Ó The Author (2006). Published by Oxford University Press. All rights reserved. For permissions, please email: journals.pe...
to be simple and based on the data derived frominformation systems that are routinely available withinhealth care organisa...
The reliability of the questionnaire was validated byChronbach’s alpha coefficient showing good consis-tency for the three...
were fitted using the Amos 4 module of the SPSSsoftware package.ResultsThe analysis included a total of 213 PHCT out of th...
and accessibility’ dimension were: organisation of theservices, appropriate consultation time, satisfactionwith the teleph...
Despite interactions between aspects related to teamorganisation, physician–patient relationship, andscientific-technical ...
valid than that derived from audits of clinical recordswhich, usually, are of small sample size. However,the increasing co...
Upcoming SlideShare
Loading in …5

personalised care, access, quality and team coordination are the main dimensions of family medicine output


Published on

  • Be the first to comment

  • Be the first to like this

personalised care, access, quality and team coordination are the main dimensions of family medicine output

  1. 1. Ó The Author (2006). Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oxfordjournals.orgdoi:10.1093/fampra/cml056 Family Practice Advance Access published on 1 November 2006Personalised care, access, quality and teamcoordination are the main dimensions offamily medicine outputJoan Gene´-Badiaa,b,c, Carlos Ascasod, Georgia Escaramis-Babianod,Laura Sampietro-Colome, Arantxa Catala´n-Ramosa,Mireia Sans-Corralesa,fand Enriqueta Pujol-RiberaaGene´-Badia J, Ascaso C, Escaramis-Babiano G, Sampietro-Colom L, Catala´n-Ramos A,Sans-Corrales M and Pujol-Ribera E. Personalised care, access, quality and teamcoordination are the main dimensions of family medicine output. Family Practice 2007; 24:41–47.Background. Health organisations continually seek good output indicators of family medi-cine health care provision because they are accountable to society, they need to compareservices, and need to evaluate the impact of organisational reforms.Objectives. Using the sources of information routinely available in health-service manage-ment, we sought to assess the groups of components of primary health care output that bestserve to define the outcome of family medicine services.Design. Cross-sectional descriptive study.Site. Primary health care in Catalunya.Participants. Two hundred and thirteen primary health care teams.Measurements. Information was collected on team structure, user satisfaction, quality-of-professional-life of the health care professionals, and physicians’ drug prescription. Confirma-tory Factor Analysis was used to assess the number of dimensions that best explained thefamily medicine outcome.Results. The model that best fits the structure of the data (AGFI = 0.778) is that which consistsof three dimensions i.e. (1) the individual accessibility to the services and professional–patientrelationship; (2) the coordination within the health care team; (3) the scientific-technical qualityof the service. The first two of these dimensions were correlated between themselves, but thethird was totally independent of the other two.Conclusions. Using sources of information that are routinely employed in primary healthcare services management, the model enables the measurement of the output of family medi-cine by considering the dimensions such as inter-personnel relationships, internal coordina-tion of the team and the scientific-technical quality of the service. Despite its simplicity, thismeasure of the output incorporates the views not only of the users but also of the health careprofessionals.IntroductionHealth care systems need performance indicators offamily medicine services for public accountability,for comparison between centres and countries1andfor evaluating the impact of health care reforms. Tobe generally applicable for comparing differentservice-provider organisations, these indicators needReceived 21 February 2006; Accepted 2 October 2006.aInstitut Catala` de la Salut (ICS), Spain, bConsorci d’Atencio´ Primaria de Salut de l’Eixample (CAPSE), Spain, cDepartament deSalut Pu´ blica Universitat de Barcelona, Spain, dDepartament de Salut Pu´ blica, Unitat de Bioestadı´stica, Universitat de Barcelona,Spain, eUnitat de Plans Estrate` gics, Departament de Salut, Generalitat de Catalunya, Barcelona, Spain and fDepartament deMedicina, Campus de Bellvitge, Universitat de Barcelona, Spain. Correspondence to Joan Gene´-Badia, Consorci d’Atencio´Primaria de Salut de l’Eixample (CAPSE), C/Rosello´ 161, Barcelona 08036, Spain; Email: jgene@clinic.ub.es41
