Factors associated with enablement in general practice: cross-sectional study using routinely-collected data

Reducing health inequalities through general practice: a realist review and action framework

Background

Socio-economic inequalities in health have been in the public agenda for decades. General practice has an influential role to play in mitigating the impact of inequalities especially regarding chronic conditions. At the moment, general practice is dealing with serious challenges in relation to workforce shortages, increasing workload and the impact of the COVID-19 pandemic. It is important to identify effective ways so that general practice can play its role in reducing health inequalities.

Objectives

We explored what types of interventions and aspects of routine care in general practice decrease or increase inequalities in health and care-related outcomes. We focused on cardiovascular disease, cancer, diabetes and/or chronic obstructive pulmonary disease. We explored for whom these interventions and aspects of care work best, why, and in what circumstances. Our main objective was to synthesise this evidence into specific guidance for healthcare professionals and decision-makers about how best to achieve equitable general practice.

Design

Realist review.

Main outcome measures

Clinical or care-related outcomes by socio-economic group, or other PROGRESS-Plus criteria.

Review methods

Realist review based on Pawson's five steps: (1) locating existing theories, (2) searching for evidence, (3) selecting articles, (4) extracting and organising data and (5) synthesising the evidence.

Results

Three hundred and twenty-five studies met the inclusion criteria and 159 of them were selected for the evidence synthesis. Evidence about the impact of general practice interventions on health inequalities is limited. To reduce health inequalities, general practice needs to be: • connected so that interventions are linked and coordinated across the sector; • intersectional to account for the fact that people's experience is affected by many of their characteristics; • flexible to meet patients' different needs and preferences; • inclusive so that it does not exclude people because of who they are; • community-centred so that people who receive care engage with its design and delivery. These qualities should inform action across four domains: structures like funding and workforce distribution, organisational culture, everyday regulated procedures involved in care delivery, interpersonal and community relationships.

Limitations

The reviewed evidence offers limited detail about the ways and the extent to which specific interventions increase or decrease inequalities in general practice. Therefore, we focused on the underpinning principles that were common across interventions to produce higher-level, transferrable conclusions about ways to achieve equitable care.

Conclusions

Inequalities in general practice result from complex processes across four different domains that include structures, ideas, regulated everyday procedures, and relationships among individuals and communities. To achieve equity, general practice needs to be connected, intersectional, flexible, inclusive and community-centred.

Future work

Future work should focus on how these five essential qualities can be better used to shape the organisational development of future general practice.

Study registration

This trial is registered as PROSPERO CRD42020217871.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR130694) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 7. See the NIHR Funding and Awards website for further award information.

Reducing health inequalities through general practice

Although general practice can contribute to reducing health inequalities, existing evidence provides little guidance on how this reduction can be achieved. We reviewed interventions influencing health and care inequalities in general practice and developed an action framework for health professionals and decision makers. We conducted a realist review by searching MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, and Cochrane Library for systematic reviews of interventions into health inequality in general practice. We then screened the studies in the included systematic reviews for those that reported their outcomes by socioeconomic status or other PROGRESS-Plus (Cochrane Equity Methods Group) categories. 159 studies were included in the evidence synthesis. Robust evidence on the effect of general practice on health inequalities is scarce. Focusing on common qualities of interventions, we found that to reduce health inequalities, general practice needs to be informed by five key principles: involving coordinated services across the system (ie, connected), accounting for differences within patient groups (ie, intersectional), making allowances for different patient needs and preferences (ie, flexible), integrating patient worldviews and cultural references (ie, inclusive), and engaging communities with service design and delivery (ie, community-centred). Future work should explore how these principles can inform the organisational development of general practice.

Does customised care improve satisfaction and positively enable parents in sustained home visiting for mothers and children experiencing adversity?

Background

The Maternal Early Childhood Sustained Home-visiting program (MECSH) is a structured nurse-delivered program designed to address health inequities experienced by families experiencing significant adversity. There is strong evidence for the effectiveness of this program, but limited research exploring the practice and process elements that are core to positive parent outcomes. This study aimed to examine the relationship between customised care related to the mother’s risk factors and parent satisfaction and enablement in the delivery of a MECSH-based program.

Methods

A cross-sectional study design was used. Program delivery data collected as part of a large randomised controlled trial of a MECSH-based sustained nurse home visiting program in Australia (right@home) were analysed. This study used the data collected from the intervention arm in the trial (n = 352 women). Parent satisfaction was measured at child age 24 months using the modified short-form Patient Satisfaction Questionnaire. Parent enablement was measured at child age 24 months by a modified Parent Enablement Index. Customised care was defined as appropriate provision of care content in response to four maternal risks: smoking, mental health, domestic violence and alcohol and drugs. Logistic analysis was performed to assess the impact of customised care on parent satisfaction and enablement while adjusting for covariates such as sociodemographic factors. A significance level of 95% was applied for analysis.

Results

Our results indicated high levels of satisfaction with the care provided and positive enablement. There were several sociodemographic factors associated with satisfaction and enablement, such as language spoken at home and employment experience. The mothers who received customised care in response to mental health risk and domestic violence had significantly greater satisfaction with the care provided and experienced an increase in enablement compared to those who did not receive such care.

Conclusion

This study contributes to the existing body of empirical research that examines the relationship between care processes and client outcomes in the delivery of home visiting services. It is essential for the sustained nurse home visiting service model to be flexible enough to cater for variations according to family circumstances and needs while maintaining a core of evidence-based practice.

One Health clinic promotes veterinarian-client trust among underserved pet owners and provides learning opportunities for veterinary students

OBJECTIVE

To determine the impact of a free One Health clinic with human and veterinary services on the veterinary-client relationship for underserved pet owners. A secondary aim was to understand the experience of veterinary students and volunteers who participated in the clinic.

SAMPLE

78 pet owners, 55 students and 32 volunteers who attended the Delaware Humane Association One Health Clinic between December 2018 and November 2019.

PROCEDURES

Pet owners completed an anonymous questionnaire prior to and following their veterinary appointment regarding their trust in the veterinary profession, feelings of enablement and veterinarian-client concordance. Students and volunteers completed a questionnaire within 72 hours of clinic participation about their perceptions of the educational value of the clinic.

RESULTS

Following the One Health clinic, client trust in the veterinary profession increased significantly (t = -5.50, P < 0.001). Clients also reported high levels of enablement and veterinarian-client concordance. Students and volunteers agreed the clinic was a valuable educational experience (97.7%) and reported increased compassion, enhanced leadership, communication and teamwork skills, and an improved ability to identify social issues and think critically.

CLINICAL RELEVANCE

The results support the utilization of One Health clinics to improve access to veterinary care for underserved pet owners. Clients reported high levels of trust, enablement and concordance following the clinic which could have long-lasting effects on their willingness to seek veterinary care and comply with veterinarians' recommendations. The positive experiences of students and volunteers also highlights the potential of low-cost veterinary clinics as unique educational experiences.

