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t. report number 

82-20 

2. GOVT ACCESSION NO. 

3. RECIPIENT'S CATALOG NUMBER 

4. TITLE (and Subtitle) 

Patient Satisfaction in Adjacent Family Practice 
and Non-Family Practice Navy Outpatient Clinics 

5. TYPE OF REPORT & PERIOD COVERED 

interim 

6. PERFORMING ORG REPORT NUMBER 

7. AUTHORS 

D. Stephen Nice, Ph.D. 

Mark C. Butler, Ph.D. 

Linda Dutton 

B. CONTRACT OR GRANT NUMBERf..) 

MF58.527.1C2-0001 

9. PERFORMING ORGANIZATION NAME AND ADDRESS 

Naval Health Research Center 

P.0. Box 85122 

San Diego, CA 92138 

10 PROGRAM ELEMENT, PROJECT, TASK 

AREA & WORK UNIT NUMBERS 

11. CONTROLLING OFFICE NAME AND ADDRESS 

Naval Medical Research & Development Command 
Bethesda, MD 92138 

12. REPORT DATE 

z9 November 1982 

13. NUMBER OF PAGES 

6 

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Bureau of Medicine & Surgery 

Department of the Navy 

Washington, DC 20372 

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Approved for public release; distribution unlimited. 

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18. SUPPLEMENTARY NOTES 

Presented at APA, Washington, D.C. 26 August 1982 

19. KEY WORDS (Continue on reverse aide if necessary and identify by block number) 

Patient Satisfaction 

Family Practice 

Navy Outpatient Clinics 

Non-Family Practice 

20. ABSTRACT (Continue on reverse aide if neceaaary and identify by block number) 

Patient satisfaction was assessed in adjacent family practice (N =341) and 
non-family practice (N = 390) clinics at a Naval Regional Medical Center. 
Results indicated that patients in the family practice clinic were signifi¬ 
cantly more satisfied with care than those in the non-family practice clinic. 
Although older people and males were generally more satisfied with care, demo¬ 
graphic factors did not differentially affect patient preferences for the 
family practice approach to ambulatory care. 


DD i ^ n rm 73 1 473 EDITION OF 1 NOV 65 IS OBSOLETE 
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PATIENT SATISFACTION IN ADJACENT FAMILY PRACTICE AND 
NON-FAMILY PRACTICE NAVY OUTPATIENT CLINICS 


D. S. NICE 
M. C. BUTLER 
L. DUTTON 


REPORT NO. 82-20 



NAVAL HEALTH RESEARCH CENTER 


( 


P. 0. BOX 85122 


SAN DIEGO, CALIFORNIA 92138 


NAVAL MEDICAL RESEARCH AND DEVELOPMENT COMMAND 

BETHESDA, MARYLAND 



Patient Satisfaction in Adjacent Family Practice and 


Non-Family Practice Navy Outpatient Clinics 


D. Stephen Nice, Ph.D.* 
Mark C. Butler, Ph.D.* 
and 

Linda Dutton, B.A.* 


Naval Health Research Center 
P.O. Box 85122 

San Diego, California 92138 


Report No. 82-20 was supported by the Naval Medical Research and Development Command, Bethesda, 
Maryland, Department of the Navy, under research Work Unit MF58.527.1C2-0001. The views presented 
in this paper are those of the authors. No endorsement by the Department of the Navy has been given 
or should be inferred. 

The authors wish to thank Mrs. Dorothy Benson for her help in the collection of data, and 
the staff at the Naval Regional Medical Center, Camp Pendleton, for their cooperation in carrying 
out the study. 


*Health Psychology Department 


Summary 


Patient satisfaction was assessed in adjacent family practice (N = 341) and non-family practice 
(N = 390) clinics at a Naval Regional Medical Center. Results indicated that patients in the 
family practice clinic were significantly more satisfied with care than those in the non-family 
practice clinic. Although older people and males were generally more satisfied with care, demo¬ 
graphic factors did not differentially affect patient preferences for the family practice ap¬ 
proach to ambulatory care. 


