Family Practice Vol. 17, No. 1, 21-29
© Oxford University Press 2000
Patient perception of quality following a visit to a doctor in a primary care unit
Groupe de Recherche Interdisciplinaire en Santé and
a Centre Hospitalier Universitaire de Montréal, Université de Montréal, Montréal, PQ, Canada.
Slim Haddad, Université de Montréal, Groupe de Recherche Interdisciplinaire en Santé, Pavillon Marguerite d'Youville, C.P. 6128, Succursale A, Montréal, Québec, H3C 3J7 Canada.
Haddad S, Potvin L, Roberge D, Pineault R, Remondin M. Patient perception of quality following a visit to a doctor in a primary care unit. Family Practice 2000; 17: 21–29.
Received 12 April 1999; Revised 25 August 1999; Accepted 6 September 1999.
 |
Abstract |
|---|
 Top Abstract IntroductionMethodsResultsDiscussionAppendix 1 QuestionnaireReferences |
|---|
Background. Assessment of the quality of primary care services may be enhanced by including patient perceptions as well as professional judgment of quality. There is a need for reliable and valid instruments to measure these perceptions.
Objectives. (i) To present a scale for measuring patient perception of quality of care following a visit to a doctor; and (ii) to analyse the responses given by patients recruited in primary care units in the Montreal region. The scale is composed of 22 items regrouped into three sub-scales referring to the patient–physician relationship (five items); the technical aspects of care (12 items); and the outcomes of the visit (five items). Distinctive features of the scale are that it focuses on patients' opinions about quality rather than on satisfaction, and that it includes items related to outcomes of the visit.
Methods. A survey was conducted on 473 patients who visited a physician in 11 primary care units in the Montreal region. Randomly selected patients received mailed questionnaires 5–7 days following their visit. Various statistical procedures were used to assess the reliability and the validity of the global scale and the sub-scales, and to analyse patients' patterns of response.
Results. The analysis of the psychometric properties of the global scale and the three sub-scales provides favourable evidence concerning their reliability and validity. The results of the factor analysis, the inter-item correlations and the Cronbach's alpha coefficients all support the distinction made between the interpersonal processes, the technical processes and the outcomes, and, at the same time, confirm the complex nature of the notion of perceived quality. The analysis of patients' responses allows the identification of items associated with global perception about quality of care. This global perception results from patients' perception of the physician's professional and interpersonal skills as well as from the outcomes of care.
Conclusion. The scale can be used by physicians or primary health care units and has a wide range of applications.
Keywords. Measurement, patient perception, primary care, quality of care..
|
Introduction |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionAppendix 1 QuestionnaireReferences |
|---|
The assessment of quality of care, which has long been based on the application of professional standards, is now increasingly tending to integrate measurements of patient perception.1–4 Support for this integration is based on a variety of arguments such as the desire to involve patients more in decisions that concern them5 and to better meet their expectations,6 or the need to evaluate the effects of budget restrictions on accessibility and quality.7 Measurement of patient perceptions also presents concrete advantages for evaluation. (i) Patients constitute an essential and even exclusive source of information about accessibility or effectiveness of care.8 (ii) A patient's opinion directly influences his or her compliance with treatment and the continuity of the patient–physician relationship, and hence care outcomes.9–12 (iii) The measurement of patient perceptions constitutes a positive approach to the evaluation of quality, in contrast to negative approaches that focus on the measurement of inadequate processes or undesired outcomes.7 (iv) It has been acknowledged that compared with other methods of evaluating quality, assessment of patient perceptions offers several practical advantages: it can be measured rapidly following the delivery of care; it is inexpensive; it does not depend on the quality of data found in medical records; and it is more sensitive to differences in the quality of care than indicators such as adjusted mortality rates or complications rates.7
