Résumé

Objectif

Examiner la perception des patients quant au potentiel d'amélioration des soins de santé primaires dans 34 pays.

Méthodes

Nous avons mené une enquête transversale sur 69 201 patients qui venaient juste de consulter des médecins généralistes dans des établissements de soins de santé primaires. Les patients ont évalué cinq caractéristiques des soins de santé primaires axés sur la personne: accessibilité/disponibilité, continuité, exhaustivité, implication du patient et communication entre le médecin et le patient. Un dixième des patients ont classé l'importance de chaque caractéristique sur une échelle allant d'un à quatre, et neuf dixièmes ont noté leur expérience des soins reçus. Nous avons calculé le potentiel d'amélioration en multipliant la proportion d'expériences négatives des patients avec le score moyen d'importance danschaque pays. Les scores ont été répartis en potentiels d'amélioration faible, moyen et élevé. Nous avons effectué des corrélations par paire entre les scores d'amélioration et les trois dimensions de la structure des soins de santé primaires: gouvernance, conditions économiques et constitution de la main-d'œuvre.

Résultats

Dans 26 pays, une ou plusieurs caractéristiques des soins de santé primaires présentaient des potentiels d'amélioration moyen ou élevé. L'exhaustivité des soins avait un potentiel d'amélioration moyen à élevé dans 23 des 34 pays. Dans tous les pays, la communication entre le médecin et le patient présentait un potentiel d'amélioration faible. Une structure globale plus forte des soins de santé primaires était corrélée avec un potentiel plus faible d'amélioration pour la continuité et l'exhaustivité des soins. Dans les pays avec une gouvernance plus forte des soins de santé primaires, les patients percevaient un moindre potentiel pour améliorer la continuité des soins. Les pays présentant de meilleures conditions économiques pour les soins de santé primaires avaient un moindre potentiel pour l'amélioration de toutes les caractéristiques des soins de santé axés sur la personne.

Conclusion

Dans les pays avec une structure plus forte des soins de santé primaires, les patients perçoivent un moindre potentiel d'amélioration pour les soins de santé primaires.

Resumen

Objetivo

Investigar las percepciones de los pacientes acerca de la mejora en la atención primaria en 34 países.

Métodos

Se realizó una encuesta transversal de 69 201 pacientes que acababan de visitar médicos generales en centros de atención primaria. Los pacientes evaluaron cinco características de la atención primaria centrada en la persona: accesibilidad y disponibilidad, continuidad, exhaustividad, implicación del paciente, así como comunicación entre médico y paciente. Una décima parte de los pacientes clasificó la importancia de cada característica en una escala de uno a cuatro y nueve de cada diez pacientes evaluaron sus experiencias de la atención recibida. Se calculó el potencial de mejora multiplicando la proporción de experiencias negativas de pacientes con la puntuación media de la importancia en cada país. Las puntuaciones se dividieron en potencial de mejora bajo, medio y alto. Se realizaron correlaciones por pares entre las puntuaciones de mejora y las tres dimensiones de la estructura de atención primaria, a saber, gestión, condiciones económicas y desarrollo laboral.

Resultados

En 26 países, una o más características de la atención primaria tenían potenciales de mejora medios o altos. El carácter integral de la atención tenía un potencial de mejora entre medio y alto en 23 de 34 países. En todos los países, la comunicación entre médico y paciente tenía un potencial de mejora bajo. Una estructura global más fuerte de la atención primaria se correlacionó con un menor potencial de mejora en la continuidad y exhaustividad de la atención. En los países con una política de dirección de la atención primaria más sólida, los pacientes percibieron un potencial menor de mejora de la continuidad de la atención. Los países con mejores condiciones económicas para la atención primaria presentaron un potencial menor para la mejora de todas las características de la atención centradas en la persona.

Conclusión

En países con una estructura de atención primaria más sólida, los pacientes perciben un menor potencial de mejora de la atención primaria.

ملخص

الغرض

تحري تصورات المرضى حول احتمالات التحسين في مجال الرعاية الأولية في 34 بلداً.

