Comparison of Primary Care Experience in Hospital-Based Practices and Community-Based Office Practices in Japan

The role of primary care attributes in preventing loss or change of usual source of care: a nationwide cohort study

BACKGROUND

The existence of a stable usual source of care (USC) is fundamental to the provision of quality health care. However, no longitudinal studies have examined whether core primary care attributes influence the stability of USC status.

OBJECTIVES

We aimed to examine the association between primary care attributes (first contact, longitudinality, coordination, comprehensiveness, and community orientation) and the loss or change of USC.

METHODS

This nationwide cohort study was conducted during the coronavirus disease 2019 pandemic using a representative sample of the Japanese adult population aged 40-75 years. The primary outcome measures were loss of USC and voluntary change in USC during the 12-month follow-up period. Primary care attributes were evaluated in the baseline survey using the Japanese version of Primary Care Assessment Tool (JPCAT).

RESULTS

Data were analyzed for 725 participants who had a USC at baseline. Among them, 93 (12.8 %) lost their USC and 46 (6.3%) changed their USC during the follow-up period. Multivariable multinominal logistic regression analyses showed that the JPCAT total score was associated with decreased loss of USC and change in USC. Among the JPCAT domains, longitudinality, comprehensiveness (services available), and community orientation were associated with reductions in both USC loss and change.

CONCLUSIONS

Our study indicates that primary care attributes play an important role in preventing the loss or change of USC and contribute to the stability of USC status. These findings provide additional rationale for policymakers, healthcare providers, and managers to seek to strengthen core attributes of primary care.

Validation and Clinical Application of the Japanese Version of the Patient-Reported Experience Measures for Intermediate Care Services: A Cross-Sectional Study

Older adult patients account for 70% of all hospitalized patients in Japan, and intermediate care based on patient-centered care (PCC) that ensures continuity and quality of care at the interface between home services and acute care services and restores patient's independence and confidence is necessary for them to continue living independently. At present, no concept of intermediate care is established in Japan, and the implementation of PCC has been delayed. Thus, in this study, a Japanese version of the intermediate care evaluation index (patient-reported experience measure (PREM)) was created on the basis of the original PREM developed in the UK, and data in wards with intermediate care functions in Japan were collected to confirm internal consistency and validity from 2020 to 2022. The Japanese version of PREM was found to have a factor structure with two potential factors. Given the clear correlation with the shared decision-making evaluation index, which is the pinnacle of PCC, the theoretical validity of the Japanese version of PREM, which is based on PCC as a theoretical basis, was confirmed.

Factors associated with the status of usual source of care during the COVID-19 pandemic: a nationwide survey in Japan

BACKGROUND

To ensure that high-quality primary care is available to every individual, increasing the proportion of residents with a usual source of care (USC) is a challenge for each country. However, the status of USC after the spread of COVID-19 and the factors associated with it remain unclear internationally. Therefore, we aimed to explore the associations of sociodemographic and clinical factors with the presence and type of USC (kakaritsukei in Japanese) during the pandemic in Japan.

METHODS

We conducted a nationwide cross-sectional survey of a representative sample of the general Japanese adult population in May 2021. The main outcome measures were the presence and type of USC. We assessed sociodemographic and clinical factors, including age, gender, marital status, years of education, employment status, annual household income, social isolation, health literacy, number of chronic conditions, and health-related quality of life.

RESULTS

Of the 1,757 participants, 1,011 (57.5%) had a USC. There were 769 (76.1%) participants who had a USC in a clinic and 227 (22.5%) in a hospital. As a result of multivariable modified Poisson regression analysis, male gender, no chronic condition, lower health literacy, and social isolation were significantly associated with not having a USC. Among participants with a USC, male gender, the presence of one or more chronic conditions, and lower health-related quality of life were associated with having a hospital-based USC.

CONCLUSIONS

We identified factors associated with the status of USC during the COVID-19 pandemic, including health literacy and social isolation. These findings provide primary care providers and policymakers with insight into the potential barriers to having a USC in the aftermath of the pandemic.

Patient Experience Performance at a Primary Cancer Center Versus Affiliated Community Facilities

Purpose

Patient experience tools are used throughout health care to evaluate physician and departmental performance. In radiation medicine, these tools are important in evaluating patient-specific metrics throughout their care journey. This study compared patient experience outcomes from a central tertiary cancer program with network clinics in a health care network.

Methods and Materials

Radiation medicine patient experience surveys (Press Ganey, LLC) were collected from a central facility and 5 network locations from January 2017 through June 2021. Surveys were distributed to patients after treatment completion. The study cohort was divided into the central facility and satellites. Questions were converted to a 0 to 100 scale from the Likert scale (1-5). To compare scores between site types, 2-way analysis of variance tests for the significance of sites adjusted for years of operations and adjustments for multiple comparisons (Dunnett's test) were completed on each question.

