The Impact of Patient Experience on Loyalty in the Context of Medical-Aesthetic Health Services

Abstract

The purpose of this study was to determine the antecedents and consequences of patient experience in the context of medical-aesthetic health services. A quantitative study was conducted and data was collected through online surveys. Moreover, data were provided in the field via the administration of questionnaires to patients of medical clinics. The data were analyzed according to structural equation modeling procedures. The results showed that both the relational (communication and involvement) and functional (environment, tangibles, processes, outcomes, competence, monetary cost) dimensions of care have a direct and positive impact on customer experience (CE). This study shows the prevalence of the functional dimension when compared to the relational one, which more strongly influences a patient’s CE. Moreover, CE positively impacts perceived quality, overall satisfaction, and loyalty behaviors.

Introduction

The customer experience (CE) is a concept that has been gaining more attention in the last 3 decades, being described as a strategic process to achieve differentiation and sustainable competitive advantage.^1–4 It is defined as a cluster of feelings, perceptions, and attitudes built up throughout the decision-making process and consumption chain, which involves an integrated series of interactions with people, objects, processes, and the environment, leading to cognitions, emotions, sensory, and behavioral responses. ⁴

In health services, the care for customers and the ability to personalize and adapt interactions according to each customer are key factors in providing a unique and memorable care experience and quality service.^1,3–5 The term CE is used to refer to any process the patient, as a customer, may observe, which include subjective experiences (eg, controlled pain), objective experiences (eg, waiting time for appointments), and perceptions about the behavior of doctors, nurses, technicians, assistants, and other professionals (eg, whether the doctor provided all the necessary information). ⁶ Thus, CE refers to the results of the interaction between a provider and a patient during their encounter, consequently, a good CE means that the individual's perception of all points of interaction has met their expectations as a patient. ⁷

Moreover, CE is a complex multidimensional phenomenon ⁸ that can be perceived differently by different health system stakeholders. ⁹

Drawing from previous studies, CE determinants can be classified into relational or functional aspects of care ¹⁰ Relational aspects refer to the interpersonal aspects of care which are strongly associated with the customer-centricity of healthcare (Table 1). Improvements at this level will create rapport and trust between customers and healthcare providers. ¹¹ The functional aspects are related to the basic expectations of how care is provided (Table 1).

Table 1.

Determinants and Consequences of Customer Experience (CE) in Healthcare.