2 


Patient Satisfaction in Adjacent Family Practice 
And Non-Family Practice Navy Outpatient Clinics 

Interest in patient satisfaction is based largely on the changing roles of the .patient in the 
health care system. This change from passive to more active patient roles has been precipitated 
by increasing bureaucracy within the health industry and by general sociopolitical movements toward 
human rights, self-care, and individual responsibility. As van den Heuvel 1 points out, the recent 
emergence of a business-bureaucratic approach to health care promotes the economic concepts of supply 
and demand and recasts the patient into a more active role as a consumer in the health industry. 

The patient's role in the health care process has also been affected by the growth of con¬ 
sumerism as a general social movement. The heightened levels of awareness which emanated from the 
turbulence of the sixties and early seventies played a key role in increasing consumer involvement 
in all walks of life. In recent years consumer involvement in health services planning, organiza¬ 
tion, and delivery has been stressed vigorously by the World Health Organization 2 and has gained 
increasing acceptance among health care planners and providers. 3 

Interest in patient satisfaction has further been advanced by the realization that satisfaction 

is a potentially important factor in health behaviors such as seeking medical care, complying with 

medical regimens, and continuing a relationship with a physician. 4 Dissatisfaction with the art 

of care, on the other hand, tends to be a significant determinant of cancer patients' rejection of 

the medical establishment in search of emotional support 5 and the instigation of malpractice suits. 6 

In addition, measures of patient satisfaction have been useful in evaluating quality of care and in 

7 8 

identifying actions to improve services. 9 

As patient satisfaction has become accepted as a standard component of evaluative research, 
interest has focused on making the organization and delivery of health care responsive to consumer 
opinion• Family practice represents an organizational approach to primary care which emphasizes 
many factors which arc generally related to patient satisfaction. In the family practice model, 
for example, the physician assumes full responsibility for the continuous and comprehensive health 
care of the members or families in his (her) practice. Continuity of care has been valued on the 
grounds that seeing one's own physician is conducive to in-depth understanding of the patient by 
the practitioner, concomitant patient trust and compliance, and high quality care. 4 ^ A number of 
studies have reported positive relationships between continuity of care and patient satisfaction. 11-13 

The establishment of a continuing patient-physician relationship also affords the family prac¬ 
tice physician an opportunity to provide health and psychological counseling and individualized pre¬ 
ventive medicine. This more comprehensive and holistic approach increases the affective support to 
the patient and facilitates communication within the physician-patient relationship. Because these 
factors have been established as important determinants of patient satisfaction, 8, 12 ' 14-17 the 
family practice approach to primary care may be an effective organizational intervention to enhance 
consumer satisfaction with ambulatory care. 

The purpose of the present study was to compare the levels of patient satisfaction in a family 
practice and a non-family practice outpatient clinic. A second purpose of this study was to identify 
demographic factors which may differentially affect patient reactions to family practice vs. non¬ 
family practice approaches to primary care. While it was expected that patients in family practice 
will generally express higher levels of satisfaction than patients in non-family practice, these 


3 


differences may be greater among some patient groups than others. The difference between family 
practice and non-family practice, for example, may be greater among married patients who experience 
continuity of family care than among those patients who are not married. Similarly, the benefits 
of family practice may be more strongly manifest among older patients who often require more continu¬ 
ing care or affective support than among younger patients. 

Method 

Subjects 

The sample was comprised of all patients eighteen years of age or older who visited the family 
practice (N = 341) or primary care clinic (N = 390) of a Naval Regional Medical Center located on a 
Marine Corps base. Because the families of active duty and retired personnel are typically seen in 
these base hospital clinics rather than in the smaller active duty field clinics, the majority of 
the patients in this sample were female (63%). In addition, the patients in the sample were primarily 
married (88%) and Caucasian (86%). The average age of the sample was 46 years with a standard devia¬ 
tion of 18 years and a range from 18 to 91 years. 