  2. 2. to be simple and based on the data derived frominformation systems that are routinely available withinhealth care organisations.2The Institute of Medicine in the USA recommendedthat family medicine practitioners should publish theirperformance indicators relating to costs, quality, acces-sibility and satisfaction of the patient as well as that ofthe health care professional.3Further advice was tosearch for other indicators that would better illustratethe impact of the service on the citizen, and whichwould evaluate aspects related to the main componentsdefining primary health care.4A recent systematicreview of the literature highlighted that such attributesof family medicine (accessibility, continuity, consulta-tion duration, patient–physician relationship, coor-dination between services and implementation ofpreventive measures) were related to improvementsin health, or in the satisfaction of the patient.5Focus-group studies which collected the opinions ofhealth care professionals, managers and users of familymedicine services, identified four dimensions of thehealth care product. Combining their fundamentalattributes these were: (1) access to the services; (2)coordination within the primary health care teams(PHCT), and with other levels of health care facilities;(3) relationship between the health care professionalsand the users of the service; (4) scientific-technicalquality of the PHCT and the range of services provi-ded. Equity, satisfaction and efficiency were identifiedas the main cross-sectional axes of the components ofoutput.6Inevitably, there are different groupings of the samedimensions because many of them are intimatelyrelated.7,8Hence, with the objective of attempting tounify the dimensions used in evaluating these services,we planned this study to describe the groupings thatbest define the output of family medicine serviceswhile using the sources of information that are routi-nely available in health care management.Materials and methodsA cross-sectional study was designed to analyse theoutput of family medicine services from 267 PHCTwhich, in the year 2003, were integrated within theInstitut Catala` de la Salut (ICS; the Catalan Health Ser-vice). This organization covers primary health carerequirements for 77% of the population of the Auto-nomous Region of Catalonia (Spain). The other 23%of the population are covered by other health careproviders.Data sourcesThe variables studied were obtained from the follow-ing databases used routinely in the administration ofthe ICS in the year 2003. These included the structuraldatabase of the health care teams, a questionnaire ofuser satisfaction, a questionnaire assessing quality-of-professional-life, and the database of drug prescription.Team structure. The database of team structure con-tains characteristics of the team such as geographicallocation, professional composition, extent of the catch-ment population, and quantitative indicators of clinicalactivity.User satisfaction. The primary health care serviceuser’s questionnaire was designed to measure user sat-isfaction. These aspects included: team organization;performance of the physicians, nurses and clericalstaff; care received; extent to which the health problemwas resolved; and the physical premises of the PrimaryCare Centre (PCC). The questionnaire was voluntaryand self-reporting. Each question of each section wasmeasured on a scale of 0 (very dissatisfied) to 10 (verysatisfied). Each PCC received 200 questionnairesbiannually. The selection for the study sample was byquotas such that, of the 200 questionnaires, 50 were forpaediatrics, 100 for the population aged between 15and 64 years (50% for females and 50% for males),and the 50 remaining questionnaires distributed tothe population 64 years of age (25 for females and25 for males). Failures to respond were covered bysubstitution.The questionnaire was validated in a sample of 1780individuals, mean age 46.4 years (SD 15.5), 64.2%were women, who were attending 9 urban PCC overa period of 1 week in the year 2000.9The reliability ofthe questionnaire was validated using Cronbach’salpha coefficient which demonstrated an optimal con-sistency of the five factors: the