HEALTH SERVICES RESEARCH 0
RECHERCHE EN SERVICES DE SOINS DE SANTE
Public opinions about health care Health Services Research Group A unique perspective on the status of the health care system may be obtained from the public's perceptions of health care, especially those related to satisfaction with health services. Direct and indirect methods may be used to assess these perceptions. Direct methods (discussed in an earlier article in this series') assess patients' satisfaction with the care given by specific providers in particular health care facilities. Indirect methods involve surveying people for their opinions about the system as a whole and health care providers collectively. The information acquired through the two methods is generally used differently. Data from direct methods may guide initiatives to improve the structure, process or outcome of health care delivery or influence decisions about the future of specific services. Data from indirect methods contribute to an understanding of the effects of health care policies and decisions about resource allocation and provide insight into consumers' understanding of the workings of the health care system. In this article we discuss indirect measures of consumer satisfaction with health care. We very briefly touch on other population-based measures of health status and behaviour, primarily to indicate how they can be used with the indirect measures to provide a more complete overview of the population's perceptions of its health and health care system.
Measuring general satisfaction The most popular of the indirect measures
appears to be the Patient Satisfaction Questionnaire (PSQ).2-5 It has undergone extensive testing and refinement and has sufficient empiric foundation to warrant its continued use. Versions include the original, interviewer-administered PSQ (Form I) and a self-administered survey (Form II),46-7 which is more convenient and regarded as more comprehensive and reliable than Form 1.3 Scales in Form II cover areas such as access to care, availability of resources, continuity of care and overall satisfaction. Obviously some of these areas shade into measures of direct satisfaction, in that the answers to them are bound to be affected by respondents' experiences with specific health care providers and facilities. However, the goal of indirect surveys is to measure global satisfaction with the health care system, not simply respondents' satisfaction with health care received. These ratings of global satisfaction may reflect influences such as the experiences of close relatives and friends, media reports about the state of the health care system, information (accurate or not) about the care available in other jurisdictions and so on. Thus, it is not surprising that several studies have demonstrated a weak relation between responses to direct measures and those to indirect measures of satisfaction.58-" Consumers generally rate satisfaction with their own health care higher than their satisfaction with the health care system in general, a disparity that has been intuitively appreciated by medical practitioners for decades and has episodically frustrated leaders of Canadian organized medicine. For example, in 1943 Dr. T. Clarence Routley, then general secretary of the CMA, lament-
Members: Drs. Lorraine E. Ferris (principal coauthor), Department of Behavioural Science; J. Ivan Williams (principal coauthor), Department of Preventive Medicine and Biostatistics; Hilary A. Llewellyn-Thomas, Faculty of Nursing; C. David Naylor, Department of Medicine; Marsha M. Cohen, Department of Health Administration; and Antoni S.H. Basinski, Department of Family and Community Medicine, University of Toronto, Toronto, Ont. The Health Services Research Group is part of the Clinical Epidemiology Unit, Sunnybrook Health Science Centre, Toronto, Ont. Reprint requests to: Health Services Research Group, Clinical Epidemiology Unit, Sunnybrook Health Science Centre, 2075 Bayview Ave., Toronto, ON M4N 3M5 OCTOBER 15, 1992
CAN MED ASSOC J 1992; 147 (8)
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ed that positive perceptions of individual physicians as caregivers were not generalized to the profession.12 Such disparities justifiably lead to scepticism about the validity of indirect opinion surveys, which is more difficult to establish than that of direct measures. One line of argument is that the results of opinion surveys on health care are confounded by broader experiences of satisfaction (e.g., unhappiness with health care is simply a proxy for a general dissatisfaction with life). There is evidence of this in indirect but not direct measures of consumer satisfaction;9 however, the relation is very weak. Furthermore, psychologic disorders (including depression) do not affect the results of indirect or direct measures.9 None the less, if patients are satisfied with their care but more critical about the system in general, then the question becomes Should we pay more attention to evaluations of firsthand experience than to opinions based on secondhand sources that may highlight negative aspects of the system? The answer is not clear. In our earlier article' we reviewed why patients tend to offer high satisfaction ratings of specific experiences. Despite their drawbacks, general opinion surveys may act as counterweights to the positive biases associated with direct measures of satisfaction. Moreover, the opinions of the public (regardless of the depth of the knowledge that shapes them) will tend to draw the attention of policymakers.'3 One approach may be to measure both knowledge of the health care system and satisfaction with it in any population survey. Responses based on limited knowledge or misinformation might then catalyse initiatives in public education rather than policy miscues.