Taking into account patient views is thus increasingly considered to be a useful complement, indeed a necessary component of the evaluation of the quality of care.2,13–16 This interest has led to the development of many measurement instruments, i.e. questionnaires, which have been reviewed extensively elsewhere.4,10,17–19 Some questionnaires deal more specifically with patient perception following a visit to a doctor.20–34 These questionnaires vary in their presentation, content and type of services targeted (out-patient services in clinics or in private offices, visits to a GP or a specialist, etc.). While some questionnaires have been subjected to validation studies, there are two difficulties posed by reusing them in a perspective of assessment of perceived quality. The first is common to questionnaires of this type and lies in the fact that their content must be re-evaluated, and adjusted to local socio-cultural and linguistic realities, as well as to the local modes of organizing medical practice.5,35 The second difficulty lies in the approach used in these questionnaires. Most address user satisfaction rather than patients' opinions regarding quality of care, while the latter appears to be a more useful approach. As pointed out earlier, patients' evaluation of quality of care is not necessarily expressed in terms of satisfaction,6 and the measurement of satisfaction does not necessarily reflect the perception that patients have of quality of care.36 In addition, satisfaction includes a highly affective dimension37 and is considered more dependent on patient expectations than is perception of quality.7,28
The aim of this article is to present and validate a scale for measuring patient perception of quality of care following a visit to a doctor. The scale targets primary care services which, in Québec, are delivered mainly in three types of units: local community health centres (CLSCs), Family Medicine Units (FMUs) and Private Clinics (PCs).
|
Methods |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionAppendix 1 QuestionnaireReferences |
|---|
Preliminary methodological studies
The study is based on the analyses of responses to an initial questionnaire composed of 45 items and from which the present scale was derived. This questionnaire was developed in three stages, aiming to optimize the content validity, i.e. the ability to reflect the representations that patients have of quality of care. The first stage was an exhaustive review of the instruments already published. The second stage consisted of a pre-selection of a subset of criteria likely to be applied by patients to judge quality. This pre-selection was conducted starting from a bank of 130 questions that previously had been developed and validated by researchers with participation from patients, professionals and administrators.38 The third stage consisted of a qualitative study conducted on 19 patients, which aimed to rate the relative importance that they assigned to 70 criteria selected from the above-mentioned bank. Once this process was completed, 45 criteria were selected. Each criterion was then translated into a specific question focusing on the patient's perception of his/her visit. The formulation and comprehensibility of the items were then tested on 15 patients and 11 physicians and/or managers of care units. A 5-point Likert scale was used for the response format, with the possibility of expressing the following opinions: ‘negative’, ‘somewhat negative’, ‘neither negative nor positive’, ‘somewhat positive’ or ‘positive’.
Research design and data collection
The respondents are patients who visited a physician in three PCs, four FMUs and four CLSCs. In each of these units, the selection procedure consisted of drawing a systematic sample of patients from among those who had consulted during the week. The questionnaires were mailed to the patients in order to minimize the risk of interference between the patients and the physicians or other health care professionals in the units. The patients received the questionnaires 5–7 days after their visit to the doctor, thus giving them some time to consider their opinion regarding the outcomes of the visit. A reminder was sent to those who had not returned their response card within 14 days of the first mailing. In order to avoid the introduction of systematic biases, neither the participating units nor the physicians were informed specifically of the week in which the survey would be conducted.
Construction of the scale and subscales
This was based on an item analysis, a process allowing for construction of concise multiple indices.39,40 The items were selected by giving priority to the questions: (i) deemed important by the patients during preliminary studies; (ii) the most informative (those, in particular, presenting a greater variance); and (iii) contributing to reinforcing the homogeneity of the scale. The item analysis led us to isolate 22 items. Following Donabedian's distinction,15,16,41 they were regrouped into three categories depending on whether they referred to the interpersonal aspects of care, the technical aspects of care or the outcomes of the visit (Appendix 1). A global scale and three subscales were then developed. The score for each subscale was equal to the average of the responses to the items on the dimension of concern and was only calculated if a response was given to at least half of the items. The total score was equal to the average of the scores obtained in each subscale and was only calculated for respondents for whom we were able to establish scores for at least two out of the three subscales.
