Development and psychometric properties of the “Patient Assessment of Transitions in Healthcare settings (PATH)” questionnaire

Development and psychometric properties of the “Patient Assessment of Transitions in Healthcare settings (PATH)” questionnaire | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Development and psychometric properties of the “Patient Assessment of Transitions in Healthcare settings (PATH)” questionnaire Sisse Walløe, Henrik Hein Lauridsen, Esben Nedenskov Petersen, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3982192/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background The quality of care pathways that include transitions between healthcare settings may be increased by improving patients’ experiences of their care journey. Patients’ experiences can be explored through in-depth interviews, but valid and reliable patient-reported experience measures (PREMs) can be a useful and more cost-effective way of assessing patient-experienced quality. The aim of this study was to develop a valid, generic measure for assessment of PAtient-experience of Transitions in Healthcare settings, PATH. We evaluated the structural validity, internal consistency, and test-retest reliability of the PATH questionnaire in a Danish patient population with a range of diagnoses, comorbidities and diversity in age. Methods The PATH questionnaire was developed and tested through an iterative 3-step pilot-test and a comprehensive field-test. Results We found an 18-item version of PATH to be content valid and to have internal consistency and structural validity for a 2-factor solution with a single item scored separately. We found satisfactory test-retest reliability. Conclusions PATH is a generic, content valid, and reliable patient-reported experience measure for the assessment of patient-experienced quality in healthcare transitions. The PATH questionnaire is available for use in quality monitoring and quality improvement research, but we recommend further testing of its measurement properties alongside its practical application. Healthcare transitions Patient-reported experience measure PREM Patient experience Quality Psychometric properties. Figures Figure 1 Background Transitions between healthcare settings can be burdensome for patients and caregivers ( 1 – 8 ) and may lead to information loss and lower continuity of care ( 9 – 11 ). By enhancing patient-experienced quality of care in both primary and secondary sectors of the health care system, patient safety and clinical effectiveness can be improved ( 12 ). Patients’ experiences can be explored through in-depth interviews, but valid and reliable patient-reported experience measures (PREMs) can be a useful and more cost-effective way of assessing patient-experienced quality ( 13 ). Qualitative literature reviews ( 14 – 24 ) suggest that the construct “patient-experienced quality in healthcare transitions” consists of the two domains “organisation” and “human relations” [BLINDED REFERENCE]. A recent qualitative study further detailed that system flexibility and kindness were essential to patients’ experiences of quality in healthcare transitions [BLINDED REFERENCE]. Many studies have explored the quality of care in pathways including transitions between settings experienced by people with various forms of chronic disease ( 16 , 17 , 22 – 24 ), cancer or palliative care ( 14 , 15 , 18 , 21 ), or by older people ( 19 , 20 ), but it appears that the need for system flexibility and kindness is universal [BLINDED REFERENCE]. Several generic conceptual frameworks have been proposed that support the two-dimensional approach of organisation and human relations for evaluating patient-experienced quality of care ( 25 – 30 ), and numerous PREMs have been developed for specific patient contexts ( 31 – 38 ). However, none of them appear to have sufficient content validity ( 32 ) for use by a patient population with a wide range of diagnoses, comorbidities, and ages who undergo transition in the healthcare system [BLINDED REFERENCE]. The existing PREMs are either disease specific ( 33 ), or inadequate in capturing the entire care continuum across healthcare settings ( 22 , 34 , 36 ) Therefore, the aim of the current study was to develop a valid generic measure for assessment of patient-experienced quality in transitions between healthcare settings (PATH) across a broad range of conditions and diagnoses, comorbidities, and patient ages. Our second aim was to evaluate the structural validity, internal consistency, and reliability of PATH in a Danish patient population. The final 18-item Danish questionnaire was translated into English to enable its use outside of Denmark. Method The development of PATH followed a 6-step strategy as described by de Vet et al. ( 39 ) whereas the psychometric testing followed the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology ( 40 – 44 ). Development a) Development of the initial item bank In a scoping review of patient-experienced quality in healthcare transitions, we identified six themes in the domain of “organisation” and a further six themes in the domain of “human relations”, resulting in 12 relevant themes for the assessment of patient-experienced quality in healthcare transitions. These themes were relevant for adult patients independent of diagnoses, age, sex, and comorbidities. Further, we identified 21 PREMs ( 30 , 45 – 65 ) that had items in at least five of these 12 relevant themes [BLINDED REFERENCE]. Items were extracted from the 21 PREMs to produce an item bank. The 21 PREMs and the item bank were presented to an advisory board comprising a medical doctor, two managers from municipalities, two patient representatives, two senior healthcare researchers, and a hospital quality manager. A focus group meeting with the advisory board focused on the relevance, comprehensiveness, and possible deficiencies of the item bank for assessing patient-experienced quality in healthcare transitions. LM prepared the minutes of the meeting and documented the recommendations from the advisory board. b) Item development To further understand and define the constructs we aimed to measure, we assigned the items from the item bank to the themes found in our scoping review [BLINDED REFERENCE] and to codes produced in a previous qualitative study of patient experiences in healthcare transitions [BLINDED REFERENCE]. This generated an overview of existing item formulations within a number of themes or codes and formed the empirical basis of our PREM development. The item formulations were then reworded in Danish to be relevant from a user perspective, informed by our overview of the item bank and qualitative findings. This work was carried out by a group comprising a researcher with knowledge of patient-experienced quality in healthcare transitions (SW), an expert in psychometrics (HHL), a language philosopher (ENP), and an expert in clinical quality (LM). c) Pilot-testing We pilot-tested the potential PREM items in an iterative, three-phased process in which 19 respondents completed the PATH questionnaire. The respondents were 16 patients recruited to represent patients with a broad range of disease, age, and treatment course; two hospital employees with academic background and clinical quality experience; and one physiotherapist who also had patient experience of care transitions. Content validity: In the pilot-test we examined the degree to which the content of PATH was an adequate reflection of the patient-experienced quality in healthcare transitions ( 40 ). The relevance of each item was addressed with the question “How important do you find this item?” with a numerical response scale of 0–10 (0 = not at all important, 10 = very important). Answers were elicited from ten patient participants. The comprehensiveness of the questionnaire was assessed with the question “Is there anything important to your experience that we have not asked about?” The comprehensibility of the questionnaire was assessed with the question “Is there anything we asked about, which you found unclear?” Participants in the first pilot phase were asked to identify which healthcare providers were involved in their care path. The evaluation of relevant healthcare providers was then included in the second and third pilot phases. Throughout the test phases, we continuously referred back to the empirical basis and definition of the construct [BLINDED REFERENCE] to evaluate our findings and revise the questionnaire as suggested in the COSMIN methodology ( 40 ). Field-test a) Participants The field-test was conducted with a patient group that represented a broad range of patients in healthcare transitions to support our aim of developing a generic measure. Participants were recruited through the physiotherapy and occupational therapy unit at Næstved-Slagelse-Ringsted Hospitals in Region Zealand, Denmark and through the gynaecological and obstetrical unit at Odense University Hospital, Denmark. The patients had been discharged from hospital 30–60 days prior to recruitment, and inclusion criteria were ≥ 18 years of age and contact with at least two different healthcare settings (e.g. hospital, general practitioner, municipal care). b) Data collection The PATH questionnaire prefinal version 3 was distributed to patients through the electronic data capture tool REDCap ( 66 , 67 ), hosted at Open Data Explorative Network (OPEN) by links sent to potential respondents’ personal digital post-box (“e-boks”), which is a secure national system for sending and receiving electronic mail containing sensitive data ( 68 ). When potential respondents opened the link, they were presented with information about the PATH study and asked if they consented to participate. Participants were asked to assess the past three months of their care journey. Predefined healthcare providers could be chosen including an “Other healthcare provider/s” with a free-text field, giving the participants the option of adding other relevant healthcare providers. The PATH questionnaire was filled out for each chosen healthcare provider. For test-retest reliability, participants who answered the initial questionnaire within 21 days with no missing answers were invited to complete the questionnaire again. We expected patients’ experiences of quality in healthcare transitions to be stable in the 21 day period, because we assumed that most would not have had new encounters with healthcare services, e.g. readmissions, change in GP, or change in services provided by the municipality, in that time period. c) Sample size We aimed for 250–300 responses to enable factor analysis (rule of thumb is approx. 5–10 patients/item ( 39 , 69 )) so questionnaires were distributed until 300 responses were reached. We aimed for 50 repeated responses for test-retest reliability analysis and included 70 respondents allowing for dropouts. d) Statistical analyses Item characteristics were calculated including the percentage of missing items, skewness, and kurtosis ( 70 ). Structural validity: Exploratory factor analysis (EFA) with a stepwise approach ( 41 ) was used to evaluate how well the PATH scores represented the multidimensional nature of the quality of healthcare transitions as experienced by patients. First, the correlation matrix was assessed for correlations between 0.3 and 0.8 for sampling adequacy. Bartlett’s test of sphericity had a p-value 1, examination of screeplot, and parallel analysis ( 39 ). We chose a principal factor analysis with oblique Promax ( 4 ) rotation assuming correlation between factors. Factor loadings > 0.7 were desirable, but factor loadings as low as 0.30 could be accepted depending on the conceptual definition of the construct. Communalities represent the amount of variance that is explained by a given item via all factors ( 39 ). We aimed for communalities > 0.40 ( 71 ). Internal consistency of PATH, or the degree of interrelatedness among PATH items, was evaluated by estimating Cronbach’s alpha for each domain, with 0.7–0.9 considered satisfactory. Reliability (test-retest) was analysed using percentage agreement and weighted kappa with linearly decreasing weights from the diagonal for each item of the PATH questionnaire ( 72 ). In addition prevalence-adjusted and bias-adjusted kappa (PABAK) were calculated to take prevalence-skewed responses into account ( 72 – 74 ). All analyses were performed using Stata v. 18.0 ( 75 ). The field-test resulted in the final Danish version of PATH ( www.spoergeskemaer.dk/path ). Translation The final Danish version of PATH was translated into English (Appendix 1) for this article in a structured forward-backward translation process ( 76 ). Two native English speakers independently translated PATH from Danish into English. The two versions were synthesised into one questionnaire during a consensus meeting, and this was translated back into Danish by two bilingual individuals who were unacquainted with the original Danish items. The English version was then compared to the