The association between patient shortage and patient satisfaction with general practitioners

Vaccine hesitancy among physicians: a qualitative study with general practitioners and paediatricians in Austria and Germany

OBJECTIVE

This study aims to understand reasons for vaccine hesitancy (VH) among general practioners (GPs) and paediatricians. We aim to analyse how and when the healthcare workers (HCWs) developed vaccine-hesitant views and how they transfer these to patients.

DESIGN AND SETTING

Semistructured interviews with vaccine-hesitant GPs and paediatricians were conducted in Austria and Germany using an explorative qualitative research design.

PARTICIPANTS

We contacted 41 physicians through letters and emails and 10 agreed to participate, five were male and five female.

DATA COLLECTION AND ANALYSIS

Ten interviews were recorded, transcribed verbatim and anonymised. The material was analysed inductively following a grounded theory approach with open coding using the software atlas.ti.

RESULTS

Key themes that were identified were education and career path, understanding of medicine and medical profession, experiences with vaccines, doctor-patient interactions and continuous education activities and the link to VH. GPs and paediatricians' vaccine-hesitant attitudes developed during their medical training and, in particular, during extracurricular training in homeopathy, which most of the participants completed. Most participants work in private practices rather than with contracts with social insurance because they are not satisfied with the health system. Furthermore, they are critical of biomedicine. Most of the interview partners do not consider themselves antivaccination, but are sceptical towards vaccines and especially point out the side effects. Most do not vaccinate in their practices and some do only occasionally. Their vaccine-hesitant views are often fostered through respective online communities of vaccine-hesitant HCWs.

CONCLUSIONS

More studies on a connection between complementary medicine and vaccine-hesitant views of HCWs are needed. Education about vaccines and infectious diseases among healthworkers must increase especially tailored towards the use of internet and social media. Physicians should be made aware that through time and empathy towards their patients they could have a positive impact on undecided patients and parents regarding vaccine decisions.

The Norwegian patient experiences with GP questionnaire (PEQ-GP): reliability and construct validity following a national survey

OBJECTIVES

The aim of this study was to test the reliability and validity of a new questionnaire for measuring patient experiences with general practitioners (PEQ-GP) following a national survey.

SETTING

Postal survey among patients on any of 500 GPs patient lists in Norway. GPs were stratified by practice size and geographical criteria.

PARTICIPANTS

4964 patients who had at least one consultation with their regular GP in the foregoing 12 months were included in the study. The patients were randomly selected after the selection of GPs. 2377 patients (49%) responded to the survey.

PRIMARY AND SECONDARY OUTCOME MEASURES

The items were assessed for missing data and ceiling effects. Factor structure was assessed using exploratory factor analyses. Reliability was tested with item-total correlation, Cronbach's alpha and test-retest correlations. Item discriminant validity was tested by correlating items with all scales. Construct validity was assessed through associations of scale scores with health status, the patients' general satisfaction with the services, whether the patient had been incorrectly treated by the GP and whether the patient would recommend the GP to others.

RESULTS

Item missing varied from 1.0% to 3.1%, while ceiling effects varied from 16.1% to 45.9%. The factor analyses identified three factors. Reliability statistics for scales based on these three factors, and two theoretically derived scales, showed item-total correlations ranging from 0.63 to 0.85 and Cronbach's alpha values from 0.77 to 0.93. Test-retest correlation for the five scales varied from 0.72 to 0.88. All scales had the expected association with other variables.

CONCLUSIONS

The PEQ-GP has good evidence for data quality, internal consistency and construct validity. The PEQ-GP is recommended for use in local, regional and national surveys in Norway, but further studies are needed to assess the instrument's ability to detect differences over time and between different GPs.

Disenrollment from general practitioners among chronic patients: a register-based longitudinal study of Norwegian claims data

Background

Norwegian general practitioners (GPs) consult on a variety of conditions with a mix of patient types. Patients with chronic diseases benefit from appropriate continuity of care and generally visit their GPs more often than the average patient. Our aim was to study disenrollment patterns among patients with chronic diseases in Norway, because such patterns could indicate otherwise unobserved GP quality. For instance, higher quality GPs could have both a greater share of patients with chronic diseases and lower disenrollment rates.

