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QUALITY IMPROVEMENT RESEARCH
Research on patients’ views in the evaluation and
improvement of quality of care
M Wensing, G Elwyn
.............................................................................................................................
Qual Saf Health Care
2002;11:153–157
The identification of methods for assessing the views of
patients on health care has only developed over the last
decade or so. The use of patients’ views to improve
healthcare delivery requires valid and reliable
measurement methods. Four approaches are
recognised: inclusion of patients’ views in the
information to those seeking health care, identification
of patient preferences in episodes of care, patient
feedback on delivery of health care, and patients’ views
in decision making on healthcare systems. Outcome
measures for the evaluation of the use of patients’ views
should reflect the aims in terms of processes or outcomes
of care, including possible negative consequences.
Rigorous methodologies for the evaluation of methods
have yet to be implemented.
..........................................................................
C
ollecting the views of service users has
been a key feature of recent developments
in society, but it is only over the last decade
or so that the healthcare sector has identified
methods for assessing the views of patients. A
range of methods is available to integrate
patients’ views on the delivery and improvement
of health care, including short questionnaires to
assess patients’ needs before a consultation with
the clinician, focus groups to include patients’
views on clinical guidelines, and surveys to
provide patient feedback to care providers. If such
methods are used for the evaluation and improve-
ment of healthcare systems, they should be stud-
ied in terms of effectiveness, efficiency, and
maybe even safety.1This review shows that this
research area has yet to implement rigorous
approaches to the collection and synthesis of
patients’ views. Some of the key issues related to
the measurement of patients’ views and their use
in healthcare improvement are considered, to-
gether with ways in which the methods them-
selves may be evaluated.
MEASURES
Patients’ views have different dimensions (table
1). This papers focuses on patients’ views of
health care—specifically on their preferences,
evaluations, and reports.
Preferences
Preferences are ideas about what should occur in
healthcare systems.2Related concepts are expec-
tations, perceived needs, desires, wants, requests
and priorities. Expectations have two distinct
meanings: beliefs about what should occur or
what people want of care (“normative expecta-
tions”), and beliefs about what will actually hap-
pen, irrespective of whether this is wanted (“pre-
dicted expectations”).2The term “preferences”,
which has its origins in cognitive psychology and
economics, is most often used to refer to
individual patients’ views about their clinical
treatment. The term “priorities” is more often
used to describe preferences for healthcare
services in a population of patients or citizens.3
Qualitative as well as quantitative methods can be
used to study preferences.
Qualitative research methods such as indi-
vidual interviews and focus groups can be used to
elicit preferences. These methods often use open
ended approaches such as topic lists rather than
structured questionnaires. It is often difficult for
patients to decide what is important in general
terms, given the limited experience of any one
individual. Focus groups generate interaction
among participants which may lead to shared
views that transcend individual experiences. It
may be helpful to present realistic but hypotheti-
cal situations as a trigger for discussions. Facilita-
tion skills may be needed to test whether the
group views are well considered and stable.
Quantitative methods for eliciting preferences
include surveys and consensus methods such as
the Delphi and nominal group techniques. Differ-
ent types of data can be collected including scale
responses that range from “not important” to
“extremely important”; rankings—for example,
preferences expressed in paired comparisons of
alternatives; choice of alternatives—for example,
a vote for the most desirable alternatives.
Table 1 Classification of measures of
patients’ views
Reports Ratings
Health
status
Functional status
measures, measures
for disability and
handicap; measures
of beliefs related to
health status (e.g.
health locus of
control)
Quality of life
measures, measures
for coping with health
problems
Health
care
Reports on the use of
health care, health
care received, and
treatment adherence;
measures of beliefs
related to health care
(e.g. efficacy of care
providers)
Expectations, needs,
preferences, priorities,
attitudes, evaluations,
complaints and
satisfaction related to
health care
See end of article for
authors’ affiliations
.......................
Correspondence to:
Dr M Wensing, Centre for
Quality of Care Research,
University Medical Centre
St Radboud, P O Box
9101, 6500 HB
Nijmegen, The
Netherlands;
M.Wensing@hsv.kun.nl
.......................
