General characteristics
The general characteristics of participants were presented for outpatients and inpatients, respectively (Table 2). Over 60% outpatients were female while sex distribution among inpatients were nearly equal. Compared to outpatients, more inpatients were older than 55 years, less wealthy, had lower education level, and rated their diseases as serious.
Psychometric evaluation of the outpatient PREM-CCH
First round of exploratory factor analysis
The KMO value was 0.9 and the Bartlett’s test of sphericity was statistically significant. Eigenvalues ranged from 1.0 to 10.3. Factor loadings varied between 0.4 and 0.9. Nine Factors were extracted at this stage.
Factor 1 assessed three themes, i.e. Communication and information, Professional competence, Environment and facilities. Twelve items were assigned to this one Factor.
Factor 2 assessed Communication and information. Items assigned to this Factor were related to the content and effect of communication between medical professionals and patients as well as the attitudes of doctors during communication.
Factor 3 assessed Medical costs. Four items assessed how patients perceived the health care expenses on registry, diagnosis and treatment, medications, tests and examinations and the overall experience of medical expenses during this visit. One item assessed the appropriateness of the quantity of medications prescribed by doctors.
Factor 4 assessed Efficiency, which assessed patient experience of waiting time at different sections during this visit.
Factor 5 assessed Communication and information and Professional competence. Three items were assigned to this Factor. Two items assessed the responsiveness during the communication between doctors and patients. The other one assessed whether medical staff followed standards during the patient’s visit, i.e. checking the patient’s identity before conducting diagnosis and treatment.
Factor 6 assessed Hospital recommendation. One item evaluated patient willingness to revisit the same hospital and the other evaluated patient willingness to recommend this hospital to others.
Factor 7 assessed Professional competence. Two items assigned to this Factor assessed whether medical staff followed standards during the patient’s visit.
Factor 8 assessed Communication and information. One item was centered on patient involvement during the communication with doctors. The other two items were concerned with privacy protection of the patient during diagnosis and treatment.
Factor 9 assessed Environment and facilities. One item examined various ways of registration, and the other checked the channels of making complaints and suggestions to the hospital.
First round of internal consistency assessment
The Cronbach’s a of the whole outpatient PREM-CCH was 0.9, and the Cronbach’s alpha of different Factors ranged from 0.3 to 0.9. As the Cronbach’s a of Factors 7, 8 and 9 were <0.7, we excluded those three Factors. For Factor 1, the inter-item correlations between Q41 and another four items were <0.3, therefore we excluded Q41. The inter-item correlations between Q26, Q36 and Q40 were <0.3, and among the item-total correlations of those three items, the one of Q26 was the smallest, hence we excluded Q26. The inter-item correlation between Q18 and Q36 was <0.3, and the item-total correlation of Q18 was larger than that of Q36, so we excluded Q36. As a result, 29 items were included into the second round of exploratory factor analysis and internal consistency assessment.
Second round of exploratory factor analysis
The KMO value was 0.9 and the Bartlett’s test of sphericity was statistically significant. Eigenvalues ranged from 1.1 to 9.0. Factor loadings varied between 0.5 and 0.8. Six Factors were extracted at this stage.
Factor 1 contained 11 items with four items covering Communication and information, four items covering Environment and facilities and the other three covering Professional competence.
Factor 2 assessed Medical costs. Same items were assigned to this Factor as in the first round of exploratory factor analysis.
Factor 3 assessed Communication and information, which was relevant to the effect of communication between doctors and patients, e.g. whether doctors made concrete explanations and whether patients could understand their illness and treatment afterwards.
Factor 4 assessed Efficiency. Items assigned to this Factor were the same as those in the first round of exploratory factor analysis.
Factor 5 assessed Communication and information and Professional competence, which were the same as Factor 5 in the first round of exploratory factor analysis.
Factor 6 assessed Hospital recommendation. The two items assigned to this Factor were the same as those in the first round of exploratory factor analysis.
