Family Practice Vol. 17, No. 5, 372-379
© Oxford University Press 2000
The General Practice Assessment Survey (GPAS): tests of data quality and measurement properties
Department of General Practice and Primary Care, GKT School of Medicine, Kings College, London SE11 6SP,
a London School of Hygiene and Tropical Medicine, London WC1E 7HT and
b National Primary Care Research and Development Centre, University of Manchester, Manchester M13 6PL, UK.
John L. Campbell, Department of General Practice and Primary Care, GKT School of Medicine, Kings College, London SE11 6SP, UK.
Ramsay J, Campbell JL, Schroter S, Green J and Roland M. The General Practice Assessment Survey (GPAS): tests of data quality and measurement properties. Family Practice 2000; 17: 372–379.
Received 23 March 2000; Revised 11 May 2000; Accepted 16 May 2000.
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Abstract |
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 Top Abstract IntroductionMethodsResultsDiscussionAppendix 1 References |
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Objectives. The aim of this study was to describe the psychometric properties of the General Practice Assessment Survey (GPAS) and its acceptability to patients in the UK. GPAS comprises seven multiple item scales and two single item scales addressing nine key areas of primary care activity (access, technical care, communication, inter-personal care, trust, knowledge of patient, nursing care, receptionists and continuity of care). A further four single items relate to patients' perceptions of the GP's role in referral and co-ordination of care, their willingness to recommend their GP and their overall satisfaction with care received.
Methods. Two hundred consecutive patients attending routine consulting sessions at 55 inner London practices were invited to complete the GPAS questionnaire. The acceptability, reliability and validity of GPAS was assessed using standard psychometric techniques.
Results. Out of 11 000 patients, 7247 (66%) completed a questionnaire in a GP surgery. Fifty-five out of a separate sample of 77 patients attending one practice completed a second questionnaire mailed to them 1 week following their attendance. GPAS was acceptable to patients as evidenced by low proportions of missing data for all items, and a full range of possible scores for all but one of the nine scales. Reliability of the instrument was good. Multiple item scales had excellent internal consistency, high item–total correlations, and test–retest reliability. Scaling assumptions were confirmed, with six of the seven scales achieving 100% scaling success (convergent and discriminant validity). Construct validity was evident, although this requires further evaluation against external measures.
Conclusions. GPAS is a useful instrument for assessing several important dimensions of primary care. It is acceptable, reliable and valid, and has the potential for versatility in mode of administration. It will be a useful instrument for practices, primary care groups and primary care researchers evaluating key areas of primary care activity. Further work is required to evaluate its performance in non-inner-city settings and to evaluate further its validity against external criteria.
Keywords. General Practice Assessment Survey (GPAS), GPs, inner-city, quality questionnaire.
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Introduction |
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TopAbstractIntroductionMethodsResultsDiscussionAppendix 1 References |
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A key challenge in general practice and primary care today is the assessment and promotion of quality in the service. To meet this challenge, it is essential that the views and interests of all stakeholders are subjected to rigorous and thorough evaluation, including an assessment of patients' views of, and satisfaction with, the provision of care.1,2 The views of patients and health professionals as to what constitutes ‘quality’ are not always convergent.3,4 Grol et al.5 have suggested that for quality to improve, more attention should be given to the contributory role of patients. In this context, there is a need for well-validated instruments to measure levels of patient satisfaction with primary care.
Studies of patients' views to date2,4,6 identify five areas of primary care service which are of importance to patients. These include availability and accessibility, the technical competence of the GP, the doctor's ability to communicate effectively with the patient, the doctor's inter-personal attributes and an efficiently organized system of care where co-ordination and continuity are emphasized. A number of self-report satisfaction questionnaires have been developed for use in the UK.7–12 None of these measures, however, adequately measure the five primary care domains identified as being important to patients, and not all have been evaluated scientifically.13 This report describes the use and psychometric evaluation of a new patient survey instrument which addresses these five key areas of primary care activity. The work is being undertaken as part of a larger study examining the performance of practices of various sizes in inner London (Campbell JL, Ramsay J, Green J. Processes and outcomes of general practice care. In preparation).