Analyses
SPSS for Windows42 was used to perform all of the statistical analyses. They were conducted in two stages. First, the psychometric properties (reliability and validity) of the global scale and the subscales were established. The reliability of the obtained scores was estimated by Cronbach's alpha coefficient. In order to compare the average scores between different treatment units, the reliability of the obtained scores was estimated using O'Brien's method,43 based on the calculation of the intraclass coefficients (ICCs). The ICC indicates reliability of a measure based on a single individual, and the estimated number of individuals required for targeted levels of reliability is calculated using the Spearman Brown formula.44 The assumption of validity is deduced from various procedures which aim to determine to what extent the scores observed are an accurate representation of patients' perceptions with regard to quality of care. A factor analysis aims to weigh the dimensionality of the global index and to verify if the items categorized a priori in the same dimension do in fact fall within the same factor. The construct validity of the index was then studied by examining the congruence of the scores calculated with the responses to the general questions dealing with perceptions of quality of care. Criterion validity rests on the analysis of the associations between the scores calculated and certain socio-demographic variables or variables of intent that are known generally to be correlated with patients' perceptions.
To explore further the content and the construct validity of the scale, the results from these analyses were re-examined, focusing on patients' response patterns. The distributions of the responses to the items were examined, followed by the relative contribution of different items to the judgement made on the quality of care and the interrelationships between the different dimensions of perceived quality.
|
Results |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionAppendix 1 QuestionnaireReferences |
|---|
A total of 473 people responded to the questionnaires, giving a response rate of 60%. This is a higher value than the average response rate observed in studies using mailed questionnaires to patients. The majority of respondents were women (76%) and their average age was 46 years, with 13 years of education. Three-quarters (76%) of them perceived their health as good, very good or excellent. One out of 10 considered the health problem for which they had consulted their physician to be serious. For 7% of them, this was their first visit to a treatment unit, and 56% of them had seen their doctor more than three times in the previous year. The majority of them expressed the intention to return to consult the same physician (93%) and stated that they were ready to recommend this physician to others (93%). Thirty-six per cent of the respondents consulted in a CLSC, 29% in a PC and 39% in a FMU.
Reliability and validity of the scales
The Cronbach's alpha coefficients ranged from 0.83 to 0.94 (Table 1
). Thus, they demonstrate a high level of internal consistencies of the scale and subscales. The intraclass coefficient values were low (Table 1). This result, which was predictable, reflects the fact that in the absence of control for inter-individual variations, the intra-unit variation was higher than the inter-unit variation. The ICC of the ‘outcomes' subscale was negligible, which indicates that the perceptions of respondents concerning outcomes were, as one would expect, determined more by their own characteristics, i.e. the nature and severity of the problem, age, sex, etc., than by the treatment setting. Table 2 also presents the results of a sensitivity analysis on two parameters: reliability of aggregate measures and sample size by treatment unit. The sample sizes reported are those which, in the absence of any control over individual variations, e.g. in the absence of stratification of respondents, would be required to reach a targeted level of reliability for the units' average scores. Thus, supposing that one wanted to compare the average scores between two units, without stratification, in order to achieve a 0.8 coefficient reliability on a total score, a minimum of 239 respondents per unit would be required.
|
|
Given that the development of scales was based in part on the results of factor analyses, these cannot be considered as confirmatory in this case. The groupings observed nevertheless appear highly congruent with the classification into three dimensions (Table 3
). Factorial loadings show that the first factor is constituted of items belonging to the ‘interpersonal aspects' dimension, while the second group of items concerns the ‘technical aspects' and the third ‘care outcomes'. The adjustment of the model appears acceptable: 20 of the 22 items yield a commonality >0.4, thus reflecting convergence of the information gathered by each item. Lastly, the total proportion of variance explained by the three factors exceeds 60%.
