Family Practice Vol. 16, No. 1, 4-11
© Oxford University Press 1999
Patients' priorities with respect to general practice care: an international comparison
Centre for Quality of Care Research, Universities of Nijmegen/Maastricht, The Netherlands,
a Research Unit for General Practice, Aarhus University, Denmark,
b Centre for Social Studies, University Coimbra, Portugal,
c Eli Lilly National Clinical Audit, University of Leicester, UK,
d Department of General Practice, University of Oslo, Norway,
e Department of Family Medicine, University of Uppsala, Sweden,
f Department of Family Health Care, The Technion, Haifa, Israel and
g Institute on Applied Quality Improvement and Research in Health Care, Göttingen, Germany.
Grol R, Wensing M, Mainz J, Ferreira P, Hearnshaw H, Hjortdahl P, Oleson F, Ribacke M, Spenser T and Szécsényi J. Patients' priorities with respect to general practice care: an international comparison. Family Practice 1999; 16: 4–11.
Received 19 May 1998; Accepted 7 October 1998.
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Abstract |
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Background and objectives. Improving the sensitivity of general practice to Patients' needs demands a good understanding of Patients' expectations and priorities in care provision. Insight into differences in expectations of patients in different cultures and health care systems may support decision-making on desirable models for care provision in general practice. An international study was conducted to determine priorities of patients in general practice care: which views do patients in different countries have in common and which views differ?
Methods. Written surveys in general practices in the UK, Norway, Sweden, Denmark, The Netherlands, Germany, Portugal and Israel were performed. Samples of patients from at least 12 practices per country, stratified according to area and type of practice, were included. Patients rated the importance of 38 different aspects of general practice care, selected on the basis of literature analysis, qualitative studies and consensus discussions. Rankings between countries were compared.
Results. A total number of 3540 patients (response rate on average 55%) completed the questionnaire. Patients in different countries had many opinions in common. Aspects that got the highest ranking were: getting enough time during the consultation; quick services in case of emergencies; confidentiality of information on patients; telling patients all they want to know about their illness; making patients feel free to talk about their problems; GPs going to courses regularly; and offering preventive services. However, differences between opinions of patients in different countries were also found for some of the selected aspects. A confounding effect of Patients' characteristics may have played a role in these differences.
Discussion. The study provides information on what patients expect of and value in general practice care. It shows that patients in different cultures and health care systems may have different views on some aspects of care, but most of all that they have many views in common, particularly as far as doctor–patient communication and accessibility of services are concerned.
Keywords. Doctor–patient communication, general practice care, international comparison, Patients' expectations, Patients' priorities..
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Introduction |
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Improving the sensitivity of primary health care to Patients' needs and demands is an important challenge in health care today. Therefore Patients' expectations of and experiences with health care are increasingly explored by means of interviews, focus group meetings and surveys among patients, the results of which are used to motivate change in care provision, if needed. This is a crucial development, since priorities in health care and primary care are still usually determined by professionals and health authorities. Studies show, however, that patients, professionals and authorities may have different notions of good quality care.1,2 By ignoring the Patients' views on preferred care we may neglect aspects of care provision which are important from the perspective of consumers of health care. Although the importance of acquiring the views of patients is increasingly confirmed, insight into Patients' views on good general practice care is still limited. A systematic review of the literature on Patients' opinions and priorities with respect to primary care disclosed that the different studies found explored different aspects of health care and were difficult to compare.3 Most were performed in the USA. It is not clear whether the results can be transferred to European countries with different health care systems. This also raises the question of the extent to which expectations and views of patients on general practice care are either universal in nature or specific to a particular culture and health care system. Health care systems and the role of general practice within these systems differ widely in the different European countries, because of differences in the reimbursement system, the gate-keeper role of the GP, the continuity of care (e.g. personal list) and the size of practices (small offices, large health centres). Such differences in systems, as well as the differences in culture may influence the expectations of patients and their views on good care.4–6 An explorative study was undertaken in eight countries to study the views of patients with respect to general practice care: which views do patients in different countries have in common and in which views do they differ?
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Methods |
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The study was conducted by the European Task Force on Patient Evaluations of General Practice (EUROPEP), with a grant of the European Union (Biomed).
Surveys, using written questionnaires, were performed in eight countries, some in Northern Europe (Norway, Sweden and Denmark), some in the western part of Europe (UK, The Netherlands and Germany) and one in the southern part of Europe (Portugal), as well as one in Israel. The survey was conducted in a consecutive sample of patients visiting the GP from at least 12 practices per country. The practices were stratified according to the area (four practices in rural areas, four in towns and four in larger cities) and the practice size (four low-staffed, four medium-staffed and four high-staffed—except in Germany, where only low- and medium-staffed practices exist). In every practice a minimum of 60 adult patients who visited the practice for a consultation had to be included consecutively, using the following inclusion criteria: aged 18 or over and being able to understand the native language. The survey was conducted anonymously, so reminders could not be sent (except for Denmark and some practices in Israel, where a semi-anonymous reminding procedure was used). The survey was conducted in the first 6 months of 1995. Patients were able to fill in the questionnaire at home and send it in a stamped addressed envelope to the research centre for further analysis.
