Dec 1, 2000 - worked more hours per week, if their GP had more years experience in ..... 7.6%. More working hours (1.03), Fewer GPs. (2.75). UK. 51%. 4.9%.
Patient satisfaction with availability of general practice: an international comparison 1 December 2000 Michel Wensing, Richard Grol This is a new paper based on the Europep study. We propose to include one co-author from each of the participating countries and see what the journal editors allow us to do. - Please provide your comments on this paper not later than 1 January 2001 and let me know who will be the co- author from your country. We will include all comments as good as possible and we planned to submit the paper in January 2001. - To be included I need a signed letter indicating that you accept to be co author for this paper, also before 1 January 2001. Without this letter you will not be included in the list of co authors. Proposed co authors: Per Hjortdahl Frede Olesen or Peter Vedstedt Joachim Szecsenyi or Anja Klingenberg Hilary Hearnshaw Luc Seuntjes or someone else Dominique Paulus Beat Künzi Janko Kersnik Juan Mendive Potential journals: -Int J Qual Assur -Health Policy -Health Services Research
Summary Objective - To identify characteristics of the general practitioner and general practice setting which are related to patient satisfaction with availability of general practice care. Methods - Written surveys were performed among patients visiting the general practitioner and among the general practitioners in nine European countries. Results - There was evidence that higher patient satisfaction was related to working more hours per week as a GP, particularly in Netherlands and Norway, and to fewer general practitioners or other care providers in the practice, particularly in Denmark, Germany, Netherlands, Norway and the United Kingdom. None of the relationships were consistently found in all countries. Conclusions - Patients prefer a general practitioner who works many hours per week in practices with few other GPs or other care providers. It is unclear how this preference can be combined with actual developments towards larger practices and GPs working fewer hours per week in many countries.
Introduction Personal continuity of care is highly valued by patients [Brampton 2000, Jung 1997, Grol 1999], but it requires that the care provider is available for patient care as much as possible. It has been suggested that the ideal of personal continuity should be replaced by that of a concept of continuity which focuses on adequate information transfer between care providers [Hjortdahl 92]. Many GPs prefer to combine their work in general practice with a family life or other activities. Personal continuity of care may also be threatened by the development towards large scale health care organisations in many countries, if patients are no longer related to one specific are provider [Christensen 98]. In this paper we explore how patients in different countries evaluate the availability of general practice care. Previous research has shown that patients are more satisfied with general practice if they have a personal GP and if they experience short waiting times [Baker 95, Hjortdahl 92, Linn 85]. Therefore we expected that patients are more satisfied with the availability of general practice care if their GP worked more hours per week, if their GP had more years experience in general practice and if their GP worked in a practice with few or no other GPs or care providers. We did not expect a relationship between patient satisfaction and GPs' age or sex, and the setting of the practice (village or city). We also hypothesized that the existence or non-existence of these relationships were not influenced by the national health care systems. We performed a study that explored a) which characteristics of the general practitioner and the general practice setting are related to patient satisfaction with availability of general practice care, b) whether the relationships are consistent across different countries in Europe. Methods This international study on patient satisfaction with general practice, Europep, was performed in 16 European countries in 1999 and it included about 24.000 responding patients. In each country a stratified sample of about 36 practices was sought; in Belgium separate studies were done in Flanders and Wallonnie. The sample of practices was stratified according to practice size and urbanization in each country to reflect the national situation as closely as possible. The patient population comprised individuals who had recently visited the general practitioner. We aimed at 1080 patients per country. The number of patients approached varied between 45 and 80 per practice, depending on the expected response rate. Patients were included if they were 18 years or older and able to understand the national language. For this paper we selected the nine countries that also provided data on GP characteristics and an unique GP identifier in the data on patients' evaluations of care. The GP handed out a written questionnaire to all eligible patients consecutively visiting their practice after a chosen starting point. The patient was asked to complete the questionnaire at home and send it in a prepaid envelope to the research unit; except in Israel, where questionnaires were collected in the practice. Where feasible, reminders were send at three weeks after handing the questionnaire. Short written questionnaires were mailed or given the each participating GP. The Europep instrument is a multidimensional instrument comprising 23 questions on evaluations of specific aspects of general practice care, using a five point answering scale