153
www.qualityhealthcare.com
Individuals can be asked to rate, rank, or vote for different care
providers (GP or hospital) or attributes of care providers—for
example, short waiting list, adequate information delivery. In
a study of patient priorities in different countries high corre-
lations were found between different methods of rating, rank-
ing of, and voting for aspects of general practice care.4A study
of different methods for eliciting treatment preferences, how-
ever, found significant differences.5A range of methods has
been developed to collect preference data such as the expect-
ancy value model, multi-attribute utility models, and conjoint
analysis models (discrete choice experiments).6
A number of methodological issues related to the use of
methods for priority setting in health care have been
described.3A first problem is how “options” are generated:
limiting the choices will limit the preference frame. Patients
should contribute to the development of a preference
framework but they usually lack the expertise to generate a
model completely on their own. Decisions in prioritisation
issues in healthcare systems inevitably involve a wide array of
factors, so methods have to be able to incorporate multidimen-
sional influences. The most realistic methods involve present-
ing constrained choices where trade offs have to be made
between different attributes or alternatives. It is important to
be explicit about the methods used for the aggregation of
individual preferences because different procedures will lead
to different results. Researchers should understand that the
choice of methods will influence results and that the
assessment processes are at least transparent if methods have
the potential to over-represent the views of some population
sectors over others. An example of the use of patient
preferences is given in box 1.
Evaluations
Patient evaluations are “health care recipients’ reactions to
salient aspects of the context, process, and result of their serv-
ice experience”.8Related concepts are “satisfaction”, “unmet
needs”, “judgements”, “complaints”, and “comments”. The
term “evaluation” suggests a cognitive process in which
specific aspects of care are assessed, while “satisfaction” refers
to an emotional response to the whole experience in health
care. The term “patient satisfaction” is probably most often
used in the literature.
Many studies have used written questionnaires that
comprise structured questions with some sort of rating scale.
The overall satisfaction with the healthcare experience is usu-
ally very high and this often masks less positive evaluations
when aspects that are more specific are explored. A literature
review showed that questionnaires that asked for evaluations
in terms of “satisfaction/dissatisfaction” showed less discrimi-
nation than questionnaires that used terms such as “good/
bad” or “agree/disagree” with very concrete aspects of care.9
Some questionnaires measure both preferences and experi-
ences and derive evaluations from these two factors by calcu-
lating difference or ratio scores.10 There is some evidence that
patients distinguish between the two concepts,11 but there is
no validated framework for deriving evaluations from prefer-
ences and experiences.12
Patients have evaluative responses to experiences in health
care which are not necessarily translated into satisfaction,13
and qualitative methods can be used to examine these in more
depth. An example is shown in box 2. Qualitative approaches
are particularly useful for exploring patients’ views in areas
that have not been fully elaborated. Thorough data analysis of
qualitative material is time consuming. Pragmatic approaches
such as logging key themes without undertaking full
transcription analyses may be used but, as far as we are aware,
the reliability and validity of such approaches have not been
assessed.
Reports
Patient reports represent objective observations of organis-
ation or process of care by patients, regardless of their prefer-
ences or evaluations.15 Patients’ experiences and their percep-
tions of professional performance are similar concepts.
Patients can, for instance, register how long they had to wait
in the waiting room, irrespective of whether this was too long
or not. Although reports reflect patients’ observations, they do
not necessarily imply a patient’s perspective on the quality of
care. Nevertheless, patient reports can be used for quality
improvement. In some situations patients’ reports are the
most accurate observation method if, for instance, the data are
required about a patient’s pathway through different health-
care institutions.
Validity of instruments
Instruments for assessment of patient views of health care
should be validated to ensure that the tools measure what they
are supposed to measure. A review of 195 studies of patient
satisfaction published in 1994 showed that only 89 (46%)
Box 1 Patient preferences for in vitro fertilisation 7
A conjoint analysis model was developed to predict indi-
viduals’ preference for receiving different components of
an in vitro fertilisation service. Six relevant attributes were
identified: chance of taking home a baby, follow up sup-
port, time on the waiting list, continuity of staff, cost, and
attitudes of staff. Note that these attributes include health
outcomes, non-health outcomes, and process attributes.
Realistic levels for these attributes were chosen; for
instance, “chance of taking home a baby” had the levels
5%, 10%, 15%, 25%, and 35%. A selection of 26
scenarios was chosen (from a possible list of 1000) to
achieve a “manageable” option listing for respondents.
The 26 scenarios were randomly split into two equal
groups and within each group 12 pair wise comparisons
were formulated for assessment by randomly selected
patients. Regression analysis techniques produced a
predictive model of patient preferences for an in vitro ferti-
lisation service. The preferred attributes in this model were
staff attitudes, continuity of care, follow up, and chance of
taking a baby home.