Patient experience of telephone consultations in gynaecology: a service evaluation

OBJECTIVE

To investigate patient perspective of telephone consultations (TCs) in gynaecology and identify which patients benefit most from a telemedicine system.

DESIGN

Service evaluation.

SETTING

Gynaecology outpatient services at a tertiary referral hospital.

POPULATION

Patients who received a TC during May and June 2020.

METHODS

Postal questionnaire combining three validated tools: QQ-10, Patient Enablement Index (PEI) and National Health Service Friends and Family Test (NHS-FFT). Quantitative data and free text responses were analysed.

MAIN OUTCOME MEASURES

Responses to QQ-10, PEI and NHS-FFT.

RESULTS

In total, 1307 patients were contacted and 504 patients responded (39%). Most (89%) described their experience as 'Very good' or 'Good' (NHS-FFT). Positive themes from responses included 'convenience', 'effectiveness' and 'equivalent care'. QQ-10 responses demonstrated a high Value score of 79 (0-100) and a low Burden score of 15. PEI scores suggested that most patients felt better or much better able to understand and cope with their condition following TC. The majority of patients (77%) would 'Strongly agree' or 'Mostly agree' to a repeat TC. Regarding patient outcomes, 21% were discharged and 71% required follow up. Menopause, fertility and endometriosis follow-up clinic patients benefited most from TC. Gynaecology-oncology patients found TC least acceptable.

CONCLUSION

We report a large questionnaire survey of patient experience of TC in gynaecology. Telemedicine is convenient, acceptable and effective for conducting care in selected groups. TC can support patients in communicating intimate symptoms.

TWEETABLE ABSTRACT

Telephone consultations are a convenient, acceptable and effective medium for conducting patient care in gynaecology.

The patient enablement instrument for back pain: reliability, content validity, construct validity and responsiveness

Background

Currently, there are no outcome measures assessing the ability of people with non-specific low back pain to self-manage their illness. Inspired by the ‘Patient Enablement Instrument’, we developed the Patient Enablement Instrument for Back Pain (PEI-BP). The aim of this study was to describe the development of the Patient Enablement Instrument for Back Pain (PEI-BP) and investigate content validity, construct validity, internal consistency, test–retest reliability, measurement error, responsiveness and floor and ceiling effects.

Methods

The PEI-BP consists of 6 items that are rated on a 0–10 Numeric Rating Scale. Measurement properties were evaluated using the COSMIN taxonomy and were based on three cohorts from primary care with low back pain: The content validity cohort (N = 14) which participated in semi-structured interviews, the GLA:D® Back cohort (N = 272) and the test–retest cohort (N = 37) which both completed self-reported questionnaires. For construct validity and responsiveness, enablement was compared to disability (Oswestry Disability Index), back pain beliefs (Brief Illness Perception Questionnaire), fear avoidance (Fear-Avoidance Beliefs Questionnaire—physical activity), mental health (SF-36), educational level and number of previous episodes of low back pain.

Results

The PEI-BP was found to have acceptable content validity, construct validity, reliability (internal consistency, test–retest reliability and measurement error) and responsiveness. The Smallest Detectable Change was 10.1 points illustrating that a patient would have to change more than 1/6 of the scale range for it to be a true change. A skewed distribution towards the high scores were found at baseline indicating a potentially problematic ceiling effect in the current population.

Conclusions

The PEI-BP can be considered a valid and reliable tool to measure enablement on people seeking care for non-specific LBP. Further testing of the PEI-BP in populations with more severe LBP is recommended.

Trial registration: Not applicable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12955-021-01758-0.

How to implement patient experience surveys and use their findings for service improvement: a qualitative expert consultation study in Australian general practice

Objective

To identify barriers (patient, provider, practice and system levels) to consider when implementing patient experience surveys in Australian general practice and enablers of their systematic use to inform service improvement in clinical practice as well as the broader health system.

Methods and analysis

An expert consultation and qualitative content analysis of cross-sectional, open-text survey data. Data were collected from key international and Australian experts in the areas of measurement and quality improvement in general practice.

Results

Responses from 20 participants from six countries were included in the study. Participants discussed the importance of ensuring value and relevance of surveys to stakeholders. Lack of resources, IT infrastructure, capacity building and sustained funding were identified as barriers to implementing surveys. Participants discussed the importance of clearly defining and communicating the purpose of surveys and agreed on the value of using patient experience to inform reflective, team-based learning at the practice level. Opinions differed on the use of patient experience data at the system level, with some questioning its utility or fairness for external performance reporting. Others recommended the aggregation and reporting of these data under certain conditions, including for the purpose of triangulation with other quality and outcome data. The study identified an evidence gap in the assessment and interpretation of patient experience data at the practice and system levels, including the analysis and contextualisation of survey findings at the system level.

Conclusion

Patient experience surveys have potential for guiding practice level quality improvement, but many barriers to their implementation remain. There is need for greater research and policy efforts to understand how this information can be used at the system level for improving Australian general practice.

Evaluation of the quality of service delivery in private sector, primary care clinics in Kenya: A descriptive patient survey

BACKGROUND

The quality of service delivery in primary care (PC) is an important determinant of clinical outcomes. The patients' perspective is one significant predictor of this quality. Little is known of the quality of such service delivery in the private sector in Kenya. The aim of the study was to evaluate the quality of service delivery in private sector, PC clinics in Nairobi, Kenya.

METHODS

The study employed a descriptive cross-sectional survey by using the General Practice Assessment Questionnaire in 378 randomly selected patients from 13 PC clinics. Data were analysed using the Statistical Package for Social Sciences.

RESULTS

Overall, 76% were below 45 years, 74% employed and 73% without chronic diseases. Majority (97%) were happy to see the general practitioner (GP) again, 99% were satisfied with their consultation and 83% likely to recommend the GP to others. Participants (97%) found in receptionist helpful and the majority were happy with the opening hours (73%) and waiting times (85%). Although 84% thought appointments were important, only 48% felt this was easy to make, and only 44% were able to access a particular GP on the same day. Overall satisfaction was higher in employed (98%) versus those unemployed (95%), studying (93%) or retired (94%) (p 0.001).

CONCLUSION

Patients reported a high quality of service delivery. Utilisation was skewed towards younger, employed adults, without chronic conditions, suggesting that PC was not fully comprehensive. Services were easily accessible, although with little expectation of relational continuity. Further studies should continue to evaluate the quality of service delivery from other perspectives and tools.

The validity and reliability of the patient enablement instrument (PEI) after GP appointments in Finnish health care centres

BACKGROUND

The aim of this study was to assess the validity and reliability of the Patient Enablement Instrument (PEI) in Finnish health care centre patients. A pilot study was conducted to assess the content validity of the PEI. A questionnaire study in three health care centres in Western Finland was performed in order to assess acceptability, construct validity, internal consistency, and measurement error of the instrument. A telephone interview 2 weeks after the appointment was performed to evaluate reproducibility.

