▁provided ▁by ▁health ▁plans , ▁phys ician ▁groups , ▁and ▁clin icians . ▁It ▁is ▁an ▁example ▁of ▁a ▁major ▁research ▁effort ▁which ▁studies ▁the ▁significance ▁of ▁consumer ▁responses ▁to ▁surve ys . ▁ ▁Research ▁By ▁ 1 9 9 8 ▁the ▁process ▁of ▁meas uring ▁and ▁reporting ▁of ▁patient ▁satisfaction ▁had ▁become ▁an ▁established ▁industry . ▁ ▁A ▁concern ▁about ▁asking ▁patients ▁about ▁the ▁quality ▁of ▁their ▁care ▁is ▁that ▁patients ▁tend ▁to ▁be ▁more ▁satisfied ▁by ▁attract ive ▁health care ▁than ▁by ▁effective ▁health care , ▁and ▁satisfaction ▁reports ▁may ▁not ▁give ▁good ▁information ▁about ▁the ▁ability ▁of ▁a ▁hospital , ▁doctor , ▁or ▁treatment ▁to ▁improve ▁their ▁health . ▁ ▁High er ▁patient ▁satisfaction ▁have ▁been ▁associated ▁with ▁less ▁emer gency ▁department ▁use ▁but ▁with ▁greater ▁in pat ient ▁use , ▁higher ▁overall ▁health ▁care ▁and ▁pres cription ▁drug ▁exp end it ures , ▁and ▁increased ▁mort ality . ▁Despite ▁these ▁concerns , ▁more ▁and ▁more ▁research ▁has ▁established ▁customer ▁satisfaction ▁as ▁a ▁valid ▁and ▁reliable ▁measure ▁of ▁customer ▁behav iors ▁and ▁organiz ational ▁performance . ▁reduced ▁compla int ▁behavior ▁about ▁their ▁primary ▁care ▁phys ician , ▁and ▁lower ▁lik elihood ▁of ▁termin ating ▁a ▁relationship ▁▁ ▁Among ▁health care ▁consum ers — i . e ., ▁patients — s atisf action ▁is ▁best ▁understood ▁as ▁a ▁multi - attribute ▁model ▁with ▁different ▁aspects ▁of ▁care ▁determ ining ▁overall ▁satisfaction . ▁Import antly , ▁lower ▁performance ▁on ▁an ▁attribute ▁creates ▁much ▁more ▁diss atisf action ▁than ▁the ▁satisfaction ▁generated ▁by