The primary care workforce in Europe: a cross-sectional international comparison of rural and urban areas and changes between 1993 and 2011.

Rural areas have problems in attracting and retaining primary care workforce. This might have consequences for the existing workforce. We studied whether general practitioners (GPs) in rural practices differ by age, sex, practice population and workload from those in less rural locations and whether their practices differ in resources and service profiles. We used data from 2 studies: QUALICOPC study collected data from 34 countries, including 7183 GPs in 2011, and Profiles of General Practice in Europe study collected data from 32 countries among 7895 GPs in 1993. Data were analyzed using multilevel analysis. Results show that the share of female GPs has increased in rural areas but is still lower than in urban areas. In rural areas, GPs work more hours and provide more medical procedures to their patients. Apart from these differences between locations, overall ageing of the GP population is evident. Higher workload in rural areas may be related to increased demand for care. Rural practices seem to cope by offering a broad range of services, such as medical procedures. Dedicated human resource policies for rural areas are required with a view to an ageing GP population, to the individual preferences and needs of the GPs, and to decreasing attractiveness of rural areas.

Communication between general practitioners and medical specialists in the referral process: a cross-sectional survey in 34 countries.

BACKGROUND: The communication of relevant patient information between general practitioners (GPs) and medical specialists is important in order to avoid fragmentation of care thus achieving a higher quality of care and ensuring physicians' and patients' satisfaction. However, this communication is often not carried out properly. The objective of this study is to assess whether communication between GPs and medical specialists in the referral process is associated with the organisation of primary care within a country, the characteristics of the GPs, and the characteristics of the primary care practices themselves. METHODS: An analysis of a cross-sectional survey among GPs in 34 countries was conducted. The odds ratios of the features that were expected to relate to higher rates of referral letters sent and communications fed back to GPs were calculated using ordered logistic multilevel models. RESULTS: A total of 7183 GPs from 34 countries were surveyed. Variations between countries in referral letters sent and feedback communication received did occur. Little of the variance between countries could be explained. GPs stated that they send more referral letters, and receive more feedback communications from medical specialists, in countries where they act as gatekeepers, and when, in general, they interact more with specialists. GPs reported higher use of referral letters when they had a secretary and/or a nurse in their practice, used health information technologies, and had greater job satisfaction. CONCLUSIONS: There are large differences in communication between GPs and medical specialists. These differences can partly be explained by characteristics of the country, the GP and the primary care practice. Further studies should also take the organisation of secondary care into account.

Patients' perception of communication at the interface between primary and secondary care: a cross-sectional survey in 34 countries.

BACKGROUND: Poor communication between general practitioners (GPs) and medical specialists can lead to poorer quality, and continuity, of care. Our study aims to assess patients' perceptions of communication at the interface between primary and secondary care in 34 countries. It will analyse, too, whether this communication is associated with the organisation of primary care within a country, and with the characteristics of GPs and their patients. METHODS: We conducted a cross-sectional survey among patients in 34 countries. Following a GP consultation, patients were asked two questions. Did they take to understand that their GP had informed medical specialists about their illness upon referral? And, secondly, did their GP know the results of the treatment by a medical specialist? We used multi-response logistic multilevel models to investigate the association of factors related to primary care, the GP, and the patient, with the patients' perceptions of communication at the interface between primary and secondary care. RESULTS: In total, 61,931 patients completed the questionnaire. We found large differences between countries, in both the patients' perceptions of information shared by GPs with medical specialists, and the patients' perceptions of the GPs' awareness of the results of treatment by medical specialists. Patients whose GPs stated that they 'seldom or never' send referral letters, also less frequently perceived that their GP communicated with their medical specialists about their illness. Patients with GPs indicating they 'seldom or never' receive feedback from medical specialists, indicated less frequently that their GP would know the results of treatment by a medical specialist. Moreover, patients with a personal doctor perceived higher rates of communication in both directions at the interface between primary and secondary care. CONCLUSION: Generally, patients perceive there to be high rates of communication at the interface between primary and secondary care, but there are large differences between countries. Policies aimed at stimulating personal doctor arrangements could, potentially, enhance the continuity of care between primary and secondary care.

Development and validation of measurement tools for user experience evaluation surveys in the public primary healthcare facilities in Greece: a mixed methods study.