RESULTS

The pilot study with 17 participants indicated good content validity of the PEI. In the questionnaire study, altogether 483 with a completed PEI score were included in the analyses. Factor analysis and item-scale correlations suggested high structural validity. The internal consistency of the instrument was high (Cronbach's α = 0.93). The PEI score diminished strongly over the two-week period.

CONCLUSIONS

The PEI has good content validity and acceptability, good construct validity, high internal consistency but low reproducibility. Thus, the PEI seems to be an applicable tool to measure patient enablement in Finnish primary health care.

Patient enablement after a consultation with a general practitioner-Explaining variation between countries, practices and patients

BACKGROUND

Patient enablement is a concept developed to measure quality in primary health care. The comparative analysis of patient enablement in an international context is lacking.

OBJECTIVE

To explain variation in patient enablement between patients, general practitioners (GPs) and countries. To find independent variables associated with enablement.

DESIGN

We constructed multi-level logistic regression models encompassing variables from patient, GP and country levels. The proportions of explained variances at each level and odds ratios for independent variables were calculated.

SETTING AND PARTICIPANTS

A total of 7210 GPs and 58 930 patients in 31 countries were recruited through the Quality and Costs of Primary Care in Europe (QUALICOPC) study framework. In addition, data from the Primary Health Care Activity Monitor for Europe (PHAMEU) study and Hofstede's national cultural dimensions were combined with QUALICOPC data.

RESULTS

In the final model, 50.6% of the country variance and 18.4% of the practice variance could be explained. Cultural dimensions explained a major part of the variation between countries. Several patient-level and only a few practice-level variables showed statistically significant associations with patient enablement. Structural elements of the relevant health-care system showed no associations. From the 20 study hypotheses, eight were supported and four were partly supported.

DISCUSSION AND CONCLUSIONS

There are large differences in patient enablement between GPs and countries. Patient characteristics and patients' perceptions of consultation seem to have the strongest associations with patient enablement. When comparing patient-reported measures as an indicator of health-care system performance, researchers should be aware of the influence of cultural elements.

PEN-13: A New Generic 13-Item Questionnaire for Measuring Patient Enablement (German Version)

Background: The purpose of our study was to develop and psychometrically test a German-language survey instrument that measures patient enablement generically and in greater detail than previous instruments. Methods: A multidisciplinary team developed 13 items to capture individual aspects of patient enablement (PEN-13). A pre-test with 26 subjects was followed by a random sample survey of N = 1168 subjects. An exploratory factor analysis was conducted in a random split-half sample of the data to explore PEN-13's factor structure; a confirmatory factor analysis was conducted in the validation sample. The internal consistency of the factors was evaluated using Cronbach's alpha, PEN-13's construct validity was checked by means of additional hypothesis testing. Results: The two factors self-management and patient-practitioner interaction, detected in the exploratory analysis, were confirmed with a few modifications in the confirmatory factor analysis, with the comparative fit index (CFI) amounting to 0.903. The Cronbach's alpha values of those two factors amounted to α = 0.90 and α = 0.82, respectively. The correlations of the PEN-13 score with the 'general self-efficacy' and 'health literacy' (HLS-EU-Q16) scores further confirmed its construct validity; the respective correlation coefficients amounted to 0.57 and 0.60. Conclusion: The German version of the survey instrument Patient Enablement Scale-13 items (PEN-13) shows acceptable psychometric properties. Practical implications: PEN-13 seems particularly suitable for health services research purposes. We recommend checking the results in another sample as well as evaluating its responsiveness to enablement-enhancing interventions.

Patient involvement in assessing consultation quality: validation of patient enablement instrument (PEI) in Lithuanian general practice

Background

The Patient Enablement Instrument (PEI) was designed to encapsulate consultation outcome from the perspective that increasing their understanding and coping ability would underpin a positive consultation outcome for patients. The objective of the study was the validation of the PEI in Lithuanian general practice and comparison of Lithuanian patients’ enablement with previous studies in Europe to see if factors associated with patient enablement in Lithuania were reflective of those in the previous studies.

Methods

The Patient Enablement Instrument was translated into Lithuanian and included in the questionnaire along with the questions about a person’s health, reasons for visiting the doctor and feeling about the consultation. Practices from 4 different municipalities that are situated in different geographical regions which have both town and rural areas were sampled randomly. Patients scheduled consecutively aged 18 years or more were the subjects of the study. The data analyses focused on internal reliability and concept validity.

Results

The overall mean patient enablement score was 6.43. Enablement scores declined with increasing patient age, and female patients were more enabled. Patients with biomedical problems had the highest enablement results, while patients with complex problems had the lower results. Enablement was positively related to receiving a prescription and knowing a doctor, and negatively related to wish having consultation with another doctor.

Conclusions

This study substantiates the rationality of using PEI in assessing primary care consultations in Lithuania. The correlations of enablement largely reflect the situation in Western and Central Europe: longer consultation and access to the same physician increases patient enablement.

Factors affecting patient enablement in an Asian setting: a mixed methods study

INTRODUCTION

Patient-centred medical care has been rising in importance since the turn of the century. It entails treating patients in relation to their biopsychosocial outlook so as to support the management of their conditions. The extent to which a patient is enabled to acquire skills and knowledge can be measured with the Patient Enablement Instrument (PEI) proposed by Howie and colleagues, and it has been noted to be more reflective of a good consultation compared to patient satisfaction scores. This study aimed to determine the level of patient enablement in the Singaporean context and the factors facilitating it.

METHODS

We conducted an embedded mixed method study with primary care patients in two phases: (a) a PEI questionnaire was completed by 150 patients; and (b) a qualitative approach using focused group discussions and individual interviews was used to explore factors associated with high enablement.

RESULTS

The mean PEI score was 4.5 ± 4.4, with significantly higher scores among patients attending specialised primary care clinics. Important physician factors were doctors' advice, attitude and relationship with the patient. Critical system factors included good continuity of care, workload and financial support, while patient factors included their beliefs, preparedness, inquisitiveness and trust, with considerable impact from the influence of community.

CONCLUSION

The PEI score in the Singaporean context is similar to that of other Asian contexts, but slightly higher than that reported in Western studies. Good doctor-patient relationships, efficient systems facilitating continuity of care, and motivated and informed patients all contribute to increased enablement.

Comparison of the Patient Enablement Instrument (PEI) with two single-item measures among Finnish Health care centre patients

Background

The Patient Enablement Instrument (PEI) is an established patient-reported outcome measure (PROM) that reflects the quality of appointments with general practitioners (GPs). It is a six-item questionnaire administered to the patient immediately after a consultation. The aim of this study was to evaluate whether a single-item measure could replace the PEI when measuring patient enablement among Finnish health care centre patients.

Methods

Two single-item measures, Q1 and Q2, were chosen for comparison with the PEI. Firstly, a pilot study with questionnaire testing and brief interviews with the respondents were performed in order to assess the content validity of the PEI and the single-item measures. Secondly, a questionnaire study after a single appointment with a GP was carried out in three health care centres in Western Finland in order to evaluate the construct and criterion validity of the single-item measures. A telephone interview was performed 2 weeks after the appointment in order to assess the test-retest reliability of the single-item measures. The sensitivity, specificity, and both positive and negative predictive values of Q1 and Q2 were calculated with different PEI score cut-off points.

