Family Practice Vol. 19, No. 2, 197-201
© Oxford University Press 2002
Original Paper |
Primary care reform: a pilot study to test the evaluative potential of the Patient Enablement Instrument in Poland
Department of Primary Care and Population Sciences, University College London, Archway Campus, London N19 3UA, UK,
a Gdansk Medical Academy, Department of Family Medicine, 80-210 Gdansk, Poland and
b Department of Community Health Sciences–General Practice, University of Edinburgh, 20 West Richmond Street, Edinburgh EH8 9DX, UK.
Pawlikowska TRB, Nowak PR, Szumilo-Grzesik W and Walker JJ. Primary care reform: a pilot study to test the evaluative potential of the Patient Enablement Instrument in Poland. Family Practice 2002; 19: 197–201.
Received 2 February 2001; Revised 27 July 2001; Accepted 1 November 2001.
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Abstract |
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Background. Primary health care reform is underpinned by a move towards patient-centred holistic care. This pilot study uses the Patient Enablement Instrument (PEI) to assess outcome at a fundamental level: that of the patient and their doctor at consultation.
Objectives. Our aim was to assess the evaluative potential of the PEI in relation to a reform programme in Poland by (i) comparing the outcomes of consultations (using the PEI) carried out by nine doctors (three diploma GPs who had participated in the training programme, three GPs who had not participated in the training programme and three polyclinic internists); and (ii) relating PEI scores to a proxy quality process measure (consultation length).
Methods. A cross-sectional quantitative questionnaire survey was carried out using the PEI. The subjects were patients consulting with nine doctors distributed within a single region around Gdansk.
Results. The overall results with the PEI and consultation length reflected UK experience. In addition, there were significant differences between groups in this pilot study. Patients seen by diploma GPs achieved higher patient enablement scores (mean 4.33, 95% confidence interval 4.09–4.58) relative to GPs (mean 3.44, 3.21–3.67) and polyclinic doctors (mean 3.23, 2.99–3.47). However, there is evidence of appreciable between-doctor variation in PEI scores within groups. The difference in patient enablement between groups was not affected by patient case mix, in contrast to the duration of consultation, which was. Holistically trained diploma GPs spent longer with patients with psychological problems. Patients seen by diploma GPs received longer consultations (mean 12.65 min, 95% confidence interval 12.18–13.13) relative to their colleagues (the GPs' mean was 10.11, 9.82–10.41 min; that of the polyclinic internists was 10.16, 9.81–10.50 min). The duration of consultation was positively correlated with patient enablement.
Conclusion. The results of such training courses should be examined from the perspective of both the patient and their doctor. Significant differences were found in both patient enablement and consultation length between patients attending groups of doctors delivering primary care, but working from different paradigms. This pilot shows promising results which, if repeated in a larger study, would provide an objective means of evaluating such reform programmes.
Keywords. Consultation, general practice, health care reform, patient enablement, patient-centred care.
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Introduction |
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Primary care is the foundation of a health care system, and the doctor–patient interchange is fundamental to delivery. Medical education often underpins primary care reform. Despite the fact that reform has been proceeding rapidly in many of the former Communist countries, there is a dearth of systematic evidence regarding effectiveness.1 Projects are evaluated by terms of reference formulated by donors. Success is judged in terms of numbers of ‘new’ GPs and a change in their curriculum.
Patient empowerment is a key issue,2 and there is a shift from an authoritarian model to a more holistic patient-centred one.3 This pilot study is an attempt to evaluate one educational project in terms of an output that reflects such change.
Focusing on quality in consultation, Howie4 and colleagues have developed an approach which relates needs, process and the outcome measure of ‘patient enablement’. The post-consultation Patient Enablement Instrument (PEI) consists of six questions dealing with patients' ability to cope and their understanding of their problem. The derivation of this is holistic and patient-centred, which makes it an appropriate measure to apply to such reform programmes.
Duration of consultation is a useful proxy measure of quality. There is a positive correlation between length of consultation and PEI score.4 Studies5,6 have found longer consultation times with the recognition of a psychological component. Time was used here in parallel with the PEI score as a simple reproducible measure of consultation.
