Primary Care Assessment Survey Research Articles

Instrument Development and Validation to Assess Care Barriers for Patients in Saudi Arabia with Oral Clefts.

The study objective was to construct and validate a tool to assess, measure, and evaluate the barriers and obstacles that patients with orofacial clefts (OFCs), and their families, face during treatment. The Effective Accessibility and Accommodation subscale, based on the translated Primary Care Assessment Survey and Primary Care Assessment Tool scales, was used as a reference for the questionnaire. A total of 165 parents from three main cleft referral centers in Saudi Arabia were interviewed. Questionnaire content validity was conducted by calculation of a content validity index for each item (I-CVI) as well as for the total scale (S-CVI). Reliability was tested using Cronbach’s alpha. Factor analysis and principal components analysis were performed to determine the factor structure of the instrument. The final questionnaire had nine items. Rating results showed both I-CVI and S-CVI scores of 1 and Cronbach’s alpha was 0.86. There were three factors (geographic accessibility, appointment availability and accessibility, and scheduling-related barriers) with eigenvalues above 1.00, which collectively accounted for 73% of the variance. In conclusion, this tool is valid and reliable to evaluate accessibility and barriers to care of patients with OFCs in Saudi Arabia.

Determinants of Satisfaction With Health Services by Dimensions of Care: An Age-Stratified Analysis

Studies that examined satisfaction with care in older adults are scarce. The aim of this research was to analyse satisfaction among older adults considering mental health, socio-clinical and health system factors and by age category. Data come from the Étude sur la Santé des Aînés Services study including 1,624 adults aged ≥65 years recruited between 2011-2013 in primary care in Quebec. Patient satisfaction was assessed during interviews with questions adapted from the Primary Care Assessment Survey. Mental health (anxiety, depression, suicidal ideation, psychological distress, cognition), social support, quality of life, the presence of pain and chronic conditions were self-reported. Health service use was extracted from administrative registries. Logistic regressions stratified by age were used to examine the associations of low satisfaction in three dimensions of care. For continuity of care, the determinants of low satisfaction were pain and attraction index for psychiatric services in adults 65 to 75 years versus anxiety, cognition and hospitalizations in adults 75 years and older. For patient-provider interactions, the determinants were psychological distress, attraction index for psychiatric services in adults 65 to 75 years versus quality of life and cognition in adults 75 years and older. For adequacy of care, anxiety, psychological distress, social support, pain, quality of life and attraction index for psychiatric services were significant in adults 65 to 75 years versus quality of life and cognition in adults 75 years and older. Results highlight different patterns of satisfaction by age category that should be used to improve care delivered in primary care.

Mental health and satisfaction with primary care services in older adults: a study from the patient perspective on four dimensions of care.

Few studies have examined the association between mental health and satisfaction with primary care services in community-dwelling older adults. To examine the association between mental health in older adults and low satisfaction with primary care services within four dimensions of care. This secondary data analysis included 1624 older adults participating in the 'Étude sur la Santé des Aînés Services' (ESA-Services study) and recruited in primary care practices between 2011 and 2013 in the province of Quebec. Patient satisfaction and experience with care were assessed during face-to-face interviews with questions adapted from the Primary Care Assessment Survey. Self-reported mental health indicators included depression, anxiety, suicidal ideation, psychological distress and cognition. We conducted four logistic regressions to examine the associations between mental health and low satisfaction in the following dimensions of care: continuity of care, provider-patient interactions, adequacy of care and physical environment. Nearly half of participants (48.5%) reported low satisfaction in at least one dimension of care examined. High psychological distress was associated with low satisfaction with provider-patient interactions [odds ratio (OR) = 1.02; 95% confidence interval (CI) = 1.00-1.04] and adequacy of care (OR = 1.04; 95% CI = 1.01-1.06). The presence of an anxiety disorder was associated with low satisfaction in adequacy of care (OR = 1.64; 95% CI = 1.00-2.72). Worse cognitive functioning was associated with low satisfaction in continuity of care, provider-patient interaction and adequacy of care. Mental health was consistently associated with low satisfaction within dimensions of care. Results support the need for increased attention when delivering care to older adults with mental health problems.