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Methods |
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TopAbstractIntroductionMethodsResultsDiscussionAppendix 1 References |
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The General Practice Assessment Survey questionnaire
The General Practice Assessment Survey (GPAS), developed at the National Primary Care Research and Development Centre in Manchester,14 is a patient-completed measure consisting of 53 items. The questionnaire addresses each of the five key dimensions of care previously described. It is based on an instrument developed for use in the USA, the Primary Care Assessment Survey (PCAS).15,16 The psychometric properties of the PCAS have been evaluated, and the instrument was found to have ‘excellent measurement properties, and perform consistently well’ across varied segments of a large sample of adult Massachusetts state employees.15 Researchers in Manchester modified the PCAS to reflect differences in primary care provision between the USA and the UK, with some items from the USA version being omitted or altered and several new items being added. This involved rewording of some questions, removal of some questions judged not to be relevant to the UK (e.g. financial barrier to accessing care), addition of scales relating to technical competence and practice nursing, and removal of the incorporated SF12 questionnaire.14
The GPAS (Appendix 1) comprises seven multiple item scales (access, technical care, communication, inter-personal care, trust, knowledge of patient and nursing care), two single item scales (receptionists and continuity of care) and four single GPAS items (referral, co-ordination of care, patient recommendation of GP and overall satisfaction). Here we report the evaluation of the psychometric properties of the GPAS including internal consistency, test–retest reliability and its acceptability to patients in the UK.
Participants and procedure
A stratified random sample of 143 GP principals from two inner London health authority areas were invited to contribute to the study. Stratification was based on the number of GP principals in the practice. In study practices, reception staff were asked to distribute GPAS questionnaires to the first 200 consecutive patients attending routine surgeries of the GP principal. The sample size was derived from power calculations relating to the principle outcome measure of the study, namely length of general practice consultations. Telephone contact with and personal visits to all participating practices throughout the data collection phase identified and resolved procedural difficulties and encouraged continuing commitment to the study. Adults were invited to complete questionnaires on behalf of child patients aged less than 12 years old. Patients who agreed to take part completed the GPAS questionnaire in the waiting room of the practice prior to seeing the GP. A detailed investigation of patient response rates was undertaken in four practices, one practice being selected at random from contributing practices having either one, two, three or four, or five or more doctors, respectively. In these practices, questionnaires were matched to the sample of 200 consecutive patients selected for the survey, thus allowing definition of patient response rates.
A sample of 77 patients attending one practice over a 2 day period were approached for purposes of establishing the test–retest reliability of GPAS. All were informed of the study in the waiting room of their practice but advised that they would be asked to complete two identical questionnaires, one to be completed at the practice that day and one to be posted to them 1 week later. The retest questionnaires and a stamped addressed envelope were mailed to patients 1 week after their initial visit to the practice.
Analysis
Scores for the nine scales (access, receptionists, continuity of care, technical care, communication, inter-personal care, trust, knowledge of patient and nursing care) were computed in accord with the GPAS scoring manual.17 For each, zero is the lowest possible score and 100 is the highest possible score. Each thus can be interpreted as a percentage of the maximum possible score. Similarly, scores for the four individual items (co-ordination, referral, recommend and overall satisfaction) were transformed into percentages of the maximum possible score.
The reliability of the GPAS was evaluated using standard psychometric techniques18 including an analysis of internal consistency (Cronbach's alpha) and test–retest reliability. Item–total correlations were used to evaluate the homogeneity of the measure. Item convergent and discriminant correlations were used to test the scaling assumptions of the GPAS. The acceptability of the GPAS was evaluated through an examination of the proportion of missing data for each item and the distribution of responses across response categories. A question relating to overall satisfaction was ‘the overall satisfaction item’ (scored on a seven-point scale from ‘completely satisfied, couldn't be better’ to ‘completely dissatisfied, couldn't be worse’), which was used to split the sample into those who were satisfied (score 1 or 2) and those who were not satisfied (score 
3). t-tests were used to compare mean scale scores for these two groups of respondents.
All data manipulation and analysis was conducted using the Statistical Package for the Social Sciences (SPSS).19
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Results |
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Response rates and demographics
Sixty out of 143 (42%) inner-London practices approached initially agreed to collaborate in the study. Five of these practices subsequently withdrew, thereby reducing the practice sample to 55 (adjusted response rate 39%). Characteristics of the participating practices are given in Table 1
.