Box 2 Patient evaluations of low back pain
management14
Twenty patients who consulted the general practitioner for
low back pain were interviewed shortly after their visit. The
general practitioners were also interviewed. A topic list of
the key components of a low back pain clinical guideline
was used. The data were transcribed and analysed quali-
tatively. The results revealed that patients often had limited
expectations of the consultation. They wanted to hear a
diagnosis and expected to receive simple advice. All
patients said they complied with the most important
advice, which is to stay active, although a few had ideas
about possible damage to their back after physical
exercise. Patients said they would only take medication if
it was strictly necessary, although the guideline recom-
mended analgesics at regular intervals independent of
pain. Only one patient demanded physical therapy,
although many general practitioners perceived that
patients wanted this. Although patients and their general
practitioners were satisfied with the chosen management,
this study provided deeper understanding of the gap
between professional advice and patient motivation to
change or act on advice.
154 Wensing, Elwyn
www.qualityhealthcare.com
reported some validity or reliability data and only 11 (6% of
181 quantitative studies) reported content validity and
criterion validity or construct validity and reliability.16
Ideally, the instrument should be compared with a gold
standard or a criterion measure (an instrument with
established validity). For instance, patient reports on the care
received can be compared with the medical records or
clinicians’ reports on the care delivered (box 3). This approach
is comparable with the validation of a diagnostic test. A crite-
rion measure for preferences or evaluations is not often avail-
able, however, so other approaches are needed.
The validity of most instruments for patients’ views should
be based on conceptual frameworks that describe a specific
domain (the relevant aspects of health care) and it is
preferable if patients have been consulted regarding the selec-
tion and description of the relevant aspects. Qualitative stud-
ies are particularly suitable for that purpose. For instance, the
Europep instrument for patients’ evaluations of general prac-
tice care covers medical care, interpersonal relationships,
information and support, and organisation of care. The
aspects were selected on the basis of literature studies and
qualitative and quantitative studies (box 4).
Sometimes it is possible to verify whether patients’ views
are associated with other factors or whether the measure
meets criteria set by the theory from which the measure has
been derived (construct validity). For instance, most patient
satisfaction studies have shown that older patients have more
positive evaluations of health care than younger patients. It
can therefore be predicted that a new measure for patient sat-
isfaction will show similar associations.
Psychometrics
Quantitative instruments should have adequate psychometric
features.18 High item response rates will indicate the presence
of questions that are more likely to be relevant and
understandable. Some instruments, however, are intended to
identify rare events such as medical errors (complaint proce-
dures) or side effects of medications (surveys among drug
users). High item response rates are not relevant in such cases.
Instruments designed to measure aspects of quality should
also show good variation across patients (discrimination) and
variation between measurements at different points in time
(responsiveness). If indicators are supposed to be clustered
within dimensions, validity is supported by proven unidimen-
sionality and high internal consistency. However, not all
instruments assume clustering between indicators because
indicators may not be seen as repeated measurements. This
will be the case for many instruments that measure reports of
concrete aspects of care. Ideally, instruments will also show
good test-retest reliability.
The most often used reliability coefficients refer to the
internal consistency of items within a dimension per
patient—for example, Cronbach’s alpha. In the context of
quality improvement, however, aggregated scores per care
provider are often needed—that is, aggregation over many
individuals. These figures are based on a number of indicators
and a number of patients or events. An example is the
percentage of patients with positive evaluations of the
accessibility of care in a specific hospital based on a survey of
100 patients who answered 10 different questions on accessi-
bility. Generalisability analyses can be used to calculate
reliability coefficients for the aggregated scores.19 It appears
that an increase in the number of patients often has more
influence on the reliability of the aggregated scores than an
increase in the number of indicators.
Sampling
The inclusion criteria for the study population determine the
generalisability or external validity of a study or audit. For
instance, measurements among patients who attend a
clinician are not generalisable to the general patient popula-
tion registered at a practice or a population of Internet users
who visit a site on a health problem. Qualitative studies use
theoretical sampling to achieve a specific sample which may
be heterogeneous or homogenous, depending on the overall
purpose of the work. Quantitative studies use many different
forms of sampling methods to achieve a representative sample
(random, stratified, etc). It is important to achieve high
response rates and low dropouts in order to avoid selection
bias (except if this was sought). Non-responders are more
likely to be represented by those who are ill, less satisfied with
care provided, and less frequent users of health care than
responders.20 21 Surveys of interview methods need to consider
the impact in case these groups are excluded or drop out.