Authors	Determinants—relational aspects of healthcare
Coulter 12	Empathy
Doyle et al 13 ; Arshad et al 14 ; Bridge et al 11	Respect for the customer's preferences/values
Doyle et al 13 ; Bridge et al 11	Emotional support/ Sympathy
Doyle et al 13 ; LaVela and Gallan 15 ; Bridge et al 11 ; Kumah 10 ; Cairns et al 16	Involvement of the customer and family members in decision-making
Groene et al 17	Customer-centricity
Doyle et al 13 ; Bridge et al 11 ; Kumah 10 ; Tonio et al 18 ; Forough et al 19 ; Choi et al 20 ; Bridge et al 11 ; Gerlach et al 21 ; Flot et al 22 ; Jones et al 23 ; Arshad et al 14	Clear, comprehensible, empathetic customer-professional communication
Coulter 12	Transparency/honesty
Authors	Determinants—functional aspects of healthcare
Glickman et al 24 ; Bridge et al 11 ; Flot et al 22 ; Doyle et al 13 ; Kumah 10 ; Tonio et al 18 ; Forough et al 19 ; Choi et al 20 ; Gerlach et al 21 ; Flot et al 22 ; Jones et al 23 ; Arshad et al 14	Team Responsiveness/competence
Ferguson et al 25 ; Doyle et al 13 ; Bridge et al 11 ; Kumah 10 ; Tonio et al 18 ; Forough et al 19 ; Choi et al 20 ; Gerlach et al 21 ; Flot et al 22 ; Jones et al 23	Treatment results Pain/discomfort management
Doyle et al 13	Effective treatment by trusted professionals
Doyle et al 13 ; Coulter 12 ; Jones et al 23 ; Kumah 10 ; Tonio et al 18 ; Forough et al 19 ; Choi et al 20 ; Bridge et al 11 ; Gerlach et al 21 ; Flot et al 22	Clean and safe environment Tangible aspects
Doyle et al 13 ; Bridge et al 11 ; Kumah 10 ; Tonio et al 18 ; Forough et al 19 ; Choi et al 20 ; Gerlach et al 21 ; Flot et al 22 ; Jones et al 23	Processes—admission, release, etc
Doyle et al 13 ; Coulter 12 ; Gerlach et al 21	Effective coordination of care between professionals Trust
Bridge et al 11 ; Gerlach et al 21	Care/information continuity Teamwork
Bridge et al 11	Access and parking
Dodds et al 26	Monetary cost
Authors	CE consequences
Doyle et al 13 ; Bridge et al 11 ; Lee 7 ; Dong et al 27 ; Anhang Price et al 6	Better clinical results
Coulter 12 ; Bridge et al 11 ; Lee 7 ; Doyle et al 13 ; Dong et al 27 ; Anhang Price et al 6	Compliance with treatment/counseling/medication regimen
Doyle et al 13 ; Bridge et al 11	Preventive care and health promotion
Doyle et al 13 ; Dong et al 27 ; Lee 7 ; Bridge et al 11 ; Anhang Price et al 6	Reduced use of health resources (eg, hospitalizations, readmissions)
Isaac et al 28 ; Lee 7 ; Bridge et al 11 ; Doyle et al 13 ; Dong et al 27 ; Anhang Price et al 6	Clinical safety
Doyle et al 13	Clinical efficiency
Lee 7 ; Graham 29 ; Daouk-Oyry et al 30	Loyalty
Lee 7 ; Oliver et al 31	Intention to return Repurchase
Graham 29 ; Lee 7 ; Oliver et al 31 ; Ferguson et al 25	Word-of-mouth Recommendation
Daouk-Oyry et al 30 ; O’Connor et al 32	Costs/profitability
Lee 7 ; Kumah 10 ; LaVela and Gallan 15 ; Graham 29 ; Pakdil and Harwood 33 ; Zineldin 34 ; Bowling 35	Overall satisfaction with the service
Pakdil and Harwood 33 ; Zineldin 34	Perceived service quality

The literature review suggests a positive association between CE and the effects that partially or totally result from that experience ⁸ (Table 1). Nevertheless, the literature review requires further studies on CE in the healthcare industry ³⁶ and the adoption of patient’s perspective. ³⁷

This investigation aims to bridge the gap in measuring CE in the aesthetic sector. This is relevant because the field of aesthetic medicine is a successful new trend in the healthcare industry among patients seeking to improve their appearance through fast and non-invasive procedures; it offers quicker recovery time but with a higher risk. ³⁸

The relevance of this study lies in the analysis of the antecedents and consequences of CE in the aesthetic medicine sector in terms of a patient's self-image, self-esteem, and well-being, as reported in previous studies.

The research questions are: RQ1: Which dimensions have the most impact on CE from the patient's point of view? RQ2: Does CE impact on a patient’s perception of quality, satisfaction, and behaviors? A conceptual model was proposed based on the literature review to answer these questions (Figure 1).

Figure 1.

Proposed conceptual model and research hypotheses.

Method

For data collection, an online survey was conducted. All constructs were measured from scales adapted from the literature review (Table 2). The CE conceptual latent variable was modeled as a composed factor according to the proposed dimensions (functional and relational) in accordance with the literature review. All scale items were assessed on 7-point Likert scales ranging from ¹ strongly disagree to ⁷ fully agree. A pre-test of the survey was implemented and the necessary adjustments were made based on the relevance of the comments received.