Potential for physician communication to build favorable medication beliefs among older adults with hypertension: A cross-sectional survey.

Older adults suffering from hypertension form firm medication beliefs through lifetime medication management, which significantly affect their medication adherence and treatment outcomes. Understanding whether the patient-physician communication has the potential to change medication beliefs will help design an effective communication strategy to foster favorable medication beliefs. This study aims to determine whether the patient-physician communication is associated with medication beliefs among older adults with hypertension and controls socio-demographics and clinical characteristics. Further, it examines how the association varies with two different types of medication beliefs (medication overuse and harm) for each domain of communication (informative and interpersonal). A self-administered cross-sectional survey was conducted for members of seven senior centers in a metropolitan area of the United States between August and December of 2013. A total of 211 senior members suffering from hypertension completed the questionnaire, which included the Primary Care Assessment Survey (PCAS) and the Beliefs about Medicines Questionnaire (BMQ). The former had two domains of patient-physician communication—informative and interpersonal—while the latter measured medication harm and overuse beliefs. Interpersonal patient-physician communication significantly explained the medication overuse beliefs (β = -0.28, p < 0.05), whereas neither interpersonal nor informative communication significantly explained the medication harm beliefs. Females (β = 1.29, p < 0.01) and participants with higher education (β = 2.66, p = 0.02) more strongly believed that medications are overprescribed. However, participants with low income more strongly believed that medications are harmful. Patient-physician communication, if it touches upon interpersonal aspects, has the potential to change medication overuse beliefs among older adults with hypertension. Identification of the significant factors which affect medication beliefs, will inform the design of a patient-centric communication program that fosters favorable medication beliefs among geriatric hypertensive patients.

Does a Consumer-Targeted Deprescribing Intervention Compromise Patient-Healthcare Provider Trust?

One in four community-dwelling older adults is prescribed an inappropriate medication. Educational interventions aimed at patients to reduce inappropriate medications may cause patients to question their prescriber’s judgment. The objective of this study was to determine whether a patient-focused deprescribing intervention compromised trust between older adults and their healthcare providers. An educational brochure was distributed to community-dwelling older adults by community pharmacists in order to trigger deprescribing conversations. At baseline and 6-months post-intervention, participants completed the Primary Care Assessment Survey, which measures patient trust in doctors and pharmacists. Changes in trust were ascertained post-intervention. Proportions with 95% confidence intervals (CI), and logistic regression were used to determine a shift in trust and associated predictors. 352 participants responded to the questionnaire at both time points. The majority of participants had no change or gained trust in their doctors for items related to the choice of medical care (78.5%, 95% CI = 74.2–82.8), communication transparency (75.4%, 95% CI = 70.7–79.8), and overall trust (81.9%, 95% CI = 77.9–86.0). Similar results were obtained for participants’ perceptions of their pharmacists, with trust remaining intact for items related to the choice of medical care (79.4%, 95% CI = 75.3–83.9), transparency in communicating (82.0%, 95% CI = 78.0–86.1), and overall trust (81.6%, 95% CI = 77.5–85.7). Neither age, sex nor the medication class targeted for deprescribing was associated with a loss of trust. Overall, the results indicate that patient-focused deprescribing interventions do not shift patients’ trust in their healthcare providers in a negative direction.

The mediatory role of medication adherence in improving patients' medication experience through patient-physician communication among older hypertensive patients.