Procedure 

During a three-week period, patients in the adjacent family practice and non-family practice 
clinics of the base hospital were asked to complete a two-page questionnaire before leaving the clinic. 
This questionnaire included a survey of basic demographic information and a 24-item patient satisfac¬ 
tion scale. Based on a review of the patient satisfaction literature, items in this scale were 
written to measure a number of different aspects of health care delivery. These aspects included 
access to care, range of services available, care quality, and technical and interpersonal character¬ 
istics of the providers. Respondents were asked to indicate their level of satisfaction with each 
aspect of the health care delivery process on a five-point Likert-type scale. Response choices ranged 
from "Very dissatisfied" to "Very satisfied." For comparison purposes, responses to each of the 24 
items were summed to reflect an overall level of patient satisfaction; higher scores were thus asso¬ 
ciated with higher levels of satisfaction with services received. Coefficient alpha for the combined 
items was .961. 

Results 

The effects of demographic factors (age, sex, marital status) and organization of health care 
delivery on overall patient satisfaction were analyzed using a four-way analysis of variance. For 
the purpose of this analysis, subjects were grouped into three age classifications (18-35, 36-50, 

>50). A hierarchical approach was used such that independent variables were entered into the analysis 
in the following order: age (3 levels), sex (male, female), marital status (married, not married), 
and organization of health care delivery (family practice, non-family practice). In this procedure 
the effects of all preceding independent variables were removed from the analysis of each subsequent 
main effect and interaction term. Organization of health care delivery was entered as the final in¬ 
dependent variable so that all patient demographic effects would be removed from the relationship 
between organization of health care and patient satisfaction. 

The results of this analysis are presented in Table 1. In general, patient satisfaction was sig¬ 
nificantly related to the age and sex of the patient and to the organization of health care delivery. 

As shown in Figure 1, older patients were more satisfied with care than younger patients, males were 
more satisfied than females, and family practice patients were more satisfied than non-family practice 


4 




SATISFACTION (mean item response) 


TABLE t 


Figure 


HIERARCHICAL ANALYSIS OF VARIANCE 
OVERALL SATISFACTION 


SOURCE OF VARIATION 

SUM OF 
SQUARES 

df 

MEAN 

SQUARE 

F 


103.513 

5 

20.703 

58.810*** 

AGE 

35.483 

2 

17.742 

50.398*** 

SEX 

2.226 

1 

2.226 

6.323** 

MARITAL STATUS 

0.245 

1 

0.245 

0.695 

CLINIC (FP/PC) 

65.559 

1 

65.559 

186.233*** 


2.539 

9 

0.282 

0.801 

AGE X SEX 

0.788 

2 

0.394 

1.119 

AGE X MARITAL 

0.852 

2 

0.426 

1.210 

AGE X CLINIC 

0.251 

2 

0.126 

0.357 

SEX X MARITAL 

0.078 

1 

0.078 

0.221 

SEX X CLINIC 

0.263 

1 

0.263 

0.747 

MARITAL X CLINIC 

0.029 

1 

0.029 

0.084 


2.260 

7 

0.323 

0.917 

AGE X SEX X MARITAL 

0.959 

2 

0.480 

1.363 

AGE X SEX X CLINIC 

0.282 

2 

0.141 

0.401 

AGE X MARITAL X CLINIC 

0.069 

2 

0.034 

0.098 

SEX X MARITAL X CLINIC 

0.231 

1 

0.231 

0.657 


0.030 

7 

0.030 

0.085 

AGE X SEX X MARITAL X CLINIC 

0.030 

1 

0.030 

0.085 


***p < ,001 
**p < .01 



L. Mean Satisfaction with Family Practice vs. Primary Care (Non-Family Practice) by Sex and Age of Patient. 


5 









patients. None of the two-way or higher-order interaction effects was significant. 