الطريقة

أجرينا مسحاً متعدد القطاعات على 69201 مريضاً قاموا للتو بزيارة الممارسين العموميين في مرافق الرعاية الأولية. وقام المرضى بتقييم خمس سمات للرعاية الأولية الشخصية - التوافر/الإتاحة والاستمرارية والشمولية وإشراك المرضى والتواصل بين الأطباء والمرضى. وقام عُشر المرضى بترتيب أهمية كل سمة من السمات باستخدام مقياس من واحد إلى أربعة وسجل تسعة أعشار المرضى خبراتهم بشأن تلقي الرعاية. وقمنا بحساب احتمالات التحسين بضرب نسبة الخبرات السلبية للمرضى بمتوسط درجة الأهمية في كل بلد. وتم تقسيم الدرجات إلى احتمالات تحسين منخفضة ومتوسطة ومرتفعة. وتم إيجاد الارتباطات الثنائية بين درجات التحسين والأبعاد الثلاثة لهيكل الرعاية الأولية وهي - تصريف الشؤون والظروف الاقتصادية وتنمية القوى العاملة.

النتائج

حظيت واحدة أو أكثر من سمات الرعاية الأولية في 26 بلداً باحتمالات تحسين متوسطة أو مرتفعة. وحظيت شمولية الرعاية باحتمالات تحسين من متوسطة إلى مرتفعة في 23 بلداً من أصل 34 بلداً. وفي جميع البلدان، حظي التواصل بين الأطباء والمرضى باحتمالات تحسين منخفضة. وارتبط ازدياد هيكل الرعاية الأولية الأقوى بشكل عام بانخفاض احتمالات التحسين في الاستمرارية وشمولية الرعاية. وكان تصور المرضى في البلدان التي تتميز بتصريف شؤون أقوى فيما يتعلق بالرعاية الأولية هو انخفاض احتمالات التحسين في استمرارية الرعاية. وانخفضت احتمالات التحسين في جميع سمات الرعاية الشخصية لدى البلدان ذات الظروف الاقتصادية الأفضل للرعاية الأولية.

الاستنتاج

في البلدان ذات هيكل الرعاية الأولية الأقوى، تتسم الرعاية الأولية باحتمالات تحسين أقل وفق تصورات المرضى.

摘要

目的

调查34个国家病人对初级保健改善可能性的看法。

方法

我们对最近前往初级保健设施的全科医生就医的69201名患者进行横断面调查。病人以个人为中心的初级保健的五个特性评级：可达性/可用性、连续性、综合性、病人参与和医患沟通。十分之一的患者按每个特性从一到四的重要性等级排名，十分之九的患者按所接受护理的体验评分。我们这样计算改善的可能性：负面病人体验比例乘以每个国家重要性平均值。改善可能性分数分为低、中、高等。在改善分数和初级保健结构的三个维度（治理、经济条件和人力发展）之间进行两两相关分析。

结果

在26个国家，初级保健的一个或多个特性有中或高的改善可能性。在34个国家中有23个国家的护理综合性有中到高等的改善可能性。在所有国家中，医患沟通改善可能性较低。初级保健整体更强的结构与较低的护理连续性和综合性改善可能性相关。在初级保健治理更强的国家，患者认为不太可能改善医疗服务的连续性。初级护理经济条件更好的国家提高所有特性个人为中心护理的可能性更低。

结论

在初级保健结构更强的国家，病人能意识到的初级保健改善可能性更低。

Резюме

Цель

Исследовать восприятие пациентами потенциала улучшения первичной медицинской помощи в 34 странах.

Методы

Было проведено перекрестное исследование 69  201 пациента, которые посещали только терапевтов в учреждениях первичной медицинской помощи. Пациенты дали оценку пяти характеристикам целенаправленной первичной медицинской помощи: доступность/наличие, непрерывность, комплексность, участие пациента и коммуникация между врачом и пациентом. Одна десятая пациентов расположила по важности каждую характеристику на шкале от одного до четырех, а девять десятых пациентов оценили свой опыт получения медицинской помощи. Потенциал улучшения рассчитывался путем умножения части пациентов с отрицательным опытом на средний балл важности в каждой стране. Баллы делились на низкий, средний и высокий потенциал улучшения. Попарные корреляции выводились между баллами улучшения и тремя характеристиками структуры первичной медицинской помощи: руководством, экономическим положением и подготовкой трудовых ресурсов.

Результаты

В 26 странах одна или более характеристик первичной медицинской помощи обладали средним или высоким потенциалом улучшения. Комплексность медицинской помощи обладала потенциалом улучшения от среднего до высокого в 23 из 34 стран. Во всех странах коммуникация между врачом и пациентом имела низкий потенциал улучшения. В целом сильная структура первичной медицинской помощи была связана с низким потенциалом улучшения непрерывности и комплексности медицинской помощи. В странах с эффективным руководством первичной медицинской помощью пациенты усматривали меньший потенциал для улучшения непрерывности медицинской помощи. Страны с лучшим экономическим положением в первичной медицинской помощи обладали меньшим потенциалом улучшения всех характеристик целенаправленной помощи пациенту.