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Questionnaires were returned by 7247 out of 11 000 patients (66% response rate, an average number of questionnaires returned per practice of 131.8 ± 38.2 SD). Seventy-seven patients invited to take part in test–retest analyses completed a GPAS questionnaire at time I. At follow-up, two of the patients were untraceable, and 55 patients (73%) completed the retest questionnaire (Table 2
). Patient characteristics are summarized in Table 3. For the four practices subjected to detailed review, patient response rates for the survey were 172 (94.5%), 112 (53.3%), 163 (78.4%) and 147 (72.1%).
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Acceptability of the GPAS
A total of 655 (8.5%) completed <50% of the questionnaire. For subjects completing
50% of all items, the proportion of missing data was low for each item, ranging from 0.9 to 14.2% across all items. For all but one of the 34 items contributing to nine GPAS scales, the proportion of missing data was <10%. For the four single item measures, there were missing data for 3.1–11.0% of subjects. Responses to all items were well distributed across response categories. Respondents appeared able to complete the questionnaire within the (estimated) 10–15 minutes waiting time to see the doctor.
Estimates of central tendency, dispersion and other features of score distributions for the nine scales and four individual items are given in Table 3
. A full range of possible scores was exhibited for all but one (trust) of the nine GPAS scales and for each of the four individual items. There were no extreme ceiling or floor effects for the nine scales, but the single item ‘referral’ was endorsed at the top of the scale by 70.3% of respondents. Nonetheless, patients tended to assign higher ratings more frequently than lower scores. Mean scores for the nine GPAS scales were all 50.00 [range 64.72 (access) to 79.50 (technical care)]. Similarly, the mean scores of the four individual items ranged from 67.91 (co-ordination) to 89.35 (referral).
Reliability
Internal consistency of multiple item scales. .
With the exception of the trust scale (alpha = 0.69), all Cronbach's alpha coefficients were above the 0.70 criteria suggested for group comparisons,20 and these scales indicate excellent internal consistency (Table 4). Deletion of one item (‘My doctor cares more about keeping down costs than about doing what is needed for my health’) was found to increase the alpha for the trust scale to 0.76.
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Homogeneity. . The homogeneity of the GPAS was assessed using an evaluation of the item–total correlations. Item–total correlations compute the correlation between an item and its own scale with the item of interest eliminated from the calculation of the score. All the item–total correlations were in excess of the 0.20 criteria suggested by Streiner and Norman.16
Test–retest reliability. . Test–retest reliability was assessed to measure the stability of the instrument. Subjects agreeing to complete the questionnaire in the waiting room (n = 77) did not differ from those who declined (n = 137) with respect to age (41.1 ± 2.1 years versus 42.0 ± 2.4 years, t = 0.272, P = 0.79) or gender (63.2% versus 54.7% female, chi-square = 1.42, P = 0.23). All seven of the multi-item scales had test–retest correlations greater than the 0.70 criteria suggested by the Scientific Advisory Committee Medical Outcomes Trust.21
Tests of scaling assumptions. . The scaling assumptions of the GPAS were tested by examining the correlations between each item and its own scale and its correlation with the other scales. Each item should be more correlated to its own scale (item convergent validity) than to the other scales (item discriminant validity).22 Six of the seven multi-item scales achieved 100% scaling success, the one exception being the trust scale. This scale achieved 75% scaling success.
Validity
The construct validity of the GPAS is supported by three types of within-scale analyses. Firstly, the high internal consistency of the scales (see above) provides evidence for construct validity. Secondly, the inter-scale correlations support the construct validity of the GPAS. The moderate correlations between the scales provide evidence of good discriminant validity. Approximately half of the inter-scale correlations (16 of 36) were <0.45 (Table 5). The highest inter-scale correlations occurred between communication and technical care (r = 0.83) and between communication and inter-personal care (r = 0.83).
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Thirdly, respondents who were extremely satisfied scored significantly higher on each of the GPAS scales and single items than those who were not extremely satisfied (Table 6
). The construct validity of the GPAS needs to be evaluated further against external criteria such as measured appointment availability23 or continuity of care.24
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionAppendix 1 References |
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In this study, we have documented the acceptability, and provided evidence concerning the psychometric properties of the GPAS questionnaire when used in a UK population. Although these data support the use of the GPAS as an acceptable tool to evaluate key dimensions of patients' assessment of primary care provision, further information on validity will be helpful in determining its precise role and potential for widespread use in a UK setting. In particular, qualitative work is planned to examine what are the determinants of responses to questions regarding ‘trust’ ‘technical care’ ‘receptionist performance’, etc. The GPAS offers the potential for practices, primary care groups and primary care researchers to obtain useful information from patients regarding their perceptions of primary care activity.