original Danish version in a final consensus meeting. The English version was not culturally validated or tested. Results a) Development Item bank development We developed a bank of English items, which was presented to the advisory board. This presentation led to addition of items on the competence of healthcare providers and confirmation that items regarding human relations were indeed necessary to incorporate. There was also consensus to leave out items directly related to equity. b) Item development Following advisory board recommendations, 42 items were developed in Danish to go through pilot-testing (PATH prefinal version 1). The items were thematically related to effectiveness, efficiency, competence of healthcare providers, timeliness, navigation, access and availability, responsibility, informational continuity, patient centeredness and individualised care, kindness and compassion, relational continuity, communication, and informal caregivers. Figure 1 illustrates the development of PATH resulting in an 18-item patient-reported experience measure for the assessment of patient-experienced quality in healthcare transitions. c) Pilot-testing Phase 1: As a result of the first pilot-test, 22 items were removed, leaving 20 items, and one item (item X in Table 1) was reworded (PATH prefinal version 2). The 22 items were removed due to redundancy. Item X was reworded because of comprehension issues. Phase 2: Following pilot-test phase 2, we deleted one more item because of redundancy and re-phrased items 2 and X to improve comprehensibility and relevance (PATH prefinal version 3). The 16 patient participants (13 women and 3 men) rated items X (When I have had an appointment, there has not been waiting time. ) and 17 (When you have had appointments with health professionals, did you feel that you were given enough time? ) as the least relevant (7.4 on the 0–10 scale) items of PATH prefinal version 3, while item 11 (Have you been treated in a compassionate way by the health professionals? ) was rated most relevant (9.7 on the 0–10 scale) (Table 1). Hence, the 19 items remaining in PATH prefinal version 3 were all relevant according to the pilot-test. The participants pointed out a need to discriminate between healthcare providers for 13 of the tested items (Table 1). This resulted in an adaption of the PATH structure for the field-test, where items 6–18 were asked for each healthcare provider involved in the patient’s care pathway (i.e. hospital, GP, home healthcare, municipal rehabilitation, early childhood nurse, and/or out-of-hours GP). For the pilot-test, researchers determined which healthcare providers to include, but this was iteratively evaluated throughout the pilot-test phases and again after the field-test. Phase 3: In phase three of the pilot-test, the participants found the PATH items to be relevant, comprehensive and comprehensible. Thus, all relevant aspects of healthcare transitions were covered, and no further items were suggested. This left 19 items for field-testing (Fig. 1). Table 1 Pilot-tested items for PATH N = 16 Item number Item Relevance mean (0–10) Need for discrimination between healthcare setting 1 Do you have a regular healthcare professional who knows what is going on with you? 8.1 No 2 Have you had access to help when you have needed it? (Item re-worded after the scoring of relevance was conducted) 3 Have you had the opportunity to ask questions when you have needed to? 8.3 No 4 Has the information you have received from the health professionals been consistent? 8.2 No 5 Has there been a plan for what was going to happen to you? 9.1 No 6 Have the efforts regarding your health been well coordinated? 8.9 No 7 Have you been involved in the decisions about your health to the extent that you wanted? 9.4 Yes 8 Do you feel your concerns have been listened to? 8.8 Yes 9 Have you been involved in the scheduling of your treatment? 9.5 Yes 10 Have you been asked about how your health has affected your life? 8.4 Yes 11 Have you been treated in a compassionate way by the health professionals? 9.7 Yes 12 Have you felt comfortable telling the healthcare professionals personal things about yourself? 9 Yes 13 Have you had confidence in the professional competence of the health professionals? 8.7 Yes 14 Did the health professionals know your story? 8.7 Yes 15 Has the information you have received been understandable? 9.4 Yes 16 Have you received all the information you have needed? 9.4 Yes X When I have had an appointment, there has not been waiting time. 7.4 Yes 17 When you have had appointments with health professionals, did you feel that you were given enough time? 7.4 Yes 18 Have your relatives been involved to the extent you have wanted? 7.5 Yes Field test a) Field-test participants We sent ‘e-boks’ invitations to 1529 potential participants. Of these, 347 were excluded as they were exempt from ‘e-boks’, yielding 1182 potential respondents. 329 of the potential respondents filled out the PATH questionnaire —56 responded partially, and 273 had complete PATH responses, giving a response frequency of 37%. The respondents were evenly distributed by age and sex. Most respondents were discharged from an orthopaedic surgical ward, gynaecological ward, or obstetric ward (Table 2 ). Table 2 - Demographic description of participants in the field-test (complete and incomplete PATH Total n Complete n (%) Incomplete n (%) Sex Male 82 65 ( 79 ) 17 ( 21 ) Female 247 208 ( 84 ) 39 ( 16 ) p = 0.312 1 Age 18–29 37 32 ( 86 ) 5 ( 14 ) 30–39 61 45 ( 74 ) 16 ( 26 ) 40–49 11 10 ( 91 ) 1 ( 9 ) 50–59 34 32 (94) 2 ( 6 ) 60–69 65 58 ( 89 ) 7 ( 11 ) 70–79 88 70 ( 80 ) 18 ( 20 ) > 80 33 26 ( 79 ) 7 ( 21 ) p = 0.111 1 Discharge unit Gynecology OUH 3 40 38 (95) 2 ( 5 ) Obstetric OUH 3 89 67 ( 75 ) 22 ( 25 ) Geriatric SNR 4 13 12 (92) 1 ( 8 ) Orthopedic Surgery SNR 4 135 113 ( 84 ) 22 ( 16 ) Psychiatry SNR 4 1 1 (100) General Medicine SNR 4 2 2 (100) Physio- and Occupational therapy SNR 4 16 14 ( 88 ) 2 ( 12 ) Neurology SNR 4 9 7 ( 78 ) 2 ( 22 ) Emergency SNR 4 6 6 (100) Other 5 18 13 ( 72 ) 5 ( 28 ) p = 0.260 2 Total 329 273 ( 83 ) 56 ( 17 ) 1 Fisher’s exact test; 2 Pearson’s chi 2 test; 3 Odense University Hospital including Svendborg location; 4 Slagelse, Naestved, and Ringsted Hospitals; 5 Gastroenterology, Clinical Oncology, Pulmonary Medicine, Cardiology, and Surgical Unit SNR d) Internal consistency Cronbach’s alpha for a 2-factor solution excluding item X and 14 was 0.87 for “Access and coordination” and 0.93 for “Kindness in care”. This reflects high internal consistency (see Table 3). e) Test-retest reliability Full test-retest responses were received from 54 respondents. Weighted kappa values were between 0.37 and 0.47 for the domain “Access and coordination” and between 0.45 and 0.69 for the domain “Kindness in care” (Appendix 5). The single item on informational continuity (Item 17) yielded a weighted kappa of 0.55 (Appendix 5). This indicated only moderate test-retest reliability for PATH for a retest period of 21 days. However, there was a skewed prevalence of responses in the “To a great extent” and “To a very great extent” response categories, and the PABAK values were higher (0.46–0.67 for “Access and coordination” and 0.59–0.81 for “Kindness in care”). This, and high agreement percentages (78–93%) indicates satisfactory test-retest reliability. Translation The translation process included discussion of item 7 ( Have you been involved in the decisions about your health to the extent that you wanted? ) and item 9 ( Have you been involved in the scheduling of your treatment? ). The direct translation of item 9 from Danish into English would include the word planning , but then items 7 and 9 would have almost the same meaning in English. Thus, the translation process led to a discussion of the meaning of item 9 and whether the item was redundant. Consensus was reached to retain item 9 using the word scheduling due to empirical data indicating that patients experience quality in healthcare transitions when the healthcare system shows flexibility to the patients’ needs and time schedules. The full version of the Danish and English PATH questionnaires including a user manual can be found on www.spoergeskemaer.dk/path . Table 3 – Exploratory factor analysis of PATH – prefinal version 3 1 factor promax( 4 ) rotation 2 factor promax( 4 ) rotation 2 factor promax( 4 ) rotation All Items Item X deleted 2 Items X and 14 deleted 2 Item number Item name 1 Com 1 1 2 Com 1 Kindness in Care Access and Coordination Com 1 In charge 0.52 0.34 0.60 0.33 0.57 0.31 2 Access 0.67 0.5 0.63 0.5 0.60 0.5 3 Questions 0.78 0.71 0.81 0.71 0.77 0.71 4 Coherence 0.63 0.46 0.63 0.46 0.63 0.45 5 Plan 0.76 0.67 0.79 0.67 0.80 0.68 6 Coordination 0.79 0.75 0.85 0.75 0.84 0.75 7 Involved decisions 0.85 0.72 0.53 0.38 0.72 0.55 0.36 0.72 8 Worries 0.88 0.8 0.77 0.8 0.76 0.8 9 Involved planning 0.77 0.61 0.66 0.62 0.68 0.63 10 Holistic approach 0.62 0.42 0.67 0.42 0.68 0.42 11 Caring care 0.78 0.71 0.92 0.7 0.90 0.71 12 Trust 0.70 0.54 0.77 0.55 0.76 0.53 13 Trust qualifications 0.81 0.7 0.79 0.7 0.78 0.7 14 Know story 0.62 0.39 0.30 0.37 0.4 - - - 15 Information compre 0.80 0.64 0.53 0.32 0.64 0.55 0.30 0.64 16 Information suff 0.84 0.72 0.65 0.72 0.65 0.72 X Waiting time 0.53 0.28 - - - - - - 17 Appointment time 0.73 0.6 0.78 0.58 0.78 0.58 18 Caretaker involve 0.49 0.27 0.54 0.27 0.56 0.29 Explained variance % 84% 79% 72% 80% 71% Cronbach’s alpha 0.94 0.93 0.87 0.93 0.87 1: Communalities. 2: Empty cells = factorloadings < 0.30 b) PATH item characteristics Items had 0–21% missing responses (Appendix 2). The five items with the most missing responses were items: 16) Have you received all the information you have needed? (6–19%); 14) Did the health professionals know your story? (6–17%); X) When I have had an appointment, there has not been waiting time (5–21%); 17) When you have had appointments with health professionals, did you feel that you were given enough time? (3–21%); 18) Have your relatives been involved to the extent you have wanted? (14–19%). For the items related to “kindness in care” (items 7–18), 13–42% of respondents selected the response category “Not relevant” when answering the items for out-of-hours GP. However, only 23 responses for out-of-hours GP were available for analysis. c) Structural validity When inspecting the correlation matrix for sampling adequacy, no correlations > 0.80 were identified (Appendix 3). However, there were six item pairs with correlations < 0.30. Of these pairs, item 18) Have your relatives been involved to the extent you have wanted? was part of four of them. Our empirical background, advisory board feedback, and pilot-testing indicated that it was relevant to include an item regarding informal caregivers. Thus, the item was included in the factor analyses despite low correlations. As PATH seemed to have either a 1-factor or 2-factor structure (eigenvalue > 1; parallel analysis; screeplot; Velicer’s minimum average partial) (Appendix 4), we analysed both 1-factor and 2-factor models (see Table 3). In the 1-factor structure, 7 of the 19 analysed items had factor loadings < 0.70 and 4 items had communalities < 0.40. We therefore continued analysing a 2-factor structure. Item X ( When I have had an appointment, there has not been waiting time. ) was removed because of low factor loadings and low communalities and after re-visiting the qualitative material [BLINDED REFERENCE]. We found that waiting time at appointments was not itself essential to patients’ experiences of quality in healthcare transitions. It was rather the perception of whether their time investment was worth its while that was important. Hence, we deleted item X (see Table 3), leaving 18 items in the PATH questionnaire. After the removal of item X ( When I have had an appointment, there has not been waiting time. ), item 14 ( Did the health professionals know your story? ) had low loadings on both factors. Item 14 refers to informational continuity, which we qualitatively found to be important for patients’ assessment of healthcare transitions. We therefore decided to keep item 14 in PATH but removed it from the factor structure and instead scored the item independently (see Table 3). In the 2-factor solution with item X ( When I have had an appointment, there has not been waiting time. ) and 14 ( Did the health professionals know your story? ) deleted, there was some cross-loading of items 7 ( Have you been involved in the decisions about your health to the extent that you wanted? ) and 15 ( Has the information you have received been understandable? ). However, we found both items were necessary to maintain content validity of patient assessment of transitions in healthcare settings. As both items loaded 0.55 in factor 1 and respectively 0.30 (item 15) and 0.36 (item 7) in factor 2, we kept the items in factor 1. Thus, we accepted the 2-factor solution displayed in Table 3 with six items (item 1–6) in factor 2 and eleven items (item 7–13 and item 15–18) in