In recent years, increased emphasis has been placed upon improving the quality of health care in the United States in response to evidence indicating that quality for too many patients is not what it should or could be (Schuster, McGlynn, and Brook 1998; Chassin and Galvin 1998; Committee on the Quality of Health Care in America 2001; Kohn, Corrigan, and Donaldson 1999). A recent detailed study by McGlynn et al. (2003) identified serious widespread deficiencies in health care quality, raising further concern. Corresponding to this emphasis on quality, there has been increased interest in analyzing and monitoring patient satisfaction for purposes of quality improvement. Routine monitoring of patient satisfaction is now performed by state and federal agencies (Centers for Medicare and Medicaid Services), by accrediting bodies such as the National Committee for Quality Assurance, and by private and public health care purchasers. Myriad measures and survey instruments have been developed to assess patient satisfaction (McCracken et al. 1997; Harris et al. 1999; Stump et al. 1995). Reflecting diverse purposes, studies have examined patient satisfaction at the micro (office encounter) level using instruments such as the Patient Satisfaction Questionnaire (PSQ) (Ware et al. 1983), as well as at the macro health plan level using the Consumer Assessments of Health Plans Study (CAHPS) survey (Hays et al. 1999) and other similar instruments.
The concept of an episode of care (Hornbrook, Hurtado, and Johnson 1985; Wingert et al. 1995; DeVet et al. 2002) provides a useful framework for assessing patient satisfaction. Many patients see multiple health care providers in different treatment settings in the course of having a condition diagnosed and treated. We conducted a patient satisfaction survey, organized around an episode of care framework, as part of a larger ongoing community-based initiative designed to improve quality and health outcomes for injured workers in Washington State (Wickizer et al. 2001, 2002, 2004). The purpose of this survey was to identify sources of dissatisfaction that might provide insight into processes of care in need of improvement. Started in 2002, the quality improvement initiative is being pilot tested in two sites serving target areas in western and eastern Washington. The initiative will conclude in 2006.

In Washington State, the Department of Labor and Industries (DLI) administers the state workers' compensation system and is the sole regulator of workers' compensation health care for all covered nonfederal employees. We combined the survey data with DLI administrative claims data pertaining to disability status and then performed a two-step analysis. First, we analyzed the survey data to determine which aspects of patient satisfaction were most important in explaining the variance in patients' self-reported overall treatment experience. Second, we examined the relationship of patients' treatment experience to subsequent disability outcomes. We hypothesized that patients reporting more negative treatment experience would be more likely to be out of work and on workers' compensation disability at 6 and 12 months following the filing of their claim.

METHODS

Washington State Workers' Compensation System

Workers who sustain occupational injuries or develop occupational illnesses are eligible to receive medical care through the workers' compensation system and may also receive disability payments (partial wage replacement) for injuries or illnesses resulting in lost work time (Cart 1998; Elling 1989). Workers' compensation insurance is administered at the state level and provides first-dollar coverage (no deductibles, coinsurance, or copayments) for medical care. Workers' compensation programs vary considerably from state to state in their statutory authority, organization, and ability to direct patients to certain forms of care. Washington is a "worker choice" state. By law, injured workers have the right to choose any licensed physician, chiropractor, osteopath, podiatrist, dentist, optometrist, or naturopath for their care. Further, Washington State law requires employers to purchase workers' compensation insurance through a designated public state agency, although employers who meet specific standards can self-insure. Approximately two-thirds of the state's nonfederal workforce are insured through the state fund and a third of the workers are employed at firms that are self-insured. In fiscal year 2000, the DLI expended $472.4 million for medical care and an additional $683.3 million for temporary and permanent disability payments. These features of Washington's workers' compensation program--a uniform set of benefits covering two-thirds of the state's worker population and the guarantee of broad access to medical care services unrestricted by complex managed care arrangements--make it well suited for the current study.