What have we learned about satisfaction? A recent series of studies examined people's
experiences in obtaining medical care and their view of the performance of their health care systems in three nations (Canada, the United States and Britain).'4 It was the first comprehensive comparative analysis of consumer satisfaction with health care, and its findings were later replicated."' People's satisfaction did not necessarily relate to health care
expenditure:'4"'5 for example, in the 1988 study'4 Americans expressed the lowest levels of satisfaction with their health care system despite higher expenditures per capita than in Canada or Britain. When asked which system they preferred, 61% of the Americans preferred a system like Canada's, and 29% preferred the British system. Of the Britons, 28% preferred the Canadian system and 12% the US system. Only 8% of the Canadians preferred another system, 5% choosing the US and 3% the British one. 1134
CAN MED ASSOC J 1992; 147 (8)
Furthermore, 29% of the Americans and 17% of the Britons believed that their health care system needed to be completely rebuilt, as compared with 5% of the Canadians. Several US national surveys replicated some of the findings from the three-nation study. In April 1989 the National Broadcasting Corporation surveyed Americans and found that 67% of the respondents supported a comprehensive, national health plan similar to the Canadian scheme.'6 A national survey conducted by the Los Angeles Times'7 in March 1990 found that 66% of Americans would prefer the Canadian health care system. A Gallup poll by the Los Angeles Times'8 1 year later showed that 43% of Americans favoured the Canadian health care system, whereas only 3% of Canadians favoured the US system. In 1990 the three-nation study was augmented to include a survey of seven additional countries: the Netherlands, Italy, West Germany, France, Sweden, Australia and Japan.'5 Respondents from the United States had the highest level of dissatisfaction with their health care system, although they had the highest level of health care expenditure per capita. Italy, with the second highest dissatisfaction level, had the lowest health care expenditure except for Britain. By excluding the United States and Sweden, Blendon and associates'5 found that satisfaction was positively associated with the level of health care spending per capita, a finding different from that in the original three-nation study. They speculated that this effect may have been related to such factors as the availability of services and the quality of facilities, factors that may result in decreased waiting times and other perceived benefits. Indirect measures of consumer satisfaction also provide insight into the public perception of quality of care. For example, the three-nation study'4 asked about satisfaction with physicians and hospitals and found that respondents from all countries were largely satisfied with these aspects of the health care system. However, such questions tend to blur the distinctions between direct and indirect measures of satisfaction, in that perceptions of the quality of care may be heavily weighted by personal experiences.
Other population health surveys Other surveys have examined additional health matters, such as health status, health behaviour and knowledge, and special health needs. The field of population health surveys has been reviewed in several excellent publications, some of which deal with Canadian health surveys. 9-21 As well, there are reviews of particular measures,22-23 including some specific to Canada.24-30 We provide brief examples of some surveys for illustration. LE 15 OCTOBRE 1992
The study by the World Health Organization on international medical care utilization compared the availability of health services, satisfaction with them and indicators of health status across eight countries.31 The availability of physicians and hospitals varied by country, as did the patterns of use of their services. The variations in utilization persisted after international differences in health status and presumed need had been controlled for. Over the past 30 years the Center for Health Administration Studies, University of Chicago, has conducted a number of nationwide studies to assess inequities in the availability and accessibility of health care services.32,33 It developed two measures of access: one defined as use of services relative to self-perceived health status and the other defined in relation to needs for health care. In the United States information on health status and the utilization of services has been collected periodically since 1957 by the National Health Survey.'9 In Britain questions on chronic and acute sickness and on contacts with various health and social services have been part of the General Household Survey, operating since 1971.34 In Canada a nationally syndicated survey the Canada Health Monitor - was established in 1988, by Earl Berger, of Price Waterhouse Management Consultants, and various subscribers.35 Like the polls of Harris and associates'9 the Canada Health Monitor asks questions on policy issues as well as on lifestyle, risk factors, health status and the utilization of health services. Kars-Marshall, SpronkBoon and Pollemans36 reviewed the national surveys of nine countries and found that the topics routinely covered included health status, lifestyle and risk factors, health knowledge, attitudes and opinions, health care- utilization, health-related expenses and insurance coverage.
Further issues in measuring public opinion There are specific sampling biases associated with indirect measures of consumer satisfaction and other population health surveys. Often, the opinions of only householders are sought. People in health care facilities or long-term residential units are generally excluded, as are members of the armed forces and people living on Indian reserves or in remote regions. Moreover, since most general health surveys are conducted by telephone or in person with people at home, there may be an employment bias. In interviews lasting between 15 and 90 minutes, responsep can be limited by health problems or language barriers. Consequently, people with the greatest health problems or unmet needs may be least likely to participate. People with rare conditions or those who have been seriously ill may not be included because of an inadequate sample size; in OCT^OBER 15, 1992
fact, surveys of fewer than 10 000 people may run this risk.'4 Thus, people who receive primary care may be better represented than those those who receive specialty care. There have been surveys that address groups with special needs,25'37'38 but more are required. Before the 1970s most general health surveys used a face-to-face interview format, which yielded response rates of about 75% to 90% of eligible people sampled. Newer approaches, such as telephone surveys of people sampled through random digit dialling, have contributed to lower response rates - 50% to 60% and sometimes as low as 25%. There is debate about whether the shift in interviewing techniques and the decline in response rates have adversely affected the validity of these opinion surveys. Critics have been concerned that in population health surveys the questions on the uses of health services are limited. Respondents are usually asked whether they have visited a physician or other health care professional within the past 2 weeks and, if so, the reason for the visit; they may also be asked about the total number of visits within the past 12 months. With respect to hospitals, they are asked if they have been admitted within the past 12 months and, if so, how many times. The responses do not reveal the total use of health care, health expenditures or the adequacy of the care. Furthermore, the utilization and expenditures by the family may limit the amount spent by one individual, and this is not taken into consideration in most surveys. In 1990 the National Health Information Council and the Canadian Centre for Health Information held a workshop2l on the use of surveys to measure the health of Canadians. The participants identified 10 issues that should be the focus of efforts to improve the way in which health surveys are conducted and used. Although indirect measures of consumer satisfaction were not specifically reviewed the list of issues is pertinent: * Health surveys should have a statement of specific objectives that will guide the choice of study design. * There should be clarification of conceptual definitions of health to ensure agreement on the measures to be selected or developed. * Criteria should be established for the "determinants" of health to be included. * Whether common topics should appear in all surveys merits consideration. * Simple, reliable and valid indicators of physical health, emotional health and socioeconomic status are needed. * The coverage of groups should be expanded to include residents of institutions, native Canadians, residents of remote regions, the homeless and those without a telephone. CAN MED ASSOC J 1992; 147 (8)
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* New approaches to improve the quality of 8. Andersen R, Kravits J, Anderson OW: The public's view of the crises in medical care: An impetus for changing delivery sampling are needed. systems? Econ Bus Bull 1971; 24: 44-52 * Surveys should be linked with administrative 9. Roberts RE, Pascoe GC, Attkisson CC: Relationship of data sets. service satisfaction to life satisfaction and perceived wellbeing. Eval Program Plann 1983; 6: 373-383 * There should be discussion of the need for 10. Stewart MA, Wanklin J: Direct and indirect measures of complementarity among health surveys. patient satisfaction with physicians' services. J Community * New approaches are needed for consultation Health 1978; 3: 195-204 with various interest groups on the development and 11. Pascoe GC, Attkisson CC, Roberts RE: Comparison of indirect and direct approaches to measuring patient satisfacimplementation of health surveys. Eval Program Plann 1983; 6: 359-371 tion. To this list we would add the points already 12. Routley TC: Untitled bulletin to the Health Insurance Comraised, especially the issues involved in blending mittee-at-Large, Dec 30, 1943, CMA archives, Ottawa measures of knowledge of the health care system 13. Iglehart JK: Opinion polls on health care. N Engl J Med 1984; 310: 1616-1620 with those of overall satisfaction.