|
Criterion validity was measured through co-variance analyses (Table 4
). As in previous studies, we find that the older the respondents are, the higher they score,13,17,45–47 the better they feel about their health status before the visit to the doctor46,48,49 and the more they are prepared to return to see the doctor or to recommend him or her to a friend or relative.50,51 With the exception of the ‘outcomes' subscale, the scores are, as expected, positively and significantly associated with the number of visits made to a doctor in the past year.10,45,46,51,52 Moreover, these analyses reveal that while the scores are asymmetrical, significant differences were detectable between the different types of treatment units. This means that the indices developed are potentially discriminating, i.e. likely to reveal variations in the judgements made (given that the research design was not constructed for a comparative analysis of perceived quality, it is beyond the scope of this article to discuss the origin of the significant differences we observed).
|
Analysis of responses
As is generally the case in studies of patient perception, the results presented in Table 1
show that the opinion expressed on the quality of care is favourable with regard to the various dimensions.14,18,19,47 The factor analyses in Table 3 suggest that, in their judgements, the respondents clearly distinguish what has to do with the doctor's interpersonal skills, the technical process of care and the outcomes of the visit. The values presented in Table 5 show, however, that this differentiation does not exclude a certain congruence in the judgement made on each of the dimensions of perceived quality. In fact, the inter-factor correlations (factors resulting from the factor analysis) range from 0.43 to 0.71 and those between the scores of the three subscales fall between 0.53 and 0.76.
|
The analysis of the factor loadings provides indirect indications on the contribution of each item to each dimension (Table 3
). The two attributes of quality contributing most to the ‘interpersonal aspect' factor were the manner in which doctors greet their patients and the respect which doctors show to their patients. Six out of 12 items in the ‘technical aspects' factor yielded factor loading >0.7. Three deal with explanations and clarifications provided (health problem, tests and treatments to be performed and those being considered); three others focus on the steps key to the medical process (correct diagnosis, appropriate tests and exams and performance of tests and treatments). As for the ‘outcomes' factor, two attributes of quality were distinguished: lessening of fear and anxiety, and return to routine activities. Studying the correlations between the total score and each of the 22 items allows us to explore their relative contribution to the overall judgement made on the quality of care during a visit to a doctor. All of the total items– score correlations are positive and significant to a threshold of 1%. The highest correlations deal with two attributes of quality related to interpersonal aspects of care: the physician's reassuring attitude (r = 0.81) and the interest shown by him (r = 0.83). This was followed by one attribute from the ‘outcomes' dimension (lessening of fear and anxiety, r = 0.79), and then by two attributes from the ‘technical’ dimension: explanation/clarification of treatment (r = 0.78) and of the problem (r = 0.77). Moreover, four of the five items in the ‘interpersonal' dimension, eight of the 12 items in the ‘technical' dimension and four of the five items in the ‘outcomes' dimension yielded correlations with the total score of >0.70. The two items that are associated less strongly with the total score deal with continuity of care: the possibility of seeing the same doctor from one visit to the next (r = 0.56) and length of time spent waiting to obtain test results (r = 0.51). A posteriori, this result appears to be entirely logical. In effect, in Québec, these components of continuity of care are more dependent on structural and organizational constraints in the care units than on physician practices.