with the extremes labelled as ‘poor’ and ‘excellent’ [Wensing 2000]. For this study we focused on patients’ evaluations of five aspects of the availability of the general practitioner: getting an appointment to suit you, getting through on the phone, being able to speak to the general practitioner on the telephone, waiting time in the waiting room, and providing quick services for urgent health problems. Although these and other questions in the Europep can be seen as a consistent dimension, we thought it was more informative to focus on the individual aspects of care. We report in this paper on the percentage of patients using the two most positive answering categories (very good/excellent). The GP questionnaire comprised questions on Gps’ age (continuous variable, years), sex (male=1, female=2) and number of years working in the practice (continuous variable, years); the number of Gps (categories: 1, 2, 3-4, >=5) and the number of care providers in the practice organisation (categories: 2-4, 5-10, >10)(last two items not asked in Spain). Note that this information was collected independently from the patient survey. Finally, the researchers recorded the urbanisation level of the
area where the practice was located (village, less than 15000 inhabitants=1, city/town, more than 15000 inhabitants=2). We used a multilevel logistic regression analysis to explore relationships between GP characteristics and patients' evaluations of care. We performed separate analyses for each country and for each aspect of care evaluated by patients. The regression model included patients' age and sex as potential predictors of the variation of scores between patients and the six GP characteristics mentioned above as potential predictors of the random variation of scores related to GPs. Non-significant predictors at GP level (p>0.05) were removed to determine the final model. We report the percentages of variation explained at the patient level and at the GP level, which can be added to calculate the total amount of variation explained by the model. We also report the conditional oddsratio’s related to significant predictors at the GP level in the final logistic regression model. Results The nine countries that could be included in this study provided 15996 patients (table 1). The response rates varied between 47% and 89%; they were above 70% except in Walonia (47%) and Switzerland (69%). The mean age of patients was about 50 years and about two thirds of the patients were women. In sum 481 GPs participated in this study (table 2). Their mean age was somewhere in the fourties, except in Denmark and Germany where the mean age was 51 and 50 years, respectively. The majority were men, except in Slovenia where most GPs were women. GPs in Flanders work most hours per week. In the United Kingdom en Spain GPs typically work with several other GPs in a practice. In Slovenia and Spain GPs work in health care organisations with many other care providers. In all countries a majority of patients had very positive evaluations of the accessibility of general practice (tables 3-7). There was however significant variation in the percentage of patients who rated aspects of care as 'very good/excellent' across different countries, different patients and different GPs. Patient satisfaction with getting an appointment was highest in Germany (94% positive) and lowest in the United Kingdom (62%) (table 3). Patients in Denmark, Germany, Norway and United Kingdom were more satisfied if fewer GPs worked in the practice. Patients in the Netherlands and Norway had more positive evaluations if the GP worked more hours per week. Patients in Denmark were more satisfied if the number of care providers in the practice was lower. In Slovenia the number of care provider was related to patient satisfaction, but the direction was unclear. Patients in Germany were more satisfied if the practice was in a city, but patients in the UK were more satisfied if the practice was in a village. Finally, patients in Denmark were more satisfied if their GP was a men. Patient satisfaction with getting through the practice on the phone was again highest in Germany (95% positive) and lowest in Denmark (53%) and Norway (56%) (table 4). Patients in Denmark and the Netherlands were more positive about this aspect of care if the number of GPs in the practice was smaller. In Denmark this effect was caused by a less favourable patient evaluation of practices with two GPs. Patient satisfaction in Denmark and UK was higher if fewer care providers worked in the practice, but in Switzerland patients were less satisfied in practices with more care providers. In the UK and Slovenia patients in villages were more satisfied about this aspect of care, but in Germany patients in cities were more satisfied. In the Netherlands and Norway patients had more positive evaluations if the GP worked more hours, but in Spain and United Kingdom patients were more satisfied if the GP worked less hours. In Spain patients with younger GPs and GPs who had more experience were more satisfied. Patients were least satisfied in UK and Norway with the ability to speak to the general practitioner on the phone (51 and 54% of the patients had most positive evaluations) (table 5). In Germany, Netherlands, Norway and Switzerland a lower number of GPs in the practice was related to higher patient satisfaction, but in Denmark this effect was reversed. In the Netherlands and Norway patients were more satisfied if the GPs worked more hours per week, but in Spain this relationship was reversed. A lower number of care providers in the practice was strongly related to lower patient satisfaction in Denmark and the UK.