Instrument
A questionnaire was developed to identify Patients' priorities with respect to general practice care.2 Priorities were defined as aspects of general practice care that patients consider as more or less important. A structured list of relevant aspects was derived from the following sources: a systematic literature analysis (period 1980– 1994);3 results of some qualitative studies (focus group interviews, in-depth interviews) of Patients' views on primary care;7–8 and consensus discussions between researchers from the eight participating countries during two international workshops in 1994.
A list of 40 items or aspects of care was developed, covering important areas of general practice care. They were divided into five different sections: medical-technical care, doctor–patient relationship, information and support to patients, availability and accessibility, and organization of the services. Each section contained eight different aspects of care. Since no method of asking patients about their priorities seemed perfectly valid, three different methods were used. It was expected that the findings of these three methods would complement one another. Responders were asked: (a) to rate the importance of each separate aspect of general practice care on a five-point scale ranging from ‘not important at all’ to ‘most important’; (b) to rank per section the importance of the eight aspects of care in that section by identifying which aspect is to be seen as most important and which as second, third and fourth most important; (c) to select, at the end of the questionnaire, the three most important aspects overall, out of the five previously identified as the most important ones within the five different sections.
Finally, patients were asked about the following characteristics: age, sex, family situation, number of recent visits to the GP, hospital visits in the last half year and self-reported illness.
The questionnaire was pre-tested in a pilot-study with some patients in each country; patients were asked about their understanding of each item in the questionnaire. Next, a ‘source-version’ was developed in English. Each country translated the questionnaire into their own language using this source version and applying a structured translation procedure (independent translation by a professional translator and the GP-researchers; consensus on the final formulation of items; and testing the items among some patients).
Analysis
For a description of Patients' priorities we chose the percentage of patients that answered ‘very’ or ‘most important’ for a particular aspect of care (method (a) described above). Two aspects (19 and 37) were excluded because translation problems proved to complicate comparison across countries. Using these percentages, an importance rank order for each country was calculated, ranging from 1 (highest priority) to 38 (lowest priority), as well as an importance rank order within each section. The results were compared with the results of the other two methods for asking Patients' priorities [methods (b) and (c)] (rank sign test, P < 0.05); no significant differences were found for any of the countries. The aggregated data were used to calculate a rank order over all patients in the eight countries (n = 3540). Multivariate analysis of variance (MANOVA) was used to study differences between the answers of patients from the eight countries. Analysis of variances was also used to determine a confounding effect in the answers because of differences between patients with different characteristics. For comparisons of the significance levels a Bonferroni correction multiple comparison was applied, resulting in a P-value of 0.001 (0.05/38) to determine the significance of differences.
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Results |
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Response
In total, 6464 questionnaires were delivered, and 3540 were returned and evaluable (crude response rate 55%, country-specific range 42–86%). Stratification was largely successful. All countries except Portugal achieved a good spread of patients over the rural areas, small towns and larger cities, (Table 1
). The distribution of responders over the types of practices more or less reflect the actual situation in the different countries. As almost all German GPs work in single-handed, small-office-based practices, the percentage of patients from medium- or high-staffed practices is low. In the UK and Sweden most GPs work in group practices or health centres; the percentages of low-staffed practices in the sample were relatively low.
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The characteristics of the patients in the different countries were partly similar, partly different (Table 2
). Responders in Sweden were older on average than responders in the other countries. Patients in Germany visited their doctor more often, patients in Sweden less often than patients in the other countries. On average, patients in Portugal and Germany had many visits to the hospital, patients in Norway and Sweden few visits. Also, self-reported illness differed for specific chronic diseases. Remarkable are the high percentages of patients with cardiovascular disease in Germany and Sweden, with chronic locomotor system problems in Germany, The Netherlands and Norway, and with migraine and depression in Portugal.
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Patients' priorities
Most aspects of care, as reflected in the 38 different items, were seen as important by most of the responders from the different countries. However, the results also showed differences in ranking of the items as well as some interesting differences in views of patients from different health care systems and cultures.
Aspects that were valued most in the total sample of patients were (Tables 3 and 4): getting enough time during consultations, quick service in the case of emergencies, confidentiality of information on patients, telling patients all they want to know about their illness, making patients feel free to talk about their problems, GPs' attending courses regularly and offering preventive services. A relatively low ranking was given to aspects such as waiting time before the consultation, GPs helping patients to deal with emotional problems related to their health problems, GPs accepting it when patients seek ‘alternative treatment’, concern about cost of medical treatment by the GP and written information on surgery hours and phone numbers of the practice (Table 4).
