Family Practice Advance Access originally published online on February 3, 2006
Family Practice 2006 23(3):308-316; doi:10.1093/fampra/cmi112
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Family medicine attributes related to satisfaction, health and costs
a Institut Català de la Salut (ICS) Spain
b Universitat de Barcelona Spain
c Consorci d'Atenció Primaria de Salut de l'Eixample (CAPSE) Spain
d Agència de Salut Pública de Barcelona Spain
Correspondence to Joan Gené-Badia, MD, PhD, Consorci d'Atenció Primaria de Salut de l'Eixample (CAPSE), C/Roselló 161, 08036 Barcelona, Spain; Email: jgene{at}clinic.ub.es
Received 22 February 2005; Accepted 28 December 2005.
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Abstract |
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Objective. To identify, from a systematic review of the literature, the attributes of Family Medicine (FM) that influence the primary health care outcome as measured by users' satisfaction, improvement in patient health and in costs.
Data Sources. Literature search of Medline and the Cochrane library using MeSH terms ‘Primary Health’ or ‘Family Practice’ or ‘Family Physicians’ and ‘Outcome Assessment’ or ‘Process Assessment’. Papers were excluded if they lacked a based on primary data, if no single component of FM was assessed; if indicators of evaluation were not related to health, satisfaction or costs.
Results. A total of 356 articles were initially identified and 19 finally met the inclusion criteria. Study methods were a systematic review of randomized control trials, a double-blind randomized trial, 4 systematic reviews of observational studies, 2 cohort studies and 12 descriptive cross-sectional studies.
Conclusions. There was evidence of relationships between the attributes of FM and the service outcomes measured by indicators of satisfaction, health and cost. User satisfaction was associated with accessibility, continuity of care, consultation time and the doctor–patient relationship. Improvement in patient's health was related to continuity, consultation time, doctor–patient relationship and the implementation of preventive activities. Coordination of care showed mixed results with health outcomes. Continuity, consultation time, doctor–patient communication and prevention were cost-effective in the primary care setting.
Keywords. Family medicine, outcomes, health satisfaction, costs.
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Introduction |
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In 2002, WONCA Europe issued a new definition of GP/Family Medicine1 (FM) which encompasses the ideal content of the speciality, the core content as well as the function of this clinical discipline.2 It offers a new and universal approach while continuing to be based on the traditional attributes of FM.
As with every public service, FM should be accountable to society. Currently, there is a great variety of health care evaluation indicators. This complicates comparison between different organizations and with other types of services. Policy makers and managers often measure only partial aspects of the service.3 In many cases, we do not know if these performance indicators inform on the final health care outcome, or merely offer a description of how the health care process had been conducted.
Evaluation of the final outcome of the health care process can be considered in three dimensions: (1) impact on health dimension, as evaluated by mortality and morbidity rates or by subjective health questionnaires; (2) the satisfaction dimension, defined as the level at which the user's expectations of the service are met and (3) the economic dimension, which is the cost of the services provided.
In this article we review available evidences in international literature on relationships between the attributes of FM and the final outcomes of health care provision in terms of health, user satisfaction and cost. Despite considerable evidence indicating that better results are obtained when health systems are orientated towards primary care and FM,4 we sought to identify the specific attributes of FM that could be responsible for these positive outcomes.
The objective of the present study was to identify, via a literature search, the attributes of FM that are related to the outcomes with respect to dimensions of satisfaction, health and costs. The identification of these attributes can be of considerable use in defining a group of indicators that more effectively describe the benefits that this type of health care provides for the population.
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Method |
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We performed a literature search of the Medline database and of the Cochrane Library (The Cochrane Controlled Trial Register). Key word descriptors or MeSH Thesaurus terms were ‘Primary Health’ or ‘Family practice’ or ‘Family physician’) and ‘outcome assessment’ or ‘process assessment’. Publication type limitations excluded ‘letter’, ‘editorial’ or ‘practice guideline’. No language limits were used.
The search included all studies up to June 2005 that evaluated the attributes of FM using qualitative or quantitative methodology (observational and experimental, systematic reviews and meta-analyses).
Articles were excluded because of the following criteria: (1) papers without analyses based on primary data; (2) papers not assessing at least an attribute of FM; (3) studies where the indicators of evaluation were not related to health, user satisfaction or costs.