In all countries waiting times in the waiting room were less favourably evaluated compared to other aspects of care (table 6). Patients in Denmark and Germany were more satisfied if fewer GPs worked in the practice. In Denmark and Flanders patients in cities were more positive about this aspect of care. In Flanders and Spain patients were less satisfied if the GP worked fewer hours per week. In the UK patients with younger GPs were more satisfied, but in Slovenia patients with older GPs were most satisfied. In the UK fewer care providers in the practice was related to higher patient satisfaction, but in Slovenia more care providers was related to higher patient satisfaction with waiting times. Finally, patients in Flanders were more satisfied with waiting times if the GP was a men. Patients had very positive evaluations of the GPs' provision of services for urgent health problems (table 7). In Denmark patient satisfaction was higher if the number of GPs in the practice was larger, but in Norway this relationship was reversed. In the Netherlands patients had more positive evaluations if the GP worked more hours per week and if the practice was in a village. In Norway patients were satisfied if the GP was older. In the United Kingdom patients were more satisfied if the number of care providers in the practice was lower. Finally, in Spain patients were more positive if the GP was a women. Discussion Patients' evaluations of the availability of general practice care were very positive, but there was nevertheless some variation across patients, GPs and countries. We found partial confirmation of our expectation that higher patient satisfaction with availability is related to working more hours per week as a GP, and to fewer GPs and other care providers in the practice. There was little evidence to support our expectation that more years of experience as a GP is related to higher patient satisfaction. There were some relationships with GPs' age, sex or geographic location of the practice (village/city), but there was no clear pattern. The proportion of variation explained by the factors was small and there were also contradictory relationships. None of the relationships were consistently found in all countries, and in Belgium patient satisfaction was not related to any of the GP factors. This study used a previously validated patient satisfaction instrument and large, reasonably representative samples of patients and doctors. We did not have data on GP characteristics for all 16 countries that participated in the Europep study, which has led to an overrepresentation of countries with a stronger tradition of research in general practice. The high patient satisfaction ratings may have caused a ceiling effect, so that it was difficult to identify differences between groups anyway. So the results of this study need further exploration. The findings of this study in general practice are similar to study in a hospital settubgm which showed that patient satisfaction is higher in smaller health care organizations [Young 2000]. The authors claimed that patients perceive larger hospitals as impersonal and intimidating. An alternative interpretation would be that larger health care organizations attract a specific type of patients (patients who complain more than avarage) and care providers (care providers who deliver poor quality of care, at least from patients' perspectives). Further research shoud reveal which factors determine patients' negative evaluations of larger health care organizations. This study shows that results on determinants of patient satisfaction cannot easily be generalized across countries. There is considerable variation in the organisation of general practice care within each of the countries, so a detailed analysis of the determinants of patient satisfaction within a specific country should complement an international comparison of patient satisfaction with care [Grol 2000]. The positive relationship of patient satisfaction with the number of working hours was found in the Netherlands and Norway, while it was also visible but reversed in Spain. Do GPs in the Netherlands and Norway work too few hours, as far as patients are concerned, and GPs in Spain too many hours? The figures in table 2 show actually the opposite situation. The relationships with number of GPs or care providers were clearest in Denmark, Germany, the Netherlands, Norway and the United Kingdom. None of the countries had an exceptionally high or low mean scores for number of hours per week worked or number of GPs or care providers in the practice (table 2). This study suggests that from a patients' perspective GPs should spend many hours per week on patient care in practices with few other GPs or care providers. Note that this paper did not focus on