team’s organization =0.87; the performance of the physicians, nurses andclerical staff = 0.92; the care received = 0.96; the extentto which the health problem was resolved = 0.96;the physical premises of the PCC = 0.74 (i.e. good orexcellent in all situations).Quality of professional-life. The quality professional-life questionnaire (QPL) contained 35 items and, fromwhich, a profile composed of three summed scores canbe defined for overall QPL10: work demands, supportfrom the hierarchy, and intrinsic motivation. Each itemof the questionnaire was measured on a scale of 1 (verydissatisfied) to 10 (very satisfied). The questionnairewas distributed every year to every the PCHT duringthe month of November. The response rate to the QPLquestionnaires in 2003 was 66.68%.11The questionnaire was validated in a sample of pro-fessionals (health care and non-health-care workers)who were employed in March 1995 in 8 of the 9 Prim-ary Care Directorates (PCD) of the Subdivision of theCosta de Ponent-Tarragona-Tortosa (SAP) of the ICS.Of the 4506 professionals, 2926 responded (64.8%).42 Family Practice—an international journal
  3. 3. The reliability of the questionnaire was validated byChronbach’s alpha coefficient showing good consis-tency for the three defined factors: work demands =0.81; support from the hierarchy = 0.86; intrinsicmotivation = 0.75. Finally, the stability of the question-naire was evaluated using the test-retest system admin-istered in the Old Town Health Area of Barcelona(Area Ba´sica de Salud Go`tic de Barcelona) with aninterval of 15 days between the two administrations.Prescription. The data on prescription were obtainedfrom the invoices sent by the pharmacy offices of theparticipating centres. This database contained not onlythe cost per citizen but also the type of drug prescribedto each patient. With this information it is possible togenerate a synthetic indicator of the quality of the pre-scriptions, termed Prescription Quality Standard. It is apool of indicators that increases the score with respectto the following aspects: (1) the prescription of a highproportion of drugs with a demonstrably high efficacyand safety; (2) to limit the use of new drugs that donot add therapeutic value to the drugs already avail-able for the same clinical indications; (3) to reduce theover-prescription of some groups of drugs (antibiotics,benzodiazepines, NSAIDs and proton pump inhibitors;and finally, (4) adherence to a selection of drugsrecommended by evidence-based guidelines for thetreatment of common primary health care problems(antihypertensive, hypolipaemiants, anti-diabetics, anti-biotics, anti-asthmatics, anti-depressives, hypnotics, pro-ton pump inhibitors and NSAID). Annually, a numericalobjective is agreed for each performance indicator. Thisgoal is calculated based on the 75th percentile of theprevious year’s performance for the overall group ofphysicians. The objectives may be achieved in variousgrades scored from 0 to 130 (http://www.eurodurg.com/country%20presentations.pdf).DimensionsAmong the variables that were collected from theseinformation sources were those that could be, poten-tially, a measure of each one of the four dimensionsproposed in the qualitative study6and, further, whosevalues would reflect the activity and capacity of thePHCT (Table 1). Accessibility and physician–patientrelationship were measured with those variables evalu-ated by the service users with respect to the functionand organisation of the PHCT, in addition to the indi-cators of appropriateness of the numbers of PHCTprofessionals employed for the catchment population.Team coordination was measured from the perspectiveof the health care professionals working within thePHCT. The continuity of health care provision by thefamily physician and specialist was that perceived bythe patient. The relationship between the health careprofessional and the patient was measured from vari-ables that quantified the work-load of the physicianstogether with the patients’ opinions on the manner inwhich they were treated, the perceived quality of theservice, and the physician’s empathy. The scientific-technical quality was evaluated using the prescriptionindicators taking into account the cost and the qualityof drug appropriateness for the clinical indication. Alsoincluded was the overall consumption, the consump-tion of drugs for mental health disorders, chronicconditions and for prevention, since these aspectswere