RESEARCH Open Access Public assessment of key performance indicators of healthca - PDF document

RESEARCH Open Access Public assessment of key performance indicators of healthca
RESEARCH Open Access Public assessment of key performance indicators of healthca

RESEARCH Open Access Public assessment of key performance indicators of healthca - Description


Drawing from data collected by Government of Alberta s Department of Health and Wellness this research examines two key questions 1 Do people in the 65 age group rate the KPIs of healthcare ie availability accessibility quality outcome and satisfact ID: 1487 Download Pdf

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RESEARCHOpenAccess Publicassessmentofkeyperformanceindicators ofhealthcareinaCanadianprovince:theeffect ofageandchronichealthproblems AbuSadatNurullah 1* ,HerbertCNorthcott 1 andMichaelDHarvey 2 Abstract Thisstudyexplorestheeffectofageandchronicconditionsonpublicperceptionsofthehealthsystem,as measuredbytheKeyPerformanceIndicators(KPIs)ofhealthcare,intheprovinceofAlbertainCanada.Drawing fromdatacollectedbyGovernmentofAlberta ’ sDepartmentofHealthandWellness,thisresearchexaminestwo keyquestions:(1)Dopeopleinthe65+agegroupratetheKPIsofhealthcare(i.e.,availability,accessibility,quality, outcome,andsatisfaction)morefavorablycomparedtopeopleinyoungeragegroupsinAlberta?(2)Doesthe ratingofKPIsofhealthcareinAlbertavarywithdifferentchronicconditions(i.e.,nochronicproblem,chronic illnesseswithoutpain,andchronicpain)?Thefindingsindicatethatpeopleintheolderagegrouptendtoratethe KPIsofhealthcaremorefavorablycomparedtoyoungeragegroupsinAlberta,netofsocio-demographicfactors, painarelesslikelytoratetheKPIsofhealthcarefavorablycomparedtopeoplewithnochronichealthproblemin Alberta.Discussionincludesimplicationsofthefindingsforthehealthcaresystemintheprovince. Keywords: Keyperformanceindicators;Healthcaresystem;Agegroup;Chronicillness;Chronicpain;Alberta Introduction Performanceindicatorsofhealthcareareimportant measuresofpublicconfidenceinandsatisfactionwith thehealthcaresystem.Furthe rmore,patientscanprovide valuableinformationabout keyaspectsofhealthcare (Draperetal.,2001).Peloneetal.(2008)suggestedthat performanceindicatorsofhealthcareshouldincludeassess- mentsofeffectiveness,technicalefficiency,accessibility, equityofaccess,timeliness,an dsafety.Performanceindica- torsfostertheuseofpatients ’ viewsforidentifying problemsanddifficultiesencounteredinhealthservices andgapsinthequalityofcare,andthusallowhealth authoritiestoformulatebetterstrategiesandmanage- mentproceduresforthehealthcaresystem(Mpinga andChastonay,2011).Therefore,atpresent,thereisa ’ perceptionsof theircare(Infanteetal.,2004). Previousresearchonpublicperceptionsofhealthcare includestheeffectsofgeneralhealthstatus,chronic conditions(e.g.,arthritis,chronicbackandneckpain), mentalhealthconditions(e.g.,depression),andsocio- demographicfactorsonvariousperformanceindicators (e.g.,availability,accessibility,utilization,quality,andsatis- faction).Thesestudiesonpatientassessmentoftheircare oftenreportinconsistentfindings. Patients ’ ageandassessmentofhealthcare Existingresearchsuggeststhatolderpatients,onaver- age,aremorelikelytobesatisfiedwithhealthcareservices thattheyhavereceivedcomparedtoyoungerpatients,and thisisconsistentacrossculturesandnations(Bleichetal., 2009;Campbelletal.,2001;Cohen,1996;Crowetal.,2002; HallandDornan,1990;Lyratzopoulosetal.,2012;Moret etal.,2007;Quintanaetal.,2006;Rahmqvist,2001; RahmqvistandBara,2010;Sixmaetal.,1998;Sofaer andFirminger,2005;TuckerandKelley,2000;Young aremoresatisfiedbecausetheymaybemoreunwilling tocriticizetheservicetheyreceiveandmaybemore *Correspondence: nurullah@ualberta.ca 1 DepartmentofSociology,UniversityofAlberta,5-21ToryBuilding, Edmonton,AlbertaT6G2H4,Canada Fulllistofauthorinformationisavailableattheendofthearticle a SpringerOpen Journal ©2014Nurullahetal.;licenseeSpringer.ThisisanOpenAccessarticledistributedunderthetermsoftheCreativeCommons AttributionLicense(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse,distribution,andreproduction inanymedium,providedtheoriginalworkisproperlycited. Nurullah etal.SpringerPlus 2014, 3 :28 http://www.springerplus.com/content/3/1/28 tolerantcomparedtoyoungerpatients(Agoritsasetal.,2009;HallandDornan,1990).Jayasingheetal.