Вывод

В странах с эффективной структурой первичной медицинской помощи пациенты усматривали меньший потенциал улучшения в данной области.

Introduction

Due to the increased prevalence of comorbid conditions, people often have more than one disease that needs to be managed consistently over time.¹1 Starfield B. Is patient-centered care the same as person-focused care? Perm J. 2011 Spring;15(2):63–9. doi: http://dx.doi.org/10.7812/TPP/10-148 PMID: 21841928
https://doi.org/10.7812/TPP/10-148... ^,22 De Maeseneer J, van Weel C, Daeren L, Leyns C, Decat P, Boeckxstaens P, et al. From “patient” to “person” to “people”: the need for integrated, people-centered healthcare. Int J Pers Cent Med. 2012;2(3):601–14. Health-care providers can do this through a person-focused approach, which entails goal-oriented, rather than disease-oriented care. The goal is to manage people’s illnesses through the course of their life.¹1 Starfield B. Is patient-centered care the same as person-focused care? Perm J. 2011 Spring;15(2):63–9. doi: http://dx.doi.org/10.7812/TPP/10-148 PMID: 21841928
https://doi.org/10.7812/TPP/10-148... ^,22 De Maeseneer J, van Weel C, Daeren L, Leyns C, Decat P, Boeckxstaens P, et al. From “patient” to “person” to “people”: the need for integrated, people-centered healthcare. Int J Pers Cent Med. 2012;2(3):601–14. Therefore, person-focused care should be continuous, accessible and comprehensive. It should also be coordinated when patients have more than one provider.¹1 Starfield B. Is patient-centered care the same as person-focused care? Perm J. 2011 Spring;15(2):63–9. doi: http://dx.doi.org/10.7812/TPP/10-148 PMID: 21841928
https://doi.org/10.7812/TPP/10-148...

Patients’ assessment of health care can be divided into what patients find important and what they have experienced.³3 van Campen C, Sixma HJ, Kerssens JJ, Peters L, Rasker JJ. Assessing patients’ priorities and perceptions of the quality of health care: the development of the QUOTE-Rheumatic-Patients instrument. Br J Rheumatol. 1998 Apr;37(4):362–8. doi: http://dx.doi.org/10.1093/rheumatology/37.4.362 PMID: 9619883
https://doi.org/10.1093/rheumatology/37.... ^–55 Sixma HJ, Kerssens JJ, Campen CV, Peters L. Quality of care from the patients’ perspective: from theoretical concept to a new measuring instrument. Health Expect. 1998 Nov;1(2):82–95. doi: http://dx.doi.org/10.1046/j.1369-6513.1998.00004.x PMID: 11281863
https://doi.org/10.1046/j.1369-6513.1998... Importance refers to what people see as desired features of health care – i.e. patients’ instrumental values.⁶6 Groenewegen PP, Kerssens JJ, Sixma HJ, van der Eijk I, Boerma WG. What is important in evaluating health care quality? An international comparison of user views. BMC Health Serv Res. 2005 Feb 21;5(1):16. doi: http://dx.doi.org/10.1186/1472-6963-5-16 PMID: 15723701
https://doi.org/10.1186/1472-6963-5-16... The combination of instrumental values and patients’ experiences constitute quality judgments, which provides insight on the extent to which health-care providers meet these values. Both instrumental values and experiences of primary care patients vary between countries.⁶6 Groenewegen PP, Kerssens JJ, Sixma HJ, van der Eijk I, Boerma WG. What is important in evaluating health care quality? An international comparison of user views. BMC Health Serv Res. 2005 Feb 21;5(1):16. doi: http://dx.doi.org/10.1186/1472-6963-5-16 PMID: 15723701
https://doi.org/10.1186/1472-6963-5-16... ^–88 Grol R, Wensing M, Mainz J, Ferreira P, Hearnshaw H, Hjortdahl P, et al. Patients’ priorities with respect to general practice care: an international comparison. European Task Force on Patient Evaluations of General Practice (EUROPEP). Fam Pract. 1999 Feb;16(1):4–11. doi: http://dx.doi.org/10.1093/fampra/16.1.4 PMID: 10321388
https://doi.org/10.1093/fampra/16.1.4... These judgements can be transformed into a measure of improvement potential. When an aspect of care is experienced as poorly performed, but not considered important, this can be seen as less of a quality problem than if patients consider the aspect important.⁹9 Jung H, Wensing M, de Wilt A, Olesen F, Grol R. Comparison of patients’ preferences and evaluations regarding aspects of general practice care. Fam Pract. 2000 Jun;17(3):236–42. doi: http://dx.doi.org/10.1093/fampra/17.3.236 PMID: 10846142
https://doi.org/10.1093/fampra/17.3.236... More important aspects of care thus have higher improvement potential.