identified as being essential by, both, healthcare professionals and by the patients.6Statistical analysesThe dimensions of the output of primary care wereevaluated using the methodology of ConfirmatoryFactor Analysis.12,13The principal objective of thetechnique is to quantify the degree to which the corre-lations between several observed variables can beexplained by a few latent variables which, in ourstudy, were termed dimensions. In this sense, theprocedure attempts to reduce data dimensionality.The model parameters were estimated via maximumlikelihood, which has the advantage of being scale free.Thus, parameter estimations are all comparable inde-pendently of the scale used to measure the variables.The correlations between the model dimensions as wellas the correlations between the measurement errors ofthe variables that define each dimension were assessbased on the modification index values12; incorpora-ting those with a modification index 2. To determineregression coefficients not significantly different fromzero and, furthermore, to eliminate them from themodel, confidence intervals based on bootstrapmethodology14were used.Three models were fitted. The first model consistedof four dimensions (described in Table 1). The secondmodel had three dimensions and is the result of collap-sing the dimension of accessibility and the dimensionof the health care professional-patient relationshipfrom the previous model. The new dimension indicatesthat easy accessibility to the PCC and to its PHCTfavours the continuity of care and is conducive togood relationships between health care professionalsand patients. Finally, the third model consisted oftwo dimensions and is the result of the dimension ofaccessibility to the PCC and to its PHCT being combi-ned with the coordination dimension within the PHCT.The output remains separated into two aspects; onewhich refers to the technical quality of the healthcare and the other which groups all the aspects refer-ring to the human factor and the organization of theservices (inter-personnel relationships and team work).The process of electing the most appropriate modelwas based on the differences in the x2values (Dx2)between consecutive models, and in the adjustedgoodness-of-fit index (AGFI)12varying between0 and 1 (where 1 defines the perfect fit). The modelsDimensions of family medicine output 43
  4. 4. were fitted using the Amos 4 module of the SPSSsoftware package.ResultsThe analysis included a total of 213 PHCT out of the267 that were within the administration remit of theICS in the year 2003. Fifty-four PHCT were excludedfrom the study because of incomplete data sets.Table 2 summarises the PHCT data on those that didand did not, participate in the present study. Therewere no significant differences between these twogroups of PHCT.The model that best fitted the structure of the datawas that which consisted of three dimensions (Table 3)with an AGFI of 0.778. Figure 1 contains the mainparameter estimates of the model. The ‘relationshipbetween patient and health care professional’,‘accessibility’ and ‘coordination of the team’ dimen-sions correlated positively. Conversely, the ‘scientific-technical quality’ dimension was independent of theothers. Parameters that related the variables studiedwith each dimension had values between 0 and 1 ifthe relationship was positive and between 0 and –1 ifnegative (Figure 1). The variables related to the ‘rela-tionship between health care professional and patientTABLE 1 Selected variables and information source for each dimension of the outputDimension Dimension sub-divisions Selected variables ICS data sourceAccessibility Accessibility to services Satisfaction with service organisation USSatisfaction with clinical visit duration USSatisfaction with the general informationprovidedUSSatisfaction with telephone consultation USWorkload; population assigned/number ofteam membersPHCTCultural access Satisfaction with physician’s information USSatisfaction with nurse’s information USSatisfaction with clerical personnel’sinformationUSCoordinationwithin-team andother levelsCoordination within the team Evaluation of support from superiors QPLEvaluation of support from colleagues QPLEvaluation of feedback on personalperformanceQPLEvaluation of the team member’s proposalsbeing listened-to and taken intoconsideration by the teamQPLCoordination: family physicianand specialistsPatient satisfaction with the familyphysician/specialist