(2008)suggestedthatpatientswhoareyoungermayhavehigherexpectationsoftheservice,andwhenthoseexpectationsarenotmet,theymaytendtoassesstheservicenegatively.However,afewstudiesfoundeitheranegativeassociationornosignificantrelation-shipbetweenageandpatientsatisfaction(Boudreauxetal.,2000;JaipaulandRosenthal,2003;Kaneetal.,1997;Moretetal.,2007).Othersocio-demographiccharacteristicssuchaspa-tientssex,education,income,ethnicity,maritalstatus,familysize,livingcondition(i.e.,livingaloneorlivingwithothers)etc.failedtoshowaconsistenttrendinpre-dictingpatientsatisfactionbecausefindingswereoftencontradictory(Crowetal.,2002;Glynnetal.,2004;HallandDornan,1990;Quintanaetal.,2006;RahmqvistandBara,2010;SofaerandFirminger,2005;Upmarketal.,2007;Zhangetal.,2007).Previousresearchindicatedthatpositiveexperiencerelatedtoaccesstohealthcareincreasedwithage,witholderpatientsbeingmoresatisfiedwithaccesstocarecomparedtoyoungerones(Jayasingheetal.,2008;Kontopantelisetal.,2010;WilsonandRosenberg,2004).Inaddition,olderagewasrelatedtogreaterutilizationofmedicalservices(FieldandBriggs,2001;PappaandNiakas,2006).Somestudieshavesuggestedthatsomeolderpatientsmaynotaccuratelyrecalltheirdifficultyinaccessinghealthcareservicesinthepast12monthsduetocognitiveimpairment(KasmanandBadley,2004;Rainaetal.,2002).ChronichealthconditionsandassessmentofhealthcarePeopleexperiencingchronichealthconditionssuchaschronicpainspendmoredaysinhospitalorothercarefacilities,andaremoreinneedofmedicalcarethanthosewhodonothavechronicconditions(Millar,1996).Chronichealthproblemsaffectmostaspectsofonesliferangingfromworktosocialrelationships(Millar,1996).Studieshaveshowedconsistentlythatfactorsassociatedwithincreasedprevalenceofchronicpainincludefemalesex,increasingage,beingdivorcedorseparated,higherbodymassindex,poorself-reportedhealth,andindica-torsoflowersocioeconomicstatus,suchaslesseduca-tion,lowincome,beingunemployed,andresidenceinpublichousing(Boulangeretal.,2007;Johannesetal.,2010;Millar,1996;Moulinetal.,2002;Ramage-MorinandGilmour,2010;Reitsmaetal.,2011;Schopflocheretal.,2011;Trippetal.,2006).Researchershavesuggestedthatpeoplewithchronicpainareregularusersofavarietyofhealthcareservicesandaremorelikelytoassesstheirself-reportedhealthnegativelythanindividualswithoutchronicpain(Ramage-MorinandGilmour,2010;Trippetal.,2006).Chronicpainisassociatedwithsleepdeficiency,activ-ityandmobilitylimitations,cognitiveimpairment,otherchronicdiseases,anxiety,socialwithdrawal,loneliness,depression,negativeaffects(e.g.,atendencytoviewtheworldasthreatening),lossofself-confidenceandself-esteem,andpoorphysicalandmentalhealth(Millar,1996;OhayonandSchatzberg,2010;Ramage-Morin,2008;Toblinetal.,2011;Tsangetal.,2008).Constraintonleadinganormallifewasidentifiedasthemainproblemofchronicpain(Smithetal.,1999).Peoplewithoneormorechronicconditionsweremorelikelythanthosewithoutachronicconditiontoreportnotreceivinghealthcarewhenrequired(Kontopantelisetal.,2010;Wil-sonandRosenberg,2004).Furthermore,patientswithmul-tiplechronicillnessesreportedahigherlevelofhasslesinaccessinghealthcaresystemcomparedtopatientswithasinglechronicillness(Parchmanetal.,2005).Astudycon-ductedbyBenturetal.(2004)foundthatchronicillnesswasassociatedwithlongerwaittimesforanappointmentwithaspecialist.Self-reportedhealthstatusingeneralinfluencespublicassessmentofhealthcare.Studieshaveshownthatsatisfactionscoresarehigherinthosepatientswhohadbetterself-reportedoverallhealth(Cohen,1996;Crowetal.,2002;Halletal.,1990;JaipaulandRosenthal,2003;RahmqvistandBara,2010;SofaerandFirminger,2005;Wendtetal.,2009;XiaoandBarber,2008).Previ-ousstudiesgenerallysuggestthatpatientswhoareinpoorhealthtendtobelesssatisfiedwiththecarethattheyreceive(Al-Mandharietal.,2004;Bleichetal.,2009;Crowetal.,2002;Glynnetal.,2004;Halletal.,1999;Lyratzopoulosetal.,2012;Schoenfelderetal.,2011;Tucker,2002;Wensingetal.,1997;Zhangetal.,2007).Inalongitu-dinalsampleofpatientsaged70andabove,Halletal.(1993)testedthecausalpathwaysbetweensatisfactionandhealthstatus,andfoundthatself-perceivedgoodhealthwasrelatedtomoresatisfactionayearlater,butnotviceversa.Similarly,inalongitudinalstudy,Renetal.(2001)foundthatpatientswithbetterhealthstatusparticularlybettermentalhealthstatusweremoresatisfiedwiththeirhospitalcare.Ithasalsobeensuggestedthatpoorhealthingeneralmaydirectlyproducedissatisfactioninpatients(Halletal.,1998).However,afewstudiesfoundthathealthstatuswasnotsignificantlyrelatedtosatisfaction(Bertakisetal.,1991;Soh,1991).Finally,researchsuggeststhatsincehealthierpatientsareinclinedtoreportgreatersatisfactionwithhealthcare,itishealthstatusperse,ratherthandegreeofimprovementinhealthstatusbecauseofmedicalcare,thataffectspatientssatisfactionscores(Rapkinetal.,2008).Withregardtoaccesstocare,studiesfoundthatself-reportedgoodhealth(vs.poorhealth)wasassociatedwithbetteraccesstohealthcareservices(Glynnetal.,2004;Jayasingheetal.,2008;Pőllusteetal.,2012;deBoeretal.,2010).Jayasingheetal.(2008)suggestedthatetal.SpringerPlusPage2of13http://www.springerplus.com/content/3/1/28 patientswithbetterhealthmayneedfewervisitsforhos-pitalcare,andhencehavelesschanceofexperiencingdifficultyinaccesstocare.ObjectivesofthecurrentstudyTheaforementionedreviewofliteraturesuggeststhatalthoughaplethoraofresearchhasinvestigatedpatientsperceptionaboutaparticularindicatorofhealthcare(e.g.,satisfaction),paststudiesrarelyexaminethecom-binedimpactofmultipleindicatorsofhealthcareinageneralpopulation.Mostofthesestudiesfocusonpa-tientsindifferentsituations(inpatientfacility,out-patient,emergencycare,sufferingfromdiversediseaseconditions,etc.)andacrossdifferentsocio-demographiccharacteristics.Inaddition,onlyahandfulofstudiesexaminedthespecificexpectationsofindividualswithchronicconditions(Infanteetal.,2004),particularlychronicpain.Furthermore,thislineofresearchislack-inginthecontextofAlberta.Inordertoaddresstheseresearchgaps,thecurrentstudyexaminestwoquestions:(1)DopeopleintheolderagegroupscoretheKPIsofhealthcare(i.e.,availability,accessibility,quality,andsat-isfaction)higheronaveragecomparedtopeopleinyoungeragegroupsinAlberta?and(2)DoestheratingofKPIsofhealthcareinAlbertavarywithdifferentchronicconditions(i.e.,nochronicproblem,chronicillnesseswithoutpain,andchronicpain)?DataandsampleThedatasetusedinthisanalysiscomesfromthePublicSurveyaboutHealthandtheHealthSysteminAlberta.Thisannualsurveywaslaunchedin1996bytheDepartmentofHealthandWellnessoftheGovernmentofAlbertaandcontinuedinsimilarformatuntil2004(NorthcottandNorthcott,2004).Across-sectional,rep-resentativesampleof4,000adults(age18andabove)fromtheninehealthregionsofAlbertaparticipatedinthe2004survey.ThesurveywasconductedbythePopulationResearchLaboratoryattheUniversityofAlbertaanddatawerecollectedbytelephone(randomdigitdialingusingcomputerassistedtelephoneinter-viewing)fromFebruary10toMarch31,2004.Theori-ginalsurveywasapprovedbytheResearchEthicsBoardoftheUniversityofAlberta.Thesamplewasstratifiedbasedonage,sex,andhealthregionoftheparticipants.Theresponserateforthe2004surveywas72%.MeasuresDependentvariableThedependentvariableforthisstudyisanindexofkeyperformanceindicators(KPIs)ofthehealthcaresysteminAlberta.Theseindicatorsrevealasingleunderlyingconstructmeasuringpublicperceptionsofhealthcare(seeNorthcottandHarvey,2012fordetails).TheKPIsindexconsistsoffivegeneralindicatorsassessingtheavailability,accessibility,andperceivedqualityofhealth-careservices,overallqualityofthehealthcaresystem,andsatisfactionwiththehealthsysteminAlberta.FouroftheseKPIsweremeasuredona4-pointscaleandone(satisfaction)ona5-pointscale.Availabilitywasmea-suredbyaskingtherespondents,Overall,howwouldyouratetheofhealthcareservicesinyourcommunity?(coded1=poor,4=excellent).Accessibil-itywasmeasuredbythequestion,Howeasyordifficultisitforyoutogetthehealthcareservicesyouneedwhenyouneedthem?(coded1=verydifficult,4=veryeasy).Perceivedqualityofthehealthcareserviceswasmeasuredbythequestion,Overall,howwouldyouratequalityofhealthcareservicesthatareavailableinyourcommunity?(coded1=poor,4=excellent).Qualityofthehealthcaresystemwasmeasuredbythequestion,ThinkingnowaboutthehealthcaresysteminAlberta,overall,howwouldyourateit?(coded1=poor,4=excellent).Satisfactionwiththehealthsystemwasmeasuredbythequestion,Overall,howsatisfiedareyouwiththehealthsysteminAlberta?(coded1=verydissatisfied,5=verysatisfied).NorthcottandHarvey(2012)utilizedthesamesampleusedinthisstudyandreportedaCronbachsalphavalueof.84fortheKPIsindex,indicatinggoodinternalconsistencyforthismeasure.IndependentvariablesAgeandchronicconditionsareexaminedinthisstudyaspossiblepredictorsoftheKPIs,thatis,ofassessmentsofthehealthcaresysteminAlberta.Intheoriginalsurvey,agewasdividedintofivecategories:1824,2544,4564,6574,and75+years.Forthisanalysis,iscodedas(18to64)=0and(65+)=1.Chronicconditionwasclassifiedintothreecat-egories:nochronicproblem,atleastonechroniccondi-tion(e.g.,neurologicaldiseases,heartandcirculatorydiseases,asthmaandotherchronicrespiratorydiseases,diabetesandotherendocrinediseases,cancer,genito-urinary,reproductive,allergies,muscularorskeletal,sen-sorysystem)excludingchronicpain,andchronicpainwithorwithoutotherchronicconditions.ControlvariablesSelf-reportedgeneralhealthstatus,self-reportedphysicalandmentalhealthstatusinpast30days,knowledgeoftheavailablehealthservices,utilizationofhealthcareservices,andsocio-demographiccharacteristicswerecontrolledinthisstudy.Self-reportedgeneralhealthstatuswasmeasuredbythequestion,Ingeneral,com-paredwithotherpeopleyourage,wouldyousayyourhealthis(coded1=poor,5=excellent).Thephysicaletal.SpringerPlusPage3of13http://www.springerplus.com/content/3/1/28 andmentalhealthstatusinpast30dayswerecontinu-ousmeasures(numberofdays)comprisingtwoques-tions:Thinkingofyourphysicalhealth,whichincludesphysicalillnessandinjury,forhowmanydaysduringthepast30dayswasyourphysicalhealthThinkingofyourmentalhealth,whichincludesstress,depression,andproblemswithemotions,forhowmanydaysduringthepast30dayswasyourmentalhealthKnowledgeoftheavailablehealthserviceswasmeasuredbythequestion,Ingeneral,howwouldyourateyourknowledgeofthehealthservicesthatareavail-abletoyou?(coded1=poor,4=excellent).Utilizationofhealthcareserviceswasmeasuredbythequestion,HaveyoupersonallyreceivedanyhealthcareservicesinAlbertainthepast12months?