Conclusion The need for new and more detailed information from general health surveys is expected to increase. Here we have been concerned with the application of one specific type of health survey one that measures the public's satisfaction with the quality of the health care system in general. Although such opinion polls have drawbacks they are likely to be used increasingly as a tool by policymakers and program planners in government and private industry. The challenge for researchers in health care service is to ensure that as the demand for this information increases, the quality and interpretation of the data will meet appropriate standards and that the costs to secure it will be acceptable to consumers and information users alike.
References 1. Health Services Research Group: A guide to direct measures of patient satisfaction in clinical practice. Can Med Assoc J
1992; 146: 1727-1731 2. Ware JE Jr, Snyder MK: Dimensions of patient attitudes regarding doctors and medical care services. Med Care 1975; 13: 669-682 3. Ware JE Jr, Snyder MK, Wright WR et al: Defining and measuring patient satisfaction with medical care. Eval Program Plann 1983; 6: 247-263 4. Ware JE Jr, Snyder MK, Wright WR: Review of Literature, Overview of Methods, and Results Regarding Construction of Scales (NTIS no PB 288-329), vol 1, part A, of Development and Validation of Scales to Measure Patient Satisfaction with Health Care Services, National Technical Information Service, Springfield, Va, 1976 5. Idem: Results Regarding Scales Constructed from the Patient Satisfaction Questionnaire and Measures of Other Health Care Perceptions (NTIS no PB 288-330), vol 1, part B, of Development and Validation of Scales to Measure Patient Satisfaction with Health Care Services, National Technical Information Service, Springfield Va, 1976 6. Chu GC, Ware JE Jr, Wright WR: Health Related Research in Southernmost Illinois. a Preliminary Report (tech rep HCP-73-6), School of Medicine, Southern Illinois U, Springfield, Ill, 1973 7. Ware JE Jr, Wright WR, Snyder MK et al: Consumer perceptions of health care services: implications for academic medicine. J Med Educ 1975; 50: 839-848 1136
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14. Blendon RJ, Taylor H: Views on health care: public opinion in three nations. Health Aff 1989; spring: 149-157 15. Blendon RJ, Leitman R, Morrison I et al: Satisfaction with health systems in ten nations. Health Aff 1990; summer: 185192 16. NBC News Poll, Roper Center for Public Opinion Research, Storrs, Conn, Apr 1-25, 1989 17. Los Angeles Times Poll: Health Care in the United States (poll no 212), Roper Center for Public Opinion Research, Storrs, Conn, Mar 1990 18. Los Angeles Times/Gallup Poll: American Unhappiness with Health Care Contrasts with Canadian Contentment, Roper Center for Public Opinion Research, Storrs, Conn, Aug 1, 1991 19. Adams 0, Ramsay T, Millar W: Overview of selected health surveys in Canada. Health Rep 1992; 4: 25-52 20. Millar W, Gentleman J: An Inventory of Canadian Health Surveys, 1966-1991 (mimeo), Canadian Centre for Health Information, Statistics Canada, Ottawa, 1991 21. Stephens T: Measuring the health of Canadians: an agenda for developing health surveys. Health Rep 1991; 3: 137-145 22. Aromaa A: Health surveys in the planning and implementation of sickness insurance in Finland. In The Role of Research in Social Security, Studies and Research (no 25), International Social Security Association, Geneva, 1988: 65-84 23. Thuriaux MC: Health for all: indicators and household surveys (with particular reference to the European region of WHO). In World Health Organization, Regional Office for Europe: Consultation to Develop Common Methods and Instruments for Health Interview Surveys, Netherlands Central Bureau of Statistics, Voorburg, the Netherlands, 1989: 7-25 24. Emond A: How to Use the Instruments of the Quebec Health Survey (tech manual 87-04), Quebec Health Survey, Montreal, 1987 25. Hamilton MK: The health and activity limitation survey: disabled aboriginal persons in Canada. Health Rep 1990; 2: 279-287 26. National Survey on Drinking and Driving, 1988. Overview Report, Dept of National Health and Welfare, Ottawa, 1989 27. Eliany M, Giesbrecht N, Nelson M et al (eds): National Alcohol and Other Drugs Survey, 1989. Highlights Report, Dept of National Health and Welfare, Ottawa, 1990 28. Levasseur M: Sources and Rationalizations of Questions Used in the Quebec Health Survey (tech manual 98-03), Quebec Health Survey, Montreal, 1987 29. Premier's Council on Health Strategy: Ontario Health Survey: Information Manual, Ont Min of Health, Toronto, 1989 30. The Health and Activity Limitation Survey Highlights: Disabled Persons in Canada (cat no 820602), Statistics Canada, Ottawa, 1990 31. Kohn R, White KL (eds): Health Care: an International Study, Oxford U Pr, London, 1976 32. Aday LA, Andersen R, Fleming GV: Health Care in the US: Equitable for Whom?9, Sage, Beverly Hills, Calif, 1980 33. Andersen R, Anderson OW: A Decade of Health Services: LE 15 OCTOBRE 1992
Social Survey Trends in Use and Expenditure, U of Chicago Pr, Chicago, 1967 34. Spuhler T, Paccaud F: Overview of health interview surveys: the experience of the United States, Great Britain, the Netherlands, Italy, and Switzerland. In World Health Organization, Regional Office for Europe: Consultation to Develop Common Methods and Instruments for Health Interview Surveys, Netherland Central Bureau of Statistics, Voorburg, the Netherlands, 1989: 71-82 35. Berger E: Canada Health Monitor. Highlights Report, Survey