BackgroundUnderstanding how patient–physician communication affects patients’ medication experience would help hypertensive patients maintain their regular long-term medication therapy. This study aimed to examine whether patient–physician communication (information and interpersonal treatment) affects patients’ medication experience directly or indirectly through changing medication adherence for each of the two communication domains.MethodsA self-administered cross-sectional survey was conducted for older patients who had visited a community senior center as a member. Two communication domains were assessed using two subscales of the Primary Care Assessment Survey. Medication adherence and experience were measured using the Morisky Medication Adherence Scale and a five-point Likert scale, respectively. Mediatory effects were assessed via Baron and Kenny’s procedure and a Sobel test.ResultsPatient–physician communication had a positive prediction on patients’ medication experience (β=0.25, P=0.03), and this was fully mediated by medication adherence (z=3.62, P<0.001). Of the two components of patient–physician communication, only informative communication showed a mediatory effect (z=2.21, P=0.03).ConclusionPatient–physician communication, specifically informative communication, had the potential to improve patients’ medication experience via changes in medication adherence. This finding can inform health care stakeholders of the mediatory role of medication adherence in ensuring favorable medication experience for older hypertensive patients by fostering informative patient–physician communication.

A study on student environment, extracurricular activities, motivation and academic achievements

The relationship between medication adherence and treatment satisfaction has been consistently positive, however, this relationship has not been examined among older adults with hypertension.The aim of this study was to examine the relationship between medication adherence and treatment satisfaction among a sample of older adults with hypertension.This was a survey-based cross-sectional study in which seven community senior centers in the city of Memphis, Tennessee and its surrounding areas were visited. Individuals aged 60 years and older with self-reported hypertension who visited the community senior centers between August and December 2013 were asked to participate. The participants' satisfaction with their antihypertensive medications was assessed using a newly developed scale. The Short Form Health Survey (SF-12v2) was used to assess the health-related quality of life (HRQoL). The Primary Care Assessment Survey (PCAS) Communication scale was used to assess the satisfaction with health care provider communication. The Beliefs About Medicines Questionnaire (BMQ-General) was used to assess the participant beliefs about medications. The eight-item Morisky Medication Adherence Scale (MMAS-8) was used to assess adherence to antihypertensive medications. And the Single Item Literacy Screener (SILS) was used to assess health literacy. Multiple linear regression was conducted to examine the relationship between medication adherence and satisfaction with antihypertensive therapy controlling for multiple variables.One hundred and ninety participants with hypertension were included in the study. Most participants were white, women, aged ≥70 years, taking ≥2 prescription medications and having ≥2 medical conditions. After adjusting for age, education, number of prescription medications, race, health literacy, sex, marital status, SF-12v2 Physical Component Summary (PCS-12) and Mental Component Summary (MCS-12), and PCAS-Communication scores, the overall satisfaction score of the antihypertensive medication regimen was positively and significantly associated with MMAS-8 sore (β = 0.262; 95% confidence interval, 0.007–0.517; P = 0.043).Treatment satisfaction was associated with higher medication adherence among older adults with hypertension.

Examining the relationship between antihypertensive medication satisfaction and adherence in older patients.

The relationship between medication adherence and treatment satisfaction has been consistently positive, however, this relationship has not been examined among older adults with hypertension. The aim of this study was to examine the relationship between medication adherence and treatment satisfaction among a sample of older adults with hypertension. This was a survey-based cross-sectional study in which seven community senior centers in the city of Memphis, Tennessee and its surrounding areas were visited. Individuals aged 60 years and older with self-reported hypertension who visited the community senior centers between August and December 2013 were asked to participate. The participants' satisfaction with their antihypertensive medications was assessed using a newly developed scale. The Short Form Health Survey (SF-12v2) was used to assess the health-related quality of life (HRQoL). The Primary Care Assessment Survey (PCAS) Communication scale was used to assess the satisfaction with health care provider communication. The Beliefs About Medicines Questionnaire (BMQ-General) was used to assess the participant beliefs about medications. The eight-item Morisky Medication Adherence Scale (MMAS-8) was used to assess adherence to antihypertensive medications. And the Single Item Literacy Screener (SILS) was used to assess health literacy. Multiple linear regression was conducted to examine the relationship between medication adherence and satisfaction with antihypertensive therapy controlling for multiple variables. One hundred and ninety participants with hypertension were included in the study. Most participants were white, women, aged ≥70 years, taking ≥2 prescription medications and having ≥2 medical conditions. After adjusting for age, education, number of prescription medications, race, health literacy, sex, marital status, SF-12v2 Physical Component Summary (PCS-12) and Mental Component Summary (MCS-12), and PCAS-Communication scores, the overall satisfaction score of the antihypertensive medication regimen was positively and significantly associated with MMAS-8 sore (β=0.262; 95% confidence interval, 0.007-0.517; P=0.043). Treatment satisfaction was associated with higher medication adherence among older adults with hypertension.