|
Discussion |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionAppendix 1 QuestionnaireReferences |
|---|
The 22 item scale validated here is based on a questionnaire that can be used to provide physicians and primary care facilities with a concise, reliable and valid tool for evaluating perceived quality. Its content takes into account local realities, but on the whole remains consistent with various North American53,54 and European5,6,13,35,55 studies dealing with the criteria that patients retain as they judge quality following a visit to a doctor. With this in mind, it is likely that this questionnaire can be used in other settings, with some minor modifications where required. However, what distinguishes this questionnaire is primarily that it focuses on the opinions of patients about quality rather than on their satisfaction. The questionnaire is characterized secondly by the inclusion of five items related to the outcomes of the visit, alongside questions dealing with the processes of care. As has already been pointed out,18,19,28 patients' opinions on these aspects have been evaluated only in a limited number of instruments, although outcomes seem to constitute a central attribute when patients are judging quality of care.2,48 The instrument also includes questions dealing with patient perceptions of their physicians' technical skills. As Rees-Lewis highlights, there may not necessarily be a consensus regarding this choice.19 The various views on this issue cannot be discussed here due to editorial constraints. We will simply mention that an increasing number of instruments are attempting to document these aspects and that the main justification for this choice lies in the fact that patients always have an opinion about their physicians' professional practices and that this opinion will influence their behaviour vis-à-vis use and compliance with treatment.12,19,50 The measurement of patient perception is thus informative in any case, regardless of whether or not this perception conforms to professional standards of quality.
The analysis of the psychometric properties of the global scale and the three subscales provides favourable evidence concerning their reliability and validity. The results of the factor analysis, the inter-item correlations and the Cronbach's alpha coefficients support the distinction made, based on Donabedian's classification, between the interpersonal processes, the technical processes and the outcomes. At the same time, they allow us to assume the existence of an underlying theoretical construct uniting both the 22 items and the three sub-scales. It is, of course, too early to judge the sensitivity of the instrument to change. However, the fact that it demonstrated the ability to reveal significant differences in the judgements made in different treatment units suggests that it could be used in a positive manner to evaluate the effects of interventions intended to improve patient perception of quality of care.
The analysis of the responses confirms the complexity of the notion of perceived quality, which covers dis-tinct and yet interrelated dimensions. The perceptions concerning care outcomes and interpersonal and technical aspects are correlated, but are not confounded, and each one contributes to the overall judgement made following the visit to a doctor. The responses provided also confirm the preceding observations, showing that the patient's opinion of the physician is determined mainly by perceptions concerning the information he or she provides13,54 and his or her professional skills (clinical examination, treatment)5,13,35 and personal skills (qualities of listening, respect, attention paid to the patient).5,13,23,35,48,54
The questionnaire has a wide range of applications. One of its main interests lies in its ability to provide information to a physician or a group of physicians that may be of use to them in their daily practice or in pos-sible follow-up interventions intended to improve their responses to their patients' expectations. In this case, the authors suggest that it be integrated into more comprehensive evaluation processes associating normative indicators, i.e. taking into account professional standards, and perceptual indicators, i.e. those that reflect patient perspectives.
The questionnaire may also be used in evaluative studies that use aggregated individual scores in order to compare average patient perceptions in different health care units. One should be aware, however, that the scores may vary according to the characteristics of the patient who answered the questionnaire, the physician who provided the care and the type of organization in which this physician practises. When comparing physicians, the analysis should take into account whether or not sampled physicians were grouped within health units. When physicians are grouped, the sensitivity analysis in Table 2 provides conservative estimates of sample size per unit. When comparing health units, the required sample size would also be reduced if modelling of the physician effect as a random source of variation is feasible. In all cases, to maintain a good level of reliability for the average scores for units, it is suggested that before using such a questionnaire, one must ensure the presence of sufficient numbers and/or reduce inter-patient variability, for example through appropriate stratification of respondents.
This opens up interesting avenues for further application of the scale for a variety of purposes. In practice, and in all cases, it is recommended that careful attention be paid to the conditions in which the questionnaire is administered. The measurements of perception can be affected by these conditions26 and there is some disagreement among researchers with regard to the methods to be used to question patients about their perceptions of quality (for a summary of the advantages and disadvantages of various techniques for measuring the quality of patient service, see Ford et al.14). Thus, some researchers may prefer to use a different technique and would propose administering the questionnaire in a different place or at another time. The authors would like to stress here that this questionnaire was designed to be sent to the patients by mail and to be completed by them in their own home, approximately one week after their visit to the doctor. Therefore, one cannot presume a priori that the psychometric properties of the scale will be preserved if any of these elements are modified.
|
Appendix 1 Questionnaire |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionAppendix 1 QuestionnaireReferences |
|---|
We would like to have your opinion concerning various aspects of the quality of the care and services that you received during your last consultation in a treatment unit.
