey [SF-6]), mental disorders (PRIME-MD), symptom resolution, unmet expectations, satisfaction (RAND 9-item survey), visit costs and health utilization. Physician perception of difficulty (Difficult Doctor Patient Relationship Questionnaire), and Physician Belief Scale. Immediately after the visit, 260 (52%) patients were fully satisfied with their care, increasing to 59% at 2 weeks and 63% by 3 months. Patients older than 65 and those with better functional status were more likely to be satisfied. At all time points, the presence of unmet expectations markedly decreased satisfaction: immediately post-visit (OR: 0.14, 95% CI: 0.07-0.30), 2-week (OR: 0.07, 95% CI: 0.04-0.13) and 3-month (OR: 0.05, 95% CI: 0.03-0.09). Other independent variables predicting immediate after visit satisfaction included receiving an explanation of the likely cause as well as expected duration of the presenting symptom. At 2 weeks and 3 months, experiencing symptomatic improvement increased satisfaction while additional visits (actual or anticipated) for the same symptom decreased satisfaction. A lack of unmet expectations was a powerful predictor of satisfaction at all time-points. Immediately post-visit, other predictors of satisfaction reflected aspects of patient doctor communication (receiving an explanation of the symptom cause, likely duration, lack of unmet expectations), while 2-week and 3-month satisfaction reflected aspects of symptom outcome (symptom resolution, need for repeat visits, functional status). Patient satisfaction surveys need to carefully consider the sampling time frame as well as adjust for pertinent patient characteristics.     

Evaluation of the consumer model: relationship between patients' expectations, perceptions and satisfaction with care.

OBJECTIVE: To evaluate the consumer model in a health care system, by studying the relationship between four variables: expectations, perceived degree of fulfillment, satisfaction and changing of physicians. DESIGN: Cross-sectional study; telephone interview of patients who had visited a primary care physician 1-2 months previously. SETTING: The Maccabi health plan, Israel. STUDY PARTICIPANTS: A random sample of 759 patients, aged 18 and over residing in two towns in Israel. Response rate to telephone interview was 50.7% (n=385). MAIN OUTCOME MEASURES: Expectation, perceived expectations fulfilled by the physician, satisfaction with the visit to the primary care physician and intention to change physician. RESULTS: The gap between the expectations and their fulfillment showed a low correlation with satisfaction. For attributes where a large difference was found, no correlation was found with patient satisfaction. Attributes such as 'diagnosis', 'preventive health care' and 'answering questions' presented correlation coefficients of 0.3. The correlation between the perceived fulfillment of these attributes and satisfaction presented higher correlation coefficients (between 0.4-0.5). This limits the consumer model as a way to predict satisfaction. Satisfaction correlated highly with intention to change physician. The mean score for the satisfaction of those intending to change doctors was 3.8 compared to 5.5 in the group of consumers not intending to change doctors. CONCLUSION: The consumer model is able to explain only to a modest extent the variation in satisfaction, but dissatisfaction is a good predictor of the intention to change doctors.     

Effects of physician awareness of symptom-related expectations and mental disorders. A controlled trial

OBJECTIVE: To study whether physician awareness of symptom-related expectations and mental disorders reduces unmet expectations or improves patient satisfaction. DESIGN: Prospective, before-after trial, with control (n = 250) and intervention (n = 250) groups. Outcomes were assessed immediately after the index office visit, at 2 weeks, and at 3 months. SETTING: Ambulatory walk-in clinic. PARTICIPANTS: Five hundred adults with physical complaints. Exclusion criteria included upper respiratory tract infection and dementia. Follow-up was accomplished in 100% immediately after the visit, 92.6% at 2 weeks, and 82.6% at 3 months. INTERVENTIONS: Two-hour physician workshop followed by information provided before each visit on patient expectations, illness worry, and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) disorders. MEASUREMENTS: Symptom-related expectations, satisfaction with care, symptom improvement, functional status, physician-perceived difficulty of the encounter, visit costs, and use of health care services. RESULTS: Serious illness worry (64%), 1 or more specific expectations (98%), or a DSM-IV disorder (29%) were commonly present in study patients. Intervention patients were less likely to report unmet expectations (odds ratio, 0.52; 95% confidence interval [CI], 0.43-0.97) immediately after the visit and at 2 weeks, less likely to be perceived as difficult by their physician (odds ratio, 0.49; 95% CI, 0.24-0.98), and more likely to be fully satisfied at 2 weeks (odds ratio, 1.63; 95% CI, 1.14-2.00). By 3 months, groups were similar in terms of satisfaction and residual expectations. Symptom improvement occurred in most patients by 2 weeks (70.5%) and 3 months (81.2%), regardless of study group. There was also no difference in patients' serious illness worry during the follow-up. The intervention did not increase visit costs or use of health care services. CONCLUSION: Identifying symptom-related expectations and mental disorders in patients presenting with physical complaints may improve satisfaction with care at 2-week follow-up and physician-perceived difficulty of the encounter.     