Perceived Quality of Care of Community Health Worker and Facility-Based Health Worker Management of Pneumonia in Children Under 5 Years in Western Kenya: A Cross-Sectional Multidimensional Study

Integrated community case management (iCCM) programs that train lay community health workers (CHWs) in the diagnosis and treatment of diarrhea, malaria, and pneumonia have been increasingly adopted throughout sub-Saharan Africa to provide services in areas where accessibility to formal public sector health services is low. One important aspect of successful iCCM programs is the acceptability and utilization of services provided by CHWs. To understand community perceptions of the quality of care in an iCCM intervention in western Kenya, we used the Primary Care Assessment Survey to compare caregiver attitudes about the diagnosis and treatment of childhood pneumonia as provided by CHWs and facility-based health workers (FBHWs). Overall, caregivers rated CHWs more highly than FBHWs across a set of 10 domains that capture multiple dimensions of the care process. Caregivers perceived CHWs to provide higher quality care in terms of accessibility and patient relationship and equal quality care on clinical aspects. These results argue for the continued implementation and scale-up of iCCM programs as an acceptable intervention for increasing access to treatment of childhood pneumonia.

Exploring the factors that influence medication rating Web sites value to older adults: A cross-sectional study

In this cross-sectional study, we evaluated factors that affected the perceived value of medication rating Web sites to 284 people aged ≥60 years who were taking prescription medications. The Patient Reviews of Medication Experience (PROMEX) questionnaire score, which assessed participant opinions about the value of online reviews of medications, was positively associated with preference to share health care decision making with the health care provider and negatively associated with the Physical Component Summary (PCS-12) and Mental Component Summary scores of the Short Form 12 health survey. The Primary Care Assessment Survey Communication score, which measured participant satisfaction with the communication from the health care provider, was positively associated with PCS-12 and health literacy. In summary, older adults who had poor physical and mental health-related quality of life were more likely to believe that medication rating Web sites were useful and helpful in facilitating communication with health care providers.

Clinicians' Implicit Ethnic/Racial Bias and Perceptions of Care Among Black and Latino Patients

We investigated whether clinicians' explicit and implicit ethnic/racial bias is related to black and Latino patients' perceptions of their care in established clinical relationships. We administered a telephone survey to 2,908 patients, stratified by ethnicity/race, and randomly selected from the patient panels of 134 clinicians who had previously completed tests of explicit and implicit ethnic/racial bias. Patients completed the Primary Care Assessment Survey, which addressed their clinicians' interpersonal treatment, communication, trust, and contextual knowledge. We created a composite measure of patient-centered care from the 4 subscales. Levels of explicit bias were low among clinicians and unrelated to patients' perceptions. Levels of implicit bias varied among clinicians, and those with greater implicit bias were rated lower in patient-centered care by their black patients as compared with a reference group of white patients (P = .04). Latino patients gave the clinicians lower ratings than did other groups (P <.0001), and this did not depend on the clinicians' implicit bias (P = .98). This is among the first studies to investigate clinicians' implicit bias and communication processes in ongoing clinical relationships. Our findings suggest that clinicians' implicit bias may jeopardize their clinical relationships with black patients, which could have negative effects on other care processes. As such, this finding supports the Institute of Medicine's suggestion that clinician bias may contribute to health disparities. Latinos' overall greater concerns about their clinicians appear to be based on aspects of care other than clinician bias.