The structure of primary care can relate to person-focused care in various ways. In stronger primary care structures the providers are more likely to be involved in a wide range of health problems at different stages of the patients’ lives. This is expected to increase continuity of care and providers’ responsiveness to the patients’ values regarding continuity, comprehensiveness and communication. Patients will use services more readily if they know a broad spectrum of care is offered.¹⁰10 The world health report 2008: primary health care now more than ever. Geneva: World Health Organization; 2008. A stronger primary care structure is associated with more accessible primary care,¹¹11 Kringos D, Boerma W, Bourgueil Y, Cartier T, Dedeu T, Hasvold T, et al. The strength of primary care in Europe: an international comparative study. Br J Gen Pract. 2013 Nov;63(616):e742–50. doi: http://dx.doi.org/10.3399/bjgp13X674422 PMID: 24267857
https://doi.org/10.3399/bjgp13X674422... which is one of the core features of person-focused care. Therefore, we expect that in countries with a stronger primary care structure, the patient-perceived improvement potential of person-focused primary care is lower.

The primary care structure comprises governance, economic conditions such as the mode of financing of providers and expenditures on primary care, and workforce development – the profile and the education of the primary-care providers.¹²12 Kringos DS, Boerma WG, Hutchinson A, van der Zee J, Groenewegen PP. The breadth of primary care: a systematic literature review of its core dimensions. BMC Health Serv Res. 2010;10(1):65. doi: http://dx.doi.org/10.1186/1472-6963-10-65 PMID: 20226084
https://doi.org/10.1186/1472-6963-10-65... ^,1313 Kringos DS. The importance of measuring and improving the strength of primary care in Europe: results of an international comparative study. Türk Aile Hek Derg. 2013;17(4):14.

We wished to quantify the extent to which the structure of primary care at the national level in 34 countries is related to patient-perceived improvement potential for features of person-focused care. To study this relationship, the empirical relations between the providers – general practitioners – and patients need to be considered (Fig. 1). The primary care structure influences the behaviour of the practitioners, which will influence patients’ experiences. Patients’ characteristics – e.g. age and income – influence patients’ individual experiences and values. We focus on the system level to study characteristics that are amenable to policy interventions.

Methods

We derived aggregated data on patient-perceived improvement potential in 34 countries from the QUALICOPC study (Quality and Costs of Primary Care in Europe). In this study, patients in 31 European countries (Austria, Belgium, Bulgaria, Cyprus, Czech Republic, Denmark, Estonia, Finland, Germany, Greece, Hungary, Iceland, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, the Netherlands, Norway, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden, Switzerland, the former Yugoslav Republic of Macedonia, Turkey, the United Kingdom of Great Britain and Northern Ireland) responded to surveys. Three non-European countries (Australia, Canada, New Zealand) were also included. In each country, patients of general practitioners filled in the questionnaires (target: n = 2200 per country; Cyprus, Iceland and Luxembourg n = 800). In Belgium, Canada, Spain and Turkey, larger samples were taken to enable comparisons between regions (Table 1). We aimed to get a nationally representative sample of general practitioners. If national registers of practitioners were available, we used random sampling to select practitioners. In countries with only regional registers, random samples were drawn from regions that represented the national setting. If no registers existed, but only lists of facilities in a country, a random selection from such lists was made. The patients of only one practitioner per practice or health centre were eligible to participate. Details of the study protocol have been published elsewhere.¹⁴14 Schäfer WLA, Boerma WG, Kringos DS, De Maeseneer J, Gress S, Heinemann S, et al. QUALICOPC, a multi-country study evaluating quality, costs and equity in primary care. BMC Fam Pract. 2011;12(1):115. doi: http://dx.doi.org/10.1186/1471-2296-12-115 PMID: 22014310
https://doi.org/10.1186/1471-2296-12-115... ^,1515 Schäfer WL, Boerma WG, Kringos DS, De Ryck E, Greß S, Heinemann S, et al. Measures of quality, costs and equity in primary health care instruments developed to analyse and compare primary care in 35 countries. Qual Prim Care. 2013;21(2):67–79. PMID: 23735688