The selection of the studies and extraction of the data were performed by three investigators (MSC, EPR and JGB). All disagreements were solved by dialogue and final consensus among all six coauthors.
From each of the identified studies, the following variables were collected: identification of the study, numbers and types of participants, methodology (study design, setting of the study, participants, indicators of service evaluation and sources of the information) and the most relevant results/outcomes.
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Results |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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The literature search identified 356 articles. On applying the different selection criteria, 20 articles were finally selected. The de-selected papers were rejected because they lacked a research based on primary data (n = 16); they did not assess at least one component of FM (n = 296) and their evaluation indicators were not related to health, user satisfaction or costs (n = 24). The selection procedure is depicted in Figure 1. The methodologies of the selected papers are summarized in Table 1.
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Table 2 summarizes the studies that had found associations between attributes of FM and patient satisfaction outcome as the health care indicator.
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The accessibility indicators associated with greater satisfaction were obtaining an outpatient appointment with the family doctor for the same, or following, day5 and spending a short time (6–10 minutes) in the consultation waiting room.5
The continuity indicator that was associated with satisfaction was having the same family doctor over an extended period.5–10
The length-of-consultation indicators (or the patient's perception of the duration) showed a direct association with increased satisfaction i.e. the longer the clinical visit the greater the patient satisfaction.11–13 Short consultations classified by the author as ‘with high technical medical efficiency’ seemed to be related to poor communication and patient dissatisfaction.14
Citizens are more satisfied with the doctor who appears warm, friendly and with a reassuring manner,15 who is confident16,17 and provides patient-centred care,18,19 who shows an interest in the patient's concerns and expectations,19 who discusses the health problem, who provides a clear explanation of the diagnosis and prognosis and who shares the treatment decision with the patient.19 Greater satisfaction occurs when the patient has the perception of being listened to, of being treated with respect, humanely and as fairly as others.19 An overall personal patient–doctor relationship increased the odds of the patient being satisfied with the consultation.7 There was no support for the hypothesis that GPs' task-relevant patient-centred behaviour would predict patient enablement as well as satisfaction.12 Physicians who held patient-centred beliefs regarding power and information-sharing were rated no more positively on measures of satistaction.20
Table 3 summarizes the studies identified that had shown an association between FM attributes and health-outcome indicators.
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An association was observed between the continuity of care, such as having the same family doctor over a protracted period of time,5,6,8,10 and better health indicators. The patients attended to by the same doctor presented with less back pain, less infarcts, less liver pathologies and less stomach ulcers.21 Similarly, the doctors with longer continuity are better able to manage acute and chronic problems such as psychosocial problems, to pay more attention to diet and weight fluctuations, to smoking cessation, to vaccination, lipid profiles, blood pressure and alcohol consumption.9 Having the same health care provider was related, as well, to more effective implementation of appropriate preventative activities resulting in a reduction in morbidity and mortality.21 Patients with longer continuity had fewer hospitalizations, fewer days in intensive care, shorter hospital stays and lower percentage of emergency hospitalizations.6,10
Associations were found between the length of consultation appointment and the health dimension. When the period of consultation time was 
10 minutes, those patients with diabetes, asthma and cardiovascular disease achieved better control.8 The doctors who provided longer consultation time identified and treated more chronic problems and psychosocial disorders. They achieved greater patient compliance with treatment recommendations for specific disorders (blood pressure and dysuria), they provided more active and passive advice, implemented more preventive measures to promote better health, prescribed less drugs and provided better evidenced-based quality of treatment.13
Perceived health improvement was based on confidence in the doctor,17 integrated care, detailed physical examination, good communication and knowledge of the patient.13 Patient adherence to treatment was related to greater empathy with the doctor who had a more detailed knowledge of the patient and to those patients who evidenced a greater reliance on their doctor.13 The health status of the patient improved when the doctor provided a clear diagnosis, positively transmitted the prognosis and treatment, and paid attention to the cognitive and emotional aspects of the patient.15 When the patient and doctor had shared beliefs, there was an increase in the patient's confidence in the professional health care provider, the patient was more likely to recommend the service to other potential patients, and the doctor's advice was more likely to be adhered to.20 When the consultation was patient centred, there was a quicker recovery from the disease and a greater health-status improvement.18,19
A recent review reported positive results on the effect of care coordination on health care outcomes such as appropriate use of health services. In contrast, studies that examined health outcomes alone tended to report mixed results.22
