Managing primary care using patient satisfaction measures

Our study aimed to identify which attributes of a primary healthcare experience have the most impact on patient satisfaction as well as which aspects of each attribute are most significant in patients' response to the services they receive. The three attributes examined in this study were access, staff care, and physician care. Analyses of the aspects of each attribute controlled for age, gender, and race. Data used in this study were obtained through a survey questionnaire with random sampling, resulting in the sample size of 8,465. The psychometric properties of the questionnaire were also examined and showed appropriate reliability and validity. The multiple regression analysis showed that among the three attributes, physician care was most influential, closely followed by staff care, with access having much less influence. Further analyses revealed that specific aspects of each attribute were more influential on patient satisfaction. Within the physician care attribute, patients were found to be rational consumers who were looking for surrogate indicators of correct diagnosis and treatment options among the measures available to them. They were much less likely to be influenced by so-called bedside manner. Within the staff care attribute, willingness and compassionate behaviors of staff and prompt service were most important. Within the access attribute, patients sought caring interaction with appointment personnel. After considering the findings, we discuss possible actions for healthcare managers.     

Partnerships for improving dementia care in primary care: Extending access to primary care‐based memory clinics in Ontario,Canada

In Ontario, Canada, the Primary Care Collaborative Memory Clinic (PCCMC) model of dementia care provides a team‐based assessment and management service that has demonstrated increased capacity for dementia care at the primary care level. PCCMCs are established following completion of a multi‐faceted memory clinic training programme. Evidence of the success of this care model has been demonstrated primarily in practice settings with integrated interprofessional healthcare providers (HCPs). Desire to implement PCCMCs in less‐resourced family practice settings without integrated interprofessional HCPs has resulted in partnerships with community agencies and services to create the multifaceted teams needed for this care model. The purpose of this study was to describe the key lessons learned in the development and implementation of 18 PCCMCs in primary care practice models without integrated interprofessional HCPs. Mixed methods included tracking of clinic referrals, pre‐ (N = 122) and post‐ (N = 71) training surveys to assess practice changes and factors facilitating and challenging clinic implementation. Interviews were conducted with 40 team members to identify key lessons learned. Key enablers were access to training, organisational/ management and care provider support, availability of infrastructure supports and clinic coordination. Data were collected between January 2012 and January 2017. PCCMCs were challenged by a lack of sustainable funding, inadequate infrastructure support, competing priorities, maintaining adequate communication among team members, and coordinating multiple schedules. Suggestions to support longer term sustainability were identified, many addressing identified challenges such as securing sustainable funding, and ensuring partners understand the importance of their role and succession planning. This study demonstrated that by establishing community partnerships and leveraging existing community resources, the PCCMC model is generalisable to multiple family practice settings including those without integrated interprofessional staff. Lessons learned can inform the development of interventions for complex chronic conditions requiring interprofessional support in primary care.     

Primary care satellite clinics and improved access to general and mental health services

OBJECTIVES: To evaluate the relationship between the implementation of community-based primary care clinics and improved access to general health care and/or mental health care, in both the general population and among people with disabling mental illness. STUDY SETTING: The 69 new community-based primary care clinics in underserved areas, established by the Department of Veterans Affairs (VA) between the last quarter of FY 1995 and the second quarter of FY 1998, including the 21 new clinics with a specialty mental health care component. DATA SOURCES: VA inpatient and outpatient workload files, 1990 U.S. Census data, and VA Compensation and Pension files were used to determine the proportion of all veterans, and the proportion of disabled veterans, living in each U.S. county who used VA general health care services and VA mental health services before and after these clinics began operation. DESIGN: Analysis of covariance was used to compare changes, from late FY 1995 through early FY 1998, in access to VA services in counties in which new primary care clinics were located, in counties in which clinics that included specialized mental health components were located, and for comparison, in other U.S. counties, adjusting for potentially confounding factors. KEY FINDINGS: Counties in which new clinics were located showed a significant increase from the FY 1995-FY 1998 study dates in the proportion of veterans who used general VA health care services. This increase was almost twice as large as that observed in comparison counties (4.2% vs. 2.5%: F = 12.6, df = 1,3118, p = .0004). However, the introduction of these clinics was not associated with a greater use of specialty VA mental health services in the general veteran population, or of either general health care services or mental health services among veterans who received VA compensation for psychiatric disorders. In contrast, in counties with new clinics that included a mental health component the proportion of veterans who used VA mental health services increased to almost three times the proportion in comparison counties (0.87% vs. 0.31%: F = 8.3, df = 1,3091, p = .004). CONCLUSIONS: Community-based primary care clinics can improve access to general health care services, but a specialty mental health care component appears to be needed to improve access to mental health services.     