(coded0=no,1=yes).DemographicandsocioeconomiccharacteristicsDemographicandsocioeconomicindicatorsincludedsex,education,householdincome,andlivingarrangement.Sexwascodedasmale=0,female=1.Educationwasclas-sifiedintofourcategories:lessthanhigh-school,completedhigh-school,somepost-secondary,andcompletedpost-secondary.Annualhouseholdincomebeforetaxesanddeductionswasclassifiedintofourcategories:lessthan$30,000,$30,000to$59,999,$60,000to99,999,and$100,000+.Livingarrangementwascodedas0=livingalone,1=livingwithsomeone.TheanalysiswascarriedoutusingIBMSPSSversion20(PASW)andincludedunivariate,bivariate,andmulti-variateanalysisofdatainvolvingcomputationofper-centages,ANOVA,andhierarchicalmultipleregression.Associationamongage,chronicconditions,andtheKPIswastestedusingANOVA.Inordertoidentifythesig-nificantpredictorsoftheKPIs,multivariateordinaryleastsquared(OLS)regressionanalyseswereperformed.InitialanalyseswereperformedoneachseparateKPIs,whichshowedthatthefindingsweresignificant(resultsnotshownandareavailableuponrequest).ThiswasfollowedbyanalysesofcombinedKPIsindexinthreemodels.Datawerecheckedtoensurenoviolationoftheassumptionofnormaldistributions(TabachnickandFidell,2007).Therewerenoproblemsofmulticollinear-ityasthehighestVIF(varianceinflationfactor)scorewas3.05(Cohenetal.,2003:423).Samplingweightswereappliedforallanalysesinthisstudy(basedonthepopulationdistributionacrossthehealthregions)soastoprovidearepresentativesampleofadultAlbertans(seeNorthcottandNorthcott,2004,pp.5354).Becausehouseholdincomeismissingforapproximately22%ofthecases,aseparateregressionanalysiswasconductedexcludingincomefromthemodels(notshownhere).However,itdidnotproduceasignificantdifferenceinoutcome.Therefore,thefinalanalysisincludesincome.Table1presentsdescriptivefindingsforthesample,dependentvariable,independentvariablesandcontrolvariables.Femalesrepresented50.4%andmalesrepre-sented49.6%ofthesample.Amajorityofthesample(86.2%)werenon-seniorswhile13.8%wereseniors(552).Aboutonehalfoftherespondentshadcompletedpost-secondaryeducation(49.9%),andhadanannualhouseholdincomeof$60,000andabove(51.2%)beforetaxesanddeductions.Intermsofhouseholdarrange-ment,15.2%oftherespondentswerelivingalonewhile84.8%werelivingwithothermembersofthehousehold.Alargenumberofrespondents(71.1%)hadnochronichealthproblemthatwouldrequireregularhealthser-vices,26.5%hadoneormorechronicconditionswithoutchronicpain,and2.4%(=97)hadchronicpainwithorwithoutotherchronicconditions.Themajorityoftherespondents(86.7%)reportedthattheirgeneralhealthwasgood,verygoodorexcellent.Duringthepast30days,39.3%and37.9%oftherespondentsreportedthattheirphysicalandmentalhealth,respectively,weregood.Whenaskedabouttheirknowledgeofthehealthservicesthatwereavailabletothem,63.5%ratedtheirknowledgeaseithergoodorexcellent.Asubstan-tialproportionofrespondents(77.6%)reportedperson-allyreceivinghealthcareservice(s)intheprovinceduringthepastyear.Intermsoftheavailabilityofhealthcareservicesintheircommunity,59.4%ratedavailabilityaseithergoodorexcellent.Alittlelessthantwo-thirdsoftherespon-dents(61.2%)reportedthatitwaseithereasyorveryeasyforthemtoaccesshealthcareserviceswhentheyneededthem.Approximatelytwo-thirdsoftherespon-dentsratedthequalityofavailablehealthcareservicesandtheoverallhealthcaresysteminAlbertaaseithergoodorexcellent(68.4%and64.6%,respectively).Ama-jorityoftherespondents(73.7%)reportedthattheywereeithersomewhatorverysatisfiedwiththehealthcaresystemintheprovince.BecauseseniorsaremorelikelytoratetheKPIsmorefavorably(Bleichetal.,2009;Campbelletal.,2001;FieldandBriggs,2001;HallandDornan,1990;Kontopantelisetal.,2010;PappaandNiakas,2006;Quintanaetal.,2006;RahmqvistandBara,2010;SofaerandFirminger,2005;WilsonandRosenberg,2004;Youngetal.,2000)andbecausetherespondentschronicconditionsarenegativelyrelatedtotheirperceptionsonthehealthcaresystem(Jayasingheetal.,2008;Ramage-MorinandGilmour,2010;Schoenfelderetal.,2011;SofaerandFirminger,2005;Trippetal.,2006),itwasnecessarytoassessthepossibleinteractioneffectofageandchronicetal.SpringerPlusPage4of13http://www.springerplus.com/content/3/1/28 Table1Sample,independentvariableanddependentvariablecharacteristicsfromthe2004AlbertaHealth%orMeanSDAdjusted%Male198449.649.6Female201650.450.4Non-Seniors(1864)344886.286.2Seniors(6575+)55213.813.8Lessthanhigh-school52513.113.2Completedhigh-school92623.223.3Somepost-secondary61915.515.6Completedpost-secondary190247.549.9280.7AnnualhouseholdincomeUpto$29,99959114.819.0$30,000to$59,99992823.329.8$60,000to$99,99986221.527.6$100,000+73418.323.688622.1LivingarrangementLivingalone60715.215.2Livingwithsomeone338884.784.850.1ChronicconditionsNochronicproblem283670.971.1Chronicwithoutpain105926.526.5Chronicpain972.42.480.2Self-reportedhealthstatus3.641.03Poor1403.53.5Fair3919.89.8Good108027.027.0Verygood152338.038.1Excellent86221.621.630.1Daysinpast30daysphysicalhealthnotgood3.848.240day240660.260.77days102425.625.88+days53613.413.5330.8Daysinpast30daysmentalhealthnotgood3.317.20 Table1Sample,independentvariableanddependentvariablecharacteristicsfromthe2004AlbertaHealth0day246161.562.17days100325.125.38+days50012.512.6360.9Knowledgeoftheavailablehealthservices2.720.82Poor3027.67.6Fair114628.728.9Good187046.747.1Excellent65216.316.4300.8PersonallyreceivedhealthcareNo89522.422.4Yes310077.577.660.1Availabilityofhealthcareservices2.600.88Poor49712.412.8Fair108427.127.8Good178344.645.8Excellent53113.313.61062.6Accessibilityofhealthcare2.690.83Verydifficult2927.37.5Abitdifficult122230.631.3Easy177844.445.4Veryeasy61615.415.8912.3Qualityofhealthcareservices2.780.81Poor2837.17.3Fair94523.624.3Good200550.151.6Excellent65416.416.81122.8QualityofhealthcaresysteminAlberta2.670.77Poor3037.67.7Fair108727.227.7Good211552.953.9Excellent41910.510.7751.9SatisfactionwiththehealthsysteminAlberta3.740.99etal.SpringerPlusPage5of13http://www.springerplus.com/content/3/1/28 