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Although, overall, the differences in opinion between patients from different countries were limited (eta-values, Table 4
), some interesting differences between specific countries can be seen. For example: ‘the GP should make me feel free to tell him or her my problems’, important in almost all countries, got a relatively low ranking in Israel (16); ‘it should be possible to see the same GP at each visit’ was seen as more important in Norway (ranked 6) and Sweden (ranked 9) and less important in the UK (ranked 28); ‘a GP should be willing to make home visits’ got a high ranking in Germany (11) and a low ranking in Sweden (29); ‘a GP should be willing to check my health regularly’ got a high ranking in Portugal (9) and a low ranking in Denmark (28) and Sweden (27); ‘a GP should visit me when I am seriously ill’ was viewed as important in Denmark (8) and less important in Germany, Israel, Norway and Sweden; ‘the facilities and the practice should be convenient’ was seen as more important in Portugal (13) than in, for instance, The Netherlands, Denmark and Sweden; ‘a GP should not only cure diseases but also offer preventive services’ got a relatively low ranking in The Netherlands (15) and a very high ranking in Portugal (3). The analysis to check a confounding effect of patient characteristics (such as age, sex or chronic illness) on the differences between countries showed that for half of the 10 items with the highest ranking, younger patients had opinions significantly different from those of older patients, and female patients had views which differed from those of male patients. For the 10 items with the lowest rankings, such significant differences were found for three items.
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Discussion |
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Patients valued most of the 38 selected aspects of general practice care as important. This was to be expected, since these aspects had been selected because of their importance for patients found in the literature and in focus interviews. Nevertheless, considerable differences in points of view on the different aspects were found. The results of the questionnaires completed by more than 3500 patients in eight different countries provide a picture of what patients see as the absolute requirements of good general practice care: quick service in cases of urgent situations; in normal circumstances the possibility of making appointments within a short time; during these appointments a GP who really takes time to listen and to talk and who gives the feeling that a patient can talk freely about all his/her problems; a GP who also provides adequate information on the illness and on the diagnostic and treatment procedures necessary; a GP who is well educated and goes to courses regularly and who guarantees confidentiality of the patient information. The priorities indicated by patients in different countries particularly refer to appropriate and accessible clinical care and a little less to service-oriented areas in general practice care. Patients in different countries actually agreed in their views on many of the selected aspects. There was broad consensus on the importance of aspects concerning the doctor–patient relationship, information and support, and availability and accessibility. So, these aspects seem to be largely ‘universal’, and independent of country, health care system and culture. On the other hand, some differences were also seen between the views of patients from different countries. Examples include ‘a GP should be able to relieve my symptoms quickly’, ‘a GP should not only cure diseases, but also offer services in order to prevent diseases’, ‘a GP should be willing to check my health regularly’ or ‘it should be possible to see the same general practitioner at each visit". Such differences may partly reflect actual differences in the different health care systems: the patients may value highly the care they are used to or the care which they would like to get and which is not provided. On the other hand, these differences may also reflect cultural differences between patients in different countries, such as the extent to which they value an authoritarian or a democratic relationship with their practitioner, the extent to which they are oriented at technology and curing diseases or at prevention, or the extent to which they expect that a quick solution to each health problem is provided.4,5,9,10 However, an additional confounding effect may have played a role. Older patients had opinions which on many items differed from those of younger patients. Similarly, differences were found between female and male patients, while in some countries, more older and more female patients responded to the questionnaire than in other countries.
Setting up comparative studies in different countries poses various problems for an international research team, such as guaranteeing a good translation of the instruments in the different languages or finding comparable patient samples. The study was carefully prepared by achieving consensus on a set of 40 aspects of general practice care and arrangements on the translation. Ideally, this translation follows rigorous procedures, with forward and backward translation by two independent translations by native speakers.11 Such a procedure was only partly possible in this project, owing to practical and financial restrictions. The sampling and stratification procedure were also carefully prepared and defined. Practices in the study are, nevertheless, only partly comparable because different countries differ in organization of general practice care: some have mainly single-handed practices, others mainly health centres; some are largely urban, others mainly rural.12 So, standardization is impossible. We have to be aware also that the answers reflect the opinions of ‘users’ of general practice, those who actually visited their GP and therefore had recent experience. Asking a sample from the whole practice population might have showed different priorities. However, since in most countries about 70–80% of patients see their GP in a year, most of the potential patients are also users of the practice and will have had recent experience with general practice care. Another problem in performing reliable comparisons between the different countries is the relatively low response rate in three of the countries (UK, Germany and Portugal). Some selection bias may have occurred in favour of specific patient groups, for instance the younger patients or the frequent visitors to the practice. One may question, however, whether higher response rates would have changed the overall picture and priorities expressed by patients in Europe. So, despite possible problems, this study provides new and interesting information on what patients actually expect of and value in general practice care. This is the first international comparison of views of patients on good quality general practice care. It shows that patients in different cultures may have different views on some aspects of care, but most of all that they have many views in common, particularly as far as the doctor–patient communication and accessibility of care are concerned. The results may give direction to policies in general practice care.
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Acknowledgments |
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This study was conducted with a European Union (Biomed) grant.
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References |
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