RESEARCH Open Access Public assessment of key performance indicators of healthca

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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;Põllusteetal.,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;Põllusteetal.,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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