coordinationUSRelationshipbetween user andhealth careprofessionalAddressing the social andpsychological problemsTime dedicated to the user; Adult visits/number of team membersPHCTSatisfaction with physician’s courtesy USSatisfaction with nurse’s courtesy USSatisfaction with clerical personnel’scourtesyUSSatisfaction with the resolution of users’problemsUSEmpathy Satisfaction with the attention to user’sneedsUSSatisfaction with the respect accorded touser’s privacyUSScientific-technicalqualityPrescription Quality of prescriptions standard MCCost of prescriptions standardised by patientageMCMental health Anti-depressants prescribed: % of therecommendedMCTranquilisers prescribed: % of therecommendedMCPrevention and managementof chronic pathologiesAnti-hypertensive medications prescribed:% of the recommendedMCAnti-diabetes medications prescribed: % ofthe recommendedMCAnti-asthma medications prescribed: % ofthe recommendedMCUS: user satisfaction questionnaire; PHCT: Primary care team structure; QPL: Quality of professional life questionnaire; MC: medicationconsumption; ICS: Institut Catala` de la Salect.44 Family Practice—an international journal
  5. 5. and accessibility’ dimension were: organisation of theservices, appropriate consultation time, satisfactionwith the telephone consultation, quality of explana-tions provided by the nurse, attention to the user’sneeds, resolution of the user’s problems and concernfor the privacy of the user. With respect to the ‘coor-dination of the team’ dimension, the significant vari-able was that of colleague support. Finally, thevariables related to the ‘scientific-technical quality’dimension were: overall indicator of drug quality stan-dard and the percentage of anti-hypertensive drugsprescribed.DiscussionOur results show that many of the attributes thatdescribe family medicine output are tightlyinter-related. We identified a three dimensions modelthat explains, with high efficiently, the variability ofthe data (AGFI = 0.778). The three dimensionsare those of: inter-personnel relationships, the teamorganisation, and scientific-technical quality. The firstdimension is tightly linked to all those aspects des-cribing personal relationships between the health careprofessionals and the patient, and also includedaspects of accessibility of the patient to the services.The second refers to the capacity for team-workbased on the coordination between different healthcare professionals. The third dimension, which is tot-ally independent of the previous two, is based onscientific-technical quality, or the extent to which thehealth care procedures are based on the best evidenceavailable.Other authors have observed a relationship betweenaccessibility and continuity with respect to thephysician–patient relationship. Responses by healthcare users in Massachusetts (USA) to a questionnairewere evaluated in relation to the impact on outcomesof the different components of the health care provi-sion (accessibility, continuity, overall care, integration,clinical interaction, inter-personal relationship, confi-dence). The results indicated that the only factorsthat were associated with ‘best outcomes’ were thepatient’s confidence in the physician and the physi-cian’s knowledge of the patient.7Also of note wasthat the dimension of individualised clinical care wasindependent of the dimension of team coordination.An evaluation of the care provided by family physi-cians in Holland found that only two dimensionscontributed independently to the final output of thecare: one was related to the structure (managementand organisation of the team) and the other wasrelated to the process of clinical care.8TABLE 2 Description of the 267 primary care teams (PHCT) that are managed by the Instut Catala` de la Salut (ICS) in the year 2003segregated as a function of participation, or not, in the studyPHCT included (n = 213) PHCT not included (n = 54) Statistic PRural N (%) 90 (85.71) 15 (14.29) x2= 3.783 0.052Urban 123 (75.93) 39 (24.07)% Population 60 year Mean (SD) 17.07 (4.57) 18.45 (5.83) T = 1.622 0.109Socio-economic levelS1 (very high) N (%) 28 (82.35%) 6 (17.65%) x2= 1.743 0.627S2 80 (83.33%) 16 (16.67%)S3 71 (76.34%) 22 (23.66%)S4 (very low) 34 (77.27%) 10 (22.73%)% Immigrants Mean (SD) 8.99 (4.75) 10.44 (6.67) T = 1.835 0.068Year of clinical governanceprogramme commencementMean (SD) 1993.60 (4.82) 1993.04 (4.23) T = –0.786 0.433TABLE 3 Measure of adjustment and test of hypotheses