Comprehensiveness relates both to scope of services offered and to a wholistic clinical approach. Comprehensive services are defined as “the provision, either directly or indirectly, of a full range of services to meet most patients’ healthcare needs,” and wholeperson care is “the extent to which a provider elicits and considers the physical, emotional and social aspects of a patient’s health and considers the community context in their care.” Among instruments that evaluate primary healthcare, two had subscales that mapped to comprehensive services and to the community component of whole-person care: the Primary Care Assessment Tool (PCAT) and the Components of Primary Care Index (CPCI). Objective: To examine how well comprehensiveness is captured in validated instruments that evaluate primary healthcare from the consumer perspective. Method: 649 adults with at least one healthcare contact in the previous 12 months responded to instruments that evaluate primary healthcare. Scores were normalized for descriptive comparison. Exploratory (principal components) and confirmatory (structural equation) factor analysis examined fit to operational definition, and item response theory analysis examined item performance. Results: Over one-quarter of respondents had missing responses on services offered or doctor’s knowledge of the community. The subscales did not load on a single factor; comprehensive services and community orientation were examined separately. The community orientation subscales did not perform satisfactorily and correlated well with interpersonal communication and relational continuity. The three comprehensive services subscales fit very modestly onto two factors: 1) most healthcare needs [from one provider] (CPCI Comprehensive Care, PCAT First-contact Utilization); and 2) range of services (PCAT Comprehensive Services Available). Individual item performance revealed several problems. Conclusion: Measurement of comprehensiveness is problematic, making this a priority for measure development. Range of services offered is best obtained from providers. Whole-person care is not addressed as a separate construct, but some dimensions are covered by attributes such as interpersonal communication and respectfulness. Comprehensiveness of Care from the Patient Perspective: Detailed Report Background Conceptualizing comprehensiveness Comprehensiveness is enshrined as one of the five principles of the Canada Health Act (Madore 2005) and is often applied as a qualifier of primary healthcare (PHC) (Macinko et al. 2007; Romanow 2002), distinguishing the ideal from the merely functional, or at worst “selective” (Cueto 2004), and forms of care. While it evokes a sense of “good,” the generality of its invocation obscures precision about its meaning, posing a major challenge for its assessment. Its dictionary definition, “covering completely or broadly” (Merriam-Webster 1998), is applied in PHC to the mandate to resolve and manage the most prevalent health conditions, undifferentiated by age, sex, or disease (College of Family Physicians of Canada 2006; Medical Research Council 1997). However, comprehensiveness sometimes refers to the biopsychosocial or whole-person approach, which sees the patient as body, mind and soul within a specific social context (College of Family Physicians of Canada 2006). The closest French equivalent of comprehensiveness, globalité, invokes an image of both scope and whole-person approach. A clear operational definition of comprehensiveness is a first step in any measurement strategy to evaluate how well it is achieved in the health system. In 2004, we conducted a consensus consultation of 20 PHC experts across Canada to formulate operational definitions of PHC attributes that should be evaluated in health reforms (Haggerty et al. 2007). Comprehensiveness was identified unanimously as a core attribute of PHC, but circumscribing its measurable parameters required several rounds of consensus-building. Two distinct definitions emerged. The first, comprehensive services, corresponds to scope: “The provision, either directly or indirectly, of a full range of services to meet patients’ healthcare needs. This includes health promotion, prevention, diagnosis and treatment of common conditions, referral to other providers, management of chronic conditions, rehabilitation, palliative care and, in some models, social services.” The second definition, whole-person care, is: “The extent to which a provider elicits and considers the physical, emotional and social aspects of a patient’s health and considers the community context in their care.” Most experts agreed providers and utilization data were the best data sources for comprehensive services, and the patient, for whole-person care. One objective of Canada’s Primary Health Care Transition Fund is to expand the comprehensiveness of services, especially increasing health promotion and effective chronic disease management (Health Canada 2004). Many reforms across Canada are designed to enhance comprehensiveness by introducing team-based care and alternate payment mechanisms. Consequently, evaluating comprehensiveness of care is of vital importance in evaluating the renewal of PHC in Canada. Evaluating the comprehensiveness of primary healthcare Various validated instruments to evaluate PHC from the user perspective include assessment of comprehensiveness. Our objective was to compare the performance of different instruments to guide evaluators in their selection of an appropriate tool to meet Comprehensiveness of Care from the Patient Perspective: Detailed Report their specific objectives. This article focuses on instruments that purport to measure comprehensiveness. We wanted to compare scores and to examine whether comprehensiveness subscales from different instruments seem to measure the same underlying construct. We expected, however, that factor analysis would show at least two factors relating to both operational definitions. This would also reveal elements of the operational definition not captured in available instruments. Finally, we sought to explore in detail the psychometric performance of individual items. Our intent is not to recommend one instrument over another, but to provide evaluators with insight into how well different subscales fit the experts’ operational definitions. Method The method of this series of studies, described in detail elsewhere (Santor et al. 2009; Haggerty et al. 2009), is summarized here. Measure selection Among 13 unique and validated instruments that assess PHC services from the consumer perspective, we selected six that met our criteria; of these, two contained subscales that mapped to our operational definitions of comprehensiveness (Lévesque et al. 2009). No subscales mapped specifically to whole-person care except for subscales that address the social element of the definition: “elicits and considers the social aspects of a patient’s health and considers the community context in their care.” The Components of Primary Care Index (CPCI) (Flocke 1997) has a six-item Comprehensive Care and a two-item Community Context subscale. Both elicit degree of agreement with statements about the “regular doctor” using a six-point scale with 1 = strongly disagree and 6 = strongly agree as anchors at each extremity. The Primary Care Assessment Tool (PCAT) (Shi et al. 2001) has a four-item Services Available and a three-item Community Orientation subscale. It also assesses comprehensiveness with a Services Received subscale, which was not retained in our study since we mapped it to health promotion. Another three-item subscale on Firstcontact Utilization, initially mapped to accessibility, was included in the comprehensiveness attributes based on best psychometric fit (Haggerty, Burge et al. 2009). Questions about different aspects of care received from the “Primary Care Provider” are answered using a four-point Likert scale with labels corresponding to different degrees of probability. Concurrent validation of instruments We administered the six instruments to subjects with a regular source of care who had sought healthcare in the previous 12 months. Our sample was approximately balanced by experience of healthcare, educational level, urban/rural context and English/French language. Prior experience was based on a single screening question: “Overall, has your experience of care from your regular family doctor or medical clinic been excellent, poor or average?” Each subject filled in all six instruments and provided information on health utilization and socio-demographic descriptors. The study population is described in detail elsewhere (Haggerty, Lévesque et al. 2009). Comprehensiveness of Care from the Patient Perspective: Detailed Report Analytic strategy We looked for patterns of missing values and for ceiling or floor effects in the distribution of values. Each subscale was scored as the mean of the component item values, so that the magnitude of the score reflected the values of the response scale and was not affected by the number of items. To better compare values of subscales, we standardized the mean to a common 0-to-10 metric. We used principal components analysis (SAS 9.1 (SAS Institute 2003)), using an oblique rotation to explore whether all the items loaded on a single factor and how many underlying factors accounted for variability in responses using the criterion of eigenvalue >1. We conducted confirmatory factor analysis to evaluate the suitability of the factor structure identified through the initial exploratory factor analysis using structural equation modelling with LISREL (Jöreskog and Sörbom 1996). We compared the appropriateness of a number of models using the set of goodness-of-fit measures. We assigned items to factors based on the exploratory factor analysis or, for items with ambiguous loadings, based on our judgment of fit with the operational definition. Subjects with any missing values were exclu