Patient satisfaction, preventive services, and emergency room use among African-Americans with type 2 diabetes.

The aim of this study was to determine the relationship between patient satisfaction and diabetes- related preventive health care and emergency room (ER) use. We studied 542 urban African-Americans with type 2 diabetes aged > or =25 years who were enrolled in a primary carebased intervention trial to improve diabetes control and reduce adverse health events; 73% female, mean age 58 years, 35% had yearly household incomes of <$7500, and all participants had health insurance. All completed a baseline interview-administered questionnaire. Patient satisfaction was measured using a modified version (nine questions) of the Consumer Assessment of Health Plans Survey (CAHPS) and use of diabetes-related preventive health care and ER were assessed by self-report. We then followed participants for 12 months to determine ER use prospectively. In general, participants gave favorable ratings of their care; over 70% reported that they had no problem getting care, over 60% reported the highest ratings on the communication and courtesy domains, and mean ratings (0-10 scale) for personal doctor and overall health care were high (8.8 and 8.4, respectively). Using poisson regression models adjusted for age, education, and self-reported rating of health, several aspects of patient satisfaction were associated with subsequent ER use. Participants who reported that medical staff were usually helpful or that doctors and nurses usually spent enough time were 0.49 and 0.37 times, respectively, less likely to use the ER (all p < 0.05). However, few aspects of patient satisfaction were associated with better preventive services. These data suggest that greater patient satisfaction was associated with lower ER use in urban African-Americans. Whether measures to improve patient satisfaction would reduce ER use requires further prospective study.     

Patient satisfaction with care is associated with personal choice of physician

OBJECTIVE: To evaluate whether choosing one's own primary care doctor is associated with patient satisfaction with primary health care. To evaluate factors related to population's satisfaction with primary health care. POPULATION: A random sample of Estonian adult population (N=997). STUDY DESIGN: Cross-sectional study using a pre-categorized questionnaire which was compiled by the research group of the University of Tartu and the research provider EMOR. RESULTS: Altogether 68% of the respondents had been listed in their personal physician. Their overall satisfaction with the physician as well as satisfaction with several aspects of primary health care were significantly higher compared with those of unregistered respondents. Although some other factors (practice size, patient age, health status) also influenced patient satisfaction, presence of a personal physician appeared the most important predictor of high satisfaction with physician's punctuality and understanding, effectiveness of prescribed therapy, clarity of explanations given by the physician as well as with overall satisfaction with the physician. CONCLUSION: Personal doctor system is associated with patient satisfaction with different aspects of care.     

Continuity of primary care: to whom does it matter and when?

BACKGROUND: Inconsistent findings on the value of continuity of care can stem from variability in its importance to different subsets of patients. We therefore examined the association among patient and visit characteristics and extent to which the patient valued continuity of care (PVC). We hypothesized that continuity would be more important to patients who are older, sicker, and female, who have established a relationship with their physician, and whose visit addresses more complex problems. METHODS: A study of 4,454 consecutive outpatient visits to 138 community-based family physicians used a 3-item measure (alpha = 0.67) of PVC. The patient's report of (1) the adequacy of primary care for the visit and (2) satisfaction with the physician on that visit was assessed with multiple measures. Analyses examined the associations among PVC and patient-reported satisfaction with the physician and adequacy of the visit. RESULTS: Extremes of age, female sex, less education, Medicare and Medicaid insurance, number of chronic conditions and medications, number of visits to the practice, and worse self-reported health status were associated with higher value placed on continuity (P < .001 for all except sex, where P = .015). Patients who value continuity and did not see a regular physician rated adequacy of the visit lower (for 7 attributes of the visit) than those seeing their own physician. Satisfaction with the physician for the visit was greatest among patients who value continuity and saw their regular physician. CONCLUSIONS: Continuity of physician care is associated with more positive assessments of the visit and appears to be particularly important for more vulnerable patients. Health care systems and primary care practices should devote additional effort to maintaining a continuity relationship with these vulnerable patients.     