Implementation of preventive measures was directly related to health. Mortality and morbidity rates were reduced with the following intervention measures: prescribing aspirin to persons with high cardiovascular risk; controlling blood pressure; providing anti-smoking advice; treating cardiac insufficiency with angiotensin converting enzyme (ACE) inhibitors; prescribing statins for primary and secondary hyperlipidaemias; prescribing oral anti-coagulants for atrial fibrillation and immunizing against influenza, pneumonia and tetanus.23 Table 4 summarizes the relationships between the attributes of primary care and the costs. Having the same family doctor over a long period of time was associated with lower costs.10,21 Continuity was associated with decreased total annual health care expenditure.10 Continuity of care was related to indirect indicators of efficiency such as fewer hospital days, fewer intensive care days, shorter hospital stays and lower percentages of emergency hospitalizations.6,10 Continuity of care was associated with reduction in resource utilization and of costs.24
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Longer consultation time was associated with indirect indicators of efficiency. Doctors who spend more time in the consultation process appear to prescribe less and with more evidence-based treatment.13 A short consultation, with a high level of technical efficiency, can be very productive but with poor patient satisfaction.14
The review by McColl et al.23 analysed the cost-effectiveness of different preventative measures and concluded that the most cost-effective treatments were in the control of hypertension, in the use of statins for patients with high cardiovascular disease risk, and in the use of oral anti-coagulants for patients with atrial fibrillation and those having stroke risk-factors. Other strategies were, possibly, cost-effective as well. These included aspirin for patients with high risk of coronary artery or cerebro-vascular events, anti-tobacco advice for smokers, statins in patients with low risk of coronary artery disease and vaccination against the influenza virus in those >65 years of age.23 Indirectly, patient-centred consultation appeared to be efficient because it decreased the number of referrals and diagnostic tests.18,19 A good interpersonal relationship between doctors and patients was associated with less referrals to the specialist.19 Short consultations appeared to be more productive, although there appeared to be an inverse correlation between the consultation time and the level of patient–doctor communication.14
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Discussion |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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This review obtained evidence of associations between FM attributes and the outcomes of health care as measured by patient satisfaction, improvements in health and of costs. User satisfaction was related to continuity of care, consultation time and doctor–patient relationship. Accessibility, continuity of care, consultation time, patient–doctor relationship and the preventive health care activities were associated with improvements in the level of population health. The coordination of care has mixed results with respect to health outcomes. Continuity, consultation time, doctor–patient communication and preventive health care activities were cost-effective in the primary care setting.
These results highlight that the core values of FM stated in the new definition of WONCA relied on an empirical ratification. An effective family doctor is one who follows up the patient over the greater part of his life and who is accessible in the initial phase of his patient's every new health problem. This leads to a relationship of understanding and confidence that encourages the patient to adopt an active and responsible attitude towards his own health. The family doctor takes the time to listen and understand the patient, to apply scientific medicine, to anticipate the pathology and to maximize the benefit of this close relationship with the patient in providing preventive measures appropriate for patient's specific needs.
It is important to highlight that this classical figure of the family practitioner not only satisfies the patient but has positive effects on health, as well. A group of experts gathered under the auspices of the Robert Wood Johnson Foundation25 observed that despite people expressing a preference for a personal family physician (who is aware of the individual's clinical history and who appreciates the patient as a person) the family doctors in the United States are, currently, not fulfilling this commitment to the patient. The expert panel stated that this was the central point of the crisis in FM in some countries, particularly the USA. The profession is a caring one, and one which has tremendous difficulties in fulfilling the natural hopes and aspirations of the patients but which should, indeed, define the profession.26
It seems surprising that only a limited number of papers dealt with evaluating the core attributes of FM. It was not our aim to review the whole literature on FM attributes. We restricted the selection criteria in order to fulfil our specific research objective. We rejected papers presenting comparisons of the care provided by FM doctors to patient groups compared with other specialists if, in the article, it was not possible to identify which attribute FM was being evaluated. Other papers assessing key aspects of primary care nursing or other health care professionals were also rejected even if they were evaluating attributes that were similar to those of FM.
A possible limitation of the present study could be that not all the relevant papers on the topic had been identified. As stated in the Methods section, the literature search was performed on the main electronic databases. However, it is possible that there have been some relevant studies containing additional information but published in non-indexed journals.