#3, December 1989-January 1990, Price Waterhouse, Toronto, 1990 36. Kars-Marshall C, Spronk-Boon YW, Pollemans M: National health interview surveys for health care policy. Soc Sci Med 1988; 26: 223-233 37. Charette A: Special Study on Adults with an Activity Limitation (Health Promotion Survey tech rep ser), Dept of National Health and Welfare, Ottawa, 1988 38. Offord D, Boyle M, Racine Y: Ontario Child Health Study: Children at Risk, Queen's Printer for Ontario, Toronto, 1989
Conferences
Heather Pastorchik, conference coordinator, Computer Based Records Supporting Patient Care Management, c/o Clinicare Corporation, 4306-1Oth St. NE, Calgary, AB T2E 6K3; (403) 291-3949, fax (403) 250-8950
continuedfrom page 1124 et la soumission de communications composer le numero 1-800-621-8335. For event sponsorship or invitation to exhibit contact / pour le parrainage de conferences ou les invitations d'exposants contacter Patrick W. McGuffin, PhD, Department of Mental Health, American Medical Association, 515 N State St., Chicago, IL 60610; (312) 464-4064.
5th Annual CMA Leadership Conference * 5e Conference annuelle de l'AMC sur le leadership Feb. 25-27, 1993 / du 25 au 27 fev. 1993 L'H6tel Westin Hotel, Ottawa CMA Meetings and Travel Department / Departement des conferences et voyages de I'AMC, PO Box/CP 8650, Ottawa, ON KIG OG8; (613) 731-9331 or/ou 1-800-267-9703, fax (613) 523-0937
126th Annual Meeting of the Canadian Medical Association * 126e Assemblee generale annuelle de l'Association medicale canadienne Aug. 22-26, 1993 / du 22 au 26 aouit 1993 Calgary 127th Annual Meeting of the Canadian Medical Association * 127e Assemblee generale annuelle de l'Association medicale canadienne Aug. 14-19, 1994/ du 14 au 19 aouit 1994 Montreal CMA Meetings and Travel Department / Departement des conferences et voyages de I'AMC, PO Box/CP 8650, Ottawa, ON KIG OG8; (613) 731-9331 or/ou 1-800-267-9703, fax (613) 523-0937
Other Conferences * Conferences diverses Oct. 23, 1992: North York General Hospital Annual Pediatric Morning Prince Hotel, Toronto Gayle Willoughby, conference coordinator, North York General Hospital, 116-4001 Leslie St., North York, ON M2K IEl; (416) 756-6538, fax (416) 756-6740
Oct. 27, 1992: Computer Based Records Supporting Patient Care Management Seminar Palliser Hotel, Calgary CME credits available. OCTOBER 15, 1992
Nov. 5-7, 1992: 9th Annual Leadership Seminar Managing the Mission while Downsizing Queen Elizabeth Hotel, Montreal Freda Fraser, Catholic Health Association of Canada, 1247 Kilborn P1., Ottawa, ON KlH 6K9; (613) 731-7148, fax (613) 731-7797
Nov. 11, 1992: Computer Based Records Supporting Patient Care Management Seminar Holiday Inn, Saskatoon
CME credits available. Heather Pastorchik, conference coordinator, Computer Based Records Supporting Patient Care Management, c/o Clinicare Corporation, 4306- 10th St. NE, Calgary, AB T2E 6K3; (403) 291-3949, fax (403) 250-8950 Nov. 11, 1992: North York General Hospital Mental Health Day - John Armstrong Lectureship: Dual Diagnosis - Mental and Addictive Disorders Inn on the Park, Toronto Gayle Willoughby, conference coordinator, North York General Hospital, 116-4001 Leslie St., North York, ON M2K lEI; (416) 756-6538, fax (416) 756-6740 Nov. 12, 1992: Computer Based Records Supporting Patient Care Management Seminar Holiday Inn, Winnipeg
CME credits available. Heather Pastorchik, conference coordinator, Computer Based Records Supporting Patient Case Management, c/o Clinicare Corporation, 4306- 10th St. NE, Calgary, AB T2E 6K3; (403) 291-3949, fax (403) 250-8950 Nov. 13, 1992: Royal Postgraduate Medical School (RPMS) Institute of Obstetrics and Gynaecology Symposium - Adaptation to Extrauterine Life Queen Charlotte's and Chelsea Hospital, London Symposium secretary, RPMS Institute of Obstetrics and Gynaecology, Queen Charlotte's and Chelsea Hospital, Goldhawk Road, London W6 OXG; telephone 01 -44-1 081-740-3904, fax 01-44-1-081-741-1838
continued on page 1172 CAN MED ASSOC J 1992; 147 (8)
1137
RECHERCHE EN SERVICES DE SOINS DE SANTE
Public opinions about health care Health Services Research Group A unique perspective on the status of the health care system may be obtained from the public's perceptions of health care, especially those related to satisfaction with health services. Direct and indirect methods may be used to assess these perceptions. Direct methods (discussed in an earlier article in this series') assess patients' satisfaction with the care given by specific providers in particular health care facilities. Indirect methods involve surveying people for their opinions about the system as a whole and health care providers collectively. The information acquired through the two methods is generally used differently. Data from direct methods may guide initiatives to improve the structure, process or outcome of health care delivery or influence decisions about the future of specific services. Data from indirect methods contribute to an understanding of the effects of health care policies and decisions about resource allocation and provide insight into consumers' understanding of the workings of the health care system. In this article we discuss indirect measures of consumer satisfaction with health care. We very briefly touch on other population-based measures of health status and behaviour, primarily to indicate how they can be used with the indirect measures to provide a more complete overview of the population's perceptions of its health and health care system.