related to the selection of confirmatory factorial model that best fits the structureof the datax2g.l Dx2Dg.l P AGFIModel; 4 dimensions 479.927 178 0.776Model; 3 dimensions 480.099 180 0.172 2 0.918 0.778Model; 2 dimensions 667.408 181 187.309 1 0.001 0.701x2: Chi-squared statistic that measures the discrepancy between the structure of the data estimated by the model, and that of the observed.Dx2: Difference between the x2statistics of the model compared to the increase in the parameters required to significantly improve thegoodness-of-fit of the model.AGFI: adjusted goodness-of-fit index which ranges between 0 and 1; where 1 = perfect fit, and which penalises any increase in the parametersof the model.Dimensions of family medicine output 45
  6. 6. Despite interactions between aspects related to teamorganisation, physician–patient relationship, andscientific-technical quality,15–17our model shows thatteams that rely on good technical quality do not nec-essarily have good outputs in terms of inter-personalrelationships with patients, or with respect to teamcoordination. Conversely, it is not unreasonable toexpect that there would be an association betweenthe dimension of patient–physician relationship andthat of team coordination in primary care; teamshaving a good work-place environment having moresatisfied users, as well.18We need to highlight that the indicators introducedin the analysis were those variables that best fit theparameters identified in the qualitative study. We donot know if this same grouping would be maintainedif other variables had been used.6It would be ofconsiderable interest to assess whether our modelcontinues to be valid if applied to other health careorganisations. The method would achieve fullvalidation if the PHCT classified as ‘good’ or ‘bad’performers under the criteria of the present modelreceive the same classification if other procedures ofquality of health care evaluation of health servicesmanagement were used.It may appear surprising that the variables relatingto scientific-technical aspects were derived only frominformation available on drug prescription. We usedthis source of data because most health care organisa-tions make use of detailed prescription informationbecause of the importance of this section within ahealth-service budget. Prescription data are moreFIGURE 1 Standardised regression parameters and correlations between dimensions of the Confirmatory Factor modelselected to identify the output of family medicine services within the ambit of the Institut Catala` de la Salut (ICS). The boxesrepresent the indicators selected from the routine database of the ICS. The ellipses represent the dimensions that comprise theoutput of the services. The unidirectional arrows represent the relationships between the dimensions and the indicators andthe bidirectional arrows represent the correlations between dimensions46 Family Practice—an international journal
  7. 7. valid than that derived from audits of clinical recordswhich, usually, are of small sample size. However,the increasing computerisation of clinical records infamily medicine will enable more rapid analyses ofwhole populations and, as well, provide valid and valu-able information on the technical quality of clinicalprocedures for inclusion in this dimension of familymedicine output evaluation.Family medicine services need to be able to measuretheir health care output using their own registries andshould not have to rely on information from otherlevels of health care. As such, we chose not to includeindicators that are becoming increasing popular, suchas the concept of avoidable hospitalisation,19sincethese data are obtained from registrations of patients’discharge from hospital which, often, are not readilyavailable to PHCT.Our current model provides an overview of familymedicine output which incorporates not only hardindicators and objectives such as drug prescription,but also other more subjective indicators linked tothe opinions of the users and the healthcare profes-sionals. This perspective offers a better view of theexpectations of health-and-service provision in primarycare when the patient seeks help from the familyphysician.6,20The evaluation of the family physician’sperformance exclusively based on objective indica-tors21does not display the whole range of activitiesfulfilled in general practice.We developed a model that allows measurement ofthe output of the service provided by the family physi-cian by considering the dimensions of personal rela-tionships, internal coordination of the PHCT, and thetechnical-scientific quality of the health care provision.We used the sources of information that are easilyavailable because they are routinely employed in themanagement of primary health care services. Despiteits simplicity of data collection, the aspects identifiedas being linked to the expectations from the servicehave components that relate not only to the healthcareprofessionals but also to the users. This family medi-cine output may be useful in identifying PHCT withproblems in fulfilling their health care remit sincethese would be highlighted as outputs deviating fromthat of the majority. It also allows evaluation of theimpact of reforms introduced to help improve teamperformance, and to monitor the team’s progress inachieving previously defined targets.AcknowledgementsFundingThe study was funded, in part, by a research grant fromthe Instituto de Salud Carlos III (FIS #PI021762).References1Engels Y, Dautzenberg M, Campbell S et al. Testing a Europeanset of indicators for the evaluation of the management ofprimary care practices. Fam Pract 2006; 23: 137–147.2Lakhani A, Coles J, Eayres D, Spence C, Rachet B. Creativeuse of existing clinical and health outcome data to assessNHS performance in England: Part 1—performanceindicators linked to clinical care. Br Med J 2005; 330:1426–1431.3Institute of Medicine. Primary care: America’s health in a new era.Washington, DC: National Academy Press, 1996.4Rothemich S, Richmond V. Beware of false wizards: the need formore research on quality and outcomes in primary care. J FamPract 1997; 44: 257–259.5Sans-Corrales M, Pujol-Ribera E, Gene´-Badia J, Pasarı´n-Rua MI,Iglesias-Pe´rez B, Casajuana-Brunet J. Family medicineattributes related to satisfaction, health and costs. FamPract. 2006; 23: 308–16.6Pujol Ribera E, Gene´ Badia J, Sans Corrales M et al. El productode la atencio´n primaria definido por profesionales y usuarios.Gac Sanit. 2006; 20: 209–19.7Safran DJ. Defining the future of primary care: what can we learnfrom patients? Ann Intern Med 2003; 138: 248–255.8Ram P, Grol R, van der Hombergh vd, Rethans JJ, van derVleuten C, Aretz K. Structure and process: the relationshipbetween practice management and actual clinical performancein general practice. Fam Pract 1998; 15: 354–362.9Cabezas MC, Barniol J, Valero C et al. Consistencia internay estructura factorial de un cuestionario de satisfaccio´n delos usuarios en atencio´n primaria de salud. Gac Sanit 2002;16: 109–112.10Cabezas C. La calidad de vida de los profesionales. FMC 2000; 7:53–68.11Gene´-Badia J, Escaramis-Babiano G, Sans-Corrales M et al.Impact of economic incentives on quality of professional lifeand on end-user satisfaction in primary care. Health Policy2006 Mar 16; [Epub ahead of print].12Bollen KA. Structural Equations with Latent Variables. Wileyseries in probability and mathematical statisticsl. 1989.13Bryant FB, Yarnold PR, Michelson EA. Statistical methodology:VIII. using Confirmatory Factor Analysis (CFA) inemergency medicine research. Acad Emerg Med 1999; 6:54–66.14Efron B, Tibshirani R. An Introduction to the Bootstrap. BocaRaton: Chapman Hall, 1993.15Campbell SM, Hann M, Hacker J, Burns C, Oliver D, Thapar A.Identifying predictors of high quality care in English generalpractice: observational study. Br Med J 2001; 323: 784–787.16Cabana MD, Jee SH. Does continuity of care improve patientoutcomes? J Fam Pract 2004; 53: 974–980.17Ahmed A, Allman R, Kiefe C et al. Association of consultationbetween generalists and cardiologists with quality andoutcomes of heart failure care. Am Heart J 2003; 145:1086–1093.18Hass JS, Cook EF, Puopolo AL, Burstin HR, Cleary PD,Brennan TA. Is the professional satisfaction of generalinternists associated with the patient satisfaction? J Gen InternMed 2000; 15: 122–128.19Caminal J, Starfield B, Sanchez E, Casanova C, Morales M. Therole of primary care in preventing ambulatory care sensitiveconditions. Eur J Public Health 2004; 14: 246–251.20Palacio F, Marquet R, Oliver A, Castro P, Bel M, Pin˜ol JL. Lasexpectativas de los pacientes: ¿que´ aspectos valoran en uncentro de salud? Un estudio cualitativo Aten Primaria 2003;31: 307–314.21McColl A, Roderick P, Gabbay J, Smith H, Moore M. Perfor-mance indicators for primary care groups: an evidence basedapproach. Br Med J 1998; 317: 1354–1360.Dimensions of family medicine output 47