Patient Reports of: Lifestyle Advice in Primary Care

Patients' perceptions of preventive lifestyle in primary care practice were examined. Practice was assessed with a modified version of the Primary Care Assessment Survey (PCAS). This was mailed to random samples of patients twice, using practice mailing lists from three Ontario Family Health Networks (FHNs). Family Health Networks are physician-based group practices, with additional nurse-led telephone advisory services to provide care 24 hours a day, seven days a week. The PCAS questionnaire consisted of nine scales (ranging from 0 to 100). For preventive counselling, additional questions on diet and exercise counselling were included to determine how the physician delivered the intervention. Of the 2184 survey questionnaires mailed to patients, 22% were undeliverable. The response rate was 62% at valid addresses (49% of all mailed questionnaires). Of the nine scales, scores (± standard deviation) for preventive counselling were lowest at 33 ± 25. In particular, rates of diet (37%) and exercise (24%) counselling were low in the FHNs. For most other aspects of primary care services, patients generally rated FHNs highly. The majority of patients advised about diet and exercise were given verbal advice or pamphlets. In these primary health care organizations, considerable room exists for increased preventive counselling, especially about diet and exercise.

Management Continuity from the Patient Perspective: Comparison of Primary Healthcare Evaluation Instruments

Management continuity, operationally defined as "the extent to which services delivered by different providers are timely and complementary such that care is experienced as connected and coherent," is a core attribute of primary healthcare. Continuity, as experienced by the patient, is the result of good care coordination or integration. To provide insight into how well management continuity is measured in validated coordination or integration subscales of primary healthcare instruments. Relevant subscales from the Primary Care Assessment Survey (PCAS), the Primary Care Assessment Tool - Short Form (PCAT-S), the Components of Primary Care Instrument (CPCI) and the Veterans Affairs National Outpatient Customer Satisfaction Survey (VANOCSS) were administered to 432 adult respondents who had at least one healthcare contact with a provider other than their family physician in the previous 12 months. Subscales were examined descriptively, by correlation and factor analysis and item response theory analysis. Because the VANOCSS elicits coordination problems and is scored dichotomously, we used logistic regression to examine how evaluative subscales relate to reported problems. Most responses to the PCAS, PCAT-S and CPCI subscales were positive, yet 83% of respondents reported having one or more problems on the VANOCSS Overall Coordination subscale and 41% on the VANOCSS Specialist Access subscale. Exploratory factor analysis suggests two distinct factors. The first (eigenvalue=6.98) is coordination actions by the primary care physician in transitioning patient care to other providers (PCAS Integration subscale and most of the PCAT-S Coordination subscale). The second (eigenvalue=1.20) is efforts by the primary care physician to create coherence between different visits both within and outside the regular doctor's office (CPCI Coordination subscale). The PCAS Integration subscale was most strongly associated with lower likelihood of problems reported on the VANOCSS subscales. Ratings of management continuity correspond only modestly to reporting of coordination problems, possibly because they rate only the primary care physician, whereas patients experience problems across the entire system. The subscales were developed as measures of integration and provider coordination and do not capture the patient's experience of connectedness and coherence.

Accessibility from the Patient Perspective: Comparison of Primary Healthcare Evaluation Instruments