Measuring general satisfaction The most popular of the indirect measures
appears to be the Patient Satisfaction Questionnaire (PSQ).2-5 It has undergone extensive testing and refinement and has sufficient empiric foundation to warrant its continued use. Versions include the original, interviewer-administered PSQ (Form I) and a self-administered survey (Form II),46-7 which is more convenient and regarded as more comprehensive and reliable than Form 1.3 Scales in Form II cover areas such as access to care, availability of resources, continuity of care and overall satisfaction. Obviously some of these areas shade into measures of direct satisfaction, in that the answers to them are bound to be affected by respondents' experiences with specific health care providers and facilities. However, the goal of indirect surveys is to measure global satisfaction with the health care system, not simply respondents' satisfaction with health care received. These ratings of global satisfaction may reflect influences such as the experiences of close relatives and friends, media reports about the state of the health care system, information (accurate or not) about the care available in other jurisdictions and so on. Thus, it is not surprising that several studies have demonstrated a weak relation between responses to direct measures and those to indirect measures of satisfaction.58-" Consumers generally rate satisfaction with their own health care higher than their satisfaction with the health care system in general, a disparity that has been intuitively appreciated by medical practitioners for decades and has episodically frustrated leaders of Canadian organized medicine. For example, in 1943 Dr. T. Clarence Routley, then general secretary of the CMA, lament-
Members: Drs. Lorraine E. Ferris (principal coauthor), Department of Behavioural Science; J. Ivan Williams (principal coauthor), Department of Preventive Medicine and Biostatistics; Hilary A. Llewellyn-Thomas, Faculty of Nursing; C. David Naylor, Department of Medicine; Marsha M. Cohen, Department of Health Administration; and Antoni S.H. Basinski, Department of Family and Community Medicine, University of Toronto, Toronto, Ont. The Health Services Research Group is part of the Clinical Epidemiology Unit, Sunnybrook Health Science Centre, Toronto, Ont. Reprint requests to: Health Services Research Group, Clinical Epidemiology Unit, Sunnybrook Health Science Centre, 2075 Bayview Ave., Toronto, ON M4N 3M5 OCTOBER 15, 1992
CAN MED ASSOC J 1992; 147 (8)
1133
ed that positive perceptions of individual physicians as caregivers were not generalized to the profession.12 Such disparities justifiably lead to scepticism about the validity of indirect opinion surveys, which is more difficult to establish than that of direct measures. One line of argument is that the results of opinion surveys on health care are confounded by broader experiences of satisfaction (e.g., unhappiness with health care is simply a proxy for a general dissatisfaction with life). There is evidence of this in indirect but not direct measures of consumer satisfaction;9 however, the relation is very weak. Furthermore, psychologic disorders (including depression) do not affect the results of indirect or direct measures.9 None the less, if patients are satisfied with their care but more critical about the system in general, then the question becomes Should we pay more attention to evaluations of firsthand experience than to opinions based on secondhand sources that may highlight negative aspects of the system? The answer is not clear. In our earlier article' we reviewed why patients tend to offer high satisfaction ratings of specific experiences. Despite their drawbacks, general opinion surveys may act as counterweights to the positive biases associated with direct measures of satisfaction. Moreover, the opinions of the public (regardless of the depth of the knowledge that shapes them) will tend to draw the attention of policymakers.'3 One approach may be to measure both knowledge of the health care system and satisfaction with it in any population survey. Responses based on limited knowledge or misinformation might then catalyse initiatives in public education rather than policy miscues.