Table 2.

Definition of Constructs and Respective Measurement Scales.

Construct	Definition	Scales	Items
Relational Dimension of Care	Interpersonal aspects of care, are largely associated with customer-centricity in healthcare. 10
Communication	Treat with courtesy and respect, listen attentively to customer concerns, maintain eye contact, and explain information in a clear and understandable manner. Empathetic communication. 10	Chang and Horng 39 Dagger and Sweeney 40	◾ CM1: The staff treat me with courtesy and respect ◾ CM2: The team always listens to me carefully ◾ CM3: The team is always available for what I need ◾ CM4: The team cares about my well-being ◾ CM5: I always get personalized and prompt attention from the whole team
Customer Engagement	Reflects the relationship between the customer and the organization at different levels when customer activation is more focused on the customer-organization relationship. Customer participation is a practical expression of customer engagement during a specific customer contact with the organization.15,41	Chang et al 42	◾ E1: I discuss alternative treatments with the clinical team (doctors/nurses/physiotherapists/nutritionists) ◾ E2: I discuss information received from other sources (friends, internet, etc) with the team ◾ E3: I ask all the questions I need during my appointments/treatments ◾ E4: I contributed to the choice of treatment(s) undertaken ◾ E5: I inform the clinical team about my concerns
Functional Dimension of Care	Basic expectations about how care is provided. 10
Physical Environment	Pleasant environment where the service is provided. Presents characteristics that contribute to greater customer well-being and satisfaction—safe, clean, welcoming, comfortable, and modern.40,43	Dagger and Sweeney 40	◾ A1: I feel very comfortable when I am at the clinic/hospital ◾ A2: The atmosphere of the clinic/hospital is pleasant ◾ A3: The clinic/hospital has an interesting image ◾ A4: The temperature inside the clinic/hospital is pleasant ◾ A5: The facilities are thoroughly cleaned and smell nice
Tangible	Physical elements in the service environment; the appearance, comfort, and functionality of the physical environment. 40	Dagger and Sweeney 40 Parsuraman et al 44 Moliner 45	◾ T1: The waiting rooms and offices are comfortable ◾ T3: The facilities are modern and beautiful ◾ T4: The décor of the space makes me feel comfortable ◾ T5: The color scheme of the space is appealing ◾ T6: The lighting in the spaces is adequate ◾ T2: The equipment is modern ◾ T7: Staff are well dressed and well presented ◾ T8: Facilities allow for the confidentiality and privacy of contacts ◾ T9: The facilities are organized and clean ◾ T10: It is easy to find and easy to park
Competence	Knowledge and skills of the professional in diagnosing, treating, and caring for the customer. 40 Prompt response by professionals to the customer's needs and concerns and timely consultation and treatment. 22	Moliner 45 Dagger and Sweeney 40	◾ CP1: Professionals are up to date with their knowledge ◾ CP2: The information provided by the team is important to me ◾ CP3: Professionals are aware of all the services offered by the clinic/hospital ◾ CP4: The whole team carries out their tasks competently ◾ CP5: I feel good about the quality of care provided to me