Results

Altogether 483 patients with a completed PEI were included in the questionnaire study analyses. Altogether 149 and 175 patients had completed Q1 and Q2, respectively, both in the questionnaire and the telephone interview. The correlations between the PEI and Q1 and Q2 were 0.48 and 0.84, respectively. Both the single-item measures had a high sensitivity and a negative predictive value in relation to patients with lower PEI scores. The reliability coefficients were 0.24 for Q1 and 0.76 for Q2. The test-retest values of Q1, Q2, and the PEI were low.

Conclusions

Q2 seems to be a valid and reliable measure of patient enablement. Q1 seems to be less correlated with the PEI, but it also has a high negative predictive value in relation to low enablement scores.

Patient understanding of two commonly used patient reported outcome measures for primary care: a cognitive interview study

Background

Standardised generic patient-reported outcome measures (PROMs) which measure health status are often unresponsive to change in primary care. Alternative formats, which have been used to increase responsiveness, include individualised PROMs (in which respondents specify the outcomes of interest in their own words) and transitional PROMs (in which respondents directly rate change over a period). The objective of this study was to test qualitatively, through cognitive interviews, two PROMs, one using each respective format.

Methods

The individualised PROM selected was the Measure Yourself Medical Outcomes Profile (MYMOP). The transitional PROM was the Patient Enablement Instrument (PEI). Twenty patients who had recently attended the GP were interviewed while completing the questionnaires. Interview data was analysed using a modification of Tourangeau’s model of cognitive processing: comprehension, response, recall and face validity.

Results

Patients found the PEI simple to complete, but for some it lacked face validity. The transitional scale was sometimes confused with a status scale and was problematic in situations when the relevant GP appointment was part of a longer episode of care. Some patients reported a high enablement score despite verbally reporting low enablement but high regard for their GP, which suggested hypothesis-guessing. The interpretation of the PEI items was inconsistent between patients.

MYMOP was more difficult for patients to complete, but had greater face validity than the PEI. The scale used was open to response-shift: some patients suggested they would recalibrate their definition of the scale endpoints as their illness and expectations changed.

Conclusions

The study provides information for both users of PEI/MYMOP and developers of individualised and transitional questionnaires.

Users should heed the recommendation that MYMOP should be interview-administered, and this is likely to apply to other individualised scales. The PEI is open to hypothesis-guessing and may lack face-validity for a longer episode of care (e.g. in patients with chronic conditions). Developers should be cognisant that transitional scales can be inconsistently completed: some patients forget during completion that they are measuring change from baseline. Although generic questionnaires require the content to be more general than do disease-specific questionnaires, developers should avoid questions which allow broad and varied interpretations.

Electronic supplementary material

The online version of this article (10.1186/s12875-018-0850-2) contains supplementary material, which is available to authorized users.

Coping better with health problems after a visit to the family physician: associations with patients and physicians characteristics

BACKGROUND

Good patient experience is recognized as an important component of a strong primary care system. Among the dimensions related to experience in family medicine, the ability to cope better with health problems is considered to be a measure of the quality of a consultation with a family physician (FP). The objective is to identify factors related to patients, physicians and practice, associated with patients' ability to cope better with their health problems after a family medicine consultation.

METHODS

The data stemmed from the Swiss part of the Quality and Costs of Primary Care (QUALICOPC) study, an international cross sectional survey aiming to compare quality, cost and equity in primary care. In Switzerland, a random sample of 199 FPs and 1791 patients participated. The negative answer to the question: "After this visit, I feel I can cope better with my health problems" was modeled using multilevel logistic regressions.

RESULTS

Difficulty to cope better with health problems was positively associated with the following: younger age (OR: 1.58, 95% CI [1.03-2.41]), cultural aspects related to the Swiss area of language (French speaking people declared higher inability than German and Italian ones), presence of chronic disease (OR: 1.54 95% CI [1.00-2.39]). Conversely an intermediate number (1-4) of visits during the last 6 months (OR: 0.37 95% CI [0.23-0.62]) and the satisfaction with the physician (OR: 0.18 95% CI [0.08-0.44]) are negative predictors of the patient inability to cope better with his health problems. A self-reported effort-reward imbalance at work (OR: 0.64 95% CI [0.41-1.00]) was the only predictive FP characteristic (negatively associated).

CONCLUSIONS

Although the design of the study does not allow causal inference, this study showed that the predictors of patient difficulties to cope better with health problem are mainly centered on the patients' characteristics. The patient-physician relationship both in terms of quality and frequency of visits is probably also important. Organizational practice characteristics do not seem to play a major role but stress at work among physicians should be further investigated.

Patient Enablement After a Single Appointment With a GP: Analysis of Finnish QUALICOPC Data

Background: Patient enablement is described as patient’s ability to understand and cope with illness after a consultation. The purpose of this study was to analyze factors associated with enablement in Finnish primary health care. An additional aim was to evaluate whether a single question could be used to measure enablement. Methods: A questionnaire survey was addressed to Finnish general practitioners (GPs) within the Quality and Costs of Primary Care in Europe (QUALICOPC) study framework. A trained fieldworker contacted nine patients for every participating GP. Two to 9 patients per GP (median 9 patients) completed the questionnaire. Patient enablement was measured by a single question based on the Patient Enablement Instrument questionnaire. Multivariate and multilevel analyses were performed to find variables that have an independent association with patient enablement. Results: A total of 1196 patients completed the QUALICOPC questionnaire. A total of 898 patients (75.1%) agreed that they felt better able to cope with their health problem or illness after an appointment with a GP, reflecting patient enablement. In the theme group analyses, 11 factors were found to have a statistically significant (P < .05) association with enablement. In the final multivariable model, positive perceptions of doctor-patient communication and patient satisfaction were positively associated with enablement. Conclusions: The results, using a single question to measure enablement, are comparable to previous findings on factors associated with enablement. Further research is needed and these results should be regarded as preliminary.

The Association of Types of Training and Practice Settings with Doctors' Empathy and Patient Enablement among Patients with Chronic Illness in Hong Kong

BACKGROUND

The increase in non-communicable disease (NCD) is becoming a global health problem and there is an increasing need for primary care doctors to look after these patients although whether family doctors are adequately trained and prepared is unknown.

OBJECTIVE

This study aimed to determine if doctors with family medicine (FM) training are associated with enhanced empathy in consultation and enablement for patients with chronic illness as compared to doctors with internal medicine training or without any postgraduate training in different clinic settings.

METHODS

This was a cross-sectional questionnaire survey using the validated Chinese version of the Consultation and Relational Empathy (CARE) Measure as well as Patient Enablement Instrument (PEI) for evaluation of quality and outcome of care. 14 doctors from hospital specialist clinics (7 with family medicine training, and 7 with internal medicine training) and 13 doctors from primary care clinics (7 with family medicine training, and 6 without specialist training) were recruited. In total, they consulted 823 patients with chronic illness. The CARE Measure and PEI scores were compared amongst doctors in these clinics with different training background: family medicine training, internal medicine training and those without specialist training. Generalized estimation equation (GEE) was used to account for cluster effects of patients nested with doctors.