Discussion 

In the present study, levels of patient satisfaction were compared in adjacent family practice 
and non-family practice clinics. In both clinics results indicated that satisfaction with care was 
associated with the age and sex of the patient. The finding that older people were generally more 
satisfied with ambulatory care was consistent with previous studies. 8, 12 ' 18 Findings regarding 

the relationship between sex and patient satisfaction, on the other hand, have been less consistent 

19 

in the literature. While Hulka et al. reported that females were generally more satisfied with 
all aspects of care, others have reported non-significant sex differences. 11 ' 16 ' 20 Pope 12 found 
no overall sex effect in patient satisfaction; however, he did report that females and individuals 
higher in education and perceived social class were somewhat more characteristic of those terminating 
an HMO for reasons of dissatisfaction than other terminees. 

In the present study, females were significantly less satisfied than males. While this differ¬ 
ence between the sexes was not expected, the following interpretation is considered. In our sample, 
virtually all of the males (97%) were active duty or retired career military personnel. Very few of 
the females (2%) , on the other hand, had any direct military experience. This difference in military 
experience may affect patient willingness to express dissatisfaction. Active duty and retired males, 
for example, may experience higher levels of organizational commitment or cognitive dissonance 21 and 
be less willing to criticize the health care services. Females, on the other hand, may feel less 
closely identified with the military system and more willing to express lower levels of sa-i-isfaction. 
This speculation is somewhat consistent with the general finding that when the medical system does 
not meet their needs, women feel greater freedom to express their displeasure. 1 ^ 

The most important finding of the present study was that patients in the family practice program 
reported significantly higher levels of satisfaction with care than patients in the non-family prac¬ 
tice clinic. It is also important to note that organization of health care did not interact signifi¬ 
cantly with any demographic variable. That is to say, perceived differences in patient satisfaction 
between the family practice and non-family practice clinics were not significantly affected by the 
age, sex, or marital status of the patients. In general, all patient groups preferred the family 
practice approach to ambulatory care. 

At present the Navy sponsors residency training programs in family practice at five Naval Re¬ 
gional Medical Centers. While the concept of family practice is fairly new in the Navy, the results 
of the present investigation indicate that continued growth in this area may strengthen levels of 
patient satisfaction among both active duty and non-active duty beneficiaries. Further research, 

however, is required to address the issues of cost effectiveness, program expansion into Naval multi- 

22 

specialty training hospitals, and priority panel allocation to special groups such as families 

2 3 

anticipating deployment separation. 


6 


References 


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2 Martin JF: The active patient: A necessary development. WHO Chron 32:51, 1978 

^Kelman HR: Evaluation of health care duality by consumers. Int J Health Serv 6:431, 1976 

4 Larsen DE, Rootman I: Physician role performance and patient satisfaction. Soc Sci Med 10:29, 1976 

5 Cobb B: Why do people detour to quacks? Psychiatr Bull 3:66, 1954 

6 Vaccarino JM: Malpractice: The problem in perspective. J Am Med Assoc 238:861, 1977 

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16 DiMatteo MR, Taranta A, Friedman HS, Prince LM: Predicting patient satisfaction from physicians' 
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17 Doyle BJ, Ware JE, Jr: Physician conduct and other factors that affect consumer satisfaction with 
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1 8 

Cartwright A: Patients and their doctors: A study of general practice. New York, Atherton, 1967 

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2 0 

Tessler R, Mechanic D: Consumer satisfaction with prepaid group parctice: A comparative study. 

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2 1 

Festinger L: A theory of cognitive dissonance. Evanston, Illinois, Row, Peterson, 1957 

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Cassells JS: Systems report: The Navy health care delivery system. J Ambulatory Care Mgt 5:60,1982 


7 


23 Nice DS: 


A longitudinal analysis of Navy family separation. Naval Personnel Research and Develop¬ 


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