In nearly all countries (30), trained fieldworkers were sent to the participating practices to collect patient data using paper questionnaires. In Canada, Denmark, New Zealand, the United Kingdom and parts of Norway and Sweden, the practice staff were instructed to distribute and collect the questionnaires. The fieldworkers and practice staff were instructed to invite consecutive patients, who had had a face-to-face consultation with the practitioner and who were 18 years or older, to complete the questionnaire until 10 questionnaires per practice were collected. Of these 10 questionnaires, nine assessed the experiences in the consultation which had just occurred and one questionnaire included questions about the patient’s primary care values. The proportions of the questionnaires were based on the findings that, within a country, patients’ experiences varied widely but there was little variation in what the patients found important.⁷7 Kerssens JJ, Groenewegen PP, Sixma HJ, Boerma WG, van der Eijk I. Comparison of patient evaluations of health care quality in relation to WHO measures of achievement in 12 European countries. Bull World Health Organ. 2004 Feb;82(2):106–14. PMID: 15042232 In the patient experience questionnaire, patients were asked to indicate whether they agreed with a statement by selecting “Yes” or “No” answers. For example, the proportion of negative experiences for the statement “during the consultation the doctor had my medical records at hand” would be the proportion stating that the doctor did not have the medical records at hand. In the patient values’ questionnaire – which contained the same questions as the patient experience questionnaire – patients could indicate the importance of a statement, e.g. the importance of the doctor having medical records at hand, by selecting “not important”, “somewhat important”, “important” or “very important”. The answers were scored, ranging from 1 (not important) to 4 (very important). Missing answers were excluded from the calculations.

Ethical approval was acquired in accordance with the legal requirements in each country. The surveys were carried out anonymously. Data collection took place between October 2011 and December 2013. The patient experience questionnaire was filled in by 61 931 patients and the patient values’ questionnaire by 7270 patients. Appendices A and B contain the questionnaires (available at: http://www.nivel.nl/pdf/Appendices-Assesing-the-potential-for-improvement-of-PC-in-34-countries-WHO-Bulletin-2015.pdf).

Operationalization of concepts

Dependent variables

As an outcome indicator for health care, we used the patient-perceived improvement potential, which is based on the consumer quality (CQ) index, a validated and standardized measurement instrument.¹⁶16 Delnoij DM, Rademakers JJ, Groenewegen PP. The Dutch consumer quality index: an example of stakeholder involvement in indicator development. BMC Health Serv Res. 2010;10(1):88. doi: http://dx.doi.org/10.1186/1472-6963-10-88 PMID: 20370925
https://doi.org/10.1186/1472-6963-10-88... Person-focused primary care was measured using 16 items, such as whether the practitioner displayed knowledge about the patient’s personal living circumstances. The items were derived from the CQ index for general practice and tested in the QUALICOPC pilot study.¹⁵15 Schäfer WL, Boerma WG, Kringos DS, De Ryck E, Greß S, Heinemann S, et al. Measures of quality, costs and equity in primary health care instruments developed to analyse and compare primary care in 35 countries. Qual Prim Care. 2013;21(2):67–79. PMID: 23735688^,1717 Meuwissen LE, de Bakker DH. ‘Consumer quality’-index ‘General practice care’ measures patients’ experiences and compares general practices with each other. Ned Tijdschr Geneeskd. 2009;153:A180. [Dutch]. PMID: 19900331 Improvement potential was expressed in improvement scores, which are calculated by multiplying the proportion of negative experiences for each question – the answers which indicate lower quality – with the value scores of the corresponding statement per country. The value score was calculated by taking the mean value for each country on a scale from one to four. A higher improvement score indicates a higher need for improvement.

The improvement potential of each country was measured for the following main features: accessibility/availability (five questions), continuity (three questions), comprehensiveness (two questions), patient involvement (one question) and doctor–patient communication (five questions). For each feature, a mean patient-perceived improvement score was calculated. Based on the range of scores found (0.11–1.95) the level of improvement potential is considered relatively low (0.11–0.72), medium (0.73–1.34) or high (1.35–1.95).