Second round of internal consistency assessment
The Cronbach’s a of the whole outpatient PREM-CCH was 0.9, and Cronbach’s a of the six Factors ranged from 0.7 to 0.9. As to Factor 1, the inter-item correlations between Q21 and another three items were <0.3, so we excluded Q21. Although satisfactory internal consistency was achieved, it was difficult to interpret the results: Factors 1, 3 and 5 overlapped in themes, and Factors 1 and 5 contained multiple themes, respectively. Therefore, we grouped items of the same theme together, and reached the following five Factors and 22 items.
Factor 1 assessed Communication and information, including items Q13, Q14, Q15, Q16, Q17, Q18, Q19, Q22.
Factor 2 assessed Professional competence, including items Q28, Q32, Q34, Q40. The Cronbach’s a of this Factor was less than the threshold 0.7, but it could increase to 0.73 if we deleted Q28. Therefore, we excluded Q28.
Factor 3 assessed Medical costs, including items Q46, Q47, Q48, Q49, Q51.
Factor 4 assessed Efficiency, including items Q42, Q43, Q44, Q45.
Factor 5 assessed Hospital recommendation, including items Q54 and Q55.
As to the Factor assessing Environmental and facilities, its Cronbach’s a was 0.68 that could not increase to 0.7 no matter which item of this Factor was deleted. Hence, we excluded this Factor.
Cronbach’s a of the revised outpatient PREM-CCH was 0.9. Cronbach’s a of the five Factors ranged from 0.7 to 0.9 (Table 3). The inter-item correlations were all >0.3, ranging from 0.3 to 0.7; the corrected item-total correlations between individual items and their assigned Factors were all >0.3, ranging from 0.5 to 0.7.
Construct validity
As shown in Table 3, all individual patient experience items in the revised outpatient PREM-CCH had statistically significant correlations with the item on general satisfaction with hospital care. In the multivariate regression analysis (Table 4), all Factors were statistically significantly associated with the item on general satisfaction with hospital care.
Criterion validity
Criterion validity was supported for the revised outpatient PREM-CCH, as the total score for the instrument correlated moderately with the score for the item on general satisfaction with hospital care (rho=0.65).
Psychometric evaluation of the inpatient PREM-CCH
First round of exploratory factor analysis
The KMO value was 0.9 and the Bartlett’s test of sphericity was statistically significant. Eigenvalues ranged from 1.1 to 10.1. Factor loadings varied between 0.4 and 0.9. Nine factors were extracted at this stage.
Factor 1 assessed three themes, i.e. Communication and information, Professional competence, Environment and facilities. Twelve items were assigned to this factor.
Factor 2 assessed Medical costs. Four items assessed how patients perceived the health care expenses on registry, diagnosis and treatment, medications, tests and examinations and the overall experience of medical expenses during this visit. One item assessed self-perceived appropriateness of medications prescribed by doctors.
Factor 3 assessed Efficiency. Three items assessed patient experience of waiting time at different sections during this visit, including the waiting time for registration and paying fees, for seeing the doctor, and for examinations.
Factor 4 assessed Communication and information. Three items assigned to this factor were related to the content and effect of communication between medical professionals and patients.
Factor 5 assessed three themes, with two items under Health outcomes, one under Professional competence, and another one under Environment and facilities.
Factor 6 assessed Communicationand information and Professional competence. Two items assessed the responsiveness of medical professionals, and one item assessed whether medical professionals complied with diagnosis regulations during the patient’s visit.
Factor 7 assessed Communication and information, and Environment and facilities. Two items were concerned with privacy protection of the patient during diagnosis and treatment. One item was related to multiple ways of registration, and the other was about channels to make complaints and suggestions to the hospital.
Factor 8 assessed Hospital recommendation. One item assessed the patient’s willingness to revisit the same hospital and the other assessed the patient’s willingness to recommend this hospital to others.