Table 1 shows that there is an evident publication bias in favour of English-speaking countries. This limits the acquisition of evidence and jeopardizes the external validity of the results of this literature review. Also, the observed associations may not exist in other cultural environments, or in health service organizations with health-provision structures that are different from the National Health Systems of most Western developed countries.
We included every study identified in the literature search irrespective if they had been included in one of the four systematic reviews included in the present study i.e. the purpose of our study was not to pool patients from different studies but to conduct a literature review aimed at presenting all the published information currently available on the theme of FM attributes and patient outcomes.
Clinical trials and cohort studies offer good evidence on the causal relationship between continuity of care and health improvement, satisfaction and costs. Our systematic review of randomized controlled trials and of a cohort study offers good evidence that patient-centred care improves health outcomes and efficiency. The majority of studies included in the present analysis only evaluated associations between variables; because most were observational cross-sectional studies they were not able to propose causal relationships. We observed, for example, that doctors who provided longer consultations and better continuity of care achieved higher user satisfaction and more improvements in patient health. However, the design of these studies does not allow us to assume that by merely increasing the time per consultation and the continuity of care provided by the family physician we would automatically result in improvement in the patient's satisfaction or in the patient health status.
Physician performance is being profiled increasingly in the United States in order to provide performance data to the public and to make routinely collected data available to health care purchasers and regulators.3 Spain22,27 and many other countries are likely to follow suit. The six essential attributes of the PHC that are related to outcomes must drive the way we evaluate and organize our services and pay the salaries of the professional health care providers if we wish to maximize the impact of the clinical care provided in primary care settings. Management policies that used only FM services for cost-containment purposes have not only damaged the image of the family doctor but have underused a powerful professional who could contribute to improving user satisfaction as well as the overall health of the citizen. Conversely, applying organizational models that strengthen the attributes we have identified would induce progressive improvements in health care outcomes.
A recent sceptical editorial pointed out that "if primary care has anything at all to do with improving a person's health, then its contribution to that end will be measurable"28. The present study shows that this relevant field of research already exists with respect to FM but, given the available evidence is limited, more research is warranted. Attributes are core values of FM, but more evidence linking the intuitively valuable results to improvements in health care outcomes is needed so as to demonstrate its value to policymakers and to the paymasters who are a central part of a rational health care system.
More prospective analytical studies whose design would help to overcome the mere associations of variables are needed if we are to establish a causality of relationship between FM attributes and outcomes. It is necessary as well to unify the definitions of FM attributes since variations in the concepts of the attributes as well as in the evaluation of indicators make it difficult to make international comparisons and also impedes meta-analyses. Definitions of FM attributes need to be better defined for future studies.
Policy makers and health care managers need to conduct evidenced-based evaluations of primary care services and to make the findings known to the public as well as to the other health care professionals. Performance indicators of family practitioners need to be based on the attributes that have been identified as having an association with health outcomes, user satisfaction and costs; especially those that have an impact on the patient's health. To facilitate its implementation, cost-effective evaluation systems need to be developed to assess these dimensions efficiently and which can then be applied in monitoring primary care services. Aspects such as the doctor–patient relationship, consultation time and clinical-care continuity merit special attention.
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Acknowledgments |
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The study was funded, in part, by a grant from the Fondo de Investigaciones Sanitarias (FIS #PI021762). Financial help with manuscript preparation was from the Fundacío Jordi Gol i Gurina. Editorial assistance was by Dr Peter R. Turner of t-SciMed (Reus, Spain).
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Notes |
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Sans-Corrales M, Pujol-Ribera E, Gené-Badia J, Pasarín-Rua MI, Iglesias-Pérez B and Casajuana-Brunet J. Family medicine attributes related to satisfaction, health and costs. Family Practice 2006; 23: 308–316.
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References |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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1 WONCA Europe. The European Definition of General Practice/Family Medicine. WONCA Europe 2002. http://www.woncaeurope.org/Publications.htm.
2 Olesen F, Dickinson J, Hjortdahl P. (2000) General practice—time for a new definition. Br Med J 320:354–357.
3 Goldfield N, Gnani S, Majeed A. (2003) Primary care in the United States. Profiling performance in primary care in the United States. Br Med J. 326:744–747.
4 Starfield B. (1994) Is primary care essential? Lancet 344:1129–1133.[CrossRef][ISI][Medline]
5 Bower P, Roland M, Campbell J, Mead N. (2003) Setting standards based on patients' views on access and continuity: secondary analysis of data from the general practice assessment survey. Br Med J 326:258–260.