factor 1. The factors were labelled “Access and coordination” and “Kindness in care”. Item 14 ( Did the health professionals know your story? ) was removed from the 2-factor solution, but kept in the questionnaire (PATH final version) and scored separately. Discussion Summary We have developed an instrument for a Danish context that we expect could also be relevant outside of Denmark. The final PATH questionnaire contains 18 items, and the pilot-testing and field-testing have shown good structural validity and internal consistency, and satisfactory test-retest reliability. Development The scoping review [BLINDED REFERENCE], qualitative work [BLINDED REFERENCE], and pilot-testing showed the PATH questionnaire to be content valid in a Danish context. As the underlying conceptual framework [BLINDED REFERENCE] and factor structure are similar to other frameworks reported internationally ( 27 , 77 , 78 ), we expect that PATH may also be content valid in other countries with a universal health coverage scheme and the division of healthcare between regions and municipalities ( 79 ). In other settings we recommend evaluation of the content validity of PATH to support international comparisons of patient-experienced quality in healthcare settings. Also in line with the Danish context, the PATH questionnaire includes the healthcare settings of hospital, family doctor/general practice, home healthcare, municipal rehabilitation, early childhood nurse, and out-of-hours general practitioner. Not all these healthcare setting options would be relevant for other countries, and they are likely to require cultural adaptation alongside translation. We noted that out-of-hours general practitioner was only selected as a healthcare setting by 23 people in the field-test, and several of these people had chosen to respond “Not relevant” to several PATH items. This may indicate that the out-of-hours general practitioner or emergency medical service settings are less relevant for measurement of patient-experienced quality in healthcare transitions. Field-test In our exploratory factor analysis, the PATH questionnaire demonstrated structural validity and internal consistency (Cronbach’s alpha 0.93 and 0.87) for a 2-factor solution with 1 item scored separately when field-tested in 435 Danish adult patients. A 2-factor model is supported by Haggerty et al. ( 78 ) and our own qualitative work [BLINDED REFERENCE], but others have suggested more factors ( 25 , 46 , 51 , 80 ) or a bi-factor model ( 77 ). Thus, the structural validity of PATH should be evaluated further using confirmatory factor analysis and, possibly, item response theory methods ( 39 ). We found that informational continuity loaded on both the “Access and coordination” domain and the “Kindness in care” domain. Others have described informational continuity as a construct that forms part of the concept continuity of care ( 81 ), but there is some ambiguity in the definition and understanding of informational continuity ( 82 , 83 ). This lack of clarity means that attempts to measure the construct may be invalid. Donaldson suggests that both information asymmetry and information transfer are important aspects of informational continuity ( 83 ). This supports our findings of informational continuity loading on two factors, and our decision to score item 14 ( Did the health professionals know your story? ) separately, in that there is both an organisational aspect of information transfer and a human relational aspect of communication, kindness, and (a)symmetry between the communicating parties. Given the lack of clarity in defining informational continuity and understanding the association between this construct and patient-experienced quality in healthcare transitions, this should be explored further. Methodological considerations We find the rigidness and thoroughness of our conceptual definition and exploration of content validity to be a great strength in this study. Our recruitment strategy for the pilot-testing included a gynaecological and obstetric ward and thus skewed participant inclusion with regards to gender. As we have not seen evidence to suggest that the construct of patient-experienced quality in healthcare should be defined by gender, we expect the content validity of PATH to hold despite the gender-skewed inclusion. However, this may limit the interpretation of the content validity of the PATH questionnaire. We had a response rate of 37%. The average online survey response rate is 44% ( 84 ), leaving us at a slightly lower rate than average. Although our response rate of 37% may be considered low, this is a study of measurement properties rather than an epidemiological study. Therefore, the low response rate is not likely to have impacted the results of our EFA or test-retest reliability. We do see it as a strength that we managed to include a broad population group, as PATH is intended for use in a range of patient groups spanning different diseases and conditions, age groups, and genders. The lack of inclusion of psychiatric patients may be a limitation to the reliability of PATH in this patient group, however. Furthermore, we have assumed that PATH performs similarly in different population groups (e.g. genders, age groups) as is the custom for studies on development of measurement instruments ( 85 ). In the future, it would be beneficial to test the consistency of PATH in different subgroups to avoid incorrect inferences caused by measurement problems ( 85 ). We plan to do this in future studies of the interpretability of the PATH questionnaire. Our field-test showed only moderate test-retest reliability for PATH based on the weighted kappa. However, test-retest assumes that the underlying construct being measured is unchanged in the retest period. Due to study limitations, we were not able to explore whether the moderate test-retest reliability found is indeed due to measurement properties of PATH or an actual change in the respondents’ experiences of quality in healthcare transitions. The respondents were twice asked to assess the quality of care they received in the three most recent months, with a 21-day interval. This gave only 42-day overlap, which may explain the lower test-retest reliability. Furthermore, there was some imbalance in our table’s marginal totals with high prevalence of positive PATH scores. This may lead to the “kappa paradox” were high prevalence leads to high chance agreement and accordingly reduced kappa values ( 73 , 74 ). Thus, PABAK should likely be interpreted rather than weighted kappa. Our addition of PABAK values is a strength to the interpretation of PATH’s test-retest reliability. Others have argued that absolute measures of agreement are required to answer questions regarding test-retest reliability, rather than the relative measure of observer variation, which kappa represents ( 86 ). Calculating the proportion of specific agreement as suggested by de Vet et al. ( 86 ) may also have strengthened this studies interpretation of test-retest reliability. Yet, we find the PABAK values to indicate satisfactory test-retest reliability. It is a strength that the English version of PATH presented in this article has been systematically translated ( 76 ), ensuring consistency in the content of PATH. As this version of PATH has not been cross-culturally tested or adapted ( 76 ), however, this must be done prior to its use in English-speaking contexts. Overall, we see our systematic and consistent approach as a strength in the development of the PATH questionnaire. This provides transparency for potential users of PATH but has also facilitated the development of an instrument that can give patients a valid and reliable voice in the evaluation of transitions across healthcare settings. Equity has been suggested as a relevant aspect of patient-experienced quality of healthcare ( 26 ), but we have not formulated items directly related to equity or disparity. We believe equity is indirectly captured in the “Kindness in care” domain, but we recommend testing this hypothesis further as our study has limitations in the inclusion of subgroups particularly exposed to discrimination in healthcare. Conclusions This study is important because valid and reliable assessment of patients’ experiences of healthcare transitions is crucial to the evaluation and improvement of quality and safety in care pathways including transitions. We have developed a generic patient-reported experience measure (PREM) for the assessment of patient-experienced quality in healthcare transitions. The “ Patient Assessment of Transitions in Healthcare settings” (PATH) questionnaire was developed and tested through an iterative and rigid process that adhered to the COSMIN group’s recommendations. PATH demonstrated satisfactory validity and reliability when measuring “Kindness in care” and “Access and coordination”, with high internal consistency and structural validity in a Danish patient population with a broad range of diagnoses and ages. The PATH questionnaire is relevant and available for use in quality monitoring and quality improvement research, but we recommend further testing of its measurement properties alongside its practical application. Abbreviations PATH Patient Assessment of Transitions in Healthcare settings PREM Patient-reported experience measure COSMIN COSMIN is an initiative of an international multidisciplinary team of researchers working for COnsensus-based Standards for the selection of health Measurement Instruments (87) GP General practitioner MC Municipal care REDCap Research electronic data capture (88) OPEN Open Data Explorative Network EFA Explorative factor analysis PABAK Prevalence-adjusted and bias-adjusted kappa Declarations Ethics approval and consent to participate Data were collected in accordance with Danish Data Protection Law no. 502 of 23/05/2018 (89) and the Declaration of Helsinki (90), and were approved by the legal department at the Research and Innovation Organisation, University of Southern Denmark, Notification number 10.953. According to Danish law on ethical scientific health data processing § 14 part 1 (91), no ethics permissions were required for this study. This was recognised by the scientific ethics committee in the Region of Southern Denmark in case number 20202000-60. All experimental protocols were approved by the Graduate School at the University of Southern Denmark. Informed consent was obtained from all participants. All participants were informed about guaranteed anonymity, that they could withdraw consent at any time, and that data handling according to current standards would be kept confidential. Consent for publication Not applicable Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request, provided the request can legally be met with the granted permissions. Competing interests The authors declare that they have no competing interests. Funding The author(s) disclosed receipt of the following financial support for the research, authorship, or publication of this article: This work was supported by the local research fund at Næstved, Slagelse, and Ringsted hospitals; by a program grant for Exercise First from Region Zealand; and a faculty scholarship from the Faculty of Health Sciences at University of Southern Denmark. Authors’ contributions SW compiled the item-bank and facilitated the development process and advisory board meetings. SW also planned and conducted the pilot-tests and the field-test, and drafted the manuscript. HHL contributed substantially to the conception and aim of the study, took part in the development of PATH items, and supervised the evaluation of psychometric properties of PATH. HHL also revised the manuscript critically for important intellectual content. ENP took part in the development of PATH items and revised the manuscript critically for important intellectual content. CS made substantial contributions to the conception and design of the study and revised the manuscript critically. CG made substantial contributions to the translation of PATH and critically revised the manuscript. SM made substantial contributions to the conception, statistical analyses, and evaluation of the PATH field-test. SM also critically revised the manuscript for important intellectual content. LM contributed substantially to the conception and aim of the study, took part in the development of PATH items, revised the manuscript critically for important intellectual content, and supervised the project management All authors read and approved the final manuscript. Acknowledgements Not applicable References Allen J, Hutchinson AM, Brown R, Livingston PM. User experience and care for older people transitioning from hospital to home: Patients’ and carers’ perspectives. Health Expect Int J Public Particip Health Care Health Policy. 2018;21(2):518–27. 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Supplementary Files Appendix1PATHv5consensus.docx Appendix2Descriptiveitemsresponsefrequency20240215.docx Appendix3correlationmatrix20231027.xlsx Appendix4numberoffactors.docx Appendix5weightedkappa21days20240203.