Results	Refers to what is achieved as a result of the service and what is associated with it. 40	Dagger and Sweeney 40 Duggirala et al 43	◾ R1: I believe the results of my treatment(s) are the best possible ◾ R4: The treatment(s) performed have improved my image and health ◾ R5: I believe my life will improve as a result of undertaking the treatment(s) ◾ R6: I believe the treatment(s) were worthwhile ◾ R2: The clinic/hospital handles possible complications from treatment(s) very well ◾ R3: The treatment(s) undertaken were effective
Processes	Administrative procedures and processes involved in the overall operation of the service. 40	Dagger and Sweeney 40 Duggirala et al 43	◾ P1: The clinic/hospital is well run. ◾ P2: My case was assessed in detail. ◾ P3: Appointments are prompt and efficient. ◾ P4: Registration procedures are efficient. ◾ P5: Invoicing procedures are prompt and efficient. ◾ P6: Cancellation of treatments/consultations due to unavailability of equipment/professionals is common. ◾ P7: The opening hours of the clinic/hospital meet my needs. ◾ P8: When I complain or give any suggestion the clinic/hospital invests in improvement processes. ◾ P9: I have always received all the necessary information. ◾ P10: I received all the necessary follow-ups (in person, by phone, email, etc).
Monetary Cost	Indicator of the amount of monetary sacrifice required to purchase a product or service, which in turn can be considered as one of the indicators of the quality of that product or service. 26	Moliner 45	◾ CMN1: The money invested is well worth it ◾ CMN2: The service is good for what you pay ◾ CMN3: The economic cost is not high
Customer Experience	Refers to the results of the interaction between an organization and a customer during their relationship. Thus, a good CE means that the individual's perception during all touch points meets their expectations. 7	Klaus 46 Duggirala et al 43	◾ EC2: I like to have different experiences (in different places) to ensure the best choice. ◾ EC1: The care received was what I expected. ◾ EC3: Overall, my experience was positive.
Perceived Quality	Perception by the consumer that the health services provided increase the likelihood of obtaining desired results and are consistent with current professional knowledge. 47 Service is provided based on knowledge, experience, attention, responsiveness, and courtesy. 43	Dagger and Sweeney 40	◾ Q1: The service quality provided at the clinic/hospital is impressive. ◾ Q2: The service provided by the clinic/hospital is of a high standard throughout the contract. ◾ Q3: I believe the clinic/hospital offers a superior service compared to others. ◾ Q4: The overall quality of service provided by the clinic/hospital is excellent.
Customer Satisfaction	The consumer's affective state resulting from an overall appreciation of their relationship with the brand/service. Based on whether a customer's expectations have been met. 15	Dagger and Sweeney 40 Chang et al 42	◾ S1: My feelings towards the clinic/hospital are very positive. ◾ S2: I feel good to have carried out my treatment(s) at my chosen clinic/hospital. ◾ S3: I feel satisfied with the results of my treatment. ◾ S6: Overall, I am satisfied with the clinic/hospital and the service provided. ◾ S4: The choice for the clinic/hospital was the right one. ◾ S5: I like the clinic/hospital where I had my treatment.
Loyalty	Customer loyalty to a healthcare provider organization. 48 Repeated behaviors that generate long-term customer-company/service relationships.49,50	Chang et al 42 Moliner 45	◾ L1: I intend to continue with my treatment or any other necessary follow-up at this clinic/hospital. ◾ L3: I feel that I am a loyal customer of this clinic/hospital. ◾ L6: For me, there is no better clinic/hospital. ◾ L7: Emotionally, I feel close to the clinic/hospital.