RESULTS

Within similar clinic settings, FM trained doctors had higher CARE score than doctors with no FM training. In hospital clinics, the difference of the mean CARE score for doctors who had family medicine training (39.2, SD = 7.04) and internal medicine training (35.5, SD = 8.92) was statistically significant after adjusting for consultation time and gender of the patient. In the community care clinics, the mean CARE score for doctors with family medicine training and those without specialist training were 32.1 (SD = 7.95) and 29.2 (SD = 7.43) respectively, but the difference was not found to be significant. For PEI, patients receiving care from doctors in the hospital clinics scored significantly higher than those in the community clinics, but there was no significant difference in PEI between patients receiving care from doctors with different training backgrounds within similar clinic setting.

CONCLUSION

Family medicine training was associated with higher patient perceived empathy for chronic illness patients in the hospital clinics. Patient enablement appeared to be associated with clinic settings but not doctors' training background. Training in family medicine and a clinic environment that enables more patient doctor time might help in enhancing doctors' empathy and enablement for chronic illness patients.

An Integrative Review of Enablement in Primary Health Care

OBJECTIVES

To review how enablement is conceptualized and practiced in primary health care and to explore the factors that influence patient enablement in this setting.

METHOD

A narrative integrative literature review was undertaken.

RESULTS

Twenty-four articles specifically relating to enablement in primary health care were identified. Three literature reviews, 4 qualitative studies, and 17 quantitative studies were included in the analysis.

CONCLUSIONS

In the primary health care setting, the concept of enablement is well defined as an outcome measure of quality. The literature exploring the practice of enablement is sparse, but 2 randomized controlled trials suggest enablement is linked to better outcomes for patients with asthma and diabetes. Primary factors influencing enablement included the practitioners' open communication style, the degree to which the practitioner is patient centered, and longer consultations. Other factors found to be associated with enablement were the presenting health issue, general state of health, ethnicity, the patient's own coping strategies and degree of independence, and socioeconomic status. The association between enablement and patients' expectations and satisfaction is less clear. The majority of research on enablement was carried out among general practitioners. Further research into the degree to which patients are enabled by a wider range of health care providers is needed. Additional qualitative research would provide a deeper understanding of the attributes of enablement in the primary health care setting.

Reliability and applicability of the Patient Enablement Instrument (PEI) in a Swedish general practice setting

BACKGROUND

The Patient Enablement Instrument (PEI), which has been used to evaluate core ingredients in primary care consultations, has been proposed as a means of moving beyond patient satisfaction evaluations. The aim of the present study was to examine the reliability and applicability of the PEI to the Swedish context.

METHODS

The original PEI was translated to Swedish and included in a questionnaire that was given to consecutively scheduled patients in four primary care settings. Respondents completed identical questionnaires immediately after a consultation, as well as two days and two weeks later. The analysis focused on internal reliability, test-retest reliability and internal construct validity.

RESULTS

Mean PEI scores declined significantly between baseline (3.48, SD 3.21) and the first follow-up questionnaire (3.06, SD 3.37). All three questionnaires showed high internal consistency (Cronbach's alpha >0.85). Test-retest showed moderate agreement for all questions when comparing baseline and the first follow-up (kappa 0.54-0.65) and greater consistency between the two follow-up questionnaires (kappa 0.65-0.75). A large proportion of respondents characterized at least one of the questions as irrelevant (39%).

CONCLUSIONS

The Swedish version of the PEI instrument has high internal consistency and moderate to good reliability. It can be used in research but is not recommended as a measure of quality of care. The instrument could benefit from further development and validity testing.

Having a Family Doctor is Associated with Some Better Patient-Reported Outcomes of Primary Care Consultations

Background: Hong Kong (HK) has pluralistic primary care that is provided by a variety of doctors. The aim of our study was to assess patient-reported outcomes of primary care consultations in HK and whether having a family doctor (FD) made any difference.

Methods: We interviewed by telephone 3148 subjects from 5174 contacted households (response rate 60.8%) randomly selected from the general population of HK about the experience of their last primary care consultations in September 2007 and April 2008. We compared the patient-reported outcomes (PRO) and patient-centered process of care in those with a FD, those with other types of regular primary care doctors (ORD) and those without any regular primary care doctor (NRD). PRO included patient enablement, global improvement in health, overall satisfaction, and likelihood of recommending their doctors to family and friends. Patient-centered process of care indicators was explanations about the illness, and address of patient’s concerns.

Results: One thousand one hundred fifty, 746, and 1157 reported to have FD, ORD, and NRD, respectively. Over 80% of those with FD consulted their usual primary care doctors in the last consultation compared with 27% of those with NRD. Compared with subjects having ORD or NRD, subjects with FD reported being more enabled after the consultation and were more likely to recommend their doctors to family and friends. Subjects with FD and ORD were more likely than those having NRD to report a global improvement in health and satisfaction. FD group was more likely than the other two groups to report receiving an explanation on the diagnosis, nature, and expected course of the illness, and having their concerns addressed. Patient enablement was associated with explanation of diagnosis, nature, and expected course of illness, and address of patient’s concerns.

Conclusion: People with a regular FD were more likely to feel being enabled and to experience patient-centered care in consultations.

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.

A tool to evaluate patients’ experiences of nursing care in Australian general practice: development of the Patient Enablement and Satisfaction Survey

Australian health policy initiatives have increasingly supported the employment of nurses in general practice. An understanding of the impact of nursing care on patients in this setting is integral to assuring quality, safety and a patient-centred focus. The aim was to develop a survey to evaluate the satisfaction and enablement of patients who receive nursing care in Australian general practices. The survey was to be simple to administer and analyse, ensuring practicality for use by general practice nurses, doctors and managers. Two validated instruments formed the basis of the Patient Enablement and Satisfaction Survey (PESS). This survey was refined and validated for the Australian setting using focus groups and in-depth interviews with patients, and feedback from general practice nurses. Test-retest and alternate form methods were used to establish the survey’s reliability. Feedback resulted in 14 amendments to the original draft survey. Questions that demonstrated a strong positive correlation for the test-retest and alternate form measures were included in the final survey. The PESS is a useful, practical tool for the evaluation of nursing care in Australian general practice, its validity and reliability established through a patient-centred research approach, reflective of the needs of patients accessing nursing services in this setting.

GPAQ-R: development and psychometric properties of a version of the general practice assessment questionnaire for use for revalidation by general practitioners in the UK

Background

The General Practice Assessment Questionnaire (GPAQ) has been widely used to assess patient experience in general practice in the UK since 2004. In 2013, new regulations were introduced by the General Medical Council (GMC) requiring UK doctors to undertake periodic revalidation, which includes assessment of patient experience for individual doctors. We describe the development of a new version of GPAQ – GPAQ-R which addresses the GMC’s requirements for revalidation as well as additional NHS requirements for surveys that GPs may need to carry out in their own practices.