The aim of this pilot study was to test the feasibility of using the PEI in the context of primary care reform, and to assess its performance.
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Methods |
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Ethical Committee approval was obtained at the Royal Free Hospital School of Medicine and at Gdansk Medical Academy.
Participants
Poland was one of the first countries to commence harmonization with ‘western’ Europe. A programme to train a cadre of family care doctors commenced in 1993.
This pilot study was in Gdansk, a cathedral city and Baltic port. Its surrounding region covers a wide spectrum. Doctors volunteered after the initial re-training programme, and were recruited from nine representative sites (see Fig. 1
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This pilot compared the patients of three types of doctor who routinely provide first contact care, and have different educational backgrounds.
- Group 1: re-trained family doctors–diploma GPs. These were participants in the new programme (anticipated to have developed a ‘patient-centred’ approach, and so attain a higher PEI score).
- Group 2: family doctors. These were non-participants in the new programme. It is hypothesized that they would have intermediate outcomes.
- Group 3: polyclinic general internists. These were generalists, expected to be ‘disease-centred’, and so score less well on the PEI.
Three doctors were selected from each group to cover the spectrum. They collected data on 250 consecutive consultations with patients aged between 14 and 80 years.
Research instruments
Each patient completed a pre-consultation questionnaire to capture demographic details and the reason for encounter. A hierarchy of needs4,7 was used which described clinical situations ranging from administrative, to physical, to psychological and psychosocial, and various combinations of these. Consultation length and type (routine, fit-in, etc.) was noted. Following consultation, patients completed the PEI (Fig. 2).7
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Data handling
Questionnaires were scanned and data stored in a format compatible with further statistical analysis using SPSS (the Statistical Package for Social Sciences).
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Results |
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A total of 2289 consultations were analysed in this pilot study; 2171 (97%) patients completed the PEI, of whom 394 (17.5%) needed help. This compares with 80% completion in the UK.7
The overall mean PEI score in Poland was 3.65 (95% confidence interval 3.51–3.79). The mean PEI score for English speakers—derived from a large-scale UK study —is 3.10 (3.05–3.15), and for other language speakers is 4.54 (4.35–4.72).7
The patients of GP participants in the programme achieved significantly higher enablement scores (mean 4.33, 4.09–4.58) compared with those seen by GPs who had not taken part (mean 3.44, 3.21–3.67) and by polyclinic doctors (mean 3.23, 2.99–3.47).
In such a small study, the influence of individuals is strong: a group 1 GP who consistently attained high scores (mean 4.90, 4.50–5.30) was known for a patient-centred approach, whereas a group 3 internist with a low PEI score (mean 1.48, 1.13–1.83) was overtly authoritarian. There was overlap between individual doctor's mean PEI scores (Fig. 3): 3.72 (3.32–4.13), 4.90 (4.50–5.30), 4.27 (3.81–4.72), 3.56 (3.14–3.97), 3.41 (3.05–3.77), 3.36 (2.95–3.78), 4.03 (3.61–4.45), 1.48 (1.13–1.83) and 4.07 (3.67–4.48). A PEI score of 4.03 was attained by a group 3 doctor who later became an accredited family physician—which might have been predicted on theoretical grounds.
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Although PEI scores varied significantly with the group of the doctor (one-way ANOVA F = 22.411, d.f. = 2, P < 0.0001) and patient case mix, which paralleled that found in the UK,4,7 in this pilot the difference in patient enablement between groups of different doctors was not affected by case mix (two-way ANOVA for group by case mix with PEI score as the dependent variable F = 0.912, P = 0.555).
Polish doctors spent longer in consultation (mean 10.96 min, 95% confidence interval 10.74–11.18) than their UK counterparts and there were significant differences between groups (see Fig. 4). Diploma GPs spent significantly longer in consultation relative to their colleagues.
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As in previous work in the UK,4,7 longer consultations and higher PEI scores were correlated (Spearman's rank rs = 0.09, P < 0.01 in the UK; and rs = 0.13, P < 0.01 in Poland).
