Open Access Open Access  Restricted Access Subscription Access

Patient Experience in an Era of Primary Care Transformation: Revisiting the PACIC

Polly Hitchcock Noel, Salene Jones, Michael Parchman


Rationale, Aims and Objective: The validation study of thePatient Assessment of Chronic Illness Care (PACIC) questionnaire suggested a 5-factor structure determined a priori, but subsequent analyses have questioned the validity of the original factor structure. This study analyzed the factor structure of the PACIC using a large and diverse patient sample and evaluated the identified factors through the lens of recent transformational initiatives in primary care.

Methods: Exploratory and confirmatory factor analyses were conducted on baseline and follow-up patient questionnaire data from a cluster randomized controlled trial. Convenience samples of adults completed surveys in waiting rooms during clinic visits. Primary care patients with 1 or more chronic illnesses with complete PACIC responses at baseline from 39 clinics (n=1,567) and at follow-up from 36 clinics (n=1,536) participated. Identified factors were evaluated in terms of item loadings, content, reliability and the extent to which items reflected advances in the delivery of chronic illness care.

Results: Analyses supported the use of the PACIC summary score. Although a 5-factor model was retained, factor loadings were different from the original PACIC validation study. All factors had sufficient reliability, but findings suggested potential revisions to enhance the factor structure.

Conclusions: It may be time to revise the PACIC to enhance the stability of the subscales (factors) and better reflect recent transformations in the delivery of chronic illness care.


primary care, chronic illness, patient care experience, questionnaire, factor analysis

Full Text:



Manary, M.P., Boulding W., Staelin R. & Glickman S.W. (2013). The patient experience and health outcomes. New England Journal of Medicine 368 (3) 201-203.

Browne, K., Roseman, D., Shaller D. & Edgman-Levitan S. (2010). Analysis & commentary. Measuring patient experience as a strategy for improving primary care. Health Affairs (Millwood) 29 (5) 921-925.

Cleary, P.D. & Edgman-Levitan S. (1997). Health care quality. Incorporating consumer perspectives. Journal of the American Medical Association 278, 1608-1612.

Jenkinson, C., Coulter A., Bruster S., Richards N. & Chandola T. (2002). Patients’ experiences and satisfaction with health care: results of a questionnaire study of specific aspects of care. Quality and Safety in Health Care 11, 335-339.

Salisbury, C., Wallace, M. & Montgomery A.A. (2010). Patients’ experience and satisfaction in primary care: secondary analysis using multilevel modelling. British Medical Journal 341, c5004.

Danielsen, K., Bjertnaes O.A., Garratt, A., Forland, O., Iversen, H.H. & Hunskaar, S. (2010). The association between demographic factors, user reported experiences and user satisfaction: results from three casualty clinics in Norway. BMC Family Practice 11, 73. doi:10.1186/1471-2296-11-73.

Arain, M., Nichol, J. & Campbell, M. (2013). Patients’ experience and satisfaction with GP led walk-in centres in the UK; a cross sectional study. BMC Health Services Research 13, 142.

NCQA. NCQA’s New Distinction in Patient Experience Reporting [accessed on July 31, 2015]. Available at: (last accessed 30 December 2015)

AHRQ. The CAHPS Improvement Guide [Accessed August 10, 2015]. Available at: (last accessed 30 December 2015)

Glasgow, R.E., Wagner, E.H., Schaefer, J., Mahoney, L.D., Reid, R.J. & Greene, S.M. (2005). Development and Validation of the Patient Assessment of Chronic Illness Care (PACIC). Medical Care 43, 436-444.

Wagner, E.H., Austin, B.T., Davis, C., Hindmarsh, M., Schaefer, J. & Bonomi, A. (2001). Improving chronic illness care: translating evidence into action. Health Affairs (Millwood) 20, 64-78.

Wagner, E.H. & Groves, T. (2002). Care for chronic diseases. British Medical Journal 325, 913-914.

Gugiu, P.C., Coryn, C.L. & Applegate, B. (2010). Structure and measurement properties of the Patient Assessment of Chronic Illness Care instrument. Journal of Evaluation in Clinical Practice 16, 509-516.

Fan, J., McCoy, R.G., Ziengenfuss, J.Y., Smith, S.A., Borah, B.J., Deming, J.R., Montori, V.M. & Shah, N.D. (2015). Evaluating the structure of the Patient Assessment of Chronic Illness Care (PACIC) survey from the patient’s perspective. Annals of Behavioral Medicine 49 (1) 104-111.

Rosemann, T., Laux, G., Droesemeyer, S., Gensichen, J. & Szecsenyi, J. (2007). Evaluation of a culturally adapted German version of the patient assessment of chronic illness care (PACIC 5A) questionnaire in a sample of osteoarthritis patients. Journal of Evaluation in Clinical Practice 13, 806-813.

Aragones, A., Schaefer, E.W., Stevens, D., Gourevitch, M.N., Glasgow, R.E. & Shah, N.R. (2008). Validation of the Spanish translation of the Patient Assessment of Chronic Illness Care (PACIC) Survey. Preventing Chronic Disease 5 (4) 1-10.

Wensing, M., van Lieshout, J., Jung, H.P., Hermsen, J. & Rosemann, T. (2008). The Patients Assessment Chronic Illness Care (PACIC) questionnaire in the Netherlands: a validation study in rural general practice. BMC Health Services Research 8, 182.

Gugiu, P.C., Coryn, C., Clark, R. & Kuehn, A. (2009). Development and evaluation of the short version of the patient assessment of chronic illness care instrument. Chronic Illness 5 (4) 268-276.