Methods

Questionnaires were given out by doctors or practice staff after routine consultations in line with the guidance given by the General Medical Council for surveys to be used for revalidation. Data analysis and practice reports were provided independently.

Results

Data were analysed for questionnaires from 7258 patients relating to 164 GPs in 29 general practices. Levels of missing data were generally low (typically 4.5-6%). The number of returned questionnaires required to achieve reliability of 0.7 were around 35 for individual doctor communication items and 29 for a composite score based on doctor communication items. This suggests that the responses to GPAQ-R had similar reliability to the GMC’s own questionnaire and we recommend 30 completed GPAQ-R questionnaires are sufficient for revalidation purposes. However, where an initial screen raises concern, the survey might be repeated with 50 completed questionnaires in order to increase reliability.

Conclusions

GPAQ-R is a development of a well-established patient experience questionnaire used in general practice in the UK since 2004. This new version can be recommended for use in order to meet the UK General Medical Council’s requirements for surveys to be used in revalidation of doctors. It also meets the needs of GPs to ask about patient experience relating to aspects of practice care that are not specific to individual general practitioners (e.g. receptionists, telephone access) which meet other survey requirements of the National Health Service in England. Use of GPAQ-R has the potential to reduce the number of surveys that GPs need to carry out in their practices to meet the various regulatory requirements which they face.

Preferences, predictions and patient enablement: a preliminary study

BACKGROUND

The widely used patient enablement instrument (PEI) is sometimes contrasted against measures of patient satisfaction as being a more objective measure of consultation quality, in that it is less likely to be positively influenced by fulfilling pre-existing expectations for specific consultation outcomes (such as prescriptions or referrals). However the relationship between expectation and enablement is underexplored, as is the relationship between 'expectation' understood as a patient preference for outcome, and patient prediction of outcome. The aims of the study are to 1) assess the feasibility of measuring the relationship between expectation fulfilment and patient enablement, and 2) measure the difference (if any) between expectation understood as preference, and expectation understood as prediction.

METHODS

A questionnaire study was carried out on 67 patients attending three General Practices in the Australian Capital Territory. Patient preferences and predictions for a range of possible outcomes were recorded prior to the consultation. PEI and the actual outcomes of the consultation were recorded at the conclusion of the consultation. Data analysis compared expectation fulfilment as concordance between the preferred, predicted, and actual outcomes, with the PEI as a dependant variable.

RESULTS

No statistically significant relationship was found between either preference-outcome concordance and PEI, or prediction-outcome concordance. Statistically insignificant trends in both cases ran counter to expectations; i.e. with PEI (weakly) positively correlated with greater discordance. The degree of concordance between preferred outcomes and predicted outcomes was less than the concordance between either preferred outcomes and actual outcomes, or predicted outcomes and actual outcomes.

CONCLUSIONS

The relationship between expectation fulfilment and enablement remains uncertain, whether expectation is measured as stated preferences for specific outcomes, or the predictions made regarding receiving such outcomes. However the lack of agreement between these two senses of 'patient expectation' suggests that explicitly demarcating these concepts during study design is strongly advisable.

Patient enablement requires physician empathy: a cross-sectional study of general practice consultations in areas of high and low socioeconomic deprivation in Scotland

Background

Patient 'enablement' is a term closely aligned with 'empowerment' and its measurement in a general practice consultation has been operationalised in the widely used patient enablement instrument (PEI), a patient-rated measure of consultation outcome. However, there is limited knowledge regarding the factors that influence enablement, particularly the effect of socio-economic deprivation. The aim of the study is to assess the factors influencing patient enablement in GP consultations in areas of high and low deprivation.

Methods

A questionnaire study was carried out on 3,044 patients attending 26 GPs (16 in areas of high socio-economic deprivation and 10 in low deprivation areas, in the west of Scotland). Patient expectation (confidence that the doctor would be able to help) was recorded prior to the consultation. PEI, GP empathy (measured by the CARE Measure), and a range of other measures and variables were recorded after the consultation. Data analysis employed multi-level modelling and multivariate analyses with the PEI as the dependant variable.

Results

Although numerous variables showed a univariate association with patient enablement, only four factors were independently predictive after multilevel multivariate analysis; patients with multimorbidity of 3 or more long-term conditions (reflecting poor chronic general health), and those consulting about a long-standing problem had reduced enablement scores in both affluent and deprived areas. In deprived areas, emotional distress (GHQ-caseness) had an additional negative effect on enablement. Perceived GP empathy had a positive effect on enablement in both affluent and deprived areas. Maximal patient enablement was never found with low empathy.

Conclusions

Although other factors influence patient enablement, the patients' perceptions of the doctors' empathy is of key importance in patient enablement in general practice consultations in both high and low deprivation settings.

A cluster randomised controlled trial of the clinical and cost-effectiveness of a 'whole systems' model of self-management support for the management of long- term conditions in primary care: trial protocol

BACKGROUND

Patients with long-term conditions are increasingly the focus of quality improvement activities in health services to reduce the impact of these conditions on quality of life and to reduce the burden on care utilisation. There is significant interest in the potential for self-management support to improve health and reduce utilisation in these patient populations, but little consensus concerning the optimal model that would best provide such support. We describe the implementation and evaluation of self-management support through an evidence-based 'whole systems' model involving patient support, training for primary care teams, and service re-organisation, all integrated into routine delivery within primary care.

METHODS

The evaluation involves a large-scale, multi-site study of the implementation, effectiveness, and cost-effectiveness of this model of self-management support using a cluster randomised controlled trial in patients with three long-term conditions of diabetes, chronic obstructive pulmonary disease (COPD), and irritable bowel syndrome (IBS). The outcome measures include healthcare utilisation and quality of life. We describe the methods of the cluster randomised trial.

DISCUSSION

If the 'whole systems' model proves effective and cost-effective, it will provide decision-makers with a model for the delivery of self-management support for populations with long-term conditions that can be implemented widely to maximise 'reach' across the wider patient population.

TRIAL REGISTRATION NUMBER

ISRCTN: ISRCTN90940049.

Verbal and non-verbal behavior of doctors and patients in primary care consultations - how this relates to patient enablement

OBJECTIVE

To assess the relationship between observable patient and doctor verbal and non-verbal behaviors and the degree of enablement in consultations according to the Patient Enablement Instrument (PEI) (a patient-reported consultation outcome measure).

METHODS

We analyzed 88 recorded routine primary care consultations. Verbal and non-verbal communications were analyzed using the Roter Interaction Analysis System (RIAS) and the Medical Interaction Process System, respectively. Consultations were categorized as patient- or doctor-centered and by whether the patient or doctor was verbally dominant using the RIAS categorizations.

RESULTS

Consultations that were regarded as patient-centered or verbally dominated by the patient on RIAS coding were considered enabling. Socio-emotional interchange (agreements, approvals, laughter, legitimization) was associated with enablement. These features, together with task-related behavior explain up to 33% of the variance of enablement, leaving 67% unexplained. Thus, enablement appears to include aspects beyond those expressed as observable behavior.

