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© Health Research and Educational Trust Objective: To study the relationships between the different domains of quality of primary health care for the evaluation of health system performance and for informing policy decision making. Data Sources: A total of 137 quality indicators collected from 7,607 English practices between 2011 and 2012. Study Design: Cross-sectional study at the practice level. Indicators were allocated to subdomains of processes of care (“quality assurance,” “education and training,” “medicine management,” “access,” “clinical management,” and “patient-centered care”), health outcomes (“intermediate outcomes” and “patient-reported health status”), and patient satisfaction. The relationships between the subdomains were hypothesized in a conceptual model and subsequently tested using structural equation modeling. Principal Findings: The model supported two independent paths. In the first path, “access” was associated with “patient-centered care” (β = 0.63), which in turn was strongly associated with “patient satisfaction” (β = 0.88). In the second path, “education and training” was associated with “clinical management” (β = 0.32), which in turn was associated with “intermediate outcomes” (β = 0.69). “Patient-reported health status” was weakly associated with “patient-centered care” (β = −0.05) and “patient satisfaction” (β = 0.09), and not associated with “clinical management” or “intermediate outcomes.”. Conclusions: This is the first empirical model to simultaneously provide evidence on the independence of intermediate health care outcomes, patient satisfaction, and health status. The explanatory paths via technical quality clinical management and patient centeredness offer specific opportunities for the development of quality improvement initiatives.

Original publication




Journal article


Health Services Research

Publication Date





430 - 449