A New Comprehensive Measure of High-Value Aspects of Primary Care

Rebecca S. Etz, PhD; Stephen J. Zyzanski, PhD; Martha M. Gonzalez; Sarah R. Reves, MSN, FNP-C; Jonathan P. O'Neal; Kurt C. Stange, MD, PhD


Ann Fam Med. 2019;17(3):221-230. 

In This Article

Abstract and Introduction


Purpose: To develop and evaluate a concise measure of primary care that is grounded in the experience of patients, clinicians, and health care payers.

Methods: We asked crowd-sourced samples of 412 patients, 525 primary care clinicians, and 85 health care payers to describe what provides value in primary care, then asked 70 primary care and health services experts in a 2½ day international conference to provide additional insights. A multidisciplinary team conducted a qualitative analysis of the combined data to develop a parsimonious set of patient-reported items. We evaluated items using factor analysis, Rasch modeling, and association analyses among 2 online samples and 4 clinical samples from diverse patient populations.

Results: The resulting person-centered primary care measure parsimoniously represents the broad scope of primary care, with 11 domains each represented by a single item: accessibility, advocacy, community context, comprehensiveness, continuity, coordination, family context, goal-oriented care, health promotion, integration, and relationship. Principal axes factor analysis identified a single factor. Factor loadings and corrected item-total correlations were >0.6 in online samples (n = 2,229) and >0.5 in clinical samples (n = 323). Factor scores were fairly normally distributed in online patient samples, and skewed toward higher ratings in point-of-care patient samples. Rasch models showed a broad spread of person and item scores, acceptable item-fit statistics, and little item redundancy. Preliminary concurrent validity analyses supported hypothesized associations.

Conclusions: The person-centered primary care measure reliably, comprehensively, and parsimoniously assesses the aspects of care thought to represent high-value primary care by patients, clinicians, and payers. The measure is ready for further validation and outcome analyses, and for use in focusing attention on what matters about primary care, while reducing measurement burden.


Measures matter because they focus the precious commodity of attention.[1] Increasingly, measures also are used to concentrate material resources and infrastructure, and even to influence the right to practice, often with unintended consequences.[2,3]

Ideally, measures should provide information that is understandable and actionable by key stakeholders.[1,4] The growing number of patient-reported measures recognize the patient as the most knowledgeable informant about many important aspects of care,[5–11] including the Patient Reported Outcomes Information Systems measures.[12]

Narrowly focused measures make sense for narrowly focused care. But primary care, subjected to the largest burden of measurement,[13,14] is also subjected to a measurement model that does not match the importance of much that it does.[1,15–18] Adding up disease-specific measures misses and devalues the higher-level functions of integrating, personalizing, and prioritizing care for people and populations.[1,13,19]

A number of measures have been developed to assess different aspects of primary care.[10,11,20–25] Unfortunately, they tend to be long and seldom used outside of the research setting. Clinical primary care settings often turn to patient experience surveys, such as the Clinician and Group Consumer Assessment of Healthcare Providers and Systems, that researchers have recently sought to shorten in order to increase its use.[26] Patient experience measures focus important attention on the consumer experience of care delivery and receipt of services, but fall short of focused attention on the broad scope of primary care.[1,15]

Needed is a measure, grounded in the combined experiences of patients, clinicians, and payers, that engages the most informed reporter—the patient—to assess vital functions of primary care that are lost by current reductionist measures. Such a measure must be responsive to the current clinical environment that is buckling under the weight of measures that are onerous to manage and time consuming to complete.[15,17,20]

Therefore, we set out to: (1) identify what matters in primary care, and use that understanding to (2) develop a parsimonious measure of what matters, made practical to use by assessing each domain with a single item, and then (3) to conduct reliability and preliminary concurrent validity analyses.