The operational definition of first-contact accessibility is "the ease with which a person can obtain needed care (including advice and support) from the practitioner of choice within a time frame appropriate to the urgency of the problem"; accommodation is "the way healthcare resources are organized to accommodate a wide range of patients' abilities to contact healthcare providers and reach healthcare services, that is to say telephone services, flexible appointment systems, hours of operation, and walk-in periods." To compare how well accessibility is measured in validated subscales that evaluate primary healthcare from the patient's perspective. 645 adults with at least one healthcare contact in the previous 12 months responded to six instruments that evaluate primary healthcare with four subscales that measure accessibility: the Primary Care Assessment Survey (PCAS), the Primary Care Assessment Tool - Short Form (PCAT-S, two subscales) and the first version of the EUROPEP (EUROPEP-I). Scores were normalized to a 0-to-10 scale for descriptive comparison. Exploratory and confirmatory (structural equation modelling) factor analysis examined fit to operational definition, and item response theory analysis examined item performance on common constructs. The subscales demonstrate similar psychometric measures to those reported by developers. The PCAT-S First-Contact Utilization subscale does not fit the accessibility construct. The remaining three subscales load reasonably onto a single factor, presumed to be accessibility, but the best-fitting model has two factors: "timeliness of obtaining needed care" (PCAT-S First-Contact Access, some EUROPEP-I items) and "how resources are organized to accommodate clients" (PCAS Organizational Access and most of EUROPEP-I organization of care). Items in the PCAS and PCAT-S subscales have good discriminability. Only three of the four subscales measure accessibility; all are appropriate for use in Canada. The PCAT-S First-Contact Access subscale is the best measure for first-contact accessibility, and PCAS Organizational Accessibility has good metric properties and measures for accommodation.

Respectfulness from the Patient Perspective: Comparison of Primary Healthcare Evaluation Instruments

Respectfulness is one measurable and core element of healthcare responsiveness. The operational definition of respectfulness is "the extent to which health professionals and support staff meet users' expectations about interpersonal treatment, demonstrate respect for the dignity of patients and provide adequate privacy." To examine how well respectfulness is captured in validated instruments that evaluate primary healthcare from the patient's perspective, whether or not their developers had envisaged these as representing respectfulness. 645 adults with at least one healthcare contact with their own regular doctor or clinic in the previous 12 months responded to six instruments, two subscales that mapped to respectfulness: the Interpersonal Processes of Care, version II (IPC-II, two subscales) and the Primary Care Assessment Survey (PCAS). Additionally, there were individual respectfulness items in subscales measuring other attributes in the Components of Primary Care Index (CPCI) and the first version of the EUROPEP (EUROPEP-I). Scores were normalized for descriptive comparison. Exploratory and confirmatory (structural equation modelling) factor analyses examined fit to operational definition. Respectfulness scales correlate highly with one another and with interpersonal communication. All items load adequately on a single factor, presumed to be respectfulness, but the best model has three underlying factors corresponding to (1) physician's interpersonal treatment (eigenvalue=13.99), (2) interpersonal treatment by office staff (eigenvalue=2.13) and (3) respect for the dignity of the person (eigenvalue=1.16). Most items capture physician's interpersonal treatment (IPC-II Compassionate, Respectful Interpersonal Style, IPC-II Hurried Communication and PCAS Interpersonal Treatment). The IPC-II Interpersonal Style (Disrespectful Office Staff) captures treatment by staff, but only three items capture dignity. Various items or subscales seem to measure respectfulness among currently available validated instruments. However, many of these items related to other constructs, such as interpersonal communication. Further studies should aim at developing more refined measures - especially for privacy and dignity - and assess the relevance of the broader concept of responsiveness.

Validation of Instruments to Evaluate Primary Healthcare from the Patient Perspective: Overview of the Method

Patient evaluations are an important part of monitoring primary healthcare reforms, but there is little comparative information available to guide evaluators in the choice of instruments or to determine their relevance for Canada. To compare values and the psychometric performances of validated instruments thought to be most pertinent to the Canadian context for evaluating core attributes of primary healthcare. AMONG VALIDATED INSTRUMENTS IN THE PUBLIC DOMAIN, WE SELECTED SIX: the Primary Care Assessment Survey (PCAS); the Primary Care Assessment Tool - Short Form (PCAT-S); the Components of Primary Care Index (CPCI); the first version of the EUROPEP (EUROPEP-I); the Interpersonal Processes of Care Survey, version II (IPC-II); and part of the Veterans Affairs National Outpatient Customer Satisfaction Survey (VANOCSS). We mapped subscales to operational definitions of attributes. All were administered to a sample of adult service users balanced by English/French language (in Nova Scotia and Quebec, respectively), urban/rural residency, high/low education and overall care experience. The sample was recruited from previous survey respondents, newspaper advertisements and community posters. We used common factor analysis to compare our factor resolution for each instrument to that of the developers. Our sample of 645 respondents was approximately balanced by design variables, but considerable effort was required to recruit low-education and poor-experience respondents. Subscale scores are statistically different by excellent, average and poor overall experience, but interpersonal communication and respectfulness scores were the most discriminating of overall experience. We found fewer factors than did the developers, but when constrained to the number of expected factors, our item loadings were largely similar to those found by developers. Subscale reliability was equivalent to or higher than that reported by developers. These instruments perform similarly in the Canadian context to their original development context, and can be used with confidence. Interpersonal and respectfulness scores are most discriminating of excellent, average or poor overall experience and are crucial dimensions of patient evaluations.