Response rates in surveys among patients vary consider-
ably. A literature review reported a mean of 60% in response
rates and a standard deviation of 21%.22 Many factors may
influence the response rate of a survey,such as the motivation
of the clinician to recruit patients, the attractiveness of the lay
out of a questionnaire, the method of administering the ques-
tionnaire to patients, the use of monetary incentives, and pos-
sibly the use of information technology for administering
Box 3 Accuracy of patient reports15
Reports of 380 patients obtained through telephone
surveys were compared with medical records which were
considered to be a gold standard (a disputable
perspective as omissions and document loss confound the
measures). For chest radiography, mammography, and
electrocardiography, patient reports showed high sensitiv-
ity and specificity. For serum cholesterol tests, patients
proved to be sensitive but not specific reporters. For blood
pressure measurements, faecal tests, and rectal examina-
tion, false negative rates were below 0.10. They were
somewhat higher for breast self-examination instruction
and pelvic examination (0.21–0.22). For testicular
self-examination instruction patient reports failed to
confirm medical record documentation (false negative
rate=0.53).
Box 4 Europep instrument 17
The Europep questionnaire elicits patients’ evaluations of
general practice care and provides feedback to general
practitioners. The originators aimed to develop an
instrument that reflected patients’ priorities regarding the
main areas of general practice care. Validation studies
focused on an adequate selection of aspects of care and
phrasing of items using a series of systematic evaluations.
Literature studies and patient surveys in eight countries
were performed to determine these priorities. Preliminary
questionnaires were tested in qualitative and quantitative
pilot studies. The pre-final 44 item version was formally
prepared for international use using forward and
backward questionnaire translations. Selection of the final
23 item version was based on the following criteria:
• The questionnaire should cover five main dimensions: inter-
personal relationship; medical care; information and
support; continuity and cooperation; facilities, availability
and accessibility.
• Specific items were included if these referred to aspects of
care which were prioritised by patients, showed high item
response and reasonable discrimination across patients in
most countries. Quantitative cut off points were defined for
these criteria.
• Items were excluded if a serious ambiguity or translation
problem was found.
Patients’ views on evaluation and improvement of quality of care 155
www.qualityhealthcare.com
questionnaires. Insight into which factors are most relevant is
limited. A comparison of handing out questionnaires to
visitors to the general practice and mailing questionnaires to
patients at home gave response rates of 72% and 63%, respec-
tively; the content of the answers of both sample populations
was, however, largely similar.23 A randomised trial showed that
written reminders could improve the response rates unless the
rate was already above 80%.24
USE OF PATIENTS’ VIEWS FOR QUALITY
IMPROVEMENT
Table 2 outlines the potential use of patients’ views in health-
care delivery and quality improvement.25 One approach
focuses on those who want to make choices about their utili-
sation of healthcare services. Health education materials may
include information on patients’ views based, for instance, on
qualitative research of their experiences in health care. Public
reports on the performance of different care providers may
include information about patients’ evaluations of care.26 A
comparison with other care providers requires adequate
adjustment for case mix, which is difficult because insight into
predictors of patient evaluations of care (and most other indi-
cators) is limited.26
Another approach focuses on patients in episodes of care
using, for instance, shared decision making strategies or
patient-held records. Identification of patient preferences is
part of most of these approaches. For instance,shared decision
making implies that the care provider gives information on
relevant options, assesses patient preferences regarding these
options, and takes a decision with or checks approval of the
patient.27
A third approach provides different types of patient
feedback on healthcare received derived from surveys, patient
groups, or complaint procedures. These views can be used for
continuing education and service improvements. Patient
views can be compared with ethical or clinical guidelines for
good practice but, in many cases, such standards are difficult
to define. An exception is a lawsuit where an ethical or legal
assessment is explicitly sought. Comparison with other care
providers can help to prioritise issues that need attention.
A fourth approach focuses on the involvement of patients
and the public in the design and planning of healthcare
systems. This requires information on patients’ views such as
studies of patient priorities or the assessment of local needs
for health care. Patient organisations express the views of
patients who coalesce around issues or conditions and these
may differ from the aggregated views of individuals in wider
populations. In these situations,patients’ views are only one of
a number of inputs into a wider policy making process.
RELEVANT OUTCOMES
Methods to identify and use patients’ views for the
improvement of health care can be seen as a technology which
should be evaluated in terms of effectiveness and efficiency.
The choice of relevant outcomes for the use of patients’ views
for quality improvement requires further attention. It appears
logical to derive outcome measures for the evaluation from the
underlying objectives of this effort (table 3).