The GPAS met the standard criteria for reliability. The only scale not to satisfy the minimum criteria of 0.70 for internal consistency was the trust scale. An inspection of the results pertaining to this scale shows that its internal consistency is compromised because one of its four items has a low item–total correlation (0.25). The item in question is ‘My doctor cares more about keeping down costs than doing what is needed for my health’. The results suggest that this item is not measuring the same construct (trust) as the three remaining items and should be omitted from the trust scale. Deletion of this item increases Cronbach's alpha for the trust scale to 0.76. It is of interest that this item is the only one to be reverse coded in GPAS. It is possible that rewording in the same direction as other items might improve the homogeneity of the scale. It is also possible that this item which was taken from the USA version is not appropriate for use in the UK. The procedures for re-ordering or omitting this item are now described in the coding manual.17
Respondents who were extremely satisfied with their care scored significantly higher on each of the GPAS scales and single items than those who were not extremely satisfied with their care. This further supports the construct validity of the GPAS as one would expect those who were ‘extremely satisfied’ overall to score higher on the individual subscales (hypothesis testing of expected differences between known groups).
In this study, the GPAS was administered to patients attending the doctor, and completed in the waiting room. Although the GPAS is designed to be administered by post to patients,13 the quality of the data collected in this present work appears to be satisfactory, and the test–retest data suggest that the instrument might be used effectively as a postal survey in a UK setting. Patient response rates were judged to be satisfactory.25 The 36.5% of non-white patients completing the questionnaire in the main study was particularly satisfactory, and suggests that the instrument may be useful in areas with a high ethnic minority population.
The stable results illustrated by the test–retest correlations demonstrate that varying the mode of questionnaire presentation in this subsample had a minimal effect on patients' response choice. The retest component was carried out with the recommended18 14 day period following initial testing. The sample size of 55 for this aspect of the work is comparable with other similar studies,26,27 and judged to be satisfactory.18 Completion of questionnaires in the waiting room does not unduly overestimate satisfaction compared with completion outside of the practice. The GPAS measures stable constructs of the dimensions of care examined and can be administered in the waiting room. However, to eliminate bias related to recency effects,28 it would seem reasonable to suggest that administration of the GPAS in practice-based settings should precede the patient–doctor consultation. Administration in the waiting room is a cheaper method than postal survey and can easily be incorporated into routine practice.
Limitations
A major limitation of the GPAS for use in inner London is that it is presented in English only. One of the main reasons for non-participation by practices was a high proportion of non-English-speaking patients on the list. Similarly, in participating practices, patients who refused to complete the questionnaire did so primarily because of language difficulties. A further limitation of the GPAS is that it does not assess patient dissatisfaction. Like other instruments designed to record patients' assessments of services provided, the GPAS does not assess dissatisfaction with services, which cannot be assumed to be merely the obverse of a ‘satisfactory’ assessment of service.29
Conclusion
This evaluation of the measurement properties of the GPAS demonstrates that it is a useful instrument for assessing several important dimensions of primary care. It is a reliable instrument with the potential for versatility in mode of administration. Current imperatives in primary care relating to the assessment and implementation of patient-sensitive quality standards suggest an important role for the GPAS within practices and primary care groups. Its potential role as a research instrument is wide ranging. Further work is planned to evaluate its performance in non-inner-city settings and to evaluate further its validity against external criteria and other currently available instruments addressing similar areas of interest in primary care.
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Appendix 1 |
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Acknowledgments |
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The authors are very grateful to Dr Dana Gelb Safran who provided detailed advice and support in developing the GPAS from the Primary Care Assessment Survey. Funding was provided by the North Thames Office of the NHS Executive Organisation and Management Research Group. We are grateful to practice staff in Lambeth, Southwark and Lewisham and City and East London Health Authority areas who facilitated access to their surgeries, and to the patients who completed the questionnaire. GPAS is copyright of Safran/The Health Institute, Boston, and the National Primary Care Research and Development Centre, Manchester. There are no restrictions on its use providing this copyright is acknowledged.
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References |
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