What have we learned about satisfaction? A recent series of studies examined people's
experiences in obtaining medical care and their view of the performance of their health care systems in three nations (Canada, the United States and Britain).'4 It was the first comprehensive comparative analysis of consumer satisfaction with health care, and its findings were later replicated."' People's satisfaction did not necessarily relate to health care
expenditure:'4"'5 for example, in the 1988 study'4 Americans expressed the lowest levels of satisfaction with their health care system despite higher expenditures per capita than in Canada or Britain. When asked which system they preferred, 61% of the Americans preferred a system like Canada's, and 29% preferred the British system. Of the Britons, 28% preferred the Canadian system and 12% the US system. Only 8% of the Canadians preferred another system, 5% choosing the US and 3% the British one. 1134
CAN MED ASSOC J 1992; 147 (8)
Furthermore, 29% of the Americans and 17% of the Britons believed that their health care system needed to be completely rebuilt, as compared with 5% of the Canadians. Several US national surveys replicated some of the findings from the three-nation study. In April 1989 the National Broadcasting Corporation surveyed Americans and found that 67% of the respondents supported a comprehensive, national health plan similar to the Canadian scheme.'6 A national survey conducted by the Los Angeles Times'7 in March 1990 found that 66% of Americans would prefer the Canadian health care system. A Gallup poll by the Los Angeles Times'8 1 year later showed that 43% of Americans favoured the Canadian health care system, whereas only 3% of Canadians favoured the US system. In 1990 the three-nation study was augmented to include a survey of seven additional countries: the Netherlands, Italy, West Germany, France, Sweden, Australia and Japan.'5 Respondents from the United States had the highest level of dissatisfaction with their health care system, although they had the highest level of health care expenditure per capita. Italy, with the second highest dissatisfaction level, had the lowest health care expenditure except for Britain. By excluding the United States and Sweden, Blendon and associates'5 found that satisfaction was positively associated with the level of health care spending per capita, a finding different from that in the original three-nation study. They speculated that this effect may have been related to such factors as the availability of services and the quality of facilities, factors that may result in decreased waiting times and other perceived benefits. Indirect measures of consumer satisfaction also provide insight into the public perception of quality of care. For example, the three-nation study'4 asked about satisfaction with physicians and hospitals and found that respondents from all countries were largely satisfied with these aspects of the health care system. However, such questions tend to blur the distinctions between direct and indirect measures of satisfaction, in that perceptions of the quality of care may be heavily weighted by personal experiences.
Other population health surveys Other surveys have examined additional health matters, such as health status, health behaviour and knowledge, and special health needs. The field of population health surveys has been reviewed in several excellent publications, some of which deal with Canadian health surveys. 9-21 As well, there are reviews of particular measures,22-23 including some specific to Canada.24-30 We provide brief examples of some surveys for illustration. LE 15 OCTOBRE 1992
The study by the World Health Organization on international medical care utilization compared the availability of health services, satisfaction with them and indicators of health status across eight countries.31 The availability of physicians and hospitals varied by country, as did the patterns of use of their services. The variations in utilization persisted after international differences in health status and presumed need had been controlled for. Over the past 30 years the Center for Health Administration Studies, University of Chicago, has conducted a number of nationwide studies to assess inequities in the availability and accessibility of health care services.32,33 It developed two measures of access: one defined as use of services relative to self-perceived health status and the other defined in relation to needs for health care. In the United States information on health status and the utilization of services has been collected periodically since 1957 by the National Health Survey.'9 In Britain questions on chronic and acute sickness and on contacts with various health and social services have been part of the General Household Survey, operating since 1971.34 In Canada a nationally syndicated survey the Canada Health Monitor - was established in 1988, by Earl Berger, of Price Waterhouse Management Consultants, and various subscribers.35 Like the polls of Harris and associates'9 the Canada Health Monitor asks questions on policy issues as well as on lifestyle, risk factors, health status and the utilization of health services. Kars-Marshall, SpronkBoon and Pollemans36 reviewed the national surveys of nine countries and found that the topics routinely covered included health status, lifestyle and risk factors, health knowledge, attitudes and opinions, health care- utilization, health-related expenses and insurance coverage.
Further issues in measuring public opinion There are specific sampling biases associated with indirect measures of consumer satisfaction and other population health surveys. Often, the opinions of only householders are sought. People in health care facilities or long-term residential units are generally excluded, as are members of the armed forces and people living on Indian reserves or in remote regions. Moreover, since most general health surveys are conducted by telephone or in person with people at home, there may be an employment bias. In interviews lasting between 15 and 90 minutes, responsep can be limited by health problems or language barriers. Consequently, people with the greatest health problems or unmet needs may be least likely to participate. People with rare conditions or those who have been seriously ill may not be included because of an inadequate sample size; in OCT^OBER 15, 1992
fact, surveys of fewer than 10 000 people may run this risk.'4 Thus, people who receive primary care may be better represented than those those who receive specialty care. There have been surveys that address groups with special needs,25'37'38 but more are required. Before the 1970s most general health surveys used a face-to-face interview format, which yielded response rates of about 75% to 90% of eligible people sampled. Newer approaches, such as telephone surveys of people sampled through random digit dialling, have contributed to lower response rates - 50% to 60% and sometimes as low as 25%. There is debate about whether the shift in interviewing techniques and the decline in response rates have adversely affected the validity of these opinion surveys. Critics have been concerned that in population health surveys the questions on the uses of health services are limited. Respondents are usually asked whether they have visited a physician or other health care professional within the past 2 weeks and, if so, the reason for the visit; they may also be asked about the total number of visits within the past 12 months. With respect to hospitals, they are asked if they have been admitted within the past 12 months and, if so, how many times. The responses do not reveal the total use of health care, health expenditures or the adequacy of the care. Furthermore, the utilization and expenditures by the family may limit the amount spent by one individual, and this is not taken into consideration in most surveys. In 1990 the National Health Information Council and the Canadian Centre for Health Information held a workshop2l on the use of surveys to measure the health of Canadians. The participants identified 10 issues that should be the focus of efforts to improve the way in which health surveys are conducted and used. Although indirect measures of consumer satisfaction were not specifically reviewed the list of issues is pertinent: * Health surveys should have a statement of specific objectives that will guide the choice of study design. * There should be clarification of conceptual definitions of health to ensure agreement on the measures to be selected or developed. * Criteria should be established for the "determinants" of health to be included. * Whether common topics should appear in all surveys merits consideration. * Simple, reliable and valid indicators of physical health, emotional health and socioeconomic status are needed. * The coverage of groups should be expanded to include residents of institutions, native Canadians, residents of remote regions, the homeless and those without a telephone. CAN MED ASSOC J 1992; 147 (8)
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* New approaches to improve the quality of 8. Andersen R, Kravits J, Anderson OW: The public's view of the crises in medical care: An impetus for changing delivery sampling are needed. systems? Econ Bus Bull 1971; 24: 44-52 * Surveys should be linked with administrative 9. Roberts RE, Pascoe GC, Attkisson CC: Relationship of data sets. service satisfaction to life satisfaction and perceived wellbeing. Eval Program Plann 1983; 6: 373-383 * There should be discussion of the need for 10. Stewart MA, Wanklin J: Direct and indirect measures of complementarity among health surveys. patient satisfaction with physicians' services. J Community * New approaches are needed for consultation Health 1978; 3: 195-204 with various interest groups on the development and 11. Pascoe GC, Attkisson CC, Roberts RE: Comparison of indirect and direct approaches to measuring patient satisfacimplementation of health surveys. Eval Program Plann 1983; 6: 359-371 tion. To this list we would add the points already 12. Routley TC: Untitled bulletin to the Health Insurance Comraised, especially the issues involved in blending mittee-at-Large, Dec 30, 1943, CMA archives, Ottawa measures of knowledge of the health care system 13. Iglehart JK: Opinion polls on health care. N Engl J Med 1984; 310: 1616-1620 with those of overall satisfaction.