6 Wasson JH, Sauvigne AE, Mogielnicki RP, et al. (1984) Continuity of outpatient medical care in elderly men. A randomised trial. JAMA 252:2413–2417.[Abstract]
7 Hjortdahl P and Laerum P. (1992) Continuity of care in general practice: effect on patient satisfaction. Br Med J 304:1287–1290.[ISI][Medline]
8 Campbell SM, Hann M, Hacker J, Burns C, Oliver D, Thapar A. (2001) Identifying predictors of high quality care in English general practice: observational study. Br Med J 323:784–787.
9 Sturmberg J and Schattner P. (2001) Personal doctoring. Its impact on continuity of care as measured by the comprehensiveness of care score. Aust Fam Physician 30:513–518.[Medline]
10 Cabana MD and Jee SH. (2004) Does continuity of care improve patient outcomes? J Fam Pract 53:974–980.[ISI][Medline]
11 Cape J. (2002) Consultation length, patient-estimated consultation length, and satisfaction with the consultation. Br J Gen Pract 52:1004–1006.[ISI][Medline]
12 Mead N, Bower P, Hann M. (2002) The impact of general practitioners' patient-centeredness on patients' post-consultation satisfaction and enablement. Soc Sci Med 55:283–299.[CrossRef][ISI][Medline]
13 Wilson A and Childs S. (2002) The relationship between consultation length, process and outcomes in general practice: a systematic review. Br J Gen Pract 52:1012–1020.[ISI][Medline]
14 Goedhuys J and Rethans J-J. (2001) On the relationship between the efficiency and the quality of the consultation. A validity study. Fam Pract 18:592–596.
15 Di Blasi Z, Harkness E, Ernst E, Georgiou A, Kleijnen J. (2001) Influence of context effects on health outcomes: a systematic review. Lancet 357:757–762.[CrossRef][ISI][Medline]
16 Safran DJ, Taira D, Rogers W, Kosinski M, Ware J, Tarlov A. (1998) Linking primary care performance to outcomes of care. J Fam Pract 47:213–220.[ISI][Medline]
17 Tarrant C, Stokes T, Baker R. (2003) Factors associated with patients' trust in their general practitioner: a cross-sectional survey. Br J Gen Pract 53:789–800.
18 Stewart M, Brown JB, Donner A, McWhinney I, Oates J, Weston W. (2000) The impact of patient-centered care on outcomes. J Fam Pract 49:796–804.[ISI][Medline]
19 Little P, Everitt H, Williamson I, et al. (2001) Observational study of effect of patient centredness and positive approach on outcomes of general practice consultations. Br Med J 323:908–911.
20 Krupat E, Bell R, Kravitz R, Thom D, Azari R. (2001) When physicians and patients think alike: patient-centered beliefs and their impact on satisfaction and trust. J Fam Pract 50:1057–1062.[ISI][Medline]
21 Hartley LA. (2002) Examination of primary care characteristics in a community-based clinic. J Nurs Scholarsh 34:377–382.[Medline]
22 Lanier D, Roland M, Burstin H, Knottnerus JA. (2003) Doctor performance and public accountability. Lancet 362:1404–1407.[CrossRef][ISI][Medline]
23 McColl A, Roderick P, Gabbay J, Smith H, Moore M. (1998) Performance indicators for primary care groups: an evidence based approach. Br Med J 317:1354–1360.
24 Raddish M, Horn SD, Sharkey PD. (1999) Continuity of care: is it cost effective? Am J Manag Care 5:727–734.[Medline]
25 Safran DJ. (2003) Defining the future of primary care: what can we learn from patients? Ann Intern Med 138:248–255.
26 Sox HC. (2003) The Future of primary care. Ann Intern Med 138:230–232.
27 Gené-Badia J and Gallo de Puelles P. (2004) Retribución variable vinculada a la calidad asistencial. Aten Primaria 34:98–104.
28 Lancet. (2003) Is primary care research a lost cause? Lancet 361:977 (Editorial).[CrossRef][ISI][Medline]
29 Stille J, Jerant A, Bell D, Meltzer D, Elmore J. (2005) Coordinating care across diseases, settings, and clinicians: a key role for the generalist in practice. Ann Intern Med 142:700–708.
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