It is an ethical and legal rule that patients should be
informed and involved in their health care, at least to minimal
standards. Many patients wish to be involved in the decision
processes, at least to some extent.28 In line with this aim, the
process of involvement rather than its outcome is crucial and so
it is the ethical principles and patient preferences that define
the criteria for effectiveness. For instance, shared decision
making can be evaluated in terms of information delivered on
treatment options, checking of understanding and prefer-
ences, and making a shared decision.29
Patient involvement may also result in better processes and
outcomes of care. It could, for instance, make clinicians more
responsive to patient preferences, contribute to a better imple-
mentation of clinical guidelines, and result in better adher-
ence to treatment, health status and satisfaction with care.
Patients can be seen as co-producers of health care because
their decisions and behaviour influence healthcare provision
and its outcomes. Outcome measures should reflect the effects
on process or outcomes of care that are expected.
Integration of patients’ views may be driven by political and
strategic motivations such as protection of a position in a
competitive healthcare market, the wish to have democratic
control in the healthcare organisation, or the need to do
something for underserved populations. Such aims may be
difficult to assess, but measurable outcome measures can be
found in some cases—for instance, position on the healthcare
market can be evaluated in terms of attendance rates and
turnover of patients.
Finally, evaluations should consider possible negative
consequences such as unrealistic patient expectations of what
health care can deliver; defensive behaviour of care providers,
resulting in higher numbers of unnecessary clinical proce-
dures; undermining of professional morale; and increased
costs. Such consequences are not imaginary. A randomised
trial on low back pain showed that 80% would have chosen
Table 2 Use of patients’ views for
quality improvement
Provision of data to those who seek health care:
• Health education
• Internet communication
• Public reports
Eliciting patient preferences in episodes of care:
• Needs assessment
• Tailored patient education
• Shared decision making
• Patient-held records
Patients’ feedback on medical care:
• Written surveys
• Complaint procedures
• Patient participation groups
Patient involvement in healthcare systems:
• Assessment of priorities
• Involvement in guidelines
• Patient organisations
Table 3 Objectives of patient involvement and
relevant measures
Objectives Relevant measures
Adhere to ethical principles Assess the impact of the processes
of involvement at different levels
(service design, clinical
interactions, feedback systems)
with criteria derived from ethical
principles
Meet patients’ preferences Same as above, but with
patient-based criteria
Provide improved care process Assess doctor-patient
communication, medical care,
organisation of care, etc.
Provide improved patient
outcomes
Assess patient compliance, health
status, anxiety, coping, satisfaction
with care, etc.
Achieve political or strategic
aims
Assess the position on healthcare
market, democratic organisation,
etc.
156 Wensing, Elwyn
www.qualityhealthcare.com
radiography if available, but that patients who received radio-
graphy often had more pain at 3 months than the control
group and were nevertheless more satisfied with the care
provided.30
Not only should the effects of specific methods be studied,
but also their actual uptake in health care. Clinicians and
patients may lack competence or skills to use specific
instruments or have negative attitudes regarding specific
approaches. Organisational structures may limit the applica-
tion of specific methods. Such barriers need to be identified
and addressed by means of targeted strategies which should
be evaluated in terms of success of uptake of the methods.
CONCLUSIONS
A range of approaches is available to integrate patients’ views
into healthcare delivery systems and their improvement. The
methods to measure and use patients’ views should be studied
in the context of their intended application. Quantitative as
well as qualitative approaches can be used to measure
patients’ views, and the validity and reliability of the methods
should be examined. The effectiveness and efficiency of the
methods should be studied in terms of their consequences for
process and outcomes of health care. Increased patient
participation in health care can be seen as desirable in itself,
but this should not inhibit evaluation of the methods used to
achieve this aim.
.....................
Authors’ affiliations
M Wensing, Centre for Quality of Care Research, University Medical
Centre St Radboud, P O Box 9101, 6500 HB Nijmegen, The
Netherlands
G Elwyn, Department of General Practice, University of Wales College
of Medicine, Heath Park, Cardiff CF4 4XN, UK
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Key messages
• Patients’ views include preferences (ideas about what
should occur), evaluations (judgements of aspects of care),
and reports (observations of organisation or process of
care).
• The validity of measures of patients’ views should be based
on conceptual frameworks, preferably derived from
rigorous qualitative studies.
• Effective methods for reporting information on patients’
views are needed to influence and improve process and
outcomes within healthcare systems.
Patients’ views on evaluation and improvement of quality of care 157
www.qualityhealthcare.com