Referring to the scale below, for each question, circle the number that corresponds to your opinion, indicating whether it is negative, somewhat negative, neither negative nor positive, somewhat positive or positive
If you do not have an opinion about a particular item, circle 7; if the question does not apply to you, or you have not experienced this situation, circle 8.
|
|
Acknowledgments |
|---|
The authors extend sincere thanks to physicians and managers from the participating units for their contribution to this study, and Helene Kaufman for translation of the original manuscript. This study was made possible by a research grant from the Fonds de la Recherche en Santé du Québec (# 961334-104). L Potvin is supported by the Medical Research Council of Canada (MRC Career Award # H3-17299-AP007270)
|
References |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionAppendix 1 QuestionnaireReferences |
|---|
1 Ellis R, Whittington D. Quality assurance in health care. In Ellis R, Whittington D (eds). Quality Assurance Handbook. London: Edward Arnold, 1993: 1–8.
2 Palmer RH. Considerations in defining quality of care. In Palmer RH (ed.). Striving for Quality in Health Care: An Inquiry into Policy and Practice. Ann Arbor: Health Administration Press, 1991: 1–59.
3 Racine JF. A double take on the history of quality in health care. In Graham NO (ed.). Quality in Health Care. Theory, Application and Evolution. Gaithersburg, MD: Aspen, 1995: 15–31.
4 Wensing M, Grol RSA. Quality judgements by patients on general practice care: a literature analysis. Social Sci Med 1994; 38: 45–53.
5 Calnan M. Lay evaluation of medicine and medical practice: report of a pilot study. Int J Health Serv 1988; 18: 311–322.[Web of Science][Medline]
6 Calnan MW. The patient's perspective. Int J Technol Assess Health Care 1998; 14: 24–34.[Web of Science][Medline]
7 Rosenthal GE, Shannon SE. The use of patient perceptions in the evaluation of health-care delivery systems. Med Care 1997; 35 (11 Suppl): NS58–NS68.[Web of Science][Medline]
8 Donabedian A. The role of outcomes in quality assessment and assurance. Qual Rev Bull 1992; 18: 356–60.
9 Ware J, Hayes R. Methods for measuring patient satisfaction with specific medical encounters. Med Care 1988; 26: 393–402.[Web of Science][Medline]
10 Pascoe G. Patient satisfaction in primary health care: a literature review and analysis. Eval Program Planning 1983; 6: 185–210.[Medline]
11 Rubin H. Can patients evaluate the quality of hospital care? Med Care Rev 1990; 47: 267–326.[Medline]
12 Haddad S, Potvin L, Pineault R. Les études de satisfaction mesurent —elles des attributs des patients ou les caractéristiques des services qui leur sont fournis? In Chytil MK et al. (eds). Fifth International Conference on System Science in Health Care. 1992: 1169–1173.
13 Williams, S, Calnan M. Convergence and divergence: assessing criteria of consumer satisfaction across general practice, dental and hospital care settings. Social Sci Med 1991; 33: 707–716.
14 Ford RC, Bach SA, Fottler MD. Methods of measuring patient satisfaction in health care organizations. Health Care Manag Rev 1997; 22: 74–89.[Web of Science][Medline]
15 Donabedian A. The Definition of Quality and Approaches to its Assessment. Vol. 1. Ann Arbor: Health Administration Press, 1980.