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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17:35:35","extension":"docx","order_by":7,"title":"","display":"","copyAsset":false,"role":"supplement","size":46208,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix2Descriptiveitemsresponsefrequency20240215.docx","url":"https://assets-eu.researchsquare.com/files/rs-3982192/v1/18468cee451d3410d3ceb2e9.docx"},{"id":52542517,"identity":"5a83eb12-b50a-4b2b-8121-11a360a61d55","added_by":"auto","created_at":"2024-03-12 17:43:35","extension":"xlsx","order_by":8,"title":"","display":"","copyAsset":false,"role":"supplement","size":13503,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix3correlationmatrix20231027.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-3982192/v1/17eead4bf02ee4037175e7a5.xlsx"},{"id":52541822,"identity":"3d29fbe9-e8db-4061-a64b-a4df86cd6eb5","added_by":"auto","created_at":"2024-03-12 17:35:35","extension":"docx","order_by":9,"title":"","display":"","copyAsset":false,"role":"supplement","size":126897,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix4numberoffactors.docx","url":"https://assets-eu.researchsquare.com/files/rs-3982192/v1/932973074a24f5cb3248bb4e.docx"},{"id":52541821,"identity":"24aa4d12-84e8-4492-82db-530e178c826e","added_by":"auto","created_at":"2024-03-12 17:35:35","extension":"docx","order_by":10,"title":"","display":"","copyAsset":false,"role":"supplement","size":16717,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix5weightedkappa21days20240203.docx","url":"https://assets-eu.researchsquare.com/files/rs-3982192/v1/3b91e1dab507dd505f39c9cd.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Development and psychometric properties of the “Patient Assessment of Transitions in Healthcare settings (PATH)” questionnaire","fulltext":[{"header":"Background","content":"\u003cp\u003eTransitions between healthcare settings can be burdensome for patients and caregivers (\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5 CR6 CR7\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) and may lead to information loss and lower continuity of care (\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). By enhancing patient-experienced quality of care in both primary and secondary sectors of the health care system, patient safety and clinical effectiveness can be improved (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Patients\u0026rsquo; experiences can be explored through in-depth interviews, but valid and reliable patient-reported experience measures (PREMs) can be a useful and more cost-effective way of assessing patient-experienced quality (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eQualitative literature reviews (\u003cspan additionalcitationids=\"CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22 CR23\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) suggest that the construct \u0026ldquo;patient-experienced quality in healthcare transitions\u0026rdquo; consists of the two domains \u0026ldquo;organisation\u0026rdquo; and \u0026ldquo;human relations\u0026rdquo; [BLINDED REFERENCE]. A recent qualitative study further detailed that system flexibility and kindness were essential to patients\u0026rsquo; experiences of quality in healthcare transitions [BLINDED REFERENCE]. Many studies have explored the quality of care in pathways including transitions between settings experienced by people with various forms of chronic disease (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e), cancer or palliative care (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e), or by older people (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), but it appears that the need for system flexibility and kindness is universal [BLINDED REFERENCE].\u003c/p\u003e \u003cp\u003eSeveral generic conceptual frameworks have been proposed that support the two-dimensional approach of organisation and human relations for evaluating patient-experienced quality of care (\u003cspan additionalcitationids=\"CR26 CR27 CR28 CR29\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e), and numerous PREMs have been developed for specific patient contexts (\u003cspan additionalcitationids=\"CR32 CR33 CR34 CR35 CR36 CR37\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). However, none of them appear to have sufficient content validity (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) for use by a patient population with a wide range of diagnoses, comorbidities, and ages who undergo transition in the healthcare system [BLINDED REFERENCE]. The existing PREMs are either disease specific (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e), or inadequate in capturing the entire care continuum across healthcare settings (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eTherefore, the aim of the current study was to develop a valid generic measure for assessment of patient-experienced quality in transitions between healthcare settings (PATH) across a broad range of conditions and diagnoses, comorbidities, and patient ages. Our second aim was to evaluate the structural validity, internal consistency, and reliability of PATH in a Danish patient population. The final 18-item Danish questionnaire was translated into English to enable its use outside of Denmark.\u003c/p\u003e"},{"header":"Method","content":"\u003cp\u003eThe development of PATH followed a 6-step strategy as described by de Vet et al. (\u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e) whereas the psychometric testing followed the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology (\u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e44\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDevelopment\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ea) Development of the initial item bank\u003c/p\u003e\n\u003cp\u003eIn a scoping review of patient-experienced quality in healthcare transitions, we identified six themes in the domain of \u0026ldquo;organisation\u0026rdquo; and a further six themes in the domain of \u0026ldquo;human relations\u0026rdquo;, resulting in 12 relevant themes for the assessment of patient-experienced quality in healthcare transitions. These themes were relevant for adult patients independent of diagnoses, age, sex, and comorbidities. Further, we identified 21 PREMs (\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e45\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e65\u003c/span\u003e) that had items in at least five of these 12 relevant themes [BLINDED REFERENCE].\u003c/p\u003e\n\u003cp\u003eItems were extracted from the 21 PREMs to produce an item bank. The 21 PREMs and the item bank were presented to an advisory board comprising a medical doctor, two managers from municipalities, two patient representatives, two senior healthcare researchers, and a hospital quality manager. A focus group meeting with the advisory board focused on the relevance, comprehensiveness, and possible deficiencies of the item bank for assessing patient-experienced quality in healthcare transitions. LM prepared the minutes of the meeting and documented the recommendations from the advisory board.\u003c/p\u003e\n\u003cp\u003eb) Item development\u003c/p\u003e\n\u003cp\u003eTo further understand and define the constructs we aimed to measure, we assigned the items from the item bank to the themes found in our scoping review [BLINDED REFERENCE] and to codes produced in a previous qualitative study of patient experiences in healthcare transitions [BLINDED REFERENCE]. This generated an overview of existing item formulations within a number of themes or codes and formed the empirical basis of our PREM development.\u003c/p\u003e\n\u003cp\u003eThe item formulations were then reworded in Danish to be relevant from a user perspective, informed by our overview of the item bank and qualitative findings. This work was carried out by a group comprising a researcher with knowledge of patient-experienced quality in healthcare transitions (SW), an expert in psychometrics (HHL), a language philosopher (ENP), and an expert in clinical quality (LM).\u003c/p\u003e\n\u003cp\u003ec) Pilot-testing\u003c/p\u003e\n\u003cp\u003eWe pilot-tested the potential PREM items in an iterative, three-phased process in which 19 respondents completed the PATH questionnaire. The respondents were 16 patients recruited to represent patients with a broad range of disease, age, and treatment course; two hospital employees with academic background and clinical quality experience; and one physiotherapist who also had patient experience of care transitions.\u003c/p\u003e\n\u003cp\u003eContent validity: In the pilot-test we examined the degree to which the content of PATH was an adequate reflection of the patient-experienced quality in healthcare transitions (\u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e). The relevance of each item was addressed with the question \u003cem\u003e\u0026ldquo;How important do you find this item?\u0026rdquo;\u003c/em\u003e with a numerical response scale of 0\u0026ndash;10 (0\u0026thinsp;=\u0026thinsp;not at all important, 10\u0026thinsp;=\u0026thinsp;very important). Answers were elicited from ten patient participants. The comprehensiveness of the questionnaire was assessed with the question \u003cem\u003e\u0026ldquo;Is there anything important to your experience that we have not asked about?\u0026rdquo;\u003c/em\u003e The comprehensibility of the questionnaire was assessed with the question \u003cem\u003e\u0026ldquo;Is there anything we asked about, which you found unclear?\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants in the first pilot phase were asked to identify which healthcare providers were involved in their care path. The evaluation of relevant healthcare providers was then included in the second and third pilot phases.\u003c/p\u003e\n\u003cp\u003eThroughout the test phases, we continuously referred back to the empirical basis and definition of the construct [BLINDED REFERENCE] to evaluate our findings and revise the questionnaire as suggested in the COSMIN methodology (\u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eField-test\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ea) Participants\u003c/p\u003e\n\u003cp\u003eThe field-test was conducted with a patient group that represented a broad range of patients in healthcare transitions to support our aim of developing a generic measure. Participants were recruited through the physiotherapy and occupational therapy unit at N\u0026aelig;stved-Slagelse-Ringsted Hospitals in Region Zealand, Denmark and through the gynaecological and obstetrical unit at Odense University Hospital, Denmark. The patients had been discharged from hospital 30\u0026ndash;60 days prior to recruitment, and inclusion criteria were \u0026ge;\u0026thinsp;18 years of age and contact with at least two different healthcare settings (e.g. hospital, general practitioner, municipal care).\u003c/p\u003e\n\u003cp\u003eb) Data collection\u003c/p\u003e\n\u003cp\u003eThe PATH questionnaire prefinal version 3 was distributed to patients through the electronic data capture tool REDCap (\u003cspan class=\"CitationRef\"\u003e66\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e67\u003c/span\u003e), hosted at Open Data Explorative Network (OPEN) by links sent to potential respondents\u0026rsquo; personal digital post-box (\u0026ldquo;e-boks\u0026rdquo;), which is a secure national system for sending and receiving electronic mail containing sensitive data (\u003cspan class=\"CitationRef\"\u003e68\u003c/span\u003e). When potential respondents opened the link, they were presented with information about the PATH study and asked if they consented to participate.\u003c/p\u003e\n\u003cp\u003eParticipants were asked to assess the past three months of their care journey. Predefined healthcare providers could be chosen including an \u0026ldquo;Other healthcare provider/s\u0026rdquo; with a free-text field, giving the participants the option of adding other relevant healthcare providers. The PATH questionnaire was filled out for each chosen healthcare provider.\u003c/p\u003e\n\u003cp\u003eFor test-retest reliability, participants who answered the initial questionnaire within 21 days with no missing answers were invited to complete the questionnaire again. We expected patients\u0026rsquo; experiences of quality in healthcare transitions to be stable in the 21 day period, because we assumed that most would not have had new encounters with healthcare services, e.g. readmissions, change in GP, or change in services provided by the municipality, in that time period.\u003c/p\u003e\n\u003cp\u003ec) Sample size\u003c/p\u003e\n\u003cp\u003eWe aimed for 250\u0026ndash;300 responses to enable factor analysis (rule of thumb is approx. 