Conclusion The need for new and more detailed information from general health surveys is expected to increase. Here we have been concerned with the application of one specific type of health survey one that measures the public's satisfaction with the quality of the health care system in general. Although such opinion polls have drawbacks they are likely to be used increasingly as a tool by policymakers and program planners in government and private industry. The challenge for researchers in health care service is to ensure that as the demand for this information increases, the quality and interpretation of the data will meet appropriate standards and that the costs to secure it will be acceptable to consumers and information users alike.
References 1. Health Services Research Group: A guide to direct measures of patient satisfaction in clinical practice. Can Med Assoc J
1992; 146: 1727-1731 2. Ware JE Jr, Snyder MK: Dimensions of patient attitudes regarding doctors and medical care services. Med Care 1975; 13: 669-682 3. Ware JE Jr, Snyder MK, Wright WR et al: Defining and measuring patient satisfaction with medical care. Eval Program Plann 1983; 6: 247-263 4. Ware JE Jr, Snyder MK, Wright WR: Review of Literature, Overview of Methods, and Results Regarding Construction of Scales (NTIS no PB 288-329), vol 1, part A, of Development and Validation of Scales to Measure Patient Satisfaction with Health Care Services, National Technical Information Service, Springfield, Va, 1976 5. Idem: Results Regarding Scales Constructed from the Patient Satisfaction Questionnaire and Measures of Other Health Care Perceptions (NTIS no PB 288-330), vol 1, part B, of Development and Validation of Scales to Measure Patient Satisfaction with Health Care Services, National Technical Information Service, Springfield Va, 1976 6. Chu GC, Ware JE Jr, Wright WR: Health Related Research in Southernmost Illinois. a Preliminary Report (tech rep HCP-73-6), School of Medicine, Southern Illinois U, Springfield, Ill, 1973 7. Ware JE Jr, Wright WR, Snyder MK et al: Consumer perceptions of health care services: implications for academic medicine. J Med Educ 1975; 50: 839-848 1136
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14. Blendon RJ, Taylor H: Views on health care: public opinion in three nations. Health Aff 1989; spring: 149-157 15. Blendon RJ, Leitman R, Morrison I et al: Satisfaction with health systems in ten nations. Health Aff 1990; summer: 185192 16. NBC News Poll, Roper Center for Public Opinion Research, Storrs, Conn, Apr 1-25, 1989 17. Los Angeles Times Poll: Health Care in the United States (poll no 212), Roper Center for Public Opinion Research, Storrs, Conn, Mar 1990 18. Los Angeles Times/Gallup Poll: American Unhappiness with Health Care Contrasts with Canadian Contentment, Roper Center for Public Opinion Research, Storrs, Conn, Aug 1, 1991 19. Adams 0, Ramsay T, Millar W: Overview of selected health surveys in Canada. Health Rep 1992; 4: 25-52 20. Millar W, Gentleman J: An Inventory of Canadian Health Surveys, 1966-1991 (mimeo), Canadian Centre for Health Information, Statistics Canada, Ottawa, 1991 21. Stephens T: Measuring the health of Canadians: an agenda for developing health surveys. Health Rep 1991; 3: 137-145 22. Aromaa A: Health surveys in the planning and implementation of sickness insurance in Finland. In The Role of Research in Social Security, Studies and Research (no 25), International Social Security Association, Geneva, 1988: 65-84 23. Thuriaux MC: Health for all: indicators and household surveys (with particular reference to the European region of WHO). In World Health Organization, Regional Office for Europe: Consultation to Develop Common Methods and Instruments for Health Interview Surveys, Netherlands Central Bureau of Statistics, Voorburg, the Netherlands, 1989: 7-25 24. Emond A: How to Use the Instruments of the Quebec Health Survey (tech manual 87-04), Quebec Health Survey, Montreal, 1987 25. Hamilton MK: The health and activity limitation survey: disabled aboriginal persons in Canada. Health Rep 1990; 2: 279-287 26. National Survey on Drinking and Driving, 1988. Overview Report, Dept of National Health and Welfare, Ottawa, 1989 27. Eliany M, Giesbrecht N, Nelson M et al (eds): National Alcohol and Other Drugs Survey, 1989. Highlights Report, Dept of National Health and Welfare, Ottawa, 1990 28. Levasseur M: Sources and Rationalizations of Questions Used in the Quebec Health Survey (tech manual 98-03), Quebec Health Survey, Montreal, 1987 29. Premier's Council on Health Strategy: Ontario Health Survey: Information Manual, Ont Min of Health, Toronto, 1989 30. The Health and Activity Limitation Survey Highlights: Disabled Persons in Canada (cat no 820602), Statistics Canada, Ottawa, 1990 31. Kohn R, White KL (eds): Health Care: an International Study, Oxford U Pr, London, 1976 32. Aday LA, Andersen R, Fleming GV: Health Care in the US: Equitable for Whom?9, Sage, Beverly Hills, Calif, 1980 33. Andersen R, Anderson OW: A Decade of Health Services: LE 15 OCTOBRE 1992