Does managed care restrictiveness affect the perceived quality of primary care? A report from ASPN. Ambulatory Sentinel Practice Network

BACKGROUND: The competitive managed care marketplace is causing increased restrictiveness in the structure of health plans. The effect of plan restrictiveness on the delivery of primary care is unknown. Our purpose was to examine the association of the organizational and financial restrictiveness of managed care plans with important elements of primary care, the patient-clinician relationship, and patient satisfaction. METHODS: We conducted a cross-sectional study of 15 member practices of the Ambulatory Sentinel Practice Network selected to represent diverse health care markets. Each practice completed a Managed Care Survey to characterize the degree of organizational and financial restrictiveness for each individual health care plan. A total of 199 managed care plans were characterized. Then, 1475 consecutive outpatients completed a patient survey that included: the Components of Primary Care Instrument as a measure of attributes of primary care; a measure of the amount of inconvenience involved with using the health care plan; and the Medical Outcomes Study Visit Rating Form for assessing patient satisfaction. RESULTS: Clinicians' reports of inconvenience were significantly associated (P < .001) with the financial and organizational restrictiveness scores of the plan. There was no association between plan restrictiveness and patient report of multiple aspects of the delivery of primary care or patient satisfaction with the visit. CONCLUSIONS: Plan restrictiveness is associated with greater perceived hassle for clinicians but not for patients. Plan restrictiveness seems to be creating great pressures for clinicians, but is not affecting patients' reports of the quality of important attributes of primary care or satisfaction with the visit. Physicians and their staffs appear to be buffering patients from the potentially negative effects of plan restrictiveness.     

Gender and patient satisfaction with primary care: tuning in to women in quality measurement

This study analyzes the relationship between patient gender and satisfaction with primary care visits, using 1999 survey data on 1691 women and 760 men making primary care visits at multiple sites affiliated with a large academic health system designated as a National Center of Excellence in Women's Health (COE). The main findings are that in multivariate analyses controlling for patient and visit characteristics, different aspects of the content of primary care visits are important to women and men. Women's overall satisfaction with visits is more dependent than men's on informational content, continuity of care, and multidisciplinarity. Men's overall satisfaction is more dependent on the personal interest shown in them by providers. No differences in satisfaction are found between those seen in sites affiliated with the COE and other primary care sites within the health system that are not core sites of the COE. We conclude that quality improvement and research in women's primary care could benefit from gender analysis of patient satisfaction data and from more gender-sensitive patient satisfaction measures.     

The teamlet model of primary care

The 15-minute visit does not allow the physician sufficient time to provide the variety of services expected of primary care. A teamlet (little team) model of care is proposed to extend the 15-minute physician visit. The teamlet consists of 1 clinician and 2 health coaches. A clinical encounter includes 4 parts: a previsit by the coach, a visit by the clinician together with the coach, a postvisit by the coach, and between-visit care by the coach. Medical assistants or other practice personnel would require retraining to assume the health coach role. Some organizations have instituted aspects of the teamlet model. Primary care practices interested in trying out the teamlet concept need to train 2 health coaches for each full-time equivalent clinician to ensure smooth patient flow.     

Quality of primary care practice in a large HMO according to physician specialty.