CONCLUSION

For enablement consultations should be patient-centered and doctors should facilitate socio-emotional interchange. Observable behavior included in communication skills training probably contributes to only about a third of the factors that engender enablement in consultations.

PRACTICE IMPLICATIONS

To support patient enablement in consultations, clinicians should focus on agreements, approvals and legitimization whilst attending to patient agendas.

Determinants of patient enablement at primary health care centres in central Ethiopia: a cross-sectional study

Background

Patient enablement is associated with behaviours like treatment adherence and self-care and is becoming a well-accepted indicator of quality of care. However, the concept of patient enablement has never been subjected to scientific inquiry in Ethiopia.

Objectives

The aim of this study was to determine the degree of patient enablement and its predictors after consultation at primary health care centres in central Ethiopia.

Method

Data were collected from 768 outpatients from six primary health care centres in central Ethiopia during a cross-sectional study designed to assess patient satisfaction. Consecutive patients, 15 years or older, were selected for the study from each health centre. Multinomial logistic regression was performed to identify predictors of patient enablement using SPSS (version 16.0).

Results

The study showed that 48.4% of patients expressed an intermediate level of enablement, while 25.4% and 26.2% of the patients expressed low and high levels of patient enablement, respectively. Four models were developed to identify predictors of patient enablement. The first model included socio-demographic variables, showing that residence, educational status and occupational status were significantly associated with patient enablement (p < 0.05). This model explained only 20.5% of the variation. The second and third models included institutional aspects, and perceived doctor–patient interaction and information sharing about illness, respectively. They explained 31.1% and 64.9% of the variation. The fourth model included variables that were significantly associated with patient enablement in the first, second and third models and explained 72% of the variation. In this model, perceived empathy and technical competency, non-verbal communication, familiarity with the provider, information sharing about illness and arrangement for follow-up visits were strong predictors of patient enablement (p < 0.05).

Conclusion

The present study revealed specific predictors of patient enablement, which health care providers should consider in their practice to enhance patient enablement after consultation.

Delays in response and triage times reduce patient satisfaction and enablement after using out-of-hours services

BACKGROUND

several different models of out-of-hours primary care now exist in the UK. Important outcomes of care include users' satisfaction and enablement to manage their illness or condition, but the determinants of these outcomes in the unscheduled care domain are poorly understood. Aim. To identify predictors of user satisfaction and enablement across unscheduled care or GP out-of-hours service providers in Wales. The design of the study is a cross-sectional survey. The setting of the study is nine GP out-of-hours services, three Accident and Emergency units and an all Wales telephone advice service in Wales.

METHODS

postal survey using the Out-of-hours Patient Questionnaire. Logistic regression was used to fit both satisfaction and enablement models, based on demographic variables, service provider and treatment received and perceptions or ratings of the care process.

RESULTS

eight hundred and fifty-five of 3250 users responded (26% response rate, range across providers 14-41%, no evidence of non-response bias for age or gender). Treatment centre consultations were significantly associated with decreased patient satisfaction and decreased enablement compared with telephone advice. Delays in call answering or callback for triage and shorter consultations were significantly associated with lower satisfaction. Waiting more than a minute for initial call answering was associated with lower enablement.

CONCLUSIONS

giving users more time to discuss their illness in consultations may enhance satisfaction and enablement but this may be resource intensive. More simple interventions to improve access by quicker response and triage, and keeping users informed of waiting times, could also serve to increase satisfaction and ultimately impact on their enablement.

The need to improve the interface between in-hours and out-of-hours GP care, and between out-of-hours care and self-care

BACKGROUND

considerable changes have occurred over the last 5 years in the organization of out-of-hours care in the UK. Users' experiences of their care are an important part of 'quality of care' and are valuable for identifying areas for improvement.

AIM

to identify strengths and weaknesses of out-of hours service provision in Wales. The design of the study is a cross-sectional survey. The setting of the study is nine GP services, three Accident and Emergency units and NHS Direct in Wales.

METHOD

survey using the validated Out-of-Hours questionnaire. We identified the four most and least favourably rated items regarding users' experience of care. These were analysed by type of care provided, telephone advice, treatment centre and home visit groups.

RESULTS

eight hundred and fifty-five of 3250 users responded (26% response rate). Across providers and types of care, consistent strengths were the 'manner of treatment by call operator' and the 'explanation of the next step by call operator'. Consistent weaknesses were the 'speed of call back by the clinician', the 'information provided by the GP', 'getting medication after the consultation' and 'when to contact the (in-hours) GP'.

CONCLUSIONS

users of out-of-hours care identify clear and consistent strengths and weaknesses of service provision across Wales. Specific areas for improvement concern the interface between in-hours care and out-of-hours care and between out-of-hours care and self-care. GP surgeries need to give better information on how to access the out-of-hours services. Out-of-hours providers should improve their advice on how and when to access in-hours surgeries and also improve the availability of medicines after out-of-hours consultations.

A pilot study on the validity and reliability of the Patient Enablement Instrument (PEI) in a Chinese population

BACKGROUND

The Patient Enablement Instrument (PEI) was developed to measure patients' enablement, which is an indicator of the effectiveness of a primary care consultation; however, to date, the PEI has not been tested in Asian populations.

OBJECTIVES

The purpose of this study is to test the acceptability, validity, reliability and other psychometric properties of a Chinese [Hong Kong (HK)] translation of the PEI in Chinese patients in Hong Kong and whether these properties would be affected by different timing of administration.

METHODS

A Chinese (HK) translation of the PEI was developed by iterative forward-backward translations and the content validity was assessed by a cognitive debriefing interview with 10 Chinese patients. It was then administered to 152 adult patients attending a government-funded primary care clinic in Hong Kong both immediately after the consultation and 2-3 weeks later by telephone. Internal construct validity was assessed by item-scale correlations and factor analysis, test-retest reliability was assessed by intraclass correlation (ICC) and sensitivity was assessed by known group comparison.

RESULTS

The Chinese (HK) PEI was semantically equivalent to the original PEI for all items. Acceptability of the PEI was high with 83.1% response and 100% completion rates. Statistical analyses showed no difference between test and retest means as well as good reproducibility (ICC 0.75). Internal reliability determined by Cronbach's alpha was >0.8 irrespective of timing of administration. Scale construct validity was confirmed by strong (r>0.4) item-scale correlations and resumed to a one-factor hypothesized structure. PEI scores were significantly higher in younger patients supporting sensitivity. There was no significant difference in the psychometric properties or scores between the assessment results from immediately after and 2-weeks post-consultation.

CONCLUSIONS

A Chinese (HK) translation of the PEI equivalent to the original is now available for application to Chinese populations. Pilot testing supported its acceptability, validity, reliability and sensitivity. Further studies to confirm its construct validity and responsiveness will help to establish the Chinese (HK) PEI as an outcome measure of the effectiveness of primary care consultations in Chinese patients.