conditionsontheKPIsusingatwo-wayANOVAtest. Figure1illustratesthattheinteractionwasnotstatisti- callysignificant, F (2,3813)=2.102, p =.122. Multivariateordinaryleastsquared(OLS)regression modelswereusedtoestimatethepredictorsofthe KPIsofthehealthcaresysteminAlberta.Ageand chronicconditionswereenteredatstep1,othersocio- demographicindicatorswereenteredatstep2,self- reportedhealthstatusesandknowledgeaboutand utilizationofhealthcareserviceswereenteredatstep3, resultingin3predictivemodels(seeAdditionalfile1for codingofthevariables).AsillustratedinModel1of Table2,age(  =0.114, p .001)andchronicconditions [chronicwithoutpain,  =  0.114, p .001,andchronic pain,  =  0.104, p .001]significantlypredictedthe KPIsassessingthehealthcaresystem, F (3,2865)=29.04, p .001.Moreover,theinclusionofsocio-demographic variablesinModel2didnotsignificantlyalterthecoeffi- cientvaluesofageandchronicconditions. AsillustratedinModel3,havinganychronichealth problemexcludingchronicpain(  =  0.044, p =.033) andhavingchronicpainnegativelypredictedtheKPIs (  =  0.054, p =.004)assessinghealthcareinAlberta.In addition,beinginthesenioragegrouppositively(  = 0.063, p =.001)predictedtheKPIs.Inotherwords,rela- tivetothosewithnochroniccondition,thosewithone ormorechronicproblemsexcludingchronicpainmore negativelyassessedtheKPIsandthosewithchronicpain assessedtheKPIsevenmorenegatively.Ontheother hand,seniorparticipantsmorepositivelyevaluatedthe KPIscomparedtothosewhowerenon-seniors.Sexpre- dictedtheKPIssuchthatcomparedtomales,thecoeffi- cientforfemaleswasnegativelyassociatedwiththeKPIs (  =  0.072, p .001).Participants ’ highereducation (  =  0.066, p =.032)andhigherannualhouseholdin- come(  =  0.060, p =.025)werenegativelyassociated withtheKPIs.However,thelivingarrangementofthe participantswasnotasignificantpredictoroftheKPIs (  =0.030, p =.114).Participants ’ self-reportedhealth status(  =0.074, p =.001),andknowledge(  =0.213, p .001)andutilizationofhealthcareservices(  =0.039, p =.036)positivelypredictedtheKPIs.Participants ’ poor physicalhealthstatusduringthepast30days(8+days) negativelypredictedtheKPIs(  =  0.065, p =.002). Finally,participants ’ mentalhealthstatusduringthepast 30days(1to7daysand8+days,respectively)negatively predictedtheKPIs(  =  0.060, p =.001,and  =0.145, p .001,respectively).Overall,knowledgeofhealthcare servicesandmentalhealthstatusduringthepast30days werethestrongestpredictorsoftheKPIs(basedontheir Table1Sample,independentvariableanddependent variablecharacteristicsfromthe2004AlbertaHealth survey (Continued) Verydissatisfied1393.53.5 Somewhatdissatisfied42710.710.8 Neither47411.812.0 Somewhatsatisfied220855.255.9 Verysatisfied70517.617.8 Missing 471.2 KeyPerformanceIndicators (KPIs)Index 2.900.67 Totalcases371993.0 Missing 2817.0 Note: N =4,000.TheMeanandStandardDeviationvaluesareshowninitalics. Figure1 MeanscoresofKPIIndexcomparingchronicconditionsbyagegroup. Nurullah etal.SpringerPlus 2014, 3 :28 Page6of13 http://www.springerplus.com/content/3/1/28 Table2UnstandardizedandstandardizedbetacoefficientsofkeyperformanceindicatorsofthehealthsysteminAlbertaModel1Model2Model3VariablesChronichealthproblemstatusNochronicproblem(Ref)———Chronicwithoutpain0.175(0.03)0.114***0.165(0.03)0.107***0.067(0.03)Chronicpain0.451(0.08)0.104***0.435(0.08)0.100***0.232(0.08)0.054**Non-seniors(Ref)———Seniors0.238(0.04)0.114***0.248(0.04)0.119***0.130(0.04)0.063***Male(Ref)Female0.075(0.03)0.096(0.02)0.072***Lessthanhigh-school(Ref)Completedhigh-school0.069(0.05)0.0430.035(0.04)0.022Somepost-secondary0.037(0.05)0.0200.002(0.05)Completedpost-secondary0.001(0.04)0.089(0.04)AnnualhouseholdincomeUpto29,999(Ref)$30,000to$59,9990.029(0.04)0.052(0.04)$60,000to$99,9990.018(0.04)0.071(0.04)$100,000+0.031(0.04)0.094(0.04)LivingarrangementLivingalone(Ref)Livingwithsomeone0.068(0.04)0.0360.057(0.04)0.030Self-reportedhealthstatus0.049(0.01)0.074***Daysphysicalhealthnotgood0day(Ref)7days0.024(0.03)8+days0.129(0.04)0.065**Daysmentalhealthnotgood0day(Ref)7days0.091(0.03)0.060***8+days0.293(0.04)0.145***etal.SpringerPlusPage7of13http://www.springerplus.com/content/3/1/28 Table2UnstandardizedandstandardizedbetacoefficientsofkeyperformanceindicatorsofthehealthsysteminAlbertaKnowledgeofavailablehealthservices0.177(0.02)0.213***PersonallyreceivedhealthcareservicesNo(Ref)0.063(0.03)0.039*Constant2.947***2.921***2.384***29.038***2.377*71.911***0.0300.0360.1190.0280.0320.1130.006*0.044***Note:Weighted=2,870.Standarderrorsareinparentheses..05,**.01,***.001(two-tailedtests).Ref=Referencecategory.etal.SpringerPlusPage8of13http://www.springerplus.com/content/3/1/28 