OBJECTIVE: To determine whether physician specialty was associated with differences in the quality of primary care practice and patient satisfaction in a large, group model HMO. DATA SOURCES/STUDY SETTING: 10,608 patients ages 35-85 years, selected using stratified probability sampling from the primary care panels of 60 family physicians (FPs), 245 general internists (GIMs), and 55 subspecialty internists (SIMs) at 13 facilities in the Kaiser Permanente Medical Care Program of Northern California. Patients were surveyed in 1995. STUDY DESIGN: A cross-sectional patient survey measured patient reports of physician performance on primary care measures of coordination, comprehensiveness, and accessibility of care, preventive care procedures, and health promotion. Additional items measured patient satisfaction and health values and beliefs. PRINCIPAL FINDINGS: Patients were remarkably similar across physician specialty groups in their health values and beliefs, ratings of the quality of primary care, and satisfaction. Patients rated GIMs higher than FPs on coordination (adjusted mean scores 68.0 and 58.4 respectively, p<.001) and slightly higher on accessibility and prevention; GIMs were rated more highly than SIMs on comprehensiveness (adjusted mean scores 76.4 and 73.8, p<.01). There were no significant differences between specialty groups on a variety of measures of patient satisfaction. CONCLUSIONS: Few differences in the quality of primary care were observed by physician specialty in the setting of a large, well-established group model HMO. These similarities may result from the direct influence of practice setting on physician behavior and organization of care or, indirectly, through the types of physicians attracted to a well-established group model HMO. In some settings, practice organization may have more influence than physician specialty on the delivery of primary care.     

Are continuity clinic patients less satisfied when residents have a heavy inpatient workload?

The purpose of this study was to assess the influence of resident non-clinic workload on the satisfaction of continuity clinic patients. Over a 2-month period in 2002, residents and patients were surveyed at the University of Kentucky internal medicine continuity clinic. Residents provided a self-report of their non-clinic workload as light or medium versus heavy or extremely heavy. Patient satisfaction was assessed with a 7-item, 10-point scale with items derived from commonly used patient satisfaction instruments. In 168 patient encounters, patients were significantly less satisfied with their clinic visit if they were seen by a resident who had a heavier workload. In addition, these patients gave significantly lower ratings with regard to the amount of time spent with the patient during the visit, and how well the resident listened and paid attention. Although alternative explanations exist, we propose that heavy hospital workload is associated with decreased patient satisfaction in resident continuity clinic.     

The multidimensionality of patient satisfaction with a clinic visit

Three hypotheses regarding the factor structure of patient satisfaction with an ambulatory health care encounter were tested in a New York medical center outpatient sample. All three hypotheses were generally supported. It was found that patients evaluated four distinct aspects of the clinic visit: doctor conduct, convenience, appointment getting, and the visit in general. A significant proportion of the variance in general satisfaction was explained by satisfaction with doctor conduct and satisfaction with convenience. Three factor scales of patient satisfaction were developed with demonstrable internal consistency reliability. Some possible effects of response method on satisfaction ratings were studied; these method effects were not substantial, and it is suggested that this type of psychometric procedure be used in further studies of patient satisfaction.Susie Linder-Pelz, M.P.H., Ph.D., is with the Commonwealth Institute of Health in Australia. Elmer L. Struening, Ph.D., is with the New York State Psychiatric Institute and Columbia University.This research was supported in part by a World Health Organization graduate fellowship. Address communications to: Dr. Susie Linder-Pelz, Commonwealth Institute of Health, University of Sydney, N.S.W. 2008, Australia.     

The development and validation of the primary care satisfaction survey for women.

Assessing patient satisfaction with health care is becoming an integral component of quality monitoring in health care systems, but existing tools typically were developed to minimize differences related to gender. This paper reports the development and psychometric properties of a new survey instrument to measure women's satisfaction with their primary care. A multisite, cross-sectional validation survey of 1,202 women receiving care in primary care settings in Michigan, North Carolina, and Pennsylvania was conducted. Item response theory (IRT) and factor analysis methods were used to identify three scales in the Primary Care Satisfaction Survey for Women (PCSSW): Communication, Administration and Office Procedures, and Care Coordination and Comprehensiveness. Internal consistency reliability is reported, as well as convergent validity in relation to two generic measures (Medical Outcomes Study [MOS] Visit Satisfaction and Consumer Assessment of Health Plans Survey [CAHPS] overall quality rating); discriminant validity in relation to groups expected to have differing satisfaction levels based on previous literature; predictive validity in relation to behavioral intentions; and explanatory power in overall satisfaction ratings. The 24-item PCSSW may be self-administered or conducted by telephone and may be used in studies to evaluate or improve the quality of primary care for women.     