Bringing care to the community: expanding access to health care in rural Malawi through mobile health clinics

Setting: Malawi has chronic shortages of health workers, high burdens of human immunodeficiency virus (HIV) infection and malaria and a predominately rural population. Mobile health clinics (MHCs) could provide primary health care for adults and children in hard-to-reach areas.Objectives: To determine the feasibility, volume, and types of services provided by three MHCs from 2011 to 2013 in Mulanje District, Malawi.Design: Cross-sectional retrospective study.Results: The MHCs conducted 309 492 visits for primary health care, and in 2013 services operated on 99% of planned days. Despite an improvement in service provision, overall patient visits declined over the study period. Malaria and respiratory and gastro-intestinal conditions constituted 60% of visits. Females (n = 11 543) significantly outnumbered males (n = 2481) tested for HIV, yet males tested HIV-positive (27%) more often than females (14%). Malaria accounted for 26 421 (35%) visits for children aged <5 years, with a significant increase in the rainy season. Implementation of rapid diagnostic testing was associated with a decline in numbers treated for malaria. Antibiotic stockouts at government clinics were associated with increased MHC visits.Conclusion: MHCs can routinely provide primary health care for adults and children living in rural Malawi and complement fixed clinics. Moving from a complementary role to integration within the government health system remains a challenge.     

Hospitalization rates as indicators of access to primary care

Variations in hospitalization rates for selected conditions are being used as indicators of the effectiveness of primary care in small areas. Are these rates actually sensitive to problems in local primary care systems? This study examines the relationship between ambulatory care sensitive condition (ACSC) hospital admission rates and primary care resources and the economic conditions in primary care market areas in North Carolina in 1994. The data show a high degree of correlation between the rates and income but not primary care resources. The distribution of rates did agree with expert assessments of the location of places with poor access to health services. The data confirm that access to effective primary care reflected in lower rates of ACSC admissions is a function of more than the professional resources available in a market area. The solution to reducing disparities in health status may not lie within the health system.     

Physical access to primary health care in Andean Bolivia

Limited physical access to primary health care is a major factor contributing to the poor health of populations in developing countries, particularly in mountain areas with rugged topography, harsh climates and extensive socioeconomic barriers. Assessing physical access to primary health care is an important exercise for health care planners and policy makers. The development of geographic information system (GIS) technology has greatly improved this assessment process in industrialized countries where digital cartographic data are widely available. In developing countries particularly in mountain areas, however, detailed cartographic data, even in hardcopy form, are nonexistent, inaccurate or severely lacking. This paper uses GIS technology to assess physical access to primary health care in a remote and impoverished region of Andean Bolivia. In addition, it proposes an alternative model of health personnel distribution to maximize physical accessibility. Methods involved extensive fieldwork in the region, utilizing GPS (global positioning system) technology in the development of the GIS and gathering other pertinent health data for the study. Satellite imagery also contributed to the development of the GIS and in the modeling process. The results indicate significant variation in physical access to primary health care across the three study sites. More importantly, this paper highlights the use of GIS technology as a powerful tool in improving physical accessibility in mountain areas of developing countries.     

Spatial analysis of elderly access to primary care services

Background  

Admissions for Ambulatory Care Sensitive Conditions (ACSCs) are considered preventable admissions, because they are unlikely to occur when good preventive health care is received. Thus, high rates of admissions for ACSCs among the elderly (persons aged 65 or above who qualify for Medicare health insurance) are signals of poor preventive care utilization. The relevant geographic market to use in studying these admission rates is the primary care physician market. Our conceptual model assumes that local market conditions serving as interventions along the pathways to preventive care services utilization can impact ACSC admission rates.     