Interpersonal Communication from the Patient Perspective: Comparison of Primary Healthcare Evaluation Instruments

The operational definition of interpersonal communication is "the ability of the provider to elicit and understand patient concerns, to explain healthcare issues and to engage in shared decision-making if desired." To examine how well interpersonal communication is captured in validated instruments that evaluate primary healthcare from the patient's perspective. 645 adults with at least one healthcare contact in the previous 12 months responded to instruments that evaluate primary healthcare. Eight subscales measure interpersonal communication: the Primary Care Assessment Survey (PCAS, two subscales); the Components of Primary Care Index (CPCI, one subscale); the first version of the EUROPEP (EUROPEP-I); and the Interpersonal Processes of Care Survey, version II (IPC-II, four subscales). Scores were normalized for descriptive comparison. Exploratory and confirmatory (structural equation) factor analysis examined fit to operational definition, and item response theory analysis examined item performance. Items not pertaining to interpersonal communication were removed from the EUROPEP-I. Most subscales are skewed positively. Normalized mean scores are similar across subscales except for IPC-II Patient-Centred Decision-Making and IPC-II Hurried Communication. All subscales load reasonably well on a single factor, presumed to be interpersonal communication. The best model has three underlying factors corresponding to eliciting (eigenvalue = 26.56), explaining (eigenvalue = 2.45) and decision-making (eigenvalue = 1.34). Both the PCAS Communication and the EUROPEP-I Clinical Behaviour subscales capture all three dimensions. Individual subscales within IPC-II measure each sub-dimension. The operational definition is well reflected in the available measures, although shared decision-making is poorly represented. These subscales can be used with confidence in the Canadian context to measure this crucial aspect of patient-centred care.

What Patients Tell Us about Primary Healthcare Evaluation Instruments: Response Formats, Bad Questions and Missing Pieces

Instruments have been developed that measure consumer evaluations of primary healthcare using different approaches, formats and questions to measure similar attributes. In 2004 we concurrently administered six validated instruments to adults and conducted discussion groups to explore how well the instruments allowed patients to express their healthcare experience and to get their feedback about questions and formats. We held 13 discussion groups (n=110 participants): nine in metropolitan, rural and remote areas of Quebec; four in metropolitan and rural Nova Scotia. Participants noted critical incidents in their healthcare experience over the previous year, then responded to all six instruments under direct observation and finally participated in guided discussions for 30 to 40 minutes. The instruments were: the Primary Care Assessment Survey; the Primary Care Assessment Tool; the Components of Primary Care Index; the EUROPEP; the Interpersonal Processes of Care Survey; and part of the Veterans Affairs National Outpatient Customer Satisfaction Survey. Two team members analyzed discussion transcripts for content. While respondents appreciated consistency in response options, they preferred options that vary to fit the question. Likert response scales functioned best; agreement scales were least appreciated. Questions that average experience over various providers or over many events diluted the capacity to detect critical negative or positive incidents. Respondents tried to answer all questions but stressed that they were not able to report accurately on elements outside their direct experience or in the provider's world. They liked short questions and instruments, except where these compromise clarity or result in crowded formatting. All the instruments were limited in their capacity to report on the interface with other levels of care. Each instrument has strengths and weaknesses and could be marginally improved, but respondents accurately detected their intent and use. Their feedback offers insight for instrument development.