patient satisfaction with medical care or communication, which was very high in all countries and showed little variation. This study raises the question whether patients' preferences can be combined with the development towards larger practices and GPs working fewer hours per week in many European countries. A better collaboration between GPs provides better opportunities for professional development, quality development and organizational flexibility, which may ultimately overcome the disadvanges of larger practices and fewer working hours per week. Maybe GPs should organise themselves in networks of small practices rather than large clinics with many health care professionals. References 1. Brampton S. Commentary: A patients' perspective of continuity. BMJ 2000;321:735-736. 2. Jung HP, Wensing M, Grol R. What makes a good general practitioner: do patients and doctors have different views? British Journal of General Practice 1997;47:805-809. 3. Grol R, Wensing M, Mainz J, Ferreira P, Hearnshaw H, Hjortdahl P, Olesen F, Ribacke M, Spenser T, Szécsényi. Patients' priorities with respect to general practice care: an international comparison. Family Practice 1999;16:4-11. 4. Christensen MB, Olesen F. Out of hours service in Denmark: evaluation five years after reform. BMJ 1998;316:1502-1505. 5. Baker R, Streatfield J. What type of general practice do patients prefer? Exploration of practice characteristics influencing patient satisfaction. Br J Gen Pract 1995;45:654-659. 6. Hjortdahl P, Laerum E. Continuity of care in general practice: effect on patient satisfaction. BMJ 1992;...:1287-1290. 7. Linn LS, Brook RH, Clark VA, Davies AR, Fink A, Kosecoff J. Physician and patient satisfaction as factors related to the organization of internal medicine group practices. Med Care 1985;10:1171-1178. 8. Grol R, Wensing M, Mainz J, Jung HP, Ferreira P, Hearnshaw H, Hjortdahl P, Olesen F, Reis S, Ribacke M, Szecsenyi J. Patients in Europe evaluate general practice care: an international comparison. Br J Gen Pract 2000;50:882-887. 9. Young GJ, Meterko M, Desai KR. Patient satisfaction with hospital care. Effects of demographic and institutional characteristics. Med Care 2000;38:325-334.
Table 1. Patient samples (n=15996)
Denmark Germany Netherlands Norway United Kingdom Belgium, Flanders Belgium, Walonia Switzerland Slovenia Spain
N patients responded 1307 2224 1772 1609 1943 2530 990 1497 1808 316
% response 83.7 77.2 87.5 89.0 73.0 81.1 47.1 69.3 83.7 72.1
Age (mean) 45.9 53.7 47.6 50.7 51.3 49.6 53.6 52.4 49.3 53.5
Sex (perc. female) 72.7 62.5 67.7 70.3 67.6 64.3 60.9 62.2 62.9 62.3
Table 2: GP samples (n=481)
Denmark Germany Netherlands Norway United Kingdom Belgium Flanders Belgium Walonien Switzerland Slovenia Spain
GP samp le size
Practi ces samp le size
Age (mea n)
Sex (perce ntage male)
Years in practic e (mean )
Hours per week (mean )
36 42 45 54 123 39 43 28 36 35
36 36 36 36 38 39 42 28 36 35
51 50 47 46 46 45 45 48 44 43
62% 65% 83% 66% 73% 89% 82% 91% 39% 60%
16 16 14 15 13 17 18 12 12 8
41 34 39 31 28 53 41 34 37
Nr. Gps in practi ce (mean ) 2.1 1.3 1.6 2.7 5.1 1.4 1.1 1.4 2.9 9.0
Nr. care provide rs in practic e (mean) 3.7 4.6 5.4 8.6 2.8 1.3 3.2 35.4 25.3
Urbani sation level (percen tage village/ town) 63% 59% 52% 58% 58% 91% 67% 43% 47% 88%
Table 3 Getting an appointment to suit you Characteristics GP
Variance at Variance at GP factors that are related to higher patient GP level patient satisfaction (odds ratio’s) level (%) (%)
Denmark
Patient satisfaction (%very good/excelle nt) 71%
6.6%
8.7%
Germany Netherlands Norway
94% 78% 77%
3.3% 6.5% 6.5%
6.1% 1.8% 12.3%
UK Belg Flanders Belg Walonia Switzerland Slovenia
62% 89% 84% 79% 85%
9.3% 3.9% 7.3% 15.9% 0.1%
4.0% 9.5%
Spain
81%
2.7%
-
Male GP (1.84), Fewer GPs (1.81), Fewer care providers (2.80) Fewer GPs (3.51), City (2.22) More working hours (1.02) More working hours (1.04), Fewer GPs (4.45) Fewer GPs (4.15), Village (1.71) Number of care providers, direction unclear (0.20) -
Legend: Predictors in the logistic regression models are: patient age and sex patient (effect sizes not reported), GP age (continuous variable, years), GP sex, GP years in practice (continuous variable, years), number of Gps in practice (1, 2, 3-4, >=5; >=5), number of care providers (1, 2-4, 5-10, >10, >10), area (city/town, village). Oddsratios refer to the comparison between the two ost extreme categories, except for the continuous variables where they refer to a change of one year. Categories have been reversed where necessary to be able to report on positive relationships in the tables (which explains that all oddsratios all higher than 1.00).