respectivestandardizedregressioncoefficients).Thead-valueformodel3was0.119,indicatingthat12%ofthevarianceintheKPIsofhealthcarewasex-plainedbythemodel.DiscussionandconclusionsThisresearchexaminedtheeffectsofageandchronicillnessonAlbertansperceptionsoftheirhealthsystem,asmeasuredbytheKPIsofhealthcare.Regardingthefirstobjectiveofthestudy,theresultsindicatedthatpeopleintheolderagegroupratedtheKPIsofhealthcare(i.e.,availability,accessibility,quality,andsatisfaction)morepositivelycomparedtotheyoungeragegroupinAlberta,aftertakingintoaccountsocio-demographicfactors,self-reportedhealthstatus,andknowledgeandutilizationofhealthservices.Thisiscon-sistentwithpreviousstudiesconductedinCanadaandelsewherethatshowedolderpeopleweremorelikelytobesatisfiedwiththeirreceivedhealthcareservicesandreportedbetteraccesstocarecomparedtothosewhowereyoung(Bleichetal.,2009;Campbelletal.,2001;Cohen,1996;HallandDornan,1990;Jayasingheetal.,2008;KasmanandBadley,2004;Lyratzopoulosetal.,2012;RahmqvistandBara,2010;Rahmqvist,2001;SofaerandFirminger,2005;TuckerandKelley,2000;WilsonandRosenberg,2004;Youngetal.,2000).Thisassociationseemstopersistirrespectiveofhealthcaredeliverysettings(i.e.,inpatientcare,emergencycare,am-bulatory,andprivateclinicvisits)(Scotti,2005).ExistingliteraturesuggestedseveralfactorsthatmayinfluenceolderpeopletopositivelyassesstheKPIsofhealthcare.Itcouldbethatolderpeoplehavemoreex-posuretothehealthsystemandthereforehavemorepragmaticexpectationsoftheircarecomparedtoyoun-gerones(Hordacreetal.,2005).Anotherpotentialrea-sonisthatolderindividualsmaybemoreunwillingtocriticizetheservicetheyreceivecomparedtoyoungerones(Agoritsasetal.,2009;HallandDornan,1990).Inaddition,ithasbeensuggestedthatsomeolderpatientsmaynotaccuratelyrecalltheirdifficultyinaccessingthehealthcareservicesinthepast12monthsduetocogni-tiveimpairment(KasmanandBadley,2004;Rainaetal.,2002).However,itwasnotpossiblewiththecross-sectionaldatausedinthisstudytodeterminethereasonforolderpeoplesmorefavorableratingoftheKPIsofhealthcare.Assuch,futureresearchshouldexplorethisissueusinglongitudinaldesignthatallowsestablishingcauseandeffect.Forthesocio-demographiccontrols,thefindingsindi-catedthatfemalesratedtheKPIsofhealthcaremorenegativelycomparedtomales,aftercontrollingforpos-siblecovariates.Thisisinagreementwithpreviousstud-iessuggestingthatwomenaremorelikelythanmentoreportexperiencingnegativeencounterswithhealthcare(Cohen,1996;Quintanaetal.,2006;Upmarketal.,2007),ordifficultyinaccessinghealthcare(KasmanandBadley,2004).Itcouldalsobethatwomensuffermorefromchronichealthproblems(includingbackpainandneckpain),depression,andrelatedillnessescomparedtomen(Boulangeretal.,2007;Malmusietal.,2011;Moulinetal.,2002;Reitsmaetal.,2011;Schopflocheretal.,2011;Tsangetal.,2008),andasaresultwomenmaytendtoratetheKPIsmorenegatively.Furthermore,thisstudyfoundthatrespondentshighereducationandhigherincomeweremarginallyandnegativelyassociatedwiththeirassessmentoftheKPIsofhealthcareinAlberta,whichisconsistentwiththefindingsofpreviousstudies(Hekkertetal.,2009;Jayasingheetal.,2008;Quintanaetal.,2006;RahmqvistandBara,2010;Sahinetal.,2006;SofaerandFirminger,2005).Withreferencetothesecondobjectiveofthisstudy,thefindingsrevealedthatpeopleexperiencingchronicpainandotherchronicillnessesratedtheKPIsofhealth-caremorenegativelycomparedwithpeoplewhohadnochronichealthprobleminAlberta.Thisisinlinewithpreviousstudiesreportingthatpatientsexperiencingse-verepainand/orchronicillnessaremorelikelytobedissatisfiedwiththecaretheyreceive(Cohen,1996;Crowetal.,2002),lesslikelytoreceivehealthcarewhenneeded(KasmanandBadley,2004),andthatpeoplewithoneormorechronicconditionsreportlessaccesstohealthcare(Kontopantelisetal.,2010;Parchmanetal.,2005;WilsonandRosenberg,2004).Theyalsoreportpoorself-perceivedhealth(Ramage-MorinandGilmour,2010;Trippetal.,2006)andvariousotherphysicalandpsychologicalproblems(Millar,1996;OhayonandSchatzberg,2010;Ramage-Morin,2008;Smithetal.,1999;Toblinetal.,2011;Tsangetal.,2008).Further-more,patientswithdifferentchronicillnesseshavehigherexpectations,needs,andprioritiesofcare,whichmayresultinlowersatisfactionwhentheydonotreceivetheexpectedservice(Jayasingheetal.,2008).Thefindingsofthisstudyalsorevealedthatrespon-dentsself-reportedoverallhealthstatuswaspositivelyrelatedtotheirassessmentoftheKPIsofhealthcareinAlberta.Thisisconsistentwithexistingstudiesshowingthatbetterself-reportedoverallhealthisassociatedwithreportsofhighersatisfactionscoresaswellasbetterac-cesstohealthcareservices(Cohen,1996;Crowetal.,2002;deBoeretal.,2010;Halletal.,1990,1993;JaipaulandRosenthal,2003;Jayasingheetal.,2008;Pőllusteetal.,2012;RahmqvistandBara,2010;Renetal.,2001;SofaerandFirminger,2005;Wendtetal.,2009;XiaoandBarber,2008).Furthermore,resultsofthisstudyindi-catedthatrespondentsspecificreportsofpoorphysicalandmentalhealthstatus(duringthepast30dayspriortothesurvey)werenegativelyrelatedtotheirassessmentoftheKPIsofhealthcare.Thisfindingisalsoinetal.SpringerPlusPage9of13http://www.springerplus.com/content/3/1/28 