Independent variables

For 30 countries (Australia, Canada, New Zealand and the former Yugoslav Republic of Macedonia were excluded), we collected data from the Primary Health Care Activity Monitor (PHAMEU) study on a set of indicators for the dimensions of governance, economic conditions and workforce development of the primary care structure.¹⁸18 Kringos DS, Boerma WG, Bourgueil Y, Cartier T, Hasvold T, Hutchinson A, et al. The European primary care monitor: structure, process and outcome indicators. BMC Fam Pract. 2010;11(1):81. doi: http://dx.doi.org/10.1186/1471-2296-11-81 PMID: 20979612
https://doi.org/10.1186/1471-2296-11-81... Examples of such indicators are the availability of evidence-based guidelines for general practitioners (governance) and the percentage of medical universities with a postgraduate programme in family medicine (workforce development).¹⁸18 Kringos DS, Boerma WG, Bourgueil Y, Cartier T, Hasvold T, Hutchinson A, et al. The European primary care monitor: structure, process and outcome indicators. BMC Fam Pract. 2010;11(1):81. doi: http://dx.doi.org/10.1186/1471-2296-11-81 PMID: 20979612
https://doi.org/10.1186/1471-2296-11-81... The PHAMEU database provides scores indicating the strength of each indicator, ranging from 1 (weak) to 3 (strong) and overall scale scores for each dimension, calculated using a two-level hierarchical latent regression model, and an overall structure score combining the three dimensions.¹¹11 Kringos D, Boerma W, Bourgueil Y, Cartier T, Dedeu T, Hasvold T, et al. The strength of primary care in Europe: an international comparative study. Br J Gen Pract. 2013 Nov;63(616):e742–50. doi: http://dx.doi.org/10.3399/bjgp13X674422 PMID: 24267857
https://doi.org/10.3399/bjgp13X674422... Additionally, we collected data for Australia, Canada, New Zealand and the former Yugoslav Republic of Macedonia using the same methods as for the PHAMEU study. Table 1 lists the relative strength of each countries’ primary care structure, Appendix C contains the indicators and Appendix D contains scale scores per dimension.

Statistical analyses

One-tailed pairwise correlations were used to measure the associations between the independent and dependent variables, because the hypothesis has one direction, namely that a stronger primary care structure is associated with more person-focused care. P < 0.05 was considered statistically significant.

Sensitivity analyses were done using an alternative method of analysis for the improvement scores. Multilevel analyses were used to calculate country-level scores of the experience and values items, using the country level residuals of the items. The scores were adjusted for several variables at the practitioner and patient level (e.g. age and gender of the general practitioners and patients). When comparing the raw improvement scores and the ones calculated on the basis of multilevel residuals no significant differences were found. Correlation coefficients between the raw improvement scores as used in this paper and the adjusted improvement scores were above 0.91.

In the PHAMEU conceptual model and corresponding database, gatekeeping (practitioners determining the necessity for referral of patients to other levels of the health system) is considered to be part of the process of primary care. However, in previous studies, gatekeeping has been used as a potential determinant of primary care performance. Therefore, additional sensitivity analysis was performed on the association between the improvement potential and gatekeeping. The results of this analysis are presented in Appendix E. Analyses were carried out using Stata version 13.0 (StataCorp. LP, College Station, United States of America) and MLWin version 2.25 (University of Bristol, Bristol, United Kingdom).

Results

Improvement potential

In total, 69 201 patients completed the questionnaire and the average response rate was 74.1% (range: 54.5%–87.6%). A detailed overview of the patients’ experience scores, values’ scores and patient-perceived improvement scores per country are provided in Appendices F–H. The background characteristics of the patients can be found in Appendix I.

For accessibility of care, five countries – Cyprus, Portugal, Slovakia, Spain and Turkey – showed a medium level of improvement potential. The remaining countries showed a low improvement potential. While most of the countries were found to have a low improvement potential regarding the continuity of care, Greece, Malta and Turkey show a medium level and Cyprus a high level. Comprehensiveness of care showed a medium level of patient-perceived improvement potential in 20 countries and a relatively high level in Cyprus, Malta and Sweden. Patients’ involvement in decision-making about their treatment had a medium level of improvement potential in nine countries and a high level in Cyprus. In all countries, values were relatively low for doctor–patient communication, indicating that the primary-care providers meet their patients’ expectations in this domain (Table 2).

The relatively high levels of patient-perceived improvement potential in Cyprus – three features with high potential and one feature with medium – indicate weak performance of primary care. In Turkey, three areas showed a medium level of patient-perceived improvement potential. Countries showing relatively low improvement potential in all features were Australia, Belgium, Canada, Ireland, Latvia, Luxembourg, New Zealand and Switzerland, indicating that primary care in these countries is perceived as person-focused.

Primary care structure

The patient-perceived improvement potential for continuity and comprehensiveness of care had a significant negative association with the overall structure of primary care. If a country has a stronger primary care structure, primary care is more person-focused for these features. For the separate structural dimensions, patients’ perceived care to be more continuous in countries with stronger primary care governance. Stronger economic conditions in primary care were found to be associated with all features of person-focused care. Although workforce development correlated negatively with all features, none of the values were significantly correlated (Table 3).

In eight countries where patient-perceived improvement potential is relatively low, the overall strength of the primary care structure varies. The relative strength is strong in Australia, Canada and New Zealand, medium in Belgium, Ireland and Latvia and weak in Luxembourg and Switzerland. The strongest associations between strength and improvement potential were found for economic conditions for primary care. These conditions are relatively strong in Australia, Belgium and New Zealand and medium in Latvia and Switzerland.

Discussion

This study evaluates the extent to which primary care in 34 countries is person-focused by asking patients of general practitioners about what they find important and their actual experiences. The combination of these aspects provides us with insight on what patients perceive as priority improvement areas. In most countries primary care shows one or more features with a medium or high level of patient-perceived improvement potential. Accessibility and continuity of care show relatively low improvement potential, while in many countries comprehensiveness is indicated as a priority area. In this study, comprehensiveness of care indicates whether general practitioners ask their patients about additional problems and whether there is opportunity to discuss psychosocial problems. Our results confirm previous studies showing that practitioners perform well on general aspects of communication.¹⁹19 Noordman J, Koopmans B, Korevaar JC, van der Weijden T, van Dulmen S. Exploring lifestyle counselling in routine primary care consultations: the professionals’ role. Fam Pract. 2013 Jun;30(3):332–40. doi: http://dx.doi.org/10.1093/fampra/cms077 PMID: 23221102
https://doi.org/10.1093/fampra/cms077... ^–2121 Grol R, Wensing M, Mainz J, Jung HP, Ferreira P, Hearnshaw H, et al.; European Task Force on Patient Evaluations of General Practice Care (EUROPEP). Patients in Europe evaluate general practice care: an international comparison. Br J Gen Pract. 2000 Nov;50(460):882–7. PMID: 11141874 One explanation for this result could be the on-going relationship between practitioners and their patients. Larger variations have been found between countries on the relevance of communication and practitioners’ performance for specific issues.²²22 van den Brink-Muinen A, Verhaak PF, Bensing JM, Bahrs O, Deveugele M, Gask L, et al. Doctor-patient communication in different European health care systems: relevance and performance from the patients’ perspective. Patient Educ Couns. 2000 Jan;39(1):115–27. doi: http://dx.doi.org/10.1016/S0738-3991(99)00098-1 PMID: 11013553
https://doi.org/10.1016/S0738-3991(99)00... Eight countries showed low improvement potential in all features, indicating positive patient experiences. Previous studies in Australia and New Zealand have also found positive patient experiences.²³23 Patient experience 2011/12: key findings of the New Zealand health survey. Wellington: Ministry of Health; 2013.^,2424 Healthy communities: Australians’ experiences with primary health care in 2010-11. Sydney: National Health Performance Authority; 2013. Another study comparing 10 European countries, found positive patient assessments in Belgium, Germany and Switzerland and less positive assessments in the United Kingdom and the Scandinavian countries.²¹21 Grol R, Wensing M, Mainz J, Jung HP, Ferreira P, Hearnshaw H, et al.; European Task Force on Patient Evaluations of General Practice Care (EUROPEP). Patients in Europe evaluate general practice care: an international comparison. Br J Gen Pract. 2000 Nov;50(460):882–7. PMID: 11141874 This is largely in line with our findings.

We could largely confirm the hypothesis that a stronger primary care structure is associated with more person-focused care. Stronger structures were associated with more continuous and comprehensive care. Continuity is an important aspect of person-focused care. Stronger governance is also associated with more continuity. In countries with stronger economic conditions for primary care we found less improvement potential in all areas.

The sensitivity analysis for the association between gatekeeping and patient-perceived improvement potential showed that gatekeeping was associated only with lower perceived improvement potential for continuity of care.

