Patients’ Global Ratings of Their Health Care Are Not Associated with the Technical Quality of Their Care John T. Chang, MD, MPH; Ron D. Hays, PhD; Paul G. Shekelle, MD, PhD; Catherine H. MacLean, MD, PhD; David H. Solomon, MD; David B. Reuben, MD; Carol P. Roth, RN, MPH; Caren J. Kamberg, MSPH; John Adams, PhD; Roy T. Young, MD; and Neil S. Wenger, MD, MPH Background: Patient global ratings of care are commonly used to assess health care. However, the extent to which these assessments of care are related to the technical quality of care received is not well understood. Objective: To investigate the relationship between patient-reported global ratings of health care and the quality of providers’ commu- nication and technical quality of care. Design: Observational cohort study. Setting: 2 managed care organizations. Patients: Vulnerable older patients identified by brief interviews of a random sample of community-dwelling adults 65 years of age or older who received care in 2 managed care organizations during a 13-month period. Measurements: Survey questions from the second stage of the Consumer Assessment of Healthcare Providers and Systems pro- gram were used to determine patients’ global rating of health care and provider communication. A set of 236 quality indicators, de- fined by the Assessing Care of Vulnerable Elders project, were used to measure technical quality of care given for 22 clinical conditions; 207 quality indicators were evaluated by using data from chart abstraction or patient interview. Results: Data on the global rating item, communication scale, and technical quality of care score were available for 236 vulnerable older patients. In a multivariate logistic regression model that in- cluded patient and clinical factors, better communication was asso- ciated with higher global ratings of health care. Technical quality of care was not significantly associated with the global rating of care. Limitations: Findings were limited to vulnerable elders who were enrolled in managed care organizations and may not be generaliz- able to other age groups or types of insurance coverage. Conclusions: Vulnerable elders’ global ratings of care should not be used as a marker of technical quality of care. Assessments of quality of care should include both patient evaluations and inde- pendent assessments of technical quality. Ann Intern Med. 2006;144:665-672. www.annals.org For author affiliations, see end of text. P atient ratings of care are commonly used by health plans, payers, providers, and consumers to assess the quality of health care received. Measuring satisfaction is common in other service industries for various purposes, including marketing and improving service delivery. Pa- tient evaluations of care, although variable across providers, are generally high (1, 2). On the contrary, there is increas- ing concern about the technical quality of patient care (3) and a growing emphasis on improving patient safety (4). Although reports and ratings of care are important indica- tors of patients’ subjective experiences with the health care system, the relationship of these perceptions with technical quality of care is not well understood. In his conceptual model of quality of care, Donabe- dian (5) defined 3 components of quality: technical quality of care, interpersonal quality, and amenities. Technical quality of care describes the extent to which the use of health care services meets predefined standards of accept- able or adequate care relative to need (5). Interpersonal quality describes the characteristics of interaction between provider and patient. Whether global ratings of care simply reflect interpersonal quality or encompass both technical and interpersonal quality (as well as amenities) is un- known. Only a few studies have investigated these relation- ships; most have focused on condition-specific evaluations, some demonstrating positive relationships and others showing equivocal findings (6 –12). To date, no study has examined the relationship between a comprehensive mea- sure of technical quality of care measured by quality indi- cators and patients’ global ratings of care. We developed and applied a conceptual model (Figure 1) based on Donabedian’s work that examines the relation- ship of quality of care, both technical and interpersonal, with patients’ global evaluations of health care. Earlier lit- erature has demonstrated that many patient characteristics are important determinants of health care preferences, and See also: Print Editors’ Notes ............................. 666 Summary for Patients ....................... I-26 Web-Only Appendix Appendix Table Conversion of figures and tables into slides Annals of Internal Medicine Improving Patient Care © 2006 American College of Physicians 665 Improving Patient Care is a special section within Annals supported in part by the U.S. Department of Health and Human Services (HHS) Agency for Healthcare Research and Quality (AHRQ). The opinions expressed in this article are those of the authors and do not represent the position or endorsement of AHRQ or HHS.