16 Donabedian A. Defining and measuring the quality of health care. In Wenzel RP (ed.). Assessing Quality Health Care. Perspectives for Clinicians. Baltimore: Williams and Wilkins, 1992.
17 Sitzia J, Wood N. Patient satisfaction: a review of issues and concepts. Social Sci Med 1997; 45: 1829–1843.
18 Hall J, Dornan M. What patients like about their medical care and how often they are asked: a meta-analysis of the satisfaction literature. Social Sci Med 1988; 27: 935–939.
19 Rees Lewis J. Patient views on quality care in general practice: literature review. Social Sci Med 1994; 39: 655–670.
20 DiMatteo M, Hays R. The significance of patients' perceptions of physician conduct: a study of patient satisfaction in a family practice center. J Commun Health 1980; 6: 18–34.[Medline]
21 Weinburger M, Greene J, Mamlin J. Patient perceptions of health care at a university-based ambulatory care clinic. J Ambulatory Care Manag 1981: 55–64.
22 Linder-Pelz S. Social psychological determinants of patient satisfaction: a test of five hypotheses. Social Sci Med 1982; 16: 583–589.
23 Smith J et al. Measuring patient perceptions of the doctor–patient relationship: development of the PDIS. Eval Health Professions 1984; 7: 77–94.
24 Lehmann F, Fontaine D, Bourque A. Measurement of patient satisfaction: the Smith–Falvo patient doctor interaction scale. Can Fam Physician 1988; 34: 2641–2645.
25 Baker R. Development of a questionnaire to assess patients' satisfaction with consultations in general practice. Br J Gen Pract 1990; 40: 487–490.[Web of Science][Medline]
26
Kinnersley P et al. A comparison of methods for measuring patient satisfaction with consultations in primary care. Fam Pract 1996; 13: 41–51.
27 Allen WW et al. Satisfaction with care received from family physicians: a comparison of Medicaid enrolees and other patients. Fam Med 1996; 28: 429–433.[Medline]
28
Howie JG et al. A comparison of a Patient Enablement Instrument (PEI) against two established satisfaction scales as an outcome measure of primary care consultations. Fam Pract 1998; 15: 165–171.
29 Feletti G, Firman D, Sanson-Fisher R. Patient satisfaction with primary-care consultations. J Behav Med 1986; 9: 389–399.[Web of Science][Medline]
30 Poulton BC. Use of the consultation satisfaction questionnaire to examine patients' satisfaction with general practitioners and community nurses: reliability, replicability and discriminant validity. Br J Gen Pract 1996; 46: 26–31.[Web of Science][Medline]
31 Williamson V. Patients' satisfaction with general practitioner services: a survey by a community health council. J R Coll Gen Pract 1989; 39: 452–455.[Web of Science][Medline]
32 Ware J et al. Defining and measuring patient satisfaction with medical care. Eval Program Planning 1983; 6: 247–263.[Medline]
33 Zyzanski S, Hulka B, Cassel J. Scale for the measurement of satisfaction with medical care: modifications in content, format and scoring. Med Care 1974; 12: 611–620.[Web of Science][Medline]
34 Sabourin S, Gendreau P. Assessing client satisfaction with mental health treatment among French-Canadians. Appl Psychol 1988; 37: 327–335.
35 Calnan M. Towards a conceptual framework of lay evaluation of health care. Social Sci Med 1988; 27: 927–933.
36 Cleary P. Satisfaction may not suffice! Int J Technol Assess Health Care 1998; 14: 35–37.[Web of Science][Medline]
37 Epstein KR et al. Patients' perceptions of office medical practice: judging quality through the patients' eyes. Am J Med Qual 1996; 11: 73–80.
38 Roberge D et al. EQUS: an innovative information system to document patients' appreciation of quality. I2th ISQUA Conference. 1995. St John's, Terre Neuve.