5\u0026ndash;10 patients/item (\u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e69\u003c/span\u003e)) so questionnaires were distributed until 300 responses were reached. We aimed for 50 repeated responses for test-retest reliability analysis and included 70 respondents allowing for dropouts.\u003c/p\u003e\n\u003cp\u003ed) Statistical analyses\u003c/p\u003e\n\u003cp\u003eItem characteristics were calculated including the percentage of missing items, skewness, and kurtosis (\u003cspan class=\"CitationRef\"\u003e70\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eStructural validity: Exploratory factor analysis (EFA) with a stepwise approach (\u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e) was used to evaluate how well the PATH scores represented the multidimensional nature of the quality of healthcare transitions as experienced by patients. First, the correlation matrix was assessed for correlations between 0.3 and 0.8 for sampling adequacy. Bartlett\u0026rsquo;s test of sphericity had a p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.001 and Kaiser-Meyer-Olkin test of sampling adequacy was 0.906, both indicating that factor analysis was appropriate. The number of factors to extract was determined using eigenvalues\u0026thinsp;\u0026gt;\u0026thinsp;1, examination of screeplot, and parallel analysis (\u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e). We chose a principal factor analysis with oblique Promax (\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e) rotation assuming correlation between factors. Factor loadings\u0026thinsp;\u0026gt;\u0026thinsp;0.7 were desirable, but factor loadings as low as 0.30 could be accepted depending on the conceptual definition of the construct. Communalities represent the amount of variance that is explained by a given item via all factors (\u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e). We aimed for communalities\u0026thinsp;\u0026gt;\u0026thinsp;0.40 (\u003cspan class=\"CitationRef\"\u003e71\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eInternal consistency of PATH, or the degree of interrelatedness among PATH items, was evaluated by estimating Cronbach\u0026rsquo;s alpha for each domain, with 0.7\u0026ndash;0.9 considered satisfactory.\u003c/p\u003e\n\u003cp\u003eReliability (test-retest) was analysed using percentage agreement and weighted kappa with linearly decreasing weights from the diagonal for each item of the PATH questionnaire (\u003cspan class=\"CitationRef\"\u003e72\u003c/span\u003e). In addition prevalence-adjusted and bias-adjusted kappa (PABAK) were calculated to take prevalence-skewed responses into account (\u003cspan class=\"CitationRef\"\u003e72\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e74\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eAll analyses were performed using Stata v. 18.0 (\u003cspan class=\"CitationRef\"\u003e75\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eThe field-test resulted in the final Danish version of PATH (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u003ca href=\"https://orcid.org/0000-0002-9212-2122\" target=\"_blank\"\u003ewww.spoergeskemaer.dk/path\u003c/a\u003e\u003c/span\u003e\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n\u003ch2\u003eTranslation\u003c/h2\u003e\n\u003cp\u003eThe final Danish version of PATH was translated into English (Appendix 1) for this article in a structured forward-backward translation process (\u003cspan class=\"CitationRef\"\u003e76\u003c/span\u003e). Two native English speakers independently translated PATH from Danish into English. The two versions were synthesised into one questionnaire during a consensus meeting, and this was translated back into Danish by two bilingual individuals who were unacquainted with the original Danish items. The English version was then compared to the original Danish version in a final consensus meeting. The English version was not culturally validated or tested.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cem\u003ea) Development\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eItem bank development\u003c/p\u003e\n\u003cp\u003eWe developed a bank of English items, which was presented to the advisory board. This presentation led to addition of items on the competence of healthcare providers and confirmation that items regarding human relations were indeed necessary to incorporate. There was also consensus to leave out items directly related to equity.\u003c/p\u003e\n\u003cp\u003eb) Item development\u003c/p\u003e\n\u003cp\u003eFollowing advisory board recommendations, 42 items were developed in Danish to go through pilot-testing (PATH prefinal version 1). The items were thematically related to effectiveness, efficiency, competence of healthcare providers, timeliness, navigation, access and availability, responsibility, informational continuity, patient centeredness and individualised care, kindness and compassion, relational continuity, communication, and informal caregivers.\u003c/p\u003e\n\u003cp\u003eFigure 1 illustrates the development of PATH resulting in an 18-item patient-reported experience measure for the assessment of patient-experienced quality in healthcare transitions.\u003c/p\u003e\n\u003cp\u003ec) Pilot-testing\u003c/p\u003e\n\u003cp\u003ePhase 1: As a result of the first pilot-test, 22 items were removed, leaving 20 items, and one item (item X in Table\u0026nbsp;1) was reworded (PATH prefinal version 2). The 22 items were removed due to redundancy. Item X was reworded because of comprehension issues.\u003c/p\u003e\n\u003cp\u003ePhase 2: Following pilot-test phase 2, we deleted one more item because of redundancy and re-phrased items 2 and X to improve comprehensibility and relevance (PATH prefinal version 3). The 16 patient participants (13 women and 3 men) rated items X \u003cem\u003e(When I have had an appointment, there has not been waiting time.\u003c/em\u003e) and 17 \u003cem\u003e(When you have had appointments with health professionals, did you feel that you were given enough time?\u003c/em\u003e) as the least relevant (7.4 on the 0\u0026ndash;10 scale) items of PATH prefinal version 3, while item 11 \u003cem\u003e(Have you been treated in a compassionate way by the health professionals?\u003c/em\u003e) was rated most relevant (9.7 on the 0\u0026ndash;10 scale) (Table\u0026nbsp;1). Hence, the 19 items remaining in PATH prefinal version 3 were all relevant according to the pilot-test.\u003c/p\u003e\n\u003cp\u003eThe participants pointed out a need to discriminate between healthcare providers for 13 of the tested items (Table\u0026nbsp;1). This resulted in an adaption of the PATH structure for the field-test, where items 6\u0026ndash;18 were asked for each healthcare provider involved in the patient\u0026rsquo;s care pathway (i.e. hospital, GP, home healthcare, municipal rehabilitation, early childhood nurse, and/or out-of-hours GP). For the pilot-test, researchers determined which healthcare providers to include, but this was iteratively evaluated throughout the pilot-test phases and again after the field-test.\u003c/p\u003e\n\u003cp\u003ePhase 3: In phase three of the pilot-test, the participants found the PATH items to be relevant, comprehensive and comprehensible. Thus, all relevant aspects of healthcare transitions were covered, and no further items were suggested. This left 19 items for field-testing (Fig.\u0026nbsp;1).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable\u0026nbsp;1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003ePilot-tested items for PATH\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth colspan=\"3\" align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eN\u0026thinsp;=\u0026thinsp;16\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eItem number\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eItem\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRelevance mean (0\u0026ndash;10)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNeed for discrimination between healthcare setting\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDo you have a regular healthcare professional who knows what is going on with you?\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHave you had access to help when you have needed it?\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(Item re-worded after the scoring of relevance was conducted)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHave you had the opportunity to ask questions when you have needed to?\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHas the information you have received from the health professionals been consistent?\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHas there been a plan for what was going to happen to you?\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHave the efforts regarding your health been well coordinated?\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHave you been involved in the decisions about your health to the extent that you wanted?\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDo you feel your concerns have been listened to?\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8.8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHave you been involved in the scheduling of your treatment?\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHave you been asked about how your health has affected your life?\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHave you been treated in a compassionate way by the health professionals?\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9.7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHave you felt comfortable telling the healthcare professionals personal things about yourself?\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHave you had confidence in the professional competence of the health professionals?\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8.7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDid the health professionals know your story?\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8.7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHas the information you have received been understandable?\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHave you received all the information you have needed?\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eWhen I have had an appointment, there has not been waiting time.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e17\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eWhen you have had appointments with health professionals, did you feel that you were given enough time?\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHave your relatives been involved to the extent you have wanted?\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\n\u003cp\u003e\u003cem\u003eField test\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ea) Field-test participants\u003c/p\u003e\n\u003cp\u003eWe sent \u0026lsquo;e-boks\u0026rsquo; invitations to 1529 potential participants. Of these, 347 were excluded as they were exempt from \u0026lsquo;e-boks\u0026rsquo;, yielding 1182 potential respondents. 329 of the potential respondents filled out the PATH questionnaire \u0026mdash;56 responded partially, and 273 had complete PATH responses, giving a response frequency of 37%. The respondents were evenly distributed by age and sex. Most respondents were discharged from an orthopaedic surgical ward, gynaecological ward, or obstetric ward (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003cstrong\u003eTable 2 - Demographic description of participants in the field-test (complete and incomplete PATH \u003c/strong\u003e\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Taba\" border=\"1\"\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eTotal n\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eComplete n (%)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eIncomplete n (%)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e82\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e65 (\u003cspan class=\"CitationRef\"\u003e79\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e17 (\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFemale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e247\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e208 (\u003cspan class=\"CitationRef\"\u003e84\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e39 (\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.312\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAge\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18\u0026ndash;29\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e37\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e32 (\u003cspan class=\"CitationRef\"\u003e86\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5 (\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e30\u0026ndash;39\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e61\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e45 (\u003cspan class=\"CitationRef\"\u003e74\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16 (\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e40\u0026ndash;49\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10 (\u003cspan class=\"CitationRef\"\u003e91\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e50\u0026ndash;59\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e34\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e32 (94)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e60\u0026ndash;69\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e65\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e58 (\u003cspan class=\"CitationRef\"\u003e89\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7 (\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e70\u0026ndash;79\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e88\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e70 (\u003cspan class=\"CitationRef\"\u003e80\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18 (\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026gt;\u0026thinsp;80\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e33\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e26 (\u003cspan class=\"CitationRef\"\u003e79\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7 (\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.111\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDischarge unit\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGynecology OUH\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e40\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e38 (95)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eObstetric OUH\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e89\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e67 (\u003cspan class=\"CitationRef\"\u003e75\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e22 (\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGeriatric SNR\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12 (92)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOrthopedic Surgery SNR\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e135\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e113 (\u003cspan class=\"CitationRef\"\u003e84\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e22 (\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePsychiatry SNR\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (100)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGeneral Medicine SNR\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (100)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePhysio- and Occupational therapy SNR\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14 (\u003cspan class=\"CitationRef\"\u003e88\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNeurology SNR\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7 (\u003cspan class=\"CitationRef\"\u003e78\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEmergency SNR\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6 (100)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOther\u003csup\u003e5\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13 (\u003cspan class=\"CitationRef\"\u003e72\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5 (\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.260\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e329\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e273\u003c/strong\u003e (\u003cspan class=\"CitationRef\"\u003e83\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e56\u003c/strong\u003e (\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd colspan=\"5\" align=\"left\"\u003e\n\u003cp\u003e1 Fisher\u0026rsquo;s exact test; 2 Pearson\u0026rsquo;s chi\u003csup\u003e2\u003c/sup\u003e test; 3 Odense University Hospital including Svendborg location; 4 Slagelse, Naestved, and Ringsted Hospitals; 5 Gastroenterology, Clinical Oncology, Pulmonary Medicine, Cardiology, and Surgical Unit SNR\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\n\u003cp\u003ed) Internal consistency\u003c/p\u003e\n\u003cp\u003eCronbach\u0026rsquo;s alpha for a 2-factor solution excluding item X and 14 was 0.87 for \u0026ldquo;Access and coordination\u0026rdquo; and 0.93 for \u0026ldquo;Kindness in care\u0026rdquo;. This reflects high internal consistency (see Table\u0026nbsp;3).\u003c/p\u003e\n\u003cp\u003ee) Test-retest reliability\u003c/p\u003e\n\u003cp\u003eFull test-retest responses were received from 54 respondents. Weighted kappa values were between 0.37 and 0.47 for the domain \u0026ldquo;Access and coordination\u0026rdquo; and between 0.45 and 0.69 for the domain \u0026ldquo;Kindness in care\u0026rdquo; (Appendix 5). The single item on informational continuity (Item 17) yielded a weighted kappa of 0.55 (Appendix 5). This indicated only moderate test-retest reliability for PATH for a retest period of 21 days. However, there was a skewed prevalence of responses in the \u0026ldquo;To a great extent\u0026rdquo; and \u0026ldquo;To a very great extent\u0026rdquo; response categories, and the PABAK values were higher (0.46\u0026ndash;0.67 for \u0026ldquo;Access and coordination\u0026rdquo; and 0.59\u0026ndash;0.81 for \u0026ldquo;Kindness in care\u0026rdquo;). This, and high agreement percentages (78\u0026ndash;93%) indicates satisfactory test-retest reliability.\u003c/p\u003e\n\u003ch3\u003eTranslation\u003c/h3\u003e\n\u003cp\u003eThe translation process included discussion of item 7 (\u003cem\u003eHave you been involved in the decisions about your health to the extent that you wanted?\u003c/em\u003e) and item 9 (\u003cem\u003eHave you been involved in the scheduling of your treatment?\u003c/em\u003e). The direct translation of item 9 from Danish into English would include the word \u003cem\u003eplanning\u003c/em\u003e, but then items 7 and 9 would have almost the same meaning in English. Thus, the translation process led to a discussion of the meaning of item 9 and whether the item was redundant. Consensus was reached to retain item 9 using the word \u003cem\u003escheduling\u003c/em\u003e due to empirical data indicating that patients experience quality in healthcare transitions when the healthcare system shows flexibility to the patients\u0026rsquo; needs and time schedules.\u003c/p\u003e\n\u003cp\u003eThe full version of the Danish and English PATH questionnaires including a user manual can be found on \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u003ca href=\"https://orcid.org/0000-0002-9212-2122\" target=\"_blank\"\u003ewww.spoergeskemaer.dk/path\u003c/a\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\n\u003cp\u003eTable\u0026nbsp;3 \u0026ndash; Exploratory factor analysis of PATH \u0026ndash; prefinal version 3\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tabb\" border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"3\" rowspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e1 factor promax(\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e) rotation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003e2 factor promax(\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e) rotation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003e2 factor promax(\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e) rotation\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eAll Items\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eItem X deleted\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eItems X and 14 deleted\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eItem number\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eItem name\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCom\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCom\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eKindness in Care\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAccess and Coordination\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCom\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eIn charge\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.52\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.34\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.60\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.33\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.57\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.31\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eAccess\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.67\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.63\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.60\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.5\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eQuestions\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.78\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.71\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.81\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.71\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.77\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.71\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eCoherence\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.63\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.46\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.63\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.46\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.63\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.45\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003ePlan\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.76\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.67\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.79\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.67\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.80\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.68\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eCoordination\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.79\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.75\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.85\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.75\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.84\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.75\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eInvolved decisions\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.85\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.72\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.53\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.38\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.72\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.55\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.36\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.72\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eWorries\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.88\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.77\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.76\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.8\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eInvolved planning\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.77\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.61\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.66\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.62\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.68\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.63\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eHolistic approach\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.62\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.42\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.67\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.42\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.68\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.42\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eCaring care\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.78\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.71\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.92\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.90\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.71\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eTrust\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.70\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.54\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.77\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.55\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.76\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.53\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eTrust qualifications\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.81\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.79\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.78\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eKnow story\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.62\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.39\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.30\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.37\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eInformation