agreementwithpreviousstudiesreportingthatpatientswhoareinpoorphysicalandmentalhealtharelesssatisfiedwiththecarethattheyreceive(Al-Mandharietal.,2004;Bleichetal.,2009;Glynnetal.,2004;Halletal.,1999;Lyratzopoulosetal.,2012;Schoenfelderetal.,2011;Tucker,2002;Wensingetal.,1997;Zhangetal.,2007).OneoftheinterestingfindingsofthisstudywasthatrespondentsknowledgeofavailablehealthservicesstronglyandpositivelypredictedtheirassessmentoftheKPIsofhealthcareinAlberta.However,itremainsun-clearastowhyknowledgeofhealthservicesemergedasoneofthestrongestpredictorsoftheKPIsbecausenosuchindicationcanbefoundinexistingliterature.Wecouldspeculatethatifpeoplehavegoodknowledgeofthehealthcareservicesattheirdisposal,theycanmakeinformeddecisionsabouttheirhealthandbecomefamiliarwiththeavailabilityofandaccessibilitytoap-propriatehealthcareservicesintheircommunity,whichinturnwouldenablethemtofeelthattheyreceivebet-tercarewhentheyneedit.Overall,thisstudyindicatedthatoldageandchronichealthproblems(particularlychronicpain)predictedsassessmentoftheKPIsofhealthcareinAlberta,netofsocio-demographicfactors,self-reportedhealthstatuses,andknowledgeandutilizationofhealthser-vices.Thefindingssuggestedthatpeoplespersonalhealthanddemographiccharacteristicsareimportantfactorsassociatedwiththeirperceptionofthehealthcaresystemintheprovince.OneofthekeystrengthsofthisstudyisthattheKPIsofhealthcarehavebeenassessedinarepresentativesampleofAlbertansratherthanonlyamongpatientsenrolledinamedicalcarefacility;thelatteristhecaseinmostofthestudiesconductedinthislineofresearch.Anotherstrengthofthisstudyistheuseofmultipleindicators(i.e.,availability,accessibility,qual-ity,andsatisfaction)tomeasuretheperformanceofhealthcareinAlberta.Finally,theresultsimpliedthatpeopleexperiencingchronichealthproblemsmayneedhealthcareservicesthataremoreresponsivetotheirThefindingsofthisstudyshouldbeinterpretedwithcautionduetoseverallimitations.First,thefindingsarebasedonaself-reportsurveywhichmaybesubjectedtoover-reportingorunderreportingbytherespondents.Forinstance,Voaklanderetal.(2006)suggestedthatdis-crepanciesmayexistbetweenself-reportedhealthsurveyresponsesandpatientsmedicalchartbasedinformation,suchthatsometypesofdiseasearemorelikelythanotherstobeover-reportedorunderreported.However,giventhatthefindingsofthisstudyaremostlyconsist-entwithexistingliterature,courtesybias(Glick,2009)isunlikelytobethecase.Furthermore,mostself-reportsurveysusedinhealthcaresettingshavebeenshowntobereliable.Forinstance,Rainaetal.(1999)analyzedthereliabilityofseveralscalesusedfrequentlyinpopulation-basedhealthsurveysinCanada(inagroupofseniors),andfoundthatmostofthemultiple-itemscaleshadac-ceptableinternalconsistency(Cronbachsalphaandmostofthesingle-itemmeasuresalsohadaccept-abletest-retestreliability(kappa�0.80).Second,measuresoftheKPIsarebasedonseveralsingle-itemquestionscapturingaspectsoffiveindicatorsofhealthcare,andassuch,theymaybesubjectedtoover-simplifyingcomplexissuesandnotaddressingthefullrangeofparticipantsconcernsabouttheperform-anceofthehealthsysteminAlberta.However,Zhangetal.(2007)showedthatasurveyinstrumentbasedonsingle-itemquestionsmaybeusefulforexaminingpa-tientsatisfaction,self-ratedhealth,andhealthconfidenceinprimarycaresettings.Third,thedatadidnotallowformeasuringthespe-cificproblemsorexperiencesofdissatisfactionwithhealthcareservicesamongtherespondents.Ithasbeennotedthatglobalsurveysofpatientexperiencegenerallypresentanoverlyoptimisticviewofthequalityofcarepro-videdanddonotidentifyareasofpoorcare(StaniszewskaandHenderson,2005).Therefore,futureresearch,employ-ingin-depthinterviewsorfocusgroups,shouldlookintopatientsexperiencesofproblemsencounteredwhiledeal-ingwiththehealthcaresysteminordertoidentifyareasforFourth,thisstudyiscross-sectionalinnature,andassuch,doesnotpermitinferringcausalrelationshipsamongthevariables,andtheresultshavelimitedgeneralizability.Tothatend,moreresearchisneededmodelinglongitudinalaspectsofpeoplesassessmentoftheirhealthcaresystem.Fifth,itwasnotpossibletocon-trolothersocio-economiccharacteristicssuchasmaritalstatus,employmentstatus,andracialandethniccom-positionforpresentanalysisbecausedatawerenotavail-able.Hence,futurestudiesshouldcontrolthesefactorsinrelationtopeoplesassessmentofhealthcareinAlberta.Finally,thisstudydidnotmeasurethetimelagbetweenrespondentsencounterwiththehealthcaresys-temandansweringthesurveyquestions,afactorthatmayleadtodifferingassessment(Jacksonetal.,2001).ImplicationsThisstudyhasseveralpolicyimplications.Aspecificim-plicationofthisstudyisthatthehealthcaresysteminAlbertashouldprovideservicesthatarebettertailoredtotheneedsofpeoplewhoexperiencechronichealthproblems.ThefacilitationofsuchsupportwouldmostlikelyleadtoincreasedpatientsatisfactionandbetterevaluationoftheKPIsofhealthcareintheprovince.Aspublicassessmentofperformanceindicatorsofetal.SpringerPlusPage10of13http://www.springerplus.com/content/3/1/28 