The duration of consultation was affected by case mix (two-way ANOVA for group by case mix with consultation length as the dependent variable F = 1.891, P = 0.017; for doctor's group alone F = 10.095, P = 0.000; and for case mix alone F = 4.611, P = 0.000). Patients with psychological problems seen by holistically trained diploma GPs received longer consultations.
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Discussion |
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The purpose of this pilot was to test the evaluative potential of the PEI. Completion and patient participation were equivalent to the UK.4,7 Automation of the questionnaire proved an efficient method of capturing data from a foreign language.
The findings of this small study using PEI in Poland mirror UK findings.4,7 The overall mean PEI result was comparable. Patients achieving higher enablement scores tended to be those having longer consultations (recognized in previous UK studies4,7).
Patient enablement was found to vary with the type of doctor in this study; it was independent of case mix. Some doctors were consistently ‘high enablers’, as in the UK.4,7
The findings of this pilot suggest that the PEI can be used to compare outcomes for patients seen by doctors educated in different paradigms.9 However, in this small pilot, between-doctor variation is too large to allow a safe generalization to the differences between intervention and control groups. Indeed, the results may have been influenced by the fact that doctors were self-selecting, and those likely to be ‘high enablers’ may also have been those most likely to volunteer to re-train. A larger study is now in progress to address these issues.
Consultations in Poland were found to be longer than in the UK, in line with expectations from European data.8 They echoed the results with the PEI in the three groups of doctors, as expected.4,7 However, consultation length varied within each type of doctor, as did patient case mix; this was also expected from parallel UK studies.
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Conclusion |
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The results of both PEI scores and consultation length mirrored UK data. The PEI demonstrated different outcomes for patients seen by three groups of doctors trained in different paradigms, as expected from its holistic derivation. This pilot shows promise and needs to be explored in a larger study. If these results are replicated, this design could be adopted in the evaluation of primary care reform programmes.
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Acknowledgments |
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We thank the doctors who summoned up the vision to participate in this research, at the end of a particularly bleak winter, NFER-Nelson Publishing Co. Ltd and their collaborators in the Department of Psychology at Lodz University for permitting use of the new Polish version of the Goldberg GHQ, Parimal Patel at FORMIC Ltd for training, support and scanning, and SmithKline Beecham Polska, Zeneca and Phytofarm for providing local support. The Scientific Foundation of The Royal College of General Practitioners are thanked for the award of a grant, which supported this study, part of an MSc in Primary health care at the University of Exeter.
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References |
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1 Grielen SJ, Boerma WG, Groenewegen PP. Science in practice: can health care reform projects in central and eastern Europe be evaluated systematically? Health Policy 2000; 53:73–89.[Medline]
2 Saltman RB, Figueras J. European Health Care Reform: Analysis of Current Strategies. WHO Regional Office of Europe, 1998.
3 Stewart M, Brown JB, Weston WW, McWhinney IR, McWilliam CL, Freeman TR. Patient-centred Medicine: Transforming the Clinical Method. Thousand Oaks (CA): Sage, 1995.
4 Howie JGR, Heaney DJ, Maxwell M. Measuring Quality in General Practice: Occasional Paper No. 75. London: Royal College of General Practitioners, 1997.
5 Morrell DC, Evans ME, Morris RW, Roland MO. The ‘five minute’ consultation: effect of time constraint on clinical content and patient satisfaction. Br Med J 1986; 292:870–873.
6 Whitehouse CR. A survey of the management of psychological illness in general practice in Manchester. J R Coll Gen Pract 1987; 37:112–115.[Medline]
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Howie JGR, Heaney DJ, Maxwell M, Walker JJ, Freeman GK, Rai H. Quality at general practice consultations: a cross sectional survey. Br Med J 1999; 319:738–743.
8 Wilson A. Consultation length in general practice: a review. Br J Gen Pract 1991; 41:119–122.[Web of Science][Medline]
9 European Consortium for Primary Care. Republic of Poland: Health Restructuring Programme: Training a Cadre of Primary Care Physicians. Manchester: British Council, 1995.
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