Results

The number of consecutively returned surveys analyzed was 3777; a response rate of 33.3% was observed. The central site conducted 117,583 linear accelerator, 1425 Gamma Knife, 273 stereotactic radiosurgery, and 830 stereotactic body radiation therapy procedures. All satellites combined conducted 76,788 linear accelerator, 131 Gamma Knife, 95 stereotactic radiosurgery, and 355 stereotactic body radiation therapy procedures. The central facility fared better than the satellites on "Convenience of parking" (95.9 vs 87.9; P = .0001) but worse in other domains of care.

Conclusions

All sites yielded exemplary patient experience rates. Community clinics scored higher than the main campus. The higher scores at the network sites require a deeper analysis of factors influencing the central facility, as the survey did not account for varying patient volumes and disparities in care complexity across sites. Attributes to satellites include lower patient volumes and easily navigable layouts. These results counter the impression that increased resources at the main campus create a better patient experience relative to network clinics and suggest that high-volume tertiary facilities will require unique initiatives to improve the patient experience.

Impact of Primary Care Attributes on Hospitalization During the COVID-19 Pandemic: A Nationwide Prospective Cohort Study in Japan

PURPOSE

During a pandemic, when there are many barriers to providing preventive care, chronic disease management, and early response to acute common diseases for primary care providers, it is unclear whether primary care attributes contribute to reducing hospitalization. We aimed to examine the association between core primary care attributes and total hospitalizations during the COVID-19 pandemic.

METHODS

We conducted a nationwide prospective cohort study during the pandemic using a representative sample of the Japanese adult population aged 40 to 75 years. Primary care attributes (first contact, longitudinality, coordination, comprehensiveness, and community orientation) were assessed using the Japanese version of Primary Care Assessment Tool (JPCAT). The primary outcome measure was any incidence of hospitalization during a 12-month period from May 2021 through April 2022.

RESULTS

Data from 1,161 participants were analyzed (92% follow-up rate). After adjustment for possible confounders, overall primary care attributes (assessed by the JPCAT total score) were associated in a dose-dependent manner with a decrease in hospitalizations (odds ratio [OR] = 0.37, 95% CI, 0.16-0.83 for the highest score quartile, compared with no usual source of care). All associations between each domain score of the JPCAT and hospitalization were statistically significant when comparing the highest quartile with no usual source of care.

CONCLUSIONS

Our study revealed that the provision of primary care, particularly high-quality primary care, was associated with decreased total hospitalization, even during a pandemic when there are many barriers to providing usual medical care. These findings support policies that seek to strengthen primary care systems during and after the COVID-19 pandemic.

Patient experience (PX) among individuals with disabilities in Japan: a mixed-methods study

Background

People with disabilities (PWDs) tend to be disadvantaged in terms of receiving preventive medicine and medical checkups. About 7.6% of the Japanese population is estimated to have a disability. Although patient experience (PX) is an effective measure of patient-centeredness, little is known about the PX of PWDs. The present study aimed to compare the PX of PWDs with those of the non-disabled both quantitatively and qualitatively.

Methods

The present study involved a questionnaire survey and a free-response question on the survey form. The quantitative part of the study involved a comparison of JPCAT scores between PWDs and non-disabled participants. JPCAT is composed of five primary care principles: First contact, Longitudinality, Coordination, Comprehensiveness (service provided and service available), and Community orientation. Descriptive statistics were used to assess age, sex, years of education, self-rated health status, and type of disability (for PWDs). Multivariable analysis was performed using a linear regression model to detect differences between PWDs and non-disabled participants in total and domain-specific JPCAT scores. The model included the following confounding variables: age, sex, years of education, and self-rated health status. The qualitative part of the study involved a thematic analysis of answers to the free-response question.

Results

Data from 338 participants (169 PWDs and 169 non-disabled participants) were analyzed (response rate of 36% for PWDs). After adjusting for age, sex, years of education, and self-rated health status, PWD scores were significantly lower than those of non-disabled participants for the Longitudinality, Community Orientation, and Comprehensiveness (services available) domains of the JPCAT. Qualitative analysis yielded six themes, each of which was further divided to have Disability-Specific and General themes.

Conclusions

JPCAT scores in PWDs were significantly lower than those of non-disabled participants for the Longitudinality, Community Orientation, and Comprehensiveness (services available) domains. Qualitative analysis revealed that PWDs shared several themes with non-disabled participants, but also to face unique challenges due to disabilities, such as the lack of a health care provider familiar with disabilities and the insurance transition at age 65, a unique feature of the Japanese health care system.

Trial registration

The study was a non-interventional, observational research trial, and thus registration was not required.

Patient experience of residents with restricted primary care access during the COVID-19 pandemic

OBJECTIVES

To evaluate primary care access for COVID-19 consultation among residents who have a usual source of care (USC) and to examine their associations with patient experience during the pandemic in Japan.