compre\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.80\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.64\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.53\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.32\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.64\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.55\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.30\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.64\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eInformation suff\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.84\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.72\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.65\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.72\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.65\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.72\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eWaiting time\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.53\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.28\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e17\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eAppointment time\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.73\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.78\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.58\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.78\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.58\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eCaretaker involve\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.49\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.27\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.54\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.27\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.56\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.29\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eExplained variance %\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e84%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e79%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e72%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e80%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e71%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCronbach\u0026rsquo;s alpha\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.94\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.93\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.87\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.93\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.87\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd colspan=\"9\" align=\"left\"\u003e\n\u003cp\u003e1: Communalities. 2: Empty cells\u0026thinsp;=\u0026thinsp;factorloadings\u0026thinsp;\u0026lt;\u0026thinsp;0.30\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eb) PATH item characteristics\u003c/p\u003e\n\u003cp\u003eItems had 0\u0026ndash;21% missing responses (Appendix 2). The five items with the most missing responses were items: 16) \u003cem\u003eHave you received all the information you have needed?\u003c/em\u003e (6\u0026ndash;19%); 14) \u003cem\u003eDid the health professionals know your story?\u003c/em\u003e (6\u0026ndash;17%); X) \u003cem\u003eWhen I have had an appointment, there has not been waiting time\u003c/em\u003e (5\u0026ndash;21%); 17) \u003cem\u003eWhen you have had appointments with health professionals, did you feel that you were given enough time?\u003c/em\u003e (3\u0026ndash;21%); 18) \u003cem\u003eHave your relatives been involved to the extent you have wanted?\u003c/em\u003e (14\u0026ndash;19%).\u003c/p\u003e\n\u003cp\u003eFor the items related to \u0026ldquo;kindness in care\u0026rdquo; (items 7\u0026ndash;18), 13\u0026ndash;42% of respondents selected the response category \u0026ldquo;Not relevant\u0026rdquo; when answering the items for out-of-hours GP. However, only 23 responses for out-of-hours GP were available for analysis.\u003c/p\u003e\n\u003cp\u003ec) Structural validity\u003c/p\u003e\n\u003cp\u003eWhen inspecting the correlation matrix for sampling adequacy, no correlations\u0026thinsp;\u0026gt;\u0026thinsp;0.80 were identified (Appendix 3). However, there were six item pairs with correlations\u0026thinsp;\u0026lt;\u0026thinsp;0.30. Of these pairs, item 18) \u003cem\u003eHave your relatives been involved to the extent you have wanted?\u003c/em\u003e was part of four of them. Our empirical background, advisory board feedback, and pilot-testing indicated that it was relevant to include an item regarding informal caregivers. Thus, the item was included in the factor analyses despite low correlations. As PATH seemed to have either a 1-factor or 2-factor structure (eigenvalue\u0026thinsp;\u0026gt;\u0026thinsp;1; parallel analysis; screeplot; Velicer\u0026rsquo;s minimum average partial) (Appendix 4), we analysed both 1-factor and 2-factor models (see Table\u0026nbsp;3). In the 1-factor structure, 7 of the 19 analysed items had factor loadings\u0026thinsp;\u0026lt;\u0026thinsp;0.70 and 4 items had communalities\u0026thinsp;\u0026lt;\u0026thinsp;0.40. We therefore continued analysing a 2-factor structure. Item X (\u003cem\u003eWhen I have had an appointment, there has not been waiting time.\u003c/em\u003e) was removed because of low factor loadings and low communalities and after re-visiting the qualitative material [BLINDED REFERENCE]. We found that waiting time at appointments was not itself essential to patients\u0026rsquo; experiences of quality in healthcare transitions. It was rather the perception of whether their time investment was worth its while that was important. Hence, we deleted item X (see Table\u0026nbsp;3), leaving 18 items in the PATH questionnaire.\u003c/p\u003e\n\u003cp\u003eAfter the removal of item X (\u003cem\u003eWhen I have had an appointment, there has not been waiting time.\u003c/em\u003e), item 14 (\u003cem\u003eDid the health professionals know your story?\u003c/em\u003e) had low loadings on both factors. Item 14 refers to informational continuity, which we qualitatively found to be important for patients\u0026rsquo; assessment of healthcare transitions. We therefore decided to keep item 14 in PATH but removed it from the factor structure and instead scored the item independently (see Table\u0026nbsp;3).\u003c/p\u003e\n\u003cp\u003eIn the 2-factor solution with item X (\u003cem\u003eWhen I have had an appointment, there has not been waiting time.\u003c/em\u003e) and 14 (\u003cem\u003eDid the health professionals know your story?\u003c/em\u003e) deleted, there was some cross-loading of items 7 (\u003cem\u003eHave you been involved in the decisions about your health to the extent that you wanted?\u003c/em\u003e) and 15 (\u003cem\u003eHas the information you have received been understandable?\u003c/em\u003e). However, we found both items were necessary to maintain content validity of patient assessment of transitions in healthcare settings. As both items loaded 0.55 in factor 1 and respectively 0.30 (item 15) and 0.36 (item 7) in factor 2, we kept the items in factor 1. Thus, we accepted the 2-factor solution displayed in Table\u0026nbsp;3 with six items (item 1\u0026ndash;6) in factor 2 and eleven items (item 7\u0026ndash;13 and item 15\u0026ndash;18) in factor 1. The factors were labelled \u0026ldquo;Access and coordination\u0026rdquo; and \u0026ldquo;Kindness in care\u0026rdquo;. Item 14 (\u003cem\u003eDid the health professionals know your story?\u003c/em\u003e) was removed from the 2-factor solution, but kept in the questionnaire (PATH final version) and scored separately.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eSummary\u003c/h2\u003e \u003cp\u003eWe have developed an instrument for a Danish context that we expect could also be relevant outside of Denmark. The final PATH questionnaire contains 18 items, and the pilot-testing and field-testing have shown good structural validity and internal consistency, and satisfactory test-retest reliability.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eDevelopment\u003c/h3\u003e\n\u003cp\u003eThe scoping review [BLINDED REFERENCE], qualitative work [BLINDED REFERENCE], and pilot-testing showed the PATH questionnaire to be content valid in a Danish context. As the underlying conceptual framework [BLINDED REFERENCE] and factor structure are similar to other frameworks reported internationally (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e, \u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e), we expect that PATH may also be content valid in other countries with a universal health coverage scheme and the division of healthcare between regions and municipalities (\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e). In other settings we recommend evaluation of the content validity of PATH to support international comparisons of patient-experienced quality in healthcare settings. Also in line with the Danish context, the PATH questionnaire includes the healthcare settings of hospital, family doctor/general practice, home healthcare, municipal rehabilitation, early childhood nurse, and out-of-hours general practitioner. Not all these healthcare setting options would be relevant for other countries, and they are likely to require cultural adaptation alongside translation. We noted that out-of-hours general practitioner was only selected as a healthcare setting by 23 people in the field-test, and several of these people had chosen to respond \u0026ldquo;Not relevant\u0026rdquo; to several PATH items. This may indicate that the out-of-hours general practitioner or emergency medical service settings are less relevant for measurement of patient-experienced quality in healthcare transitions.\u003c/p\u003e\n\u003ch3\u003eField-test\u003c/h3\u003e\n\u003cp\u003eIn our exploratory factor analysis, the PATH questionnaire demonstrated structural validity and internal consistency (Cronbach\u0026rsquo;s alpha 0.93 and 0.87) for a 2-factor solution with 1 item scored separately when field-tested in 435 Danish adult patients. A 2-factor model is supported by Haggerty et al. (\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e) and our own qualitative work [BLINDED REFERENCE], but others have suggested more factors (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e) or a bi-factor model (\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e). Thus, the structural validity of PATH should be evaluated further using confirmatory factor analysis and, possibly, item response theory methods (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWe found that informational continuity loaded on both the \u0026ldquo;Access and coordination\u0026rdquo; domain and the \u0026ldquo;Kindness in care\u0026rdquo; domain. Others have described informational continuity as a construct that forms part of the concept continuity of care (\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e), but there is some ambiguity in the definition and understanding of informational continuity (\u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e, \u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e). This lack of clarity means that attempts to measure the construct may be invalid. Donaldson suggests that both information asymmetry and information transfer are important aspects of informational continuity (\u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e). This supports our findings of informational continuity loading on two factors, and our decision to score item 14 (\u003cem\u003eDid the health professionals know your story?\u003c/em\u003e) separately, in that there is both an organisational aspect of information transfer and a human relational aspect of communication, kindness, and (a)symmetry between the communicating parties. Given the lack of clarity in defining informational continuity and understanding the association between this construct and patient-experienced quality in healthcare transitions, this should be explored further.\u003c/p\u003e\n\u003ch3\u003eMethodological considerations\u003c/h3\u003e\n\u003cp\u003eWe find the rigidness and thoroughness of our conceptual definition and exploration of content validity to be a great strength in this study. Our recruitment strategy for the pilot-testing included a gynaecological and obstetric ward and thus skewed participant inclusion with regards to gender. As we have not seen evidence to suggest that the construct of patient-experienced quality in healthcare should be defined by gender, we expect the content validity of PATH to hold despite the gender-skewed inclusion. However, this may limit the interpretation of the content validity of the PATH questionnaire.