State Medicaid fees and access to primary care physicians

Medicaid and uninsured patients are disadvantaged in access to care and are disproportionately Black and Hispanic. Using a national audit of primary care physicians, we examine the relationship between state Medicaid fees for primary care services and access for Medicaid, Medicare, uninsured, and privately insured patients who differ by race/ethnicity and sex. We found that states with higher Medicaid fees had higher probabilities of appointment offers and shorter wait times for Medicaid patients, and lower probabilities of appointment offers and longer wait times for uninsured patients. Appointment offers and wait times for Medicare and privately insured patients were unaffected by Medicaid fees. At mean state Medicaid fees, our analysis predicts a 27‐percentage‐point disadvantage for Medicaid versus Medicare in appointment offers. This decreases to 6 percentage points when Medicaid and Medicare fees are equal, suggesting that permanent fee parity with Medicare could eliminate most of the disparity in appointment offers for Medicaid patients. The predicted decrease in the disparity is smaller for Black and Hispanic patients than for White patients. Our research highlights the importance of considering the effects of policy on nontarget patient groups, and the consequences of seemingly race‐neutral policies on racial/ethnic and sex‐based disparities.     

The impact of e-visits on patient access to primary care

To improve patient access to primary care, many healthcare organizations have introduced electronic visits (e-visits) to provide patient-physician communication through secure messages. However, it remains unclear how e-visit affects physicians’ operations on a daily basis and whether it would increase physicians’ panel size. In this study, we consider a primary care physician who has a steady patient panel and manages patients’ office and e-visits, as well as other indirect care tasks. We use queueing-based performance outcomes to evaluate the performance of care delivery. The results suggest that improved operational efficiency is achieved only when the service time of e-visits is smaller enough to compensate the effectiveness loss due to online communications. A simple approximation formula of the relationship between e-visit service time and e-visit to office visit referral ratio is provided serving as a guideline for evaluating the performance of e-visit implementation. Furthermore, based on the analysis of the impact of e-visits on physician’s capacity, we conclude that it is not the more e-visits the better, and the condition for maximal panel size is investigated. Finally, the expected outcomes of implementing e-visits at Dean East Clinic are discussed.     

Understanding referral from primary care clinics in rural Kenya: using health information systems to prioritize health services

This study analyses the referral patterns of patients, over time, from primary care to secondary or tertiary level facilities in rural Africa. The data come from a health information system of a non-governmental organization with a decade of experience in health services delivery in Samburu District, Kenya. The differential referral patterns from two communities are examined in some detail to shed more light on the meaning of a 'referral rate' in this context. First, referral rates over time for two clinics are calculated and compared. These quantitative data, obtained from monthly reports from 1989 to 1997, are interpreted in the light of qualitative data obtained from interviews with community health workers, nurses and members of the communities. The main differences in referral between these ostensibly similar communities are for malaria, trauma and anaemia. Social, environmental and specific health services factors are used to explain these differences. We demonstrate that basic information from health information systems, which tell us little on their own because referral in this context is a rare event, can be combined with local knowledge from the community to provide evidence for health managers to set priorities for public health and clinical interventions.     

Retail health clinics drive innovation into primary care practices

A myriad of patient dissatisfaction issues stemming from antiquated approaches to primary care access are resulting in the establishment of retail health clinics (RHCs) throughout the country. RHCs are usually located within retail stores or stand-alone pharmacies and are staffed by nurse practitioners (NPs). They offer treatment for colds, coughs, skin rashes, and ear infections along with offering preventive care and physicals. As disruptive innovations, or innovations that offer services to ignored markets, these clinics are siphoning patient care visits away from primary care physicians because of their attention to quick access, affordable prices, and consumer-friendly approaches. In response, family and internal medicine physicians must follow three strategies to secure their patient population as well as attract new patients: build relationships with RHCs through referral networks and NP supervisory agreements, transform the provision of patient access through the development of physician-owned RHCs, and support the concept of the advanced medical home.     

Factors affecting productive efficiency in primary care clinics.

This study examines factors affecting the productive efficiency of primary care clinics. The empirical analysis uses a single-stage stochastic frontier regression model, in which factors affecting productive efficiency are specified as part of the inefficiency error component and estimated simultaneously with the production function. The study population includes primary care clinics in the US Military Health System from 1999 through 2003; the analytical data set is an unbalanced panel of 442 observations. The study's main results were that primary care clinics not associated with medical centres had significantly higher levels of productive efficiency than those associated with medical centres and that having proportionately more civilian staff (and thus less turnover) had a positive impact on productive efficiency. Due to their nature, these findings would be expected to also be applicable to the production of primary care in other settings. A key implication of the results is that improvements in productive efficiency should be a top priority, given the possibility for providing more primary care visits without increases in cost.