Cramm, J.M. & Nieboer, A.P. (2012). Factorial validation of the patient assessment of chronic illness care (PACIC) and PACIC short version (PACIC-S) among cardiovascular disease patients in the Netherlands. Health and Quality of Life Outcomes 10, 104.

McIntosh, C.N. (2008). Examining the factorial validity of selected modules from the Canadian survey of experiences with primary health care. Report from Statistics Canada, Health Information and Research Division.

Taggart, J., Chan, B., Jayasinghe, U.W., Dip, B.C., Proudfoot, J.M., Crookes, P., Beilby, J., Black, D. & Harris, M.F. (2011). Patients Assessment of Chronic Illness Care (PACIC) in two Australian studies: structure and utility. Journal of Evaluation in Clinical Practice 17, 215-221.

Spicer, J., Budge, C. & Carryer, J. (2010). Taking the PACIC back to basics: the structure of the Patient Assessment of Chronic Illness Care. Journal of Evaluation in Clinical Practice 18 (2) 307-312.

Maindal, H.T., Sokolowski, I. & Vedsted, P. (2010). Adaptation, data quality and confirmatory factor analysis of the Danish version of the PACIC questionnaire. European Journal of Public Health 22 (1) 31-36.

Gensichen, J., Serras, A., Paulitsch, M.A., Rosemann, T., König, J., Gerlach, F.M. & Petersen, J.J. (2011). The Patient Assessment of Chronic Illness Care Questionnaire: Evaluation in patients with mental disorders in primary care. Community Mental Health Journal 47 (4) 447-453.

Wagner, E.H., Ludman, E.F., Aiello Bowles, E.J., Penfold, R., Reid, R.J., Rutter, C.M., Chubak, J. & McCorkle, R. (2014). Nurse navigators in early cancer care: a randomized, controlled trial. Journal of Clinical Oncology 32 (1) 12-18.

Rittenhouse, D.R. & Shortell, S.M. (2009). The patient-centered medical home: Will it stand the test of health reform? Journzal of the American Medical Association 301 (19) 2038-2040.

Hogan, S.O. & Kissam, S.M. (2010). Measuring meaningful use. Health Affairs (Millwood) 29 (4) 601-606.

Davis, K., Abrams, M. & Stremikis, K. (2011). How the Affordable Care Act will strengthen the nation’s primary care foundation. Journal of General Internal Medicine 26 (10) 1201-1203.

Noël, P.H., Parchman, M.L., Palmer, R.F., Romero, R.L., Leykum, L.K., Lanham, H.J., Zeber, J.E. & Bowers, K.W. (2014). Alignment of patient and primary care practice member perspectives of chronic illness care: a cross-sectional analysis. BMC Family Practice 15, 57. doi: 10.1186/1471-2296-15-57.

Parchman, M.L., Pugh, J.A., Culler, S.D., Noël, P.H., Arar, N.H., Romero, R.L. & Palmer, P.F. (2008). A group randomized trial of a complexity-based organizational intervention to improve risk factors for diabetes complications in primary care. Implementation Science 3, 15. doi: 10.1186/1748-5908-3-15.

Parchman, M.L., Noël, P.H., Culler, S.D., Lanham, H.J., Leykum, L.K., Romero, R.L. & Palmer, R.F. (2013). A randomized trial of practice facilitation to improve the delivery of chronic illness care in primary care: Initial and sustained effects. Implementation Science 8 (1) 93 doi: 10.1186/1748-5908-8-93.

Browne, M.W., Cudeck, R., Tatineni, K. & Mels, G. (2010). CEFA: Comprehensive Exploratory Factor Analysis Version 3.04. March.

Chen. F., Curran, P.J., Bollen, K.A., Kirby, J. & Paxton, P. (2008). An empirical evaluation of the use of fixed cutoff points in RMSEA test statistic in structural equation models. Sociological Methods and Research 36 (4) 462-494.

Holzinger, K.J. & Swineford, F. (1937). The bifactor method. Psychometrika, 2, 41-54.

Hu, L.T. & Bentler, P.M. (1995). Structural equation modeling: Concepts, issues and applications. Thousand Oaks, CA: Sage Publications.

Bryant, F.B. & Yarnold, P.R. (1995). Principal-components analysis and exploratory and confirmatory factor analysis. In: Reading and understanding multivariate statistics. Grimm, L.G. & Yarnold, P.R., eds., pp. 99-136. Washington, DC: American Psychological Association.

Anderson, T.W. & Rubin, H. (1956). Statistical inference in factor analysis. In: Proceedings of the Third Berkeley Symposium (Vol. 5), Neyman, J., (ed), pp. 111-150. Berkeley, CA: University of California Press.

Nunnally, J.C. (1967). Psychometric theory. New York: McGraw-Hill.

Bodenheimer, T., Ghorob, A., Willard-Grace, R. & Grumbach, K. (2014). The 10 building blocks of high-performing primary care. Annals of Family Medicine 12 (2) 166-171.

Braveman, P.A., Egerter, S.A. & Mockenahaupt, R.E. (2011). Broadening the focus: The need to address social determinants of health. American Journal of Preventive Medicine 20 (Supplement 1) S4-S18.

IOM. (2014). Capturing social and behavioral domains and measures in electronic health records: Phase 2. Washington, DC: Institute of Medicine of the National Academies. National Academies Press.

Noël, P.H., Parchman, M.L., Williams, Jr, J.W., Cornell, J.E., Shuko, L., Zeber, J.E., Kazis, L.E., Lee, A.F. & Pugh, J.A. (2007). The challenges of multimorbidity from the patient perspective. Journal of General Internal Medicine 22 (Supplement 3) 419-424.



  • There are currently no refbacks.