Understanding why some ethnic minority patients evaluate medical care more negatively than white patients: a cross sectional analysis of a routine patient survey in English general practices

OBJECTIVE

To examine why patients from ethnic minorities give poorer evaluations of primary health care than white patients.

DESIGN

Cross sectional analysis of patient surveys collected in general practice.

SETTING

1098 English general practices that undertook a routine survey of patients using the General Practice Assessment Questionnaire between April 2005 and March 2006.

PARTICIPANTS

188,572 survey respondents, 95.8% of whom identified themselves as "white," "black/black British," "Asian/Asian British," or "Chinese." Analyses were restricted to between 133,441 (71%) and 147,686 (78%) respondents with complete data on relevant variables.

MAIN OUTCOME MEASURES

Patient evaluations of waiting times for general practitioner appointments, time spent waiting in surgeries for consultations to start, and continuity of care.

RESULTS

All aspects of care were rated substantially lower by respondents from the three ethnic minority groups than by white patients. Poorer evaluations of time spent waiting for consultations to begin (rated lowest by Asian patients) and continuity of care (rated lowest by Chinese patients) appeared to reflect worse reported experiences by ethnic minority groups. Substantial differences between white and ethnic minority patients' ratings of appointment waiting times persisted, however, even after adjusting for the actual time patients reported waiting. This effect disappeared for Chinese and black respondents after adjusting for evaluations of reception staff and doctors' communication skills, but Asian patients' ratings remained considerably lower than those of white respondents.

CONCLUSIONS

Important differences in assessments of care exist in different ethnic minority groups. Some negative evaluations may reflect communication issues. Among Asian patients, lower ratings of waiting times for appointments may also reflect different expectations of care. Adjusting survey results for ethnicity may be justified when comparing healthcare providers; however, health services also have a responsibility to meet legitimate patient expectations.

Patient involvement in assessing consultation quality: a quantitative study of the Patient Enablement Instrument in Poland

BACKGROUND

Promoting a more patient-responsive service has been the focus of policy initiatives in newer EU states. One measure of success should be the patient's assessment of their consultation with their doctor.

OBJECTIVES

To measure consultation quality in Polish primary care using patient enablement (a patient-driven instrument developed in the UK) and to test its theoretical framework. To compare the patient enablement outcome of different types of doctor delivering primary care in Poland following reform.

DESIGN

Cross-sectional quantitative questionnaire survey.

SETTING

Random sample of primary care doctors practising within a 60-km radius of Gdansk, Poland.

SUBJECTS AND OUTCOME MEASURES

Patient Enablement Instrument and correlates were measured in 7924 consecutive adult consultations of 48 doctors, stratified according to training: family medicine specialists (diploma holders), non-diplomates and general medicine doctors (polyclinic internists).

RESULTS

Completion was high (78%). The mean patient enablement score in Poland was 4.0 (SD 3.3) and mean consultation length was 10.3 min (SD 5.4 min). Consultation length and knowing the doctor are independently related to patient enablement in the Polish context. Variation between doctors is significant, but earlier differences in enablement between alternative providers have largely been ameliorated in practice.

CONCLUSION

It is feasible to use patient enablement on a large scale at routine consultation in primary care in Poland: acceptability was good in diverse environments. The internal consistency of enablement and its relationships broadly mirror those found in the UK. The effect of patient expectations shaped by social and cultural issues influencing enablement outcome requires further investigation.

Patient, physician, and practice characteristics related to patient enablement in general practice in Croatia: cross-sectional survey study

AIM

To investigate the quality of general practice care in Croatia by using patient enablement as a consultation outcome measure and its association with patient, physician, and practice characteristics.

METHODS

A cross-sectional questionnaire-based study performed from November 2003 to March 2004 included a national stratified random sample of 350 general practitioners, who were asked to collect data on 50 consecutive consultations with their patients aged > or =18 years. Patients provided data on patient enablement (Patient Enablement Instrument, score range 0-12), consultation length, sociodemographic data, how well they knew the physician, health self-assessment, quality of life, and reason for the visit. Physicians provided data on age, sex, vocational training, working experience, educational work, average number of patients per day, and type of practice.

RESULTS

In 5527 patients, the mean score (+/-standard deviation) for enablement at consultation was 6.6+/-3.3 and the mean consultation length was 11.5+/-5.5 minutes. Logistic regression analysis showed that lack of continuity of care (men: OR, 0.56; 95% CI, 0.47-0.67; women: OR, 0.52; 95% CI, 0.45-0.61), poor self-perceived health (men: OR, 1.76; 95% CI, 1.49-2.07; women: OR, 1.77; 95% CI, 1.53-2.04), low educational level, low quality of life for both sexes and older age in male patients predicted low enablement (P<0.05 for each). Physician age, sex, and average number of patients per day were significantly correlated with enablement for male patients and physician working experience with enablement for female patients (P<0.05 for each).

CONCLUSION

Patient enablement score in Croatia is high in comparison with countries such as the UK and Poland. Enablement at consultations was related to the continuity of care and patient health status, and other patient, physician, and practice characteristics, suggesting that these parameters should be considered when assessing quality of care in general practice.

A qualitative study of patients' views on quality of primary care consultations in Hong Kong and comparison with the UK CARE Measure

BACKGROUND

Patients' priorities and views on quality care are well-documented in Western countries but there is a dearth of research in this area in the East. The aim of the present study was to explore Chinese patients' views on quality of primary care consultations in Hong Kong and to compare these with the items in the CARE measure (a process measure of consultation quality widely used in the UK) in order to assess the potential utility of the CARE measure in a Chinese population.

METHODS

Individual semi-structured interviews were conducted on 21 adult patients from 3 different primary care clinics (a public primary healthcare clinic, a University health centre, and a private family physician's clinic). Topics discussed included expectations, experiences, and views about quality of medical consultations. Interviews were typed verbatim, and a thematic approach was taken to identify key issues. These identified issues were then compared with the ten CARE measure items, using a CARE framework: Connecting (Care Measure items 1-3), Assessing (item 4), Responding (items 5,6), and Empowering (items 7-10).

RESULTS

Patients judged doctors in terms of both the process of the consultation and the perceived outcomes. Themes identified that related to the interpersonal process of the consultation fitted well under the CARE framework; Connecting and communicating (18/21 patients), Assessing holistically (10/21 patients), Responding (18/21 patients) and Empowering (19/21 patients). Patients from the public clinic, who were generally of lower socio-economic status, were least likely to expect holistic care or empowerment. Two-thirds of patients also judged doctors on whether they performed an adequate physical examination, and three-quarters on the later outcomes of consultation (in terms of relief or cure and/or side-effects of prescribed drugs).

CONCLUSION

These findings suggest that Chinese patients in Hong Kong value engaged, empathic primary care doctors and judge the quality of consultations largely on these human skills and the attitudes and values that underpin them, as well as on the perceived outcomes of treatment. The match between themes relating to consultation process and the CARE Measure items suggests utility of this measure in this population, but further quantitative validation is required.