BACKGROUND: The public primary healthcare system in Greece has not been fully developed and is delivered by urban and rural health centers, outpatient departments in public hospitals and the recently established first-contact and decentralized local primary care units. The aim of this study was to develop a valid and reliable measurement tool for conducting periodic user experience evaluation surveys in public Primary HealthCare facilities in Greece such as outpatient clinics of public hospitals and health centers. METHODS: A mixed methods approach was applied. In particular, the methodology of developing and validating the tools included three steps: (a) establishment of the theoretical background/literature review, (b) qualitative study: development of the tools items and establishment of the face validity and (c) quantitative study: pilot testing and establishment of the structural validity and estimation of the internal consistency of the tools. Two patient focus groups participated in qualitative study: one visiting health centres and the other visiting the outpatient clinics of public hospitals. Quantitative study included 733 Primary Health Care services' users/patients and was conducted during August-October 2017. Exploratory and confirmatory factor analysis was performed to check for structural validity of the tools, while Cronbach's alpha coefficients were estimated to check for reliability. RESULTS: Confirmatory factor analysis confirmed almost perfectly the presumed theoretical model and the following six factors were identified through the tools: (a) accessibility (three items, e.g. opening hours), (b) continuity and coordination of care (three items, e.g. doctor asks for medical history), (c) comprehensiveness of care (three items, e.g. doctor provides advices for healthy life), (d) quality of medical care (four items, e.g. sufficient examination time), (e) facility (four items, e.g. comfortable waiting room) and (f) quality of care provided by nurses and other health professionals (four items, e.g. polite nurses). CONCLUSIONS: We have developed reliable and valid tools to measure users' experiences in public Primary HealthCare facilities in Greece. These tools could be very useful in examining differences between different types of public Primary Health Care facilities and different populations.

Informing primary care reform in Greece: patient expectations and experiences (the QUALICOPC study).

BACKGROUND: Primary health care is the cornerstone of a high quality health care system. Greece has been actively attempting to reform health care services in order to improve heath outcomes and reduce health care spending. Patient-centered approaches to health care delivery have been increasingly acknowledged for their value informing quality improvement activities. This paper reports the quality of primary health care services in Greece as perceived by patients and aspects of health care delivery that are valued by patients. METHODS: This study was conducted as part of the Quality and Costs of Primary Care in Europe (QUALICOPC) study. A cross-sectional sample of patients were recruited from general practitioner's offices in Greece and surveyed. Patients rated five features of person-focused primary care: accessibility; continuity and coordination; comprehensiveness; patient activation; and doctor-patient communication. One tenth of the patients ranked the importance of each feature on a scale of one to four, and nine tenths of patients scored their experiences of care received. Comparisons were made between patients with and without chronic disease. RESULTS: The sample included 220 general practitioners from both public and private sector. A total of 1964 patients that completed the experience questionnaire and 219 patients that completed the patient values questionnaire were analyzed. Patients overall report a positive experiences with the general practice they visited. Several gaps were identified in particular in terms of wait times for appointments, general practitioner access to patient medical history, delivery of preventative services, patient involvement in decision-making. Patients with chronic disease report better experience than respondents without a chronic condition, however these patient groups report the same values in terms of qualities of the primary care system that are important to them. CONCLUSIONS: Data gathered may be used to improve the quality of primary health care services in Greece through an increased focus on patient-centered approaches. Our study has identified several gaps as well as factors within the primary care health system that patient's perceive as most important which can be used to prioritize quality improvement activities, especially within the austerity period. Study findings may also have application to other countries with similar context and infrastructure.

Experiences of adult patients using primary care services in Poland - a cross-sectional study in QUALICOPC study framework.

BACKGROUND: Patients as real healthcare system users are important observers of primary care and are able to provide reliable information about the quality of care. The aim of this study was to explore the patients' experiences and their level of satisfaction with the process and outcomes of care provided by primary care physicians in Poland and to identify the characteristics of the patients, their physicians, and facilities associated with patient satisfaction. METHODS: The study is based on data from the Polish part of the Quality and Costs of Primary Care in Europe (QUALICOPC) cross-sectional, questionnaire-based study. In Poland, a nationally representative sample of 220 PC physicians and 1980 of their patients were recruited to take part in the study. As a study tool we used 3 out of 4 QUALICOPC questionnaires: "Patient Experience", "PC Physician" and "Fieldworker" questionnaires. RESULTS: The areas of the best quality perceived by Polish PC patients are: equity, accessibility of care and quality of service. Coordination and comprehensiveness of care are evaluated relatively worse. The patients' and their physicians' characteristics have a limited influence on patient satisfaction and experiences with Polish primary care. CONCLUSIONS: Primary health care in Poland is of good overall quality as perceived by the patients. Study participants were at most satisfied with accessibility and equity of care and less satisfied with coordination and comprehensiveness of care. Longer patient-doctor relationship and older age of patients were found as the most influential determinants of higher satisfaction. However, variables used in this study poorly explain the overall level of satisfaction. Further research is needed to identify the other determinants of patient satisfaction in the Polish population. Rural practices deserve additional attention due to highest proportions of both extremely satisfied and dissatisfied patients.