Assessment of medical care by elderly people: general satisfaction and physician quality.

OBJECTIVE: To identify personal characteristics and factors related to health and patterns of healthcare utilization associated with the elderly people's satisfaction with medical care. DATA SOURCES/STUDY SETTING: Data from the 1991 Medicare Current Beneficiary Survey (MCBS) on 8,859 persons age 65 and over living in the community. STUDY DESIGN: Items reflecting general satisfaction with care and views of physician quality are examined and, based on factor analysis, grouped in dimensions of two (global quality, access) and three (technical skills, interpersonal manner, information-giving), respectively. The relationship of high levels of satisfaction in each dimension to personal characteristics of elderly people, and to measures of access and utilization, is assessed using logistic regression. PRINCIPAL FINDINGS: While satisfaction is high, with over 90 percent surveyed expressing some satisfaction, there is substantial variation with less likelihood of high satisfaction among those 80 or older, with less education and income and in poorer health. Longer waiting time at visits and less frequent visits are factors in lower satisfaction as well. A favorable perception of physician quality, especially regarding technical skills, appears to play a significant role in satisfaction with global quality of care. CONCLUSIONS: Studies of patient satisfaction in elderly people are rare. Some factors expected to be related to positive assessment based on earlier studies, were, e.g., better health and shorter waiting time, while others were not, e.g., increasing age. Elderly people appear to place greater importance on physician technical skills, as opposed to interpersonal dimensions, in assessing global quality. These findings suggest the need for a better understanding of how elderly people evaluate care and what they value in interactions with the healthcare system.     

Does continuity of care improve patient outcomes?

OBJECTIVE: Continuity of care is a cornerstone of primary care that has been promoted by recent trends in medical education and in the way health care delivery is organized. We sought to determine the effect of sustained continuity of care (SCOC) on the quality of patient care. DATA SOURCES: We conducted a systematic review of all articles in Medline (January 1966 to January 2002), Educational Resources Information Center (ERIC), and PSYCH INFO using the terms "continuity of care" or "continuity of patient care." We identified additional titles of candidate articles by reviewing the bibliographies of articles from our original MEDLINE search, contacting experts in primary care, health care management, and health services research, and by reviewing bibliographies of textbooks of primary care and public health. STUDY SELECTION AND DATA EXTRACTION: Two investigators (MDC, SHJ) independently reviewed the full text to exclude articles that did not fulfill search criteria. Articles excluded were those that focused on physicians-in-training, on SCOC in a non-primary care setting, such as an inpatient ward, or on transitions from inpatient to the outpatient setting. We also excluded articles that did not correlate SCOC to a quality of care measure. DATA SYNTHESIS: From 5070 candidate titles, we examined the full text of 260 articles and found 18 (12 cross-sectional studies, 5 cohort studies and 1 randomized controlled trial) that fulfilled our criteria. Five studies focused on patients with chronic illness (eg, asthma, diabetes). RESULTS: No studies documented negative effects of increased SCOC on quality of care. SCOC is associated with patient satisfaction (4 studies), decreased hospitalizations and emergency department visits (7 studies), and improved receipt of preventive services (5 studies). CONCLUSIONS: SCOC improves quality of care, and this association is consistently documented for patients with chronic conditions. Programs to promote SCOC may best maximize impact by focusing on populations with chronic conditions.     

Entry into primary care and continuity: the effects of access.

OBJECTIVES: This study examined the relationship between access and use of primary care physicians as sources of first contact and continuity with the medical system. METHODS: Data from the 1987 National Medical expenditure Survey were used to examine the effects of access on use of primary care physicians as sources of first contact for new episodes of care (by logistic regression) and as sources of continuity for all ambulatory visits (by multi-variate linear regression). RESULTS: No after-hours care, longer office waits, and longer travel times reduced the chances of a first-contact visit with a primary care physician for acute health problems. Longer appointment waits, no insurance, and no after-hours care were associated with lower levels of continuity. Generalists provided more first-contact care than specialists acting as primary care physicians, largely because of their more accessible practices. CONCLUSIONS: These data provide support for the linkage between access and care seeking with primary care physicians.