Table 4: Getting through to the practice on the phone Characteristics GP
Variance at Variance GP factors that are related to higher patient at GP level patient satisfaction (odds ratio’s) level (%) (%)
Denmark
Patient satisfaction (% very good/excellen t) 53%
2.6%
6.3%
Germany Netherlands
95% 72%
0.5% 4.1%
1.9% 6.3%
Norway UK
56% 57%
4.3% 3.5%
3.7% 7.4%
Belg Flanders Belg Walonia Switzerland Slovenia Spain
93% 87% 96% 92% 75%
7.2% 3.0% 5.3% 2.3% 0.9%
10.0% 5.4% 19.8%
Fewer GPs (1.60), Fewer care providers (4.72) City (1.79) More working hours (1.03), Fewer GPs (1.24) More working hours (1.05) Fewer working hours (1.03) Fewer care providers (7.32), Village (1.53) More care providers (7.14) Village (2.52) GP is younger (1.09), More years in practice (1.16), Fewer working hours (1.09)
Table 5: Being able to speak to the general practitioner on the telephone Characteristics GP
Variance at Variance patient level at GP (%) level (%)
GP factors that are related to higher patient satisfaction (odds ratio’s)
Denmark
Patient satisfaction (%very good/excellen t) 69%
4.5%
5.6%
Germany Netherlands
87% 72%
2.3% 3.1%
4.6% 5.4%
Norway
54%
5.8%
7.6%
UK Belg Flanders Belg Walonia Switzerland Slovenia Spain
51% 90% 86% 91% 93% 71%
4.9% 4.3% 2.8% 10.7% 1.9% 4.7%
4.8% 4.3% 19.4%
More GPs (1.59), Fewer care providers (6.72) Fewer GPs (3.48) More working hours (1.02), Fewer GPs (1.11) More working hours (1.03), Fewer GPs (2.75) Fewer care providers (6.91) Fewer GPs (1.71) Less working hours (1.19)
Table 6: Waiting time in the waiting room Characteristics GP
Variance at Variance patient level at GP (%) level (%)
GP factors that are related to higher patient satisfaction (odds ratio’s)
Denmark Germany Netherlands Norway UK
Patient satisfaction (%very good/excellen t) 59% 70% 61% 58% 50%
9.5% 5.6% 7.6% 12.2% 7.9%
8.5% 2.6% 6.2%
Belg Flanders
66%
11.0%
7.6%
Belg Walonia Switzerland Slovenia
54% 79% 60%
7.3% 7.0% 0.8%
10.1%
Spain
63%
5.9%
5.7%
Fewer GPs (2.19), City (2.27) Fewer GPs (2.00) GP is younger (1.04), Fewer care providers (5.59) GP is male (2.06), Fewer working hours (1.02),City (1.37) GP is older (1.09), More care providers (3.06) Fewer working hours (1.09)
Table 7: Providing quick services for urgent health problems Characteristics GP
Variance at Variance patient level at GP (%) level %)
GP factors that are related to higher patient satisfaction (odds ratio’s)
Denmark Germany Netherlands
Patient satisfaction (%very good/excellen t) 81% 95% 85%
4.0% 3.8% 4.5%
4.2% 8.5%
Norway UK Belg Flanders Belg Walonia Switzerland Slovenia Spain
83% 71% 93% 87% 98% 89% 87%
3.2% 6.2% 6.4% 7.3% 3.5% 1.7% 3.8%
12.2% 3.7% 6.3%
More GPs (1.25) More working hours (1.04), Village (1.87) GP is older (1.04), Fewer GPs (5.67) Fewer care providers (5.33) GP is female (3.03)
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