Quality of primary health care in Poland from the perspective of the physicians providing it.

BACKGROUND: Primary care (PC) allows patients to address most of their health needs and is essential for high quality healthcare systems. The aim of the study was to analyze the insight of nine core dimensions of Polish PC system: "Economic conditions", "Workforce", "Accessibility", "Comprehensiveness", "Continuity", "Coordination", "Quality of care", "Efficiency" and "Equity" and to identify the characteristics of the providing physicians that influence their perception of the quality of care. METHODS: A cross-sectional study was conducted as part of an international QUALICOPC project. In Poland a nationally representative sample of 220 PC physicians was selected from the database of Polish National Health Fund by a stratified random sampling procedure. The research tool was a standardized 64-item questionnaire. Each of the respondents' answers were assigned a numerical value ranging from-1 (extremely negative) to +1 (extremely positive). The quality indicators were calculated as an arithmetic mean of variables representing particular PC dimensions. RESULTS: The mean scores for the majority of the dimensions had negative values. Accessibility of care was perceived as the best dimension, while the economic conditions were evaluated most negatively. Only a small part of variation in quality evaluation could be explained by physicians' characteristics. CONCLUSIONS: The negative evaluation of primary care reflects the growing crisis in the health care system in Poland. There is an urgent need to apply complex recovery measures to improve the quality of primary care.

Two decades of change in European general practice service profiles: conditions associated with the developments in 28 countries between 1993 and 2012.

OBJECTIVE: Evidence regarding the benefits of strong primary care has influenced health policy and practice. This study focuses on changes in the breadth of services provided by general practitioners (GPs) in Europe between 1993 and 2012 and offers possible explanations for these changes. DESIGN: Data on the breadth of service profiles were used from two cross-sectional surveys in 28 countries: the 1993 European GP Task Profile study (6321 GPs) and the 2012 QUALICOPC study (6044 GPs). GPs' involvement in four areas of clinical activity (first contact care, treatment of diseases, medical procedures, and prevention) was established using ecometric analyses. The changes were measured by the relative increase in the breadth of service profiles. Associations between changes and national-level conditions were examined though regression analyses. Data on the national conditions were used from various other public databases including the World Databank and the PHAMEU (Primary Health care Activity Monitor) database. SETTING: A total of 28 European countries. SUBJECTS: GPs. MAIN OUTCOME MEASURE: Changes in the breadth of GP service profiles. RESULTS: A general trend of increased involvement of European GPs in treatment of diseases and decreased involvement in preventive activities was observed. Conditions at the national level were associated with changes in the involvement of GPs in first contact care, treatment of diseases and, to a limited extent, prevention. Especially in countries with stronger growth of health care expenditures between 1993 and 2012 the service profiles have expanded. In countries where family values are more dominant the breadth in service profiles decreased. A stronger professional status of GPs was positively associated with the change in first contact care. CONCLUSIONS: GPs in former communist countries and Turkey have increased their involvement in the provision of services. Developments in Western Europe were less evident. The developments in the service profiles could only to a very limited extent be explained by national conditions. A main driver of reform seems to be the changes in health care expenditure, which may indicate a notion of urgency because there may be a pressure to curb the rising expenditures. KEY POINTS: Broad GP service profiles are an indicator of strong primary care in a country. It is expected that developments in the breadth of GP service profiles are influenced by various national conditions related to the urgency to reform, politics, and means. Between 1993 and 2012 the involvement of GPs in European countries in treatment of diseases increased and their involvement preventive activities decreased. The national conditions were found to be associated with changes in GPs' involvement as first contact of care, treatment of diseases, and, to a limited extent, prevention. More specifically, in countries with a stronger growth in health care expenditures, service profiles of European GPs have expanded more in the past decades.

Assessing the potential for improvement of primary care in 34 countries: a cross-sectional survey.

