Association Between Satisfaction and Familiarity with Physician Among New Adult Members

Proprietary studies have found that new Kaiser Permanente (KP) members are generally less satisfied than established members with the health care they receive. Lack of familiarity between the patient and his/her primary care physician may be one cause of this lack of satisfaction.

Our members judge us on how well they think we know and care about them as individuals.

A recent study of adults living in rural areas of the United States found that patients with relationships of three or more years with their health care physician tended to be more satisfied than those with shorter term relationships.¹ A study of individuals living in the Netherlands also found that patient-physician familiarity was associated with patient satisfaction.² Patient-physician familiarity can be measured in terms of continuity of care. A review of 22 published studies found a consistent association between higher patient satisfaction and greater continuity of care,³ while a review of 81 published studies found that greater continuity of care was generally associated with better preventive care and fewer hospitalizations.⁴

In this study, we measured the association between patient satisfaction and patient-physician^a familiarity for new adult commercial plan members of KP living in Hawaii. Administrative data was used to identify the first, second, third, fourth, or subsequent primary care visits of a member to a physician. Satisfaction with the visit was measured using the Patient Satisfaction Survey (PSat), which is routinely mailed to members who have recently visited a KP physician for health care.

Methods

The population studied was new adult commercial plan members of KP in Hawaii (KPHI) who made at least one visit to a KPHI physician for primary care during 2003 or 2004. New adult members were defined as members who were at least 18 years of age and had less than two years of tenure with KPHI at the time of the visit. Medicare and Medicaid members were not included in the study population.

Patient satisfaction was measured using the PSat survey question: “Taking everything into consideration, how satisfied were you with the visit?” A seven-point summated rating scale is used to quantify satisfaction, with the endpoints labeled: 1 as “not at all satisfied” and 7 as “extremely satisfied,” with “sad” and “happy” face symbols placed adjacent to the appropriate ends of the scale. Responses of 6 and 7 were equated with being very satisfied. A total of 274,064 surveys were mailed during 2003–2004, with a response rate of 36%.

PSat survey returns were matched to administrative data to determine tenure, physicians seen, visit dates, and if the PSat surveyed visit (index visit) was the first, second, third, fourth, or subsequent visit by the member to the physician (index physician). A study sample of 875 unique new adult members was identified; one and only one PSat survey return from each was included in this study.

The administrative data was also used to identify a cohort of new members who maintained a high degree of interpersonal continuity of care with the first KPHI physician they saw for primary care (high continuity of care cohort). A sample of 137 members of this cohort were identified using the following criteria: 1) their first primary care visit to a KPHI physician was to the index physician, 2) all of their primary care up until, and including, the index visit, was from the index physician; 3) they made at least one return visit for primary care after the index visit to the index physician; and 4) they continued to receive at least 50% of their primary care from the index physician after the index visit.

Two linear regression models were fit to the data using the least squares method. For both models, overall patient satisfaction was the dependent variable. In the first model (visit model), the independent variable was the number of previous visits to the index physician; in the second (log visit model), the independent variable was the log₁₀ of the number of previous visits +1.

Results

For overall satisfaction with visit, there was a near linear increase in average score as the number of previous visits with the physician increased (Figure 1). Regression analysis found that the underlying data fit the log visit model better than the visit model, suggesting a diminishing effect of each additional visit on patient satisfaction. There was a consistent trend of increasing satisfaction from the first through the fourth visit, with little evidence of a trend in later visits.

Figure 1.

Average satisfaction score for the first, second, third, and subsequent visits by new adult members to a physician for primary care.

There was also a near linear increase in the percentage of patients who were very satisfied as the number of previous visits with the physician increased (Figure 2).

Figure 2.

Percentage of new adult members who were very satisfied with their first, second, third, and subsequent visits to a physician for primary care.

It was uncommon for a new member to give a low score (1, 2, or 3) for a visit, however, those that were given were generally for early visits, and only rarely were they given for a fourth or subsequent visit to a physician (Table 1).

Table 1.

Frequency distribution of new adult member satisfaction scores for the first, second, third, and subsequent primary care visits to a physician

Most (673, 76.9%) of the 875 new adult members who returned a PSat survey made at least one subsequent visit to a KPHI physician for primary care. Most (60.4%) of those that were very satisfied with the index visit made at least one return visit to the index physician, although less than half (41.6%) of those who were less satisfied made a return visit to the index physician.

Just as with the broader study sample, within the high continuity of care cohort there was a consistent trend of increasing satisfaction from the first through the fourth visit. And, just as with the broader sample, the log visit model fit the data better than the visit model, suggesting a diminishing effect of each additional visit on patient satisfaction.

There was a consistent trend of increasing satisfaction from the first through the fourth visit …

Discussion

The association between a patient's overall satisfaction with a visit for primary care and the number of previous visits they made to the physician suggests that as patients and physicians become more familiar with each other, the patient's satisfaction with the physician's service increases. Others have found that patient satisfaction increases as familiarity increases^1,2 and as continuity of care increases.^3,4

Although the model of increasing familiarity leading to increasing satisfaction is intuitive and fits the data well, a second, alternative model may also explain at least part of the increase in satisfaction observed from the first visit to subsequent visits. In this alternative model, members visit different physicians, and select one that they are satisfied with; they then make repeat visits to this physician when seeking primary care. Our analysis suggests that both models of behavior may be responsible for the observed association between visits and satisfaction. Members of the high continuity of care cohort remained loyal to the first KPHI physician they visited for primary care. Within this cohort, satisfaction increased as familiarity increased. Within the larger sample, we found that patients who were very satisfied with a visit to a physician tended to select this physician for future care, while those that were less satisfied tended to visit other physicians for primary care. Determining the relative importance of familiarity and selection will require the analysis of a richer data set.

Introductory Comments

This study by William C Wells, PhD, and Dorothy Ries Faison Meder, MFA, EMBA, documents the intuitive finding that patients are more satisfied as they gain familiarity with their primary care physician. Since our success as an organization depends on attracting and retaining new members, these results reinforce our current emphasis on members having and seeing their own doctor or nurse practitioner and on personalization of care.

The increase in satisfaction over several visits parallels evidence in the literature that patients who feel well known by their doctor follow lifestyle recommendations more than twice as often as those who do not feel well known. Likewise, level of trust in the physician is associated with better adherence to medication.^1,2

Many of our newest members are linked to newly hired primary care physicians. This match-up presents challenges to the clinicians as they establish their panels, and to the patients who are deciding whether our service meets their needs. Making a strong personal connection with a new patient is one of the key skills addressed in the communication courses for clinicians offered in every region.

The news that both familiarity and satisfaction can increase within the first few visits with a primary care physician means that we have a finite opportunity to build trust and loyalty. Our members judge us on how well they think we know and care about them as individuals. The kind of data provided in this article helps us know whether we are succeeding.

— Terry Stein, MD

Director of Clinician-Patient Communication for The Permanente Medical Group