DESIGN

Nationwide cross-sectional study.

SETTING

Japanese general adult population.

PARTICIPANTS

1004 adult residents who have a USC.

MAIN OUTCOME MEASURES

Patient experience assessed by the Japanese version of Primary Care Assessment Tool Short Form (JPCAT-SF).

RESULTS

A total of 198 (19.7%) reported restricted primary care access for COVID-19 consultation despite having a USC. After adjustment for possible confounders, restricted primary care access for COVID-19 consultation was negatively associated with the JPCAT-SF total score (adjusted mean difference = -8.61, 95% CI -11.11 to -6.10). In addition, restricted primary care access was significantly associated with a decrease in all JPCAT-SF domain scores.

CONCLUSIONS

Approximately one-fifth of adult residents who had a USC reported restricted primary care access for COVID-19 consultation during the pandemic in Japan. Our study also found that restricted primary care access for COVID-19 consultation was negatively associated with a wide range of patient experience including first contact. Material, financial and educational support to primary care facilities, the spread of telemedicine and the application of a patient registration system might be necessary to improve access to primary care during a pandemic.

Association between resident status and patients' experiences of primary care: a cross-sectional study in the Greater Bay Area, China

OBJECTIVES

Patients' experiences are important part of health services quality research, but it's still unclear whether patients' experiences are influenced by resident status. This study aimed to evaluate the association between resident status and patients' primary care experiences with the focus on migrants vs local residents.

DESIGN

A cross-sectional study using multistage cluster random sampling was conducted from September to November 2019. The data were analysed using general linear models.

SETTING

Six community health centres in Guangzhou, China.

PARTICIPANTS

1568 patients aged 20 years or older.

MAIN OUTCOME MEASURES

Patients' primary care experiences were assessed using the Primary Care Assessment Tool. The 10 domains included in Primary Care Assessment Tool (PCAT) refers to first contact-utilisation, first contact-access, ongoing care, coordination (referral), coordination (information), comprehensiveness (services available), comprehensiveness (services provided), family-centredness, community orientation and cultural competence from patient's perspective.

RESULTS

1568 questionnaires were analysed. After adjusting for age, sex, education, annual family income, self-perceived health status, chronic condition, annual medical expenditure and medical insurance, the PCAT total scores of the migrants were significantly lower than those of local residents (β=-0.128; 95% CI -0.218 to -0.037). Migrants had significantly lower scores than local residents in first contact utilisation (β=-0.245; 95% CI -0.341 to -0.148), ongoing care (β=-0.175; 95% CI -0.292 to -0.059), family-centredness (β=-0.112; 95% CI -0.225 to 0.001), community orientation (β=-0.176; 95% CI -0.286 to -0.066) and cultural competence (β=-0.270; 95% CI -0.383 to -0.156), respectively.

CONCLUSION

Primary care experiences of migrants were significantly worse off than those of local residents, especially in terms of primary care utilisation, continuity and cultural competence. Given the wide disparity in primary care experiences between migrants and local residents, Chinese healthcare system reform should focus on improving quality of primary care services for migrants, overcoming language barriers and creating patient-centred primary care services.

Obstacles to access to community care in urban senior-only households: a qualitative study

Background

The increased number of older adults living alone has created a substantial care need. However, the utilization rate of services and facilities to meet these needs are surprisingly low. Many of older adults experience difficulties accessing these services, although it remains unclear how these obstacles impede access to services. This study explored the obstacles and difficulties experienced by urban older adults in seeking community care.

Methods

A phenomenological study was carried out and participatory observation and in-depth interviews were employed to investigate the process of seeking care of older adults in urban communities. A total of 18 urban community-dwelling older adults aged 75 years and over were included. Data collected were analysed by content analysis.

Results

We identified the pathways by which senior-only households sought community care and encountered obstacles. (1) lack of community care information: older adults did not know where and how to get services, even though the care institutions scattered throughout the community; (2) limited mobility: older adults often suffered from various chronic diseases, which physically hindered their access to care resources; (3) complex process of achieving care: the functional fragmentation and geographical dispersion of care institutions made the care-seeking process challenging and confusing for older adults; (4) incomprehension of needs expression: limited interaction time and communication barriers between staff of institutions and the older adults were the final obstacle. Only by surmounting these obstacles one by one can older adults access the care resources effectively.

Conclusions

When older adults in the community initiated calls for help, they encountered several obstacles. Their physiological and social disadvantages limited their ability to seek care physically. Lack of integration and clear guidance in the process of providing community care exacerbated these difficulties. Reform of care services should focus on the visibility and accessibility of services for older adults.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-02816-y.