OBJECTIVE: To investigate patients' perceptions of improvement potential in primary care in 34 countries. METHODS: We did a cross-sectional survey of 69 201 patients who had just visited general practitioners at primary-care facilities. Patients rated five features of person-focused primary care - accessibility/availability, continuity, comprehensiveness, patient involvement and doctor-patient communication. One tenth of the patients ranked the importance of each feature on a scale of one to four, and nine tenths of patients scored their experiences of care received. We calculated the potential for improvement by multiplying the proportion of negative patient experiences with the mean importance score in each country. Scores were divided into low, medium and high improvement potential. Pair-wise correlations were made between improvement scores and three dimensions of the structure of primary care - governance, economic conditions and workforce development. FINDINGS: In 26 countries, one or more features of primary care had medium or high improvement potentials. Comprehensiveness of care had medium to high improvement potential in 23 of 34 countries. In all countries, doctor-patient communication had low improvement potential. An overall stronger structure of primary care was correlated with a lower potential for improvement of continuity and comprehensiveness of care. In countries with stronger primary care governance patients perceived less potential to improve the continuity of care. Countries with better economic conditions for primary care had less potential for improvement of all features of person-focused care. CONCLUSION: In countries with a stronger primary care structure, patients perceived that primary care had less potential for improvement.

Comparison of patients' experiences in public and private primary care clinics in Malta.

Demographic changes, technological developments and rising expectations require the analysis of public-private primary care (PC) service provision to inform policy makers. We conducted a descriptive, cross-sectional study using the dataset of the Maltese arm of the QUALICOPC Project to compare the PC patients' experiences provided by public-funded and private (independent) general practitioners in Malta. Seven hundred patients from 70 clinics completed a self-administered questionnaire. Direct logistic regression showed that patients visiting the private sector experienced better continuity of care with more difficulty in accessing out-of-hours care. Such findings help to improve (primary) healthcare service provision and resource allocation.

Patient Reported Indicator Surveys (Paris): Methodological Considerations of a Field Trial in Slovenia.

Introduction: Healthcare systems collect little information about the experiences and outcomes of care from the perspectives of patients. Patient Reported Indicator Surveys (PaRIS) is an OECD initiative to measure the outcomes and experiences of people living with chronic conditions, who are managed in primary care. Objectives: To evaluate the feasibility of the methodology employed in the Field Trial of the PaRIS survey in Slovenia and propose adjustments to enhance sampling in the Main Survey. Methods: In 2022, we conducted a cross-sectional observational study in 50 family medicine practices in Slovenia with a target of recruiting 70 patients per practice. We used the Slovenian version of the PaRIS questionnaires, and evaluated sampling and data collection. Results: The sample contained 21 providers (42.0% response rate) and 454 patients (50.7% response rate). The provider sample did not differ from the population characteristics, while the patient sample differed significantly from the patient population. All providers completed the survey online, in 20.9±11.1 minutes and had 1.5±1.5 restarts. Most patients (74.9%) completed the survey online and needed 36.0±22.6 minutes, and the mean number of restarts was 1.4±2.2. Conclusion: Based on the results, we recommend conducting a methodology test for quality assessment studies before initiating the main survey. Legal issues should be addressed and considered early when developing the methodology. It is also necessary to be aware of the feasibility of the study in practice, to avoid a low participation rate.

Measures of quality, costs and equity in primary health care instruments developed to analyse and compare primary care in 35 countries.

BACKGROUND: The Quality and Costs of Primary Care in Europe (QUALICOPC) study aims to analyse and compare how primary health care systems in 35 countries perform in terms of quality, costs and equity. This article answers the question 'How can the organisation and delivery of primary health care and its outcomes be measured through surveys of general practitioners (GPs) and patients?' It will also deal with the process of pooling questions and the subsequent development and application of exclusion criteria to arrive at a set of appropriate questions for a broad international comparative study. METHODS: The development of the questionnaires consisted of four phases: a search for existing validated questionnaires, the classification and selection of relevant questions, shortening of the questionnaires in three consensus rounds and the pilot survey. Consensus was reached on the basis of exclusion criteria (e.g. the applicability for international comparison). Based on the pilot survey, comprehensibility increased and the number of questions was further restricted, as the questionnaires were too long. RESULTS: Four questionnaires were developed: one for GPs, one for patients about their experiences with their GP, another for patients about what they consider important, and a practice questionnaire. The GP questionnaire mainly focused on the structural aspects (e.g. economic conditions) and care processes (e.g. comprehensiveness of services of primary care). The patient experiences questionnaire focused on the care processes and outcomes (e.g. how do patients experience access to care?). The questionnaire about what patients consider important was complementary to the experiences questionnaire, as it enabled weighing the answers from the latter. Finally, the practice questionnaire included questions on practice characteristics. DISCUSSION: The QUALICOPC researchers have developed four questionnaires to characterise the organisation and delivery of primary health care and to compare and analyse the outcomes. Data collected with these instruments will allow us not only to show in detail the variation in process and outcomes of primary health care, but also to explain the differences from features of the (primary) health care system.