The survey was conducted with Aesthetic Medicine Clinics that had agreed to participate in the study and collaborate by sharing the survey with their patients. The survey was also shared on Facebook, Instagram, and LinkedIn, encouraging people to fill it out and then share it with friends and family, which is known as the snowball data collection technique. The data were collected between July 24 and August 15, 2020.

All participants were previously informed of the study before responding and only responded with consent (implicit in the questionnaire header). A quantitative methodological approach was carried out using the Partial Least Squares (PLS-SEM) using the SmartPLS 3 software. The main reason for choosing the PLS-SEM was the use of a compound model to shape the aggregate first-order (Communication, Customer Engagement, Environment, Competence, Tangibles, Results, Processes, Monetary Cost, Perceived Quality, Satisfaction, and Loyalty), second-order (Relational and Functional Dimensions of Care), and third-order (CE) constructs of the research model.

The PLS-SEM is a modeling technique for the validity of theoretical models^51,52 and allows for a better exploration of underlying theoretical structures in highly complex models.^53,54

In total, 616 individuals completed the survey. The characteristics of the sample revealed that most respondents were female (Nfem = 442, 71.8%). The majority is between the ages of 25 and 34 (N = 222, 36.2%) and 35 to 44 (N = 199, 32.4%). Most participants were either married or cohabiting (N = 302, 49.2%) and the remaining percent were single (N = 246, 40.1%). The majority of participants were Portuguese (97.6%). The sample had a high level of education with approximately 45% (N = 276) having a bachelor's degree and 25.9% (N = 159) having a master's degree. Regarding the main occupation, most of the sample (N = 425, 70.5%) were dependent laborers. In terms of net monthly income per household, the majority of the participants earned between 601€ and 1200€ (N = 163, 27.3%) and 1201€ and 1800€ (N = 152, 25.5%). In terms of the annual average spent on medical and beauty treatments, 46% (N = 275) of respondents reported having spent less than 100€, 26.9% (N = 161) between 101€ and 300€, 14% (N = 84) between 301€ and 600€, 7.9% (N = 47) between 601€ and 1000€, 3.5% (N = 21) between 1001€ and 2000€, and 1.7% (N = 10) more than 2001€.

Results

Measurement Model

Before analyzing the validity and reliability of the measurement model, an exploratory factor analysis was performed in order to ensure that the variables Perceived Quality, Satisfaction, and Loyalty are first-order reflective constructs. The Variable Relational Aspects of Care and Functional Aspects of Care are aggregated multidimensional constructs (first-order reflective, second-order formative), with the relational aspects having 2 dimensions (Communication and Customer Involvement) and the functional aspects having 6 dimensions (Environment, Tangibles, Competence, Results, Processes, and Monetary Cost). The major mediator variable (CE) is a third-order construct (reflective of the first and second order, and formative of the third order).

Cronbach's α was used to measure the internal consistency of the constructs. The results showed that Cronbach's α values for all constructs ranged between 0.838 and 0.978, which are considered excellent. Consistency is also verified through the rho values, where values were above 0.70 (0.885–0.981) for all factors. Compound Reliability is a good indicator of construct reliability when its value is ≥ 0.70, ⁵¹ with all constructs presenting values between 0.885 and 0.980.

Thus, in order to assess the first-order reflective constructs and reflective dimensions, this study performed an analysis of the measurement model for the total sample in which the reliability of each item, the reliability of the constructs, and the extracted variance were calculated.

Validity tests were subsequently performed—factorial, convergent, and discriminant. ⁵¹ Factorial validity occurs when the items reflect the factor that is intended to be measured and all items’ outer loadings must be ≥ 0.50. Thus, item P6 was eliminated for having a value lower than 0.50. All the remaining items were above 0.671.

Convergent validity refers to the degree to which 2 different variables that are, in theory, correlated are determined in fact to be correlated. This is achieved when the mean-variance extracted from the construct is higher than 0.5. ⁵⁵ All constructs exceeded 0.5, thus confirming all measurements to have satisfactory convergent validity.

To determine discriminant validity, that is, to verify to what extent the reflective construct is truly distinct from the others, ⁵⁶ the heterotrait-monotrait ratio was used, with a threshold value of 0.9. ⁵⁷ For this purpose, 3 items of the loyalty variables (L2, L4, and L5) were eliminated, thus refining the model. Satisfactory discriminant validity was confirmed for all constructs.

After considering the functional and relational aspects of care as second-order formative constructs and the CE as a third-order formative construct—multidimensional aggregated constructs—their weights were analyzed. These findings show that communication (0.658) is the dimension with the highest weight in the composition of the Relational Aspects of the Care construct while Tangibles (0.288) is the dimension with the highest weight in the composition of the Functional Aspects of the Care construct. Monetary Cost was the dimension with the lowest weight (0.091).

The value of the maximum variance inflation factor for these constructs was below 5.3. ⁵⁸ We concluded that the measurement model shows adequate convergent and discriminant validity for the study's research model.