Differential Item Functioning in Primary Healthcare Evaluation Instruments by French/English Version, Educational Level and Urban/Rural Location

Evaluating the extent to which groups or subgroups of individuals differ with respect to primary healthcare experience depends on first ruling out the possibility of bias. To determine whether item or subscale performance differs systematically between French/English, high/low education subgroups and urban/rural residency. A sample of 645 adult users balanced by French/English language (in Quebec and Nova Scotia, respectively), high/low education and urban/rural residency responded to six validated instruments: the Primary Care Assessment Survey (PCAS); the Primary Care Assessment Tool - Short Form (PCAT-S); the Components of Primary Care Index (CPCI); the first version of the EUROPEP (EUROPEP-I); the Interpersonal Processes of Care Survey, version II (IPC-II); and part of the Veterans Affairs National Outpatient Customer Satisfaction Survey (VANOCSS). We normalized subscale scores to a 0-to-10 scale and tested for between-group differences using ANOVA tests. We used a parametric item response model to test for differences between subgroups in item discriminability and item difficulty. We re-examined group differences after removing items with differential item functioning. Experience of care was assessed more positively in the English-speaking (Nova Scotia) than in the French-speaking (Quebec) respondents. We found differential English/French item functioning in 48% of the 153 items: discriminability in 20% and differential difficulty in 28%. English items were more discriminating generally than the French. Removing problematic items did not change the differences in French/English assessments. Differential item functioning by high/low education status affected 27% of items, with items being generally more discriminating in high-education groups. Between-group comparisons were unchanged. In contrast, only 9% of items showed differential item functioning by geography, affecting principally the accessibility attribute. Removing problematic items reversed a previously non-significant finding, revealing poorer first-contact access in rural than in urban areas. Differential item functioning does not bias or invalidate French/English comparisons on subscales, but additional development is required to make French and English items equivalent. These instruments are relatively robust by educational status and geography, but results suggest potential differences in the underlying construct in low-education and rural respondents.

Measurement of Primary Healthcare Attributes from the Patient Perspective

This special issue of Healthcare Policy/Politiques de Sante presents a series of papers reporting on the concurrent validation of instruments that assess primary healthcare (PHC) delivery from the patient's perspective. The study was funded in 2004 by the Canadian Institutes of Health Research (CIHR) at the height of the Primary Health Care Transition Fund, an $8-million investment by Health Canada to catalyze a renewal of the PHC system in Canada. In planning the evaluation for initiatives, it became evident that program evaluators and researchers had little guidance for selecting among available instruments. For example, although various instruments purported to measure accessibility, it was not obvious that all measured the same underlying construct. Nor was it clear how to compare results collected with different instruments in different jurisdictions or at different times. This research program consists of three studies. The first is a consensus consultation of PHC experts across Canada to formulate operational definitions of attributes to be evaluated (Haggerty et al. 2007). Second, we mapped the operational definitions to validated instruments (available at www.programmeprecise.ca/en/publications). Third, we administered six instruments back-to-back in Nova Scotia and Quebec to adults with a regular source of care to examine and compare how well the instruments measure essential attributes of primary healthcare. We selected six instruments in the public domain that assess usual care rather than a single visit, that are generic (not limited to a specific patient group or dimension of care) and that had been most proposed or used in Canada: Primary Care Assessment Survey (PCAS) (Safran et al. 1998); Primary Care Assessment Tool – Short Form, adult (PCAT-S) (Shi et al. 2001); Components of Primary Care Index (CPCI) (Flocke 1997); First version of the European general practice evaluation instrument (EUROPEP-I) (Grol et al. 2000); Interpersonal Processes of Care – 18-item version (IPC-II) survey (Stewart et al. 2007); Veterans Affairs National Outpatient Customer Satisfaction Survey (VANOCSS) (Borowsky et al. 2002).