The Mediating Role of Patient Satisfaction in the Relationship Between Healthcare Quality and Patient Loyalty in Health Insurance Hospitals in Alexandria, Egypt

ABSTRACT Background Healthcare quality is a key determinant of patient experience, satisfaction, and loyalty, yet the mechanisms linking quality to loyalty remain underexplored in Egypt’s Health Insurance Organization (HIO). This study examines the mediating role of patient satisfaction in the relationship between healthcare quality and patient loyalty among HIO beneficiaries. Methods A cross-sectional study was conducted with 983 beneficiaries from four HIO hospitals in Alexandria. Data was collected using a validated questionnaire covering eight healthcare-quality domains, patient satisfaction, and loyalty. Confirmatory factor analysis (CFA) assessed construct validity, and structural equation modeling (SEM) tested direct and mediated pathways. Bootstrapping (5,000 samples) evaluated mediation significance. Results Healthcare quality significantly predicted patient satisfaction (β = 0.607, p < 0.001), which in turn strongly influenced patient loyalty (β = 0.545, p < 0.001). Direct effects of healthcare quality on loyalty were reduced and non-significant when satisfaction was included. The indirect effect via patient satisfaction was significant (β = 0.331, 95% CI: 0.262–0.404), confirming partial mediation. Transition of Care, Empathy, and Responsiveness were the most influential quality domains. Model evaluation demonstrated a strong fit across all indices (CFI = 0.967, TLI = 0.960, RMSEA = 0.043). Conclusion Patient satisfaction is a key link between healthcare quality and loyalty. Enhancing communication, competence, responsiveness, and transitional care as satisfaction-driven domains can strengthen trust, continuity, and loyalty, supporting patient-centered reforms and Egypt’s Universal Health Insurance implementation. What is already known - Healthcare quality strongly influences patient satisfaction and loyalty. - Patient loyalty is critical for continuity of care, trust, and system sustainability. - Few Egyptian studies have applied structural equation modeling to explore mediation pathways between quality, satisfaction, and loyalty. What this study adds - Validation of a mediation model examining healthcare quality, patient satisfaction, and loyalty among HIO beneficiaries in Alexandria. - Patient satisfaction partially mediates the relationship between healthcare quality and loyalty. - Identifies key quality domains that drive satisfaction-related loyalty, providing actionable targets for improvement. How this study might affect research, practice, or policy - Supports integrating patient satisfaction as a core indicator in HIO performance monitoring. - Informs targeted quality-improvement interventions focusing on satisfaction-sensitive domains. - Provides a robust mediation framework to guide evidence-based UHI policy and implementation in Egypt.