39 Crocker L, Algina J. Introduction to Classical and Modern Test Theory. Holt, Rinehart and Wilson: New York, 1986.
40
Haddad S, Fournier P, Potvin L. Measuring community perceptions of the quality of primary health care services in developing countries. Validation of a 20-item scale. Int J Qual Health Care 1998; 10: 93–104.
41
Donabedian A. The quality of care. How can it be assessed? J Am Med Assoc 1988; 260: 1743–1748.
42 SPSS. SPSS for Windows. Chicago: SPSS Inc., 1993.
43 O'Brien R. Estimating the reliability of aggregate-level variables based on individual-level characteristics. Sociol Methods Res 1990; 18: 473–504.[Abstract]
44 Fleiss J. The Design and Analysis of Clinical Experiments. New York: John Wiley & Sons, 1986.
45 Ware JE, Davies-Avery A, Stewart AL. The measurement and meaning of patient satisfaction. Health Med Care Rev 1978; 1: 1–15.
46 Hall J, Dornan M. Patient sociodemographic characteristics as predictors of satisfaction with medical care: a meta-analysis. Social Sci Med 1990; 30: 811–818.
47 Locker D, Dunt D. Theoretical and methodological issues in sociological studies of consumer satisfaction with medical care. Social Sci Med 1978; 12: 283–292.
48 Pascoe G, Attkinson C. Comparison of indirect and direct approaches to measuring patient satisfaction. Eval Program Planning 1983; 6: 359–371.[Medline]
49 Hall J, Milburn M, Epstein A. A causal model of health status and satisfaction with medical care. Med Care 1993; 31: 84–94.[Web of Science][Medline]
50 Davies A, Ware J. Involving consumers in quality of care assessment. Health Affairs 1988; 7.
51 Weiss GL, Ramsey CA. Regular source of primary medical care and patient satisfaction. Qual Rev Bull 1989; 15: 180–184.
52 Weiss GL. Patient satisfaction with primary medical care. Evaluation of sociodemographic and predispositional factors. Med Care 1988; 26: 383–392.[Web of Science][Medline]
53 Lohr KN, Harris-Weling J. Medicare: a strategy for quality assurance, I: a recapitulation of the study and a definition of quality of care. Qual Rev Bull 1991; 17: 6–9.
54 Lohr K, Donaldson M, Walker A. Medicare: a strategy for quality assurance, III: beneficiary and physician focus group. Qual Rev Bull 1991; 17: 242–253.
55 Wilde B et al. Quality of care from a patient perspective: a grounded theory study. Scand J Caring 1993; 7: 113–120
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  P. M. Hansen, D. H. Peters, K. Viswanathan, K. D. Rao, A. Mashkoor, and G. Burnham Client perceptions of the quality of primary care services in Afghanistan Int. J. Qual. Health Care, December 1, 2008; 20(6): 384 - 391. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 R. G Evans, A. Edwards, S. Evans, B. Elwyn, and G. Elwyn Assessing the practising physician using patient surveys: a systematic review of instruments and feedback methods Fam. Pract., April 1, 2007; 24(2): 117 - 127. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
K. D. Rao, D. H. Peters, and K. Bandeen-Roche Towards patient-centered health services in India--a scale to measure patient perceptions of quality Int. J. Qual. Health Care, December 1, 2006; 18(6): 414 - 421. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. W. Mack, J. M. Hilden, J. Watterson, C. Moore, B. Turner, H. E. Grier, J. C. Weeks, and J. Wolfe Parent and Physician Perspectives on Quality of Care at the End of Life in Children With Cancer J. Clin. Oncol., December 20, 2005; 23(36): 9155 - 9161. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H. Kolk, H.-I. Maaroos, I. Kull, K. Labotkin, K. Loivukene, and M. Mikelsaar Open access endoscopy in an epidemiological situation of high prevalence of Helicobacter pylori infection: applicability of the guidelines of the European Society for Primary Care Gastroenterology Fam. Pract., June 1, 2002; 19(3): 231 - 235. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||