Associations of primary care structures with polypharmacy and patient-reported indicators in patients with complex multimorbidity: a multicentre cross-sectional study in Japan

OBJECTIVES

Evidence supporting the effects of primary care structures on the quality of care for patients with complex multimorbidity, which is one of the most important challenges facing primary care, is scarce internationally. This study aimed to examine the associations of the types of primary care facilities with polypharmacy and patient-reported indicators in patients with complex multimorbidity, with a focus on differences between community clinics and hospitals.

DESIGN

Multicentre cross-sectional study.

SETTING

A total of 25 primary care facilities (19 community clinics and 6 small- and medium-sized hospitals).

PARTICIPANTS

Adult outpatients with complex multimorbidity, which was defined as the co-occurrence of three or more chronic conditions affecting three or more different body systems within one person.

PRIMARY OUTCOME MEASURE

Polypharmacy, the Patient-Reported Experience Measure using the Japanese version of Primary Care Assessment Tool Short Form (JPCAT-SF) and the Patient-Reported Outcome Measure using self-rated health status (SRH).

RESULTS

Data were analysed for 492 patients with complex multimorbidity. After adjustment for possible confounders and clustering within facilities, clinic-based primary care practices were significantly associated with a lower prevalence of polypharmacy, higher JPCAT-SF scores in coordination and community orientation, and a lower prevalence of poor or fair SRH compared with hospital-based primary care practices. In contrast, the JPCAT-SF score in first contact was significantly lower in clinic-based practices. The associations between the types of primary care facilities and JPCAT-SF scores in longitudinality and comprehensiveness were not statistically significant.

CONCLUSIONS

Clinic-based primary care practices were associated with a lower prevalence of polypharmacy, better patient experience of coordination and community orientation, and better SRH in patients with complex multimorbidity compared with hospital-based primary care practices. In the primary care setting, small and tight teams may improve the quality of care for patients with complex multimorbidity.

Associations of types of primary care facilities with adult vaccination and cancer screening in Japan

OBJECTIVE

To examine the association between primary care facility types and the quality of preventive care, especially adult vaccination and cancer screening, with a focus on the differences between community clinics and hospitals.

DESIGN

Multicenter cross-sectional study.

SETTING

A primary care practice-based research network in Japan (25 primary care facilities).

PARTICIPANTS

Adult outpatients for whom the participating facility serves as their usual source of care.

INTERVENTION

None.

MAIN OUTCOME MEASURES

Influenza and pneumococcal vaccination delivery and performance of colorectal, breast and cervical cancer screening.

RESULTS

Data collected from 1725 primary care outpatients were analyzed. After adjustment of possible confounders and clustering within facilities, hospital-based practices were significantly associated with poorer uptake of influenza [adjusted odds ratio (aOR) = 0.64, 95% confidence interval (CI) 0.42-0.96] and pneumococcal vaccines (aOR = 0.55, 95% CI 0.40-0.75) and colorectal cancer screening (aOR = 0.59, 95% CI 0.39-0.88) compared with clinic-based practices. In contrast, the associations of types of primary care facilities with uptake of breast and cervical cancer screening were not statistically significant.

CONCLUSIONS

Differences in the performance of adult vaccination and cancer screening raised concerns about the provision of preventive care at hospital-based compared with clinic-based primary care practices. Efforts to improve preventive care at hospital-based primary care practices should help to promote equalization of the quality of primary care. Further study is needed on the comparisons of other quality indicators among different structures of primary care facilities.

Multimorbidity and patient-reported diagnostic errors in the primary care setting: multicentre cross-sectional study in Japan

OBJECTIVES

There is lack of evidence for the association between multimorbidity and diagnostic errors. Information on diagnostic errors from patients' perspectives is crucial to improve the diagnostic process. In this study, we aimed to investigate patient-reported diagnostic errors and to examine the relationship between multimorbidity and patient-reported diagnostic errors in the primary care setting.

DESIGN

Multicentre cross-sectional study.

SETTING

A primary care practice-based research network in Japan (25 primary care facilities).

PARTICIPANTS

Adult outpatients filled out a standardised questionnaire.

PRIMARY OUTCOME MEASURE

Patient-reported diagnostic errors.

RESULTS

Data collected from 1474 primary care outpatients were analysed. The number of participants who reported diagnostic errors was 57 (3.9%). Most of the missed diagnoses were common conditions in primary care, such as cancer, dermatitis and hypertension. After adjustment for possible confounders and clustering within facilities, multimorbidity was positively associated with patient-reported diagnostic errors (adjusted OR=1.83, 95% CI 1.01 to 3.31). The results of the sensitivity analysis were consistent with those of the primary analysis.

CONCLUSIONS

The present study showed a lower proportion of patients reporting experiences of diagnostic errors in primary care than those reported in previous studies in other countries. However, patients with multimorbidity are more likely to report diagnostic errors in primary care; thus, further research is necessary to improve the diagnostic process for patients with multimorbidity.