The relationship between measured performance and satisfaction with care among clinically complex patients

BACKGROUND: 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. OBJECTIVE: 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. MEASUREMENTS: 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 CONCLUSIONS: 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.