Structural Model

The structural model defines the relationships between the latent variables, previously operationalized by the measurement model, ⁵¹ and the nature and intensity of each association. ⁵⁹

In this study, a bootstrapping of 500 resamples was used with a bilateral Student's t distribution and 97.5% percentile confidence intervals ⁵² (Figure 2).

Figure 2.

Structural model results.

R² values indicate the variance explained by each variable, that is, for the endogenous constructs, Perceived Quality (R² = 0.711), Satisfaction (R² = 0.709), and Loyalty (R² = 0.710) in the model.

All theoretical inter-construct relationships were significant (P < .01).

A positive relationship was found between the Relational Dimension of Care and the CE (β = .195, P < .01), between the Functional Dimension of Care and the CE (β = .824, P < .01), between the CE and Perceived Quality (β = .843, P < .01), and between the Perceived Quality impacts on Satisfaction (β = .842, P < .01). We also found Satisfaction to have a positive impact on Loyalty (β = .842, P < .01).

In addition to the fact that the Functional Dimension had a greater direct impact on the CE than the Relational Dimension of care, the functional subdimension (according to the weights obtained) had the greatest weight on Tangible aspects (0.288), followed by administrative processes (0.241). In turn, the subdimension with the lowest weight was the Monetary cost of the service (0.091).

Discussion

The results obtained from the PLS-SEM analysis support all the proposed relationships of the causal model, thereby endorsing all the research hypotheses due to the positive and significant coefficients.

A positive relationship was found between the Relational Dimension of Care and the CE (β = .195, P < .01), confirming Hypothesis 1. The way healthcare teams interact with customers, their sensitivity to the customer's personal experience, the amount of information made available to the customer, and their engagement are very important for a positive experience.^25,60

Hypothesis 2 was confirmed, supporting the fact that the Functional Dimension of Care has a positive impact on the CE (β = .824, P < .01). In both health and general services, the physical environment and all tangible aspects positively influence the CE and, consequently, its overall satisfaction rate.^40,43 The fundamental administrative procedures and processes of the service provided and the results of the service have a direct and positive impact on the experience. ⁴⁰

A positive relationship is also evidenced between CE and Perceived Quality (β = .843, P < .01), thus supporting the third hypothesis. Although literature on the relationship between CE and quality is sparse, the results are in line with the arguments of those authors who consider it plausible that perceived quality be evaluated based on the experience provided, with positive experiences translating into more comprehensive relationships and perceived quality.^61,62

Our results also confirmed Hypothesis 4, verifying the positive path impact that Perceived Quality has on Satisfaction (β = .842, P < .01). Other authors state that satisfaction is a broad feeling that is affected by the service; if the quality is perceived as positive then customer satisfaction will also be positive, however, if the quality of the experience is perceived as negative, then the tendency is for customers to be dissatisfied.^6,63,64 We also found that Satisfaction had a positive impact on Loyalty (β = .842, P < .01), thus confirming Hypothesis 5.

According to several studies on different services,^{10–13,18–23} effective and empathetic communication from healthcare professionals had the strongest effect on positive CE scores and overall customer satisfaction, followed by the responsiveness/competence of the clinical team; however, the results of this study do not support this. This may be related to the particular subject under study which involves the customer's choice to use the service, and they may not be ill (which is often the case). Thus, the customer may take service qualities for granted such as communication, empathy, and customer-centered care (also due to the high level of competition), and their presence does not have a major impact on the CE. However, customers focus their assessment on tangible aspects (modern facilities and equipment, staff uniforms/presentation, etc). These are elements that customers do not take for granted and have a major impact on their assessment of the experience, confirming that the physical elements of the service are determinants of favorable experiences.