\u003c/p\u003e \u003cp\u003eWe had a response rate of 37%. The average online survey response rate is 44% (\u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e), leaving us at a slightly lower rate than average. Although our response rate of 37% may be considered low, this is a study of measurement properties rather than an epidemiological study. Therefore, the low response rate is not likely to have impacted the results of our EFA or test-retest reliability. We do see it as a strength that we managed to include a broad population group, as PATH is intended for use in a range of patient groups spanning different diseases and conditions, age groups, and genders. The lack of inclusion of psychiatric patients may be a limitation to the reliability of PATH in this patient group, however. Furthermore, we have assumed that PATH performs similarly in different population groups (e.g. genders, age groups) as is the custom for studies on development of measurement instruments (\u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e). In the future, it would be beneficial to test the consistency of PATH in different subgroups to avoid incorrect inferences caused by measurement problems (\u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e). We plan to do this in future studies of the interpretability of the PATH questionnaire.\u003c/p\u003e \u003cp\u003eOur field-test showed only moderate test-retest reliability for PATH based on the weighted kappa. However, test-retest assumes that the underlying construct being measured is unchanged in the retest period. Due to study limitations, we were not able to explore whether the moderate test-retest reliability found is indeed due to measurement properties of PATH or an actual change in the respondents\u0026rsquo; experiences of quality in healthcare transitions. The respondents were twice asked to assess the quality of care they received in the three most recent months, with a 21-day interval. This gave only 42-day overlap, which may explain the lower test-retest reliability. Furthermore, there was some imbalance in our table\u0026rsquo;s marginal totals with high prevalence of positive PATH scores. This may lead to the \u0026ldquo;kappa paradox\u0026rdquo; were high prevalence leads to high chance agreement and accordingly reduced kappa values (\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e, \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e). Thus, PABAK should likely be interpreted rather than weighted kappa. Our addition of PABAK values is a strength to the interpretation of PATH\u0026rsquo;s test-retest reliability. Others have argued that absolute measures of agreement are required to answer questions regarding test-retest reliability, rather than the relative measure of observer variation, which kappa represents (\u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e). Calculating the proportion of specific agreement as suggested by de Vet et al. (\u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e) may also have strengthened this studies interpretation of test-retest reliability. Yet, we find the PABAK values to indicate satisfactory test-retest reliability.\u003c/p\u003e \u003cp\u003eIt is a strength that the English version of PATH presented in this article has been systematically translated (\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e), ensuring consistency in the content of PATH. As this version of PATH has not been cross-culturally tested or adapted (\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e), however, this must be done prior to its use in English-speaking contexts.\u003c/p\u003e \u003cp\u003eOverall, we see our systematic and consistent approach as a strength in the development of the PATH questionnaire. This provides transparency for potential users of PATH but has also facilitated the development of an instrument that can give patients a valid and reliable voice in the evaluation of transitions across healthcare settings.\u003c/p\u003e \u003cp\u003eEquity has been suggested as a relevant aspect of patient-experienced quality of healthcare (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), but we have not formulated items directly related to equity or disparity. We believe equity is indirectly captured in the \u0026ldquo;Kindness in care\u0026rdquo; domain, but we recommend testing this hypothesis further as our study has limitations in the inclusion of subgroups particularly exposed to discrimination in healthcare.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study is important because valid and reliable assessment of patients\u0026rsquo; experiences of healthcare transitions is crucial to the evaluation and improvement of quality and safety in care pathways including transitions. We have developed a generic patient-reported experience measure (PREM) for the assessment of patient-experienced quality in healthcare transitions. The \u003cb\u003e\u0026ldquo;\u003c/b\u003ePatient Assessment of Transitions in Healthcare settings\u0026rdquo; (PATH) questionnaire was developed and tested through an iterative and rigid process that adhered to the COSMIN group\u0026rsquo;s recommendations. PATH demonstrated satisfactory validity and reliability when measuring \u0026ldquo;Kindness in care\u0026rdquo; and \u0026ldquo;Access and coordination\u0026rdquo;, with high internal consistency and structural validity in a Danish patient population with a broad range of diagnoses and ages. The PATH questionnaire is relevant and available for use in quality monitoring and quality improvement research, but we recommend further testing of its measurement properties alongside its practical application.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePATH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePatient Assessment of Transitions in Healthcare settings\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePREM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePatient-reported experience measure\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCOSMIN\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCOSMIN is an initiative of an international multidisciplinary team of researchers working for COnsensus-based Standards for the selection of health Measurement Instruments (87)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGeneral practitioner\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMunicipal care\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eREDCap\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eResearch electronic data capture (88)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eOPEN\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOpen Data Explorative Network\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEFA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eExplorative factor analysis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePABAK\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePrevalence-adjusted and bias-adjusted kappa\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eData were collected in accordance with Danish Data Protection Law no. 502 of 23/05/2018\u0026nbsp;(89)\u0026nbsp;and the Declaration of Helsinki\u0026nbsp;(90), and were approved by the legal department at the Research and Innovation Organisation, University of Southern Denmark, Notification number 10.953. According to Danish law on ethical scientific health data processing \u0026sect; 14 part 1\u0026nbsp;(91), no ethics permissions were required for this study. This was recognised by the scientific ethics committee in the Region of Southern Denmark in case number 20202000-60. All experimental protocols were approved by the Graduate School at the University of Southern Denmark. Informed consent was obtained from all participants. All participants were informed about guaranteed anonymity, that they could withdraw consent at any time, and that data handling according to current standards would be kept confidential.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request, provided the request can legally be met with the granted permissions.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe author(s) disclosed receipt of the following financial support for the research, authorship, or publication of this article: This work was supported by the local research fund at N\u0026aelig;stved, Slagelse, and Ringsted hospitals; by a program grant for Exercise First from Region Zealand; and a faculty scholarship from the Faculty of Health Sciences at University of Southern Denmark.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors\u0026rsquo; contributions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSW compiled the item-bank and facilitated the development process and advisory board meetings. SW also planned and conducted the pilot-tests and the field-test, and drafted the manuscript.\u003c/p\u003e\n\u003cp\u003eHHL contributed substantially to the conception and aim of the study, took part in the development of PATH items, and supervised the evaluation of psychometric properties of PATH. HHL also\u0026nbsp;revised the manuscript critically for important intellectual content. ENP took part in the development of PATH items and revised the manuscript critically for important intellectual content. CS made substantial contributions to the conception and design of the study and revised the manuscript critically. CG made substantial contributions to the translation of PATH and critically revised the manuscript. SM made substantial contributions to the conception, statistical analyses, and evaluation of the PATH field-test. SM also critically revised the manuscript for important intellectual content. LM contributed substantially to the conception and aim of the study, took part in the development of PATH items, revised the manuscript critically for important intellectual content, and supervised the project management\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAllen J, Hutchinson AM, Brown R, Livingston PM. User experience and care for older people transitioning from hospital to home: Patients\u0026rsquo; and carers\u0026rsquo; perspectives. Health Expect Int J Public Particip Health Care Health Policy. 2018;21(2):518\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAsif M, Cadel L, Kuluski K, Everall AC, Guilcher SJT. 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Tilg\u0026aelig;ngelig hos: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.retsinformation.dk/eli/lta/2020/1338\u003c/span\u003e\u003cspan address=\"http://www.retsinformation.dk/eli/lta/2020/1338\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Healthcare transitions, Patient-reported experience measure, PREM, Patient experience, Quality, Psychometric properties.","lastPublishedDoi":"10.21203/rs.3.rs-3982192/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3982192/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe quality of care pathways that include transitions between healthcare settings may be increased by improving patients\u0026rsquo; experiences of their care journey. Patients\u0026rsquo; experiences can be explored through in-depth interviews, but valid and reliable patient-reported experience measures (PREMs) can be a useful and more cost-effective way of assessing patient-experienced quality. The aim of this study was to develop a valid, generic measure for assessment of PAtient-experience of Transitions in Healthcare settings, PATH. We evaluated the structural validity, internal consistency, and test-retest reliability of the PATH questionnaire in a Danish patient population with a range of diagnoses, comorbidities and diversity in age.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe PATH questionnaire was developed and tested through an iterative 3-step pilot-test and a comprehensive field-test.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eWe found an 18-item version of PATH to be content valid and to have internal consistency and structural validity for a 2-factor solution with a single item scored separately. We found satisfactory test-retest reliability.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e\u003c/p\u003e \u003cp\u003ePATH is a generic, content valid, and reliable patient-reported experience measure for the assessment of patient-experienced quality in healthcare transitions. The PATH questionnaire is available for use in quality monitoring and quality improvement research, but we recommend further testing of its measurement properties alongside its practical application.\u003c/p\u003e","manuscriptTitle":"Development and psychometric properties of the “Patient Assessment of Transitions in Healthcare settings (PATH)” questionnaire","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-12 17:35:30","doi":"10.21203/rs.3.rs-3982192/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"751eaa66-0166-4ea6-933f-dc1199f60f8e","owner":[],"postedDate":"March 12th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-06-19T04:53:38+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-12 17:35:30","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3982192","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3982192","identity":"rs-3982192","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}