title: Structure, process or outcome: which contributes most to patients' overall assessment of healthcare quality?
abstract: OBJECTIVE
  The paper explores which type of quality aspects (structure, process, outcome) most strongly determines patients' overall assessment of healthcare, and whether there is a variation between different types of patient groups in this respect.
  
  
  METHODS
  Secondary analyses were undertaken on survey data from patients who underwent hip or knee surgery, cataract surgery, patients suffering from varicose veins, spinal disc herniation or rheumatoid arthritis. In these analyses, the patient-given global rating served as the dependent variable, and experiences regarding structure (waiting times, continuity of care), process (doctor-patient communication and information) and outcome aspects (improvement or worsening of symptoms) served as independent variables.
  
  
  RESULTS
  Experiences regarding process aspects explained most of the variance in the global rating (16.4-23.3%), followed by structure aspects (8.1-21.0%). Experiences regarding outcome did not explain much variance in the global rating in any of the patient groups (5.3-13.5%). The patient groups did not differ with respect to the type of quality aspects that most predicted the overall assessment.
  
  
  CONCLUSIONS
  Improving process and structure aspects of healthcare is most likely to increase patients' overall evaluation of the quality of care as expressed in a global rating. A more sophisticated method of patient reported outcome measurement, with pre- and post-treatment questionnaires and the inclusion of quality-of-life criteria, might lead to higher associations between outcome and the overall evaluation of the received care.
authors.affiliation: Netherlands Institute for Health Services Research, Utrecht, The Netherlands. j.rademakers@nivel.nl
authors.forename: Jany
authors.initials: J
authors.lastname: Rademakers
authors.forename: Diana
authors.initials: D
authors.lastname: Delnoij
authors.forename: Dolf
authors.initials: D
authors.lastname: de Boer
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care / Q000706:statistics & numerical data*; D017060:Patient Satisfaction / Q000706:statistics & numerical data*; D017064:Process Assessment, Health Care / Q000706:statistics & numerical data*; D019984:Quality Indicators, Health Care; D055815:Young Adult