Case-mix adjustments for patient reported experience and outcome measures in primary care: an empirical approach to identify patient characteristics as case-mix adjusters based on a secondary analysis of an international survey among patients and their general practitioners in 34 countries.

BACKGROUND: Case-mix adjustment of patient reported experiences (PREMs) and outcomes (PROMs) of care are meant to enable fair comparison between units (e.g. care providers or countries) and to show where improvement is possible. It is important to distinguish between fair comparison and improvement potential, as case-mix adjustment may mask improvement potential. Case-mix adjustment takes into account the effect of patient characteristics that are related to the PREMs and PROMs studied, but are outside the sphere of influence of the units being compared. We developed an approach to assess which patient characteristics would qualify as case-mix adjusters, using data from an international primary care study. RESULTS: We used multilevel analysis, with patients nested in general practices nested in countries. Case-mix adjustment is indicated under the following conditions: there is a main effect of the potential case-mix adjuster on the PREM/PROM; this effect does not vary between units; and the distribution of the potential case-mix adjuster differs between units. Random slope models were used to assess whether the impact of a potential case-mix adjuster varied between units. To assess whether a slope variance is big enough to decide that case-mix adjustment is not indicated, we compared the variances in the categories of a potential case-mix adjuster. Significance of the slope variance is not enough, because small variances may be significantly different from zero when numbers are large. We therefore need an additional criterion to consider a slope variance as important. Borrowing from the idea of a minimum clinically important difference (MCID) we proposed a difference between the variances of 0.25*variance (equivalent to a medium effect size). We applied this approach to data from the QUALICOPC (Quality and costs of primary care in Europe) study. CONCLUSIONS: Our approach provides guidance to decide whether or not patient characteristics should be considered as case-mix adjusters. The criterion of a difference between variances of 0.25*variance works well for continuous PREMs and PROMs, but seems to be too strict for binary PREMs and PROMs. Without additional information, it is not possible to decide whether important slope variation is the result of either differences in performance between general practices or countries, or cultural differences.

Task shifting from general practitioners to practice assistants and nurses in primary care: a cross-sectional survey in 34 countries.

AIM: To describe variation in task shifting from GPs to practice assistants/nurses in 34 countries and to explain differences by analysing associations with characteristics of the GPs and their practices and features of the health care systems. BACKGROUND: Redistribution of tasks and responsibilities in primary care are driven by changes in demand, such as the growing number of patients with chronic conditions, and workforce developments, including staff shortage. The need to manage an expanding range of services has led to adaptations in the skill-mix of primary care teams. These developments are hampered by barriers between professional domains. METHODS: Data were collected between 2011 and 2013 through a cross-sectional survey among approximately 7,200 general practitioners (GPs) in 34 countries. Task shifting is measured through a composite score of GPs' self-reported shifting of tasks. Independent variables at GP and practice level are as follows: innovativeness; part-time working; availability of staff; location and population of the practice. Country-level independent variables are as follows: demand for and supply of care, nurse prescribing, and professionalisation of practice assistants/nurses. Multilevel analysis is used to account for clustering of GPs in countries. FINDINGS: Countries vary in the degree of task shifting. Regarding GP and practice characteristics, use of electronic health records and availability of support staff in the practice are positively associated with task shifting and GPs' working hours negatively, in line with our hypotheses. Age of the GPs is, contrary to our hypothesis, positively related to task shifting. These variables explain 11% of the variance at GP level. Two country variables are related to task shifting: a lower percentage of practices without support staff in a country and nurse prescribing rights coincide with more task shifting. The percentage of practices without support staff has the strongest relationship, explaining 73% of the country variation.

Assessing the outcomes and experiences of care from the perspective of people living with chronic conditions, to support countries in developing people-centred policies and practices: study protocol of the International Survey of People Living with Chronic Conditions (PaRIS survey).

INTRODUCTION: In view