Social Survey Trends in Use and Expenditure, U of Chicago Pr, Chicago, 1967 34. Spuhler T, Paccaud F: Overview of health interview surveys: the experience of the United States, Great Britain, the Netherlands, Italy, and Switzerland. In World Health Organization, Regional Office for Europe: Consultation to Develop Common Methods and Instruments for Health Interview Surveys, Netherland Central Bureau of Statistics, Voorburg, the Netherlands, 1989: 71-82 35. Berger E: Canada Health Monitor. Highlights Report, Survey
#3, December 1989-January 1990, Price Waterhouse, Toronto, 1990 36. Kars-Marshall C, Spronk-Boon YW, Pollemans M: National health interview surveys for health care policy. Soc Sci Med 1988; 26: 223-233 37. Charette A: Special Study on Adults with an Activity Limitation (Health Promotion Survey tech rep ser), Dept of National Health and Welfare, Ottawa, 1988 38. Offord D, Boyle M, Racine Y: Ontario Child Health Study: Children at Risk, Queen's Printer for Ontario, Toronto, 1989
Conferences
Heather Pastorchik, conference coordinator, Computer Based Records Supporting Patient Care Management, c/o Clinicare Corporation, 4306-1Oth St. NE, Calgary, AB T2E 6K3; (403) 291-3949, fax (403) 250-8950
continuedfrom page 1124 et la soumission de communications composer le numero 1-800-621-8335. For event sponsorship or invitation to exhibit contact / pour le parrainage de conferences ou les invitations d'exposants contacter Patrick W. McGuffin, PhD, Department of Mental Health, American Medical Association, 515 N State St., Chicago, IL 60610; (312) 464-4064.
5th Annual CMA Leadership Conference * 5e Conference annuelle de l'AMC sur le leadership Feb. 25-27, 1993 / du 25 au 27 fev. 1993 L'H6tel Westin Hotel, Ottawa CMA Meetings and Travel Department / Departement des conferences et voyages de I'AMC, PO Box/CP 8650, Ottawa, ON KIG OG8; (613) 731-9331 or/ou 1-800-267-9703, fax (613) 523-0937
126th Annual Meeting of the Canadian Medical Association * 126e Assemblee generale annuelle de l'Association medicale canadienne Aug. 22-26, 1993 / du 22 au 26 aouit 1993 Calgary 127th Annual Meeting of the Canadian Medical Association * 127e Assemblee generale annuelle de l'Association medicale canadienne Aug. 14-19, 1994/ du 14 au 19 aouit 1994 Montreal CMA Meetings and Travel Department / Departement des conferences et voyages de I'AMC, PO Box/CP 8650, Ottawa, ON KIG OG8; (613) 731-9331 or/ou 1-800-267-9703, fax (613) 523-0937
Other Conferences * Conferences diverses Oct. 23, 1992: North York General Hospital Annual Pediatric Morning Prince Hotel, Toronto Gayle Willoughby, conference coordinator, North York General Hospital, 116-4001 Leslie St., North York, ON M2K IEl; (416) 756-6538, fax (416) 756-6740
Oct. 27, 1992: Computer Based Records Supporting Patient Care Management Seminar Palliser Hotel, Calgary CME credits available. OCTOBER 15, 1992
Nov. 5-7, 1992: 9th Annual Leadership Seminar Managing the Mission while Downsizing Queen Elizabeth Hotel, Montreal Freda Fraser, Catholic Health Association of Canada, 1247 Kilborn P1., Ottawa, ON KlH 6K9; (613) 731-7148, fax (613) 731-7797
Nov. 11, 1992: Computer Based Records Supporting Patient Care Management Seminar Holiday Inn, Saskatoon
CME credits available. Heather Pastorchik, conference coordinator, Computer Based Records Supporting Patient Care Management, c/o Clinicare Corporation, 4306- 10th St. NE, Calgary, AB T2E 6K3; (403) 291-3949, fax (403) 250-8950 Nov. 11, 1992: North York General Hospital Mental Health Day - John Armstrong Lectureship: Dual Diagnosis - Mental and Addictive Disorders Inn on the Park, Toronto Gayle Willoughby, conference coordinator, North York General Hospital, 116-4001 Leslie St., North York, ON M2K lEI; (416) 756-6538, fax (416) 756-6740 Nov. 12, 1992: Computer Based Records Supporting Patient Care Management Seminar Holiday Inn, Winnipeg
CME credits available. Heather Pastorchik, conference coordinator, Computer Based Records Supporting Patient Case Management, c/o Clinicare Corporation, 4306- 10th St. NE, Calgary, AB T2E 6K3; (403) 291-3949, fax (403) 250-8950 Nov. 13, 1992: Royal Postgraduate Medical School (RPMS) Institute of Obstetrics and Gynaecology Symposium - Adaptation to Extrauterine Life Queen Charlotte's and Chelsea Hospital, London Symposium secretary, RPMS Institute of Obstetrics and Gynaecology, Queen Charlotte's and Chelsea Hospital, Goldhawk Road, London W6 OXG; telephone 01 -44-1 081-740-3904, fax 01-44-1-081-741-1838
continued on page 1172 CAN MED ASSOC J 1992; 147 (8)
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