To further investigate the indirect effects of CE on consumer loyalty through the mediator’s Perceived Quality and Satisfaction, bootstrap analyses with bias and percentile correction were performed using 500 bootstrap samples to calculate 97.5% confidence intervals. The bootstrap results confirmed the existence of a positive and statistically significant mediating effect for Perceived Quality and Satisfaction between CE and Loyalty. In addition, CE has a large and significant indirect impact on consumer Satisfaction and Loyalty behaviors. The data analysis showed the functional dimension and the subdimension of tangible elements of service to present the highest indirect positive impact on customer loyalty. Moreover, the results indicate that the Monetary Cost of Service subdimension has the least direct positive impact on customer loyalty.

To summarize, the analysis of the descriptive statistics and the correlational structure of the variables showed the data to be suitable for use in the structural equation modeling technique. The indicators correlated with each other, suggesting the nature of the relationships. The AEE results indicated that the proposed model described the data in an excellent manner. The measurement model indicated that the observed variables are good indicators of the latent variables, having also evidenced the factorial, convergent, and discriminant construct validity, ensuring the reliability of the results. In addition, the structural model explained 71% of the variance in loyalty.

Limitations & Suggestions

The proposed model does not cover all possible variables that may influence the CE, so we suggest introducing other variables such as trust and safety for potential future lines of research, especially during the current period of the Covid-19 pandemic. What's more, the introduction of moderating variables would considerably enrich the study, for example, the type of organizational climate/culture and the personal characteristics of customers, such as personality traits. These relationships could possibly improve the explanatory capacity of the model by expanding the study.

One limitation in the development of this empirical study was the number of participants. Although the sample is representative of the population and the results of this study can be generalized, it could be more comprehensive if the data collection period had been longer.

Due to the number of variables that can influence the experience, many of which concern individual expectations that cannot be measured retrospectively, there are inherent limitations to any study that sets out to determine what drives customer feedback at an aggregated level.

Conclusion

This study provides a rich insight into CE in the Aesthetic Medicine sector, analyzing the antecedents and consequences of CE in this unique and rapidly growing healthcare sector. A new conceptual model is proposed regarding consumer behavior, focusing on the impact CE has on consumer loyalty toward the organization. This new conceptual model is regarded as a new tool for evaluating CE in health services from a consumer perspective, focusing on the ‘needs’ of the customers in Aesthetic Medicine Clinics. To the best of our knowledge, this is the first study to explore this explanatory model. The model emerged following some previous qualitative studies, thus giving this research a quantitative answer to the existing impacts on the different variables and dimensions analyzed.

The findings of this study, through the analysis of this model, further the current understanding of the impact of CE by providing empirical evidence that allowed us to answer the research question, showing that the relational (communication and engagement) and functional (environment, tangibles, processes, results, competence, and monetary cost) dimensions of care have a direct and positive impact on CE. The Functional dimension has the highest impact on CE, while the tangible aspects of the service subdimension have the greatest weight on this impact, and the monetary cost subdimension has the lowest impact. The results allowed us to validate that the CE has a direct and positive impact on perceived quality and this, in turn, positively influences overall customer satisfaction. Satisfaction has a positive impact on customer behavior in terms of loyalty. Thus, the research hypotheses raised in this paper are verified. The existence of a positive and statistically significant moderating effect for Perceived Quality and Satisfaction between CE and Loyalty was demonstrated. The CE has a large and significant indirect impact on consumer Satisfaction and Loyalty behavior. In terms of the care dimensions, the functional dimension and the tangible elements of the service subdimension have the highest indirect positive impact on customer loyalty, while the results indicate that Monetary Cost (from the service subdimension) has the least positive indirect impact on consumer loyalty.

The findings of this study are valuable for implementing quality improvement initiatives, identifying facilitators and barriers to CE from a customer's perspective, and identifying actionable opportunities to improve CE in treatments, thus achieving positive manifestations in terms of customer dimensions of measurement (perceived quality and satisfaction) and behavioral responses at the loyalty level. The model includes suggestions for improving both clinical practice and management, and provides a basis for future research on how CE influences different health outcomes and organizations.