Dr. Betty Gilson is Associate Professor and Associate Dean, Department of Health Services, School of Public Health and Community Medicine, University of Washington, Seattle, Washington 98195. Dr. John Gilson is Director of Medical Education, Group Health Cooperative of Puget Sound, Seattle, Washington. Dr. Bergner is Assistant Professor, Department of Health Services, School of Public Health and Community Medicine, University of Washington, Seattle, Washington. Dr. Bobbitt is Research Professor, Department of Health Services, School of Public Health and Community Medicine, University of Washington, Seattle, Washington. Ms. Kressel is Senior Administrative Analyst, Health Policy Program, San Francisco, California. Dr. Pollard is a postdoctoral fellow, Department of Psychology, Northwestern University, Evanston, Illinois. Dr. Vesselago's address is: 2012 Tenth Avenue East, Seattle, Washington. This investigation was supported by the HMO Service of the Health Services and Mental Health Administration, Contract HSM 110-72-420. This paper was presented, in abbreviated form, at the American Public Health Association Annual Meeting, San Francisco, 1974. It was accepted for publication July 21, 1975. costly services. The proliferation of innovative organizational patterns for providing health services makes it necessary to obtain data demonstrating the relative benefits of available alternatives. Evaluators use three types of measures to assess health care services: measures of structure, measures of process, and measures of outcome. 1 2 Measures of structure or process assess factors that are presumably directly related to outcome. Measures of outcome are designed to assess the effects of the health care services on the population served. Often, structure or process measures are used because no adequate or efficient measure of outcome is available. While it has been assumed that these three types of evaluation measures are highly related and that structure and process measures can serve as proxies for outcome measures, the substitution will be legitimate only when the relationship between structure or process and outcome has been established. For example, one can assess the outcome of a program such as polio immunization by examining the number of immunizations administered (a process measure), since it has been demonstrated that such immunization leads to less polio (an outcome measure). On the other hand, since it is not known whether the number of clinician visits decreases illness, measuring numbers of visits does not provide knowledge of outcome.
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