healthcareisgainingmomentum(Zhangetal.,2007),thereisaneedfortakingintoaccountpeoplesexperi-encesinidentifyingpotentialareasofimprovementinordertoincreasetheeffectivenessofhealthcaresystems(Hekkertetal.,2009).Thiscanhelpphysiciansandhealthcareproviderstoidentifyproblemsrelatedtoac-cess,availability,quality,andoutcomeofcare,andsatis-factionwiththecarereceivedfrompublicspointofview.Studiesfoundthathealthcareemployeesconsid-eredpatientsevaluationsoftheircareusefulforqualityimprovement(Hejeetal.,2011;Iversenetal.,2010).Inaddition,amajorityofhealthcareprofessionalsreportedthattheyhadimplementedimprovementmeasuresbyattendingtoproblemsidentifiedbypatients(Hejeetal.,2011;Iversenetal.,2010).Asituationwherebyrespondentsarereluctanttoex-pressnegativeopinionstoaninterviewer,leadingtooverestimationofsatisfactionwithhealthcareservices(Glick,2009).AdditionalfileAdditionalfile1:Variablecodingforthe2004AlbertaHealthKeyperformanceindicators.CompetinginterestsTheauthorsdeclarethattheyhavenocompetinginterests.TheanalysisandinterpretationofdatapresentedinthisarticledonotnecessarilyreflecttheofficialviewsorpoliciesoftheProvinceofAlbertasDepartmentofHealthandWellness.ASNandHNconceptualizedanddesignedthestudy,includingacquisitionofdata,settingtheanalyticstrategyandmaterialsandmethods.ASNanalyzedandinterpretedthedata,anddraftedthearticle.ASN,HN,andMHhavebeeninvolvedinrevisingthemanuscriptcriticallyforimportantintellectualcontent.Allauthorsreadandapprovedthefinalmanuscript.AcknowledgementsPermissiontousethepublicsurveydataexaminedinthispaperwasobtainedfromAlbertaHealthandWellness.ThePopulationResearchLaboratoryattheUniversityofAlbertaconductedthe2004surveyforAlbertaHealthandWellness.WethankFrankTrovatoandLaurelStrainfortheirhelpfulsuggestionsonanearlierversionofthisarticle.AuthordetailsDepartmentofSociology,UniversityofAlberta,5-21ToryBuilding,Edmonton,AlbertaT6G2H4,Canada.Edmonton,Alberta,Canada.Received:9October2013Accepted:10January2014Published:15January2014AgoritsasT,LubbekeA,SchiesariL,PernegerTV(2009)Assessmentofpatientstendencytogiveapositiveornegativeratingtohealthcare.QualSafHealthCare18(5):374379,doi:10.1136/qshc.2008.028175Al-MandhariAS,HassanAA,HaranD(2004)Associationbetweenperceivedhealthstatusandsatisfactionwithqualityofcare:evidencefromusersofprimaryhealthcareinOman.FamPract21(5):519527,doi:10.1093/fampra/BenturN,GrossR,Brammli-GreenbergS(2004)SatisfactionwithandaccesstocommunitycareofthechronicallyillinIsraelshealthsystem.HealthPol67136,doi:10.1016/S0168-8510(03)00086-1BertakisKD,RoterDL,PutnamSM(1991)Therelationshipofphysicianmedicalinterviewstyletopatientsatisfaction.JFamPract32(2):175BleichSN,ÖzaltinE,MurrayCJ(2009)Howdoessatisfactionwiththehealth-caresystemrelatetopatientexperience?BullWorldHealthOrgan87(4):271BoudreauxED,AryRD,MandryCV,McCabeB(2000)Determinantsofpatientsatisfactioninalarge,municipalED:theroleofdemographicvariables,visitcharacteristics,andpatientperceptions.AmJEmergMed18(4):394BoulangerA,ClarkAJ,SquireP,CuiE,HorbayGLA(2007)ChronicpaininCanada:haveweimprovedourmanagementofchronicnoncancerpain?PainResManag12(1):39CampbellJL,RamsayJ,GreenJ(2001)Age,gender,socioeconomic,andethnicdifferencesinpatientsassessmentsofprimaryhealthcare.QualHealthCare95,doi:10.1136/qhc.10.2.90CohenG(1996)Ageandhealthstatusinapatientsatisfactionsurvey.SocSciMed42(7):10851093,doi:10.1016/0277-9536(95)00315-0CohenJ,CohenP,WestSG,AikenLS(2003)Appliedmultipleregression/correlationanalysisforthebehavioralsciences,3rdedn.LawrenceErlbaumAssociates,Mahwah,NJCrowR,GageH,HampsonS,HartJ,KimberA,StoreyL,ThomasH(2002)Themeasurementofsatisfactionwithhealthcare:implicationsforpracticefromasystematicreviewoftheliterature.HealthTechnolAssess6(32):1deBoerD,DelnoijD,RademakersJ(2010)Dopatientexperiencesonpriorityaspectsofhealthcarepredicttheirglobalratingofqualityofcare?Astudyinfivepatientgroups.HealthExpect13(3):285297,doi:10.1111/j.1369-DraperM,CohenP,BuchanH(2001)Seekingconsumerviews:whatuseareresultsofhospitalpatientsatisfactionsurveys?IntJQualHealthCare13468,doi:10.1093/intqhc/13.6.463FieldKS,BriggsDJ(2001)Socio-economicandlocationaldeterminantsofaccessi-bilityandutilizationofprimaryhealth-care.HealthSocCareCommunity9308,doi:10.1046/j.0966-0410.2001.00303.xGlickP(2009)Howreliablearesurveysofclientsatisfactionwithhealthcareservices?EvidencefrommatchedfacilityandhouseholddatainMadagascar.SocSciMed68(2):368379,doi:10.1016/j.socscimed.2008.09.053GlynnLG,ByrneM,NewellJ,MurphyAW(2004)Theeffectofhealthstatusonsatisfactionwithout-of-hourscareprovidedbyafamilydoctorco-operative.FamPract21(6):677683,doi:10.1093/fampra/cmh616HallJA,DornanMC(1990)Patientsociodemographiccharacteristicsaspredictorsofsatisfactionwithmedicalcare:ameta-analysis.SocSciMed30(7):811HallJA,FeldsteinM,FretwellMD,RoweJW,EpsteinAM(1990)OlderpatientshealthstatusandsatisfactionwithmedicalcareinanHMOpopulation.MedCare28(3):261HallJA,MilburnMA,EpsteinAM(1993)Acausalmodelofhealthstatusandsatisfactionwithmedicalcare.MedCare31(1):84HallJA,MilburnMA,RoterDL,DaltroyLH(1998)Whyaresickerpa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SpringerPlus 2014 3 :28. Submit your manuscript to a journal and bene“ t from: 7 Convenient online submission 7 Rigorous peer review 7 Immediate publication on acceptance 7 Open access: articles freely available online 7 High visibility within the “ eld 7 Retaining the copyright to your article Submit your next manuscript at 7 springeropen.com Nurullah etal.SpringerPlus 2014, 3 :28 Page13of13 http://www.springerplus.com/content/3/1/28

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