Methods

Data on 384,947 chronic patients and 3,974 GPs for the years 2009–2011 were obtained from national registers, including patient and GP characteristics, disenrollment data, and patient list composition. The birth cohorts from 1940 and 1970 (146,906 patients) were included for comparison. Patient and GP characteristics, comorbidity, and patient list composition were analyzed using descriptive statistics. Patients’ voluntary disenrollment was analyzed using logistic regression models.

Results

The GPs’ proportion of patients with a given chronic disease varied more than expected when the allocation was purely random. The proportions of patients with different chronic diseases were positively correlated, partly due to comorbidity. Patients tended to have lower disenrollment rates from GPs who had higher shares of patients with the same chronic disease. Disenrollment rates were generally lower from GPs with higher shares of patients with arthritis or depression, and higher from GPs who had higher shares of patients with diabetes type 1 and schizophrenia. This was the same in the comparison group.

Conclusion

Patients with a chronic disease appeared to prefer GPs who have higher shares of patients with the same disease. High shares of patients with some diseases were also negatively associated with disenrollment for all patient groups, while other diseases were positively associated. These findings may reflect the GPs’ general quality, but could alternatively result from the GPs’ specialization in particular diseases. The supportive findings for the comparison group make it more plausible that high shares of chronic patients could indicate GP quality.

Decreasing trends in patient satisfaction, accessibility and continuity of care in Finnish primary health care - a 14-year follow-up questionnaire study

BACKGROUND

The aim here was to explore trends in patient satisfaction with primary health care and its accessibility and continuity, and to explore whether through reforms and improvements some of the essential goals had been achieved over a 14-year period of time in Finland.

METHODS

Nine questionnaire surveys were conducted over a period of 14 years among patients attending within one week in the 65 health centres in the Tampere University Hospital catchment area. A total of 147,394 responded out of a sample of 333,648 patients. The response rate varied yearly from 53% to 37%.

RESULTS

Patient satisfaction with care in Finnish health centres decreased by nearly 9 percentage units from 1998 to 2011. The fall-off was most marked in the age-group over 64 years. There was a 20 percentage unit's reduction in ease of access as reported by patients. Respondents also reported that the continuity of care had deteriorated.

CONCLUSIONS

Despite major reforms in Finnish health care policy, patients seem to be less satisfied. Our findings challenge both Finnish authorities and GPs to improve the accessibility and continuity of care in primary health services.

Personal continuity of care in Norwegian general practice: a national cross-sectional study

OBJECTIVE

Personal continuity is regarded as a core value in general practice. The aim of this study was to determine the level of personal continuity in Norwegian general practice. An investigation was made of the associations between high levels of personal continuity and patient, general practitioner (GP), and list characteristics.

DESIGN

Cross-sectional register-based study.

SETTING

Norwegian general practice in 2009.

SUBJECTS

3220 GPs and 3 725 998 patients on the GP lists.

MAIN OUTCOME MEASURES

The Usual Provider Continuity Index (UPC), which measures the proportion of consultations made by the usual GP, was estimated for patients and aggregated to the GP list level. GPs were grouped into quartiles based on the UPC. Being a GP with a UPC in the two highest quartiles (UPC ≥ 0.80) was the outcome in the statistical analyses.

STATISTICS

Poisson regression models were used to estimate relative risks (RR).

RESULTS

The overall UPC was 0.78, increasing gradually from 0.68 in patients < 15 years of age to 0.86 for patients ≥ 60 years of age, and from 0.75 to 0.83 for patients with < 3 annual consultations compared with patients with > 10 consultations. A UPC > 0.80 was associated with longer patient lists and high GP consultation rates. Working in municipalities with < 10 000 residents was negatively associated with a high UPC. The UPC level for GPs was associated with total utilization of GP consultations in the list populations.

CONCLUSION

Overall, the Norwegian goal of a personal GP has been achieved; however, there are substantial variations between GPs and lower UPCs among young patients and in smaller municipalities.

Market conditions and general practitioners' referrals

We study how market conditions influence referrals of patients by general practitioners (GPs). We set up a model of GP referral for the Norwegian health care system, where a GP receives capitation payment based on the number of patients in his practice, as well as fee-for-service reimbursements. A GP may accept new patients or close the practice to new patients. We model GPs as partially altruistic, and compete for patients. We show that a GP operating in a more competitive market has a higher referral rate. To compete for patients and to retain them, a GP satisfies patients' requests for referrals. Furthermore, a GP who faces a patient shortage will refer more often than a GP who does not. Tests with Norwegian GP radiology referral data support our theory.