Strengths of this study were the inclusion of data from many countries and that patients were asked about their actual experiences immediately after the consultation with their practitioners. There were also limitations. First, there are countries where other providers offer primary care besides general practitioners. These providers were not included in this study. Second, only the actual visitors to general practices were surveyed. This means that we do not have information about the people who do not have access to such practices. In all countries, improvement potential for accessibility of care might be higher than measured in this study. For example, a report based on the Canadian QUALICOPC data found that patient-reported access in this study is more positive compared to other previous studies.²⁵25 Laberge M, Pang J, Walker K, Wong S, Hogg W, Wodchis W, et al. QUALICOPC (Quality and Costs of Primary Care) Canada: a focus on the aspects of primary care most highly rated by current patients of primary care practices. Ottawa: Canadian Foundation for Healthcare Improvement; 2014.^–2828 Schoen C, Osborn R, Huynh PT, Doty M, Zapert K, Peugh J, et al. Taking the pulse of health care systems: experiences of patients with health problems in six countries. Health Aff (Millwood). 2005 Jul-Dec;Suppl Web Exclusives:W5-509–25. PMID: 16269444 Third, in Greece, most participating general practitioners worked in health centres, while there are also many practitioners in Greece working outside health centres. Comparing different countries should be done cautiously, since the extent to which general practitioners are involved in primary care and the types of illnesses they treat differs between countries.

When measuring instrumental values and experiences of patients, people may judge importance by what they have already experienced in health care.⁶6 Groenewegen PP, Kerssens JJ, Sixma HJ, van der Eijk I, Boerma WG. What is important in evaluating health care quality? An international comparison of user views. BMC Health Serv Res. 2005 Feb 21;5(1):16. doi: http://dx.doi.org/10.1186/1472-6963-5-16 PMID: 15723701
https://doi.org/10.1186/1472-6963-5-16... For example, when practitioners in a country perform poorly on a certain aspect, patients might have lower expectations and will find this aspect less important. Experiences and values of patients have been found to be correlated,⁶6 Groenewegen PP, Kerssens JJ, Sixma HJ, van der Eijk I, Boerma WG. What is important in evaluating health care quality? An international comparison of user views. BMC Health Serv Res. 2005 Feb 21;5(1):16. doi: http://dx.doi.org/10.1186/1472-6963-5-16 PMID: 15723701
https://doi.org/10.1186/1472-6963-5-16... perhaps because patients seek health-care providers who deliver care according to their values.

The World Health Organization advocates for primary care that puts people first. A stronger primary care structure is necessary to make progress towards this goal.¹⁰10 The world health report 2008: primary health care now more than ever. Geneva: World Health Organization; 2008.

Acknowledgements

We thank partners in the QUALICOPC project; J De Maeseneer, E De Ryck, L Hanssens, A Van Pottelberge, S Willems (Belgium); S Greß, S Heinemann (Germany); G Capitani, S De Rosis, AM Murante, S Nuti, C Seghieri, M Vainieri (Italy); D Kringos (the Netherlands); M Van den Berg, T Van Loenen (the Netherlands); D Rotar Pavlič, I Švab (Slovenia).

We thank the coordinators of the data collection in each country: L Jorm, I McRae (Australia); K Hoffmann, M Maier (Austria); P Salchev (Bulgaria); W Wodchis, W Hogg (Canada); G Samoutis (Cyprus); B Seifert, N Šrámková (Czech Republic); J Reinholdt Jensen, P Vedsted (Denmark); M Lember, K Põlluste (Estonia); E Kosunen (Finland); C Lionis (Greece); I Rurik (Hungary); J Heimisdóttir, O Thorgeirsson (Iceland); C Collins (Ireland); G Ticmane (Latvia); S Macinskas (Lithuania); M Aubart, J Leners, R Stein (Luxembourg); G Bezzina, P Sciortino (Malta); T Ashton, R McNeill (New Zealand); T Bjerve Eide, H Melbye (Norway); M Oleszczyk, A Windak (Poland); L Pisco (Portugal), D Farcasanu (Romania); E Jurgova (Slovakia); T Dedeu (Spain); C Björkelund, T Faresjö (Sweden); T Bisschoff, N Senn (Switzerland); K Stavric (The former Yugoslav Republic of Macedonia); M Akman (Turkey); C Sirdifield, N Siriwardena (United Kingdom).

FGS is also affiliated with the department of General Practice and Elderly Care Medicine/EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam, the Netherlands. PPG is also affiliated with the department of Sociology and the department of Human Geography, Utrecht University, Utrecht, the Netherlands.

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