Article Text

Download PDFPDF
Structure, process or outcome: which contributes most to patients' overall assessment of healthcare quality?
  1. Jany Rademakers1,
  2. Diana Delnoij2,
  3. Dolf de Boer1,2
  1. 1Netherlands Institute for Health Services Research, Utrecht, The Netherlands
  2. 2Centre for Consumer Experiences in Healthcare, Utrecht, The Netherlands
  1. Correspondence to Dr J J D J M Rademakers, Netherlands Institute for Health Services Research, PO Box 1568, 3500 BN Utrecht, The Netherlands; j.rademakers{at}


Research questions 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.

Discussion 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.

  • Patient satisfaction
  • patient experiences
  • healthcare quality
  • quality aspects
  • process assessment
  • outcome assessment
  • indicators
  • assessment
  • healthcare quality
  • patient outcomes
  • patient satisfaction

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Funding The data used in this study for secondary analysis have been drawn from projects funded by The Netherlands' Organisation for Health Research and Development and Stichting Miletus (The Miletus Foundation, Association of Health Insurers).

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.