Patient switching in general practice

Patients switching physicians involves costs to the patients because of less continuity of care. From a theoretical model we derive that inferior physician quality as perceived by patients, implies patient shortage for the physician and more patients switching physicians. By means of a unique panel data set covering the entire population of Norwegian general practitioners (GPs) and estimation methods that adjust for potential endogeneities, we find that the occurrence of patient shortage increases the proportion of patients switching physicians by 50%. A competing hypothesis that GPs with a shortage of patients experience less switching because of superior access is rejected by data. To assist patients in making informed decisions, we suggest that the number of switches a physician experiences should be made public.

Migrant participation in Norwegian health care. A qualitative study using key informants

Background Little is known about how migrants adapt to first-world public health systems. In Norway, patients are assigned a registered general practitioner (RGP) to provide basic care and serve as gatekeeper for other medical services. Objectives: To explore determinants of migrant compliance with the RGP scheme and obstacles that migrants may experience. Methods: Individuals in leadership positions within migrant organizations for the 13 largest migrant populations in Norway in 2008 participated in this qualitative study. Semi-structured interviews, with migrants serving as key informants, were used to elucidate possible challenges migrant patients face in navigating the local primary health-care system. Conversations were structured using an interview guide covering the range of challenges that migrant patients meet in the health-care system. Results: According to informants, integration into the RGP scheme and adequacy of patient-physician communication varies according to duration of stay in Norway, the patient's country of origin, the reason for migration, health literacy, intention to establish permanent residence in Norway, language proficiency, and comprehension of information received about the health system. Informants noted as obstacles: doctor-patient interaction patterns, conflicting ideas about the role of the doctor, and language and cultural differences. In addressing noted obstacles, one strategy would be to combine direct intervention by migrant associations with indirect intervention via the public-health system.

National survey of patients' bill of rights statutes

BACKGROUND

Despite vigorous national debate between 1999-2001 the federal patients' bill of rights (PBOR) was not enacted. However, states have enacted legislation and the Joint Commission defined an accreditation standard to present patients with their rights. Because such initiatives can be undermined by overly complex language, we surveyed the readability of hospital PBOR documents as well as texts mandated by state law.

METHODS

State Web sites and codes were searched to identify PBOR statutes for general patient populations. The rights addressed were compared with the 12 themes presented in the American Hospital Association's (AHA) PBOR text of 2002. In addition, we obtained PBOR texts from a sample of hospitals in each state. Readability was evaluated using Prose, a software program which reports an average of eight readability formulas.

RESULTS

Of 23 states with a PBOR statute for the general public, all establish a grievance policy, four protect a private right of action, and one stipulates fines for violations. These laws address an average of 7.4 of the 12 AHA themes. Nine states' statutes specify PBOR text for distribution to patients. These documents have an average readability of 15th grade (range, 11.6, New York, to 17.0, Minnesota). PBOR documents from 240 US hospitals have an average readability of 14th grade (range, 8.2 to 17.0).

CONCLUSIONS

While the average U.S. adult reads at an 8th grade reading level, an advanced college reading level is routinely required to read PBOR documents. Patients are not likely to learn about their rights from documents they cannot read.

Primary care patients' attitudes to priority setting in Sweden

OBJECTIVE

To analyse attitudes to priority setting among patients in Swedish primary healthcare.

DESIGN

A questionnaire was given to patients comprising statements on attitudes towards prioritizing, on the role of politicians and healthcare staff in prioritizing, and on patient satisfaction with the outcome of their contact with primary healthcare (PHC).

SETTINGS

Four healthcare centres in Sweden, chosen through purposive sampling.

PARTICIPANTS

All the patients in contact with the health centres during a two-week period in 2004 (2517 questionnaires, 72% returned).

MAIN OUTCOMES

Patient attitudes to priority setting and satisfaction with the outcome of their contact.

RESULTS

More than 75% of the patients agreed with statements like "Public health services should always provide the best possible care, irrespective of cost". Almost three-quarters of the patients wanted healthcare staff rather than politicians to make decisions on priority setting. Younger patients and males were more positive towards priority setting and they also had a more positive view of the role of politicians. Less than 10% of the patients experienced some kind of economic rationing but the majority of these patients were satisfied with their contact with primary care.

CONCLUSIONS

Primary care patient opinions concerning priority setting are a challenge for both politicians and GPs. The fact that males and younger patients are less negative to prioritizing may pave the way for a future dialogue between politicians and the general public.