Factor 9 assessed three subscales, i.e. Communication and information, Professional competence, and Medical costs. One item examined patient engagement into decision making concerning their treatment protocols. Two items examined whether medical professionals complied with professional procedures during treatment, e.g. informing patients of potential risks, preventative methods and follow-ups. The other one item examined the necessity of the tests and examinations taken during this visit.
First round of internal consistency
The Cronbach’s a of the whole inpatient PREM-CCH was 0.9. The Cronbach’s a of the nine Factors ranged from 0.3 to 0.9. We excluded Factors 7 and 9 as the Cronbach’s a of neither Factor was above 0.7, and even if we excluded individual items, the Cronbach’s a was still <0.7. As to Factor 1, we excluded items Q21, Q26, Q27, Q31 and Q36, between which and the other items under Factor 1, the inter-item correlations were <0.3. With regard to Factor 2, we excluded Q28, as the Cronbach’s a of Factor 2 (0.68) could increase to 0.77 if Q28 was deleted. A total of 26 items were included into the second round of exploratory factor analysis and internal consistency assessment.
Second round of exploratory factor analysis
The KMO value was 0.9 and the Bartlett’s test of sphericity was statistically significant. Eigenvalues ranged from 1.0 to 8.1. Factor loadings varied between 0.5 and 0.9. Seven Factors were extracted at this stage.
Factor 1 contained 7 items with three items covering Communication and information, two items concerning Environment and facilities, and the other two items related to Professional competence.
Factor 2 and Factor 3 assessed Medical costs and Efficiency, respectively. Same items were assigned to these two Factors as in the first round of exploratory factor analysis.
Factor 4, as Factor 5 in the first round of exploratory factor analysis, assessed three themes, with two items under Health outcomes, one under Professional competence, and another one under Environment and facilities.
Factor 5, as Factor 4 in the first round of exploratory factor analysis, assessed Communication and information.
Factor 6 assessed Communication and information, under which the two items were related to the responsiveness of medical professionals.
Factor 7, as Factor 8 in the first round of exploratory factor analysis, assessed Hospital recommendation.
Second round of internal consistency
The Cronbach’s a of the whole inpatient PREM-CCH was 0.9, and Cronbach’s a of the seven Factors ranged from 0.7 to 0.8. As there were Factors that overlapped in themes, we grouped items containing the same theme together, and reached the following six Factors and 19 items.
Factor 1 assessed Communication and information, including items Q13, Q14, Q15, Q16, Q17, Q18, Q19, Q22. As the inter-item correlations between Q14, Q15, Q16, Q17 and the other items were <0.3, we excluded those four items.
Factor 2 assessed Professional competence, including items Q32, Q34, Q40.
Factor 3 assessed Medical costs, including items Q46, Q47, Q48, Q49, Q51.
Factor 4 assessed Efficiency, including items Q42, Q43, Q44.
Factor 5 assessed Health outcomes, including items Q16 and Q17.
Factor 6 assessed Hospital recommendation, including items Q54 and Q55.
Regarding the Factor assessing Environmental and facilities, its Cronbach’s a was less than 0.7; we, therefore, excluded that Factor.
The Cronbach’s a of the revised inpatient PREM-CCH was 0.9, which representing good internal consistency. Cronbach’s a of the six Factors ranged from 0.7 to 0.8 (Table 5). The corrected item-total correlations between individual items and their assigned Factors were all >0.3, ranging from 0.5 to 0.8; the inter-item correlations were all >0.3, ranging from 0.4 to 0.7.
Construct validity
As shown in Table 5, all individual items in the revised inpatient PREM-CCH had statistically significant correlations with the item on general satisfaction with hospital care. In the multivariate regression analysis (Table 6), all Factors were statistically significantly associated with the items on general satisfaction with hospital care.
Criterion validity
Criterion validity was supported for the revised inpatient PREM-CCH, as the total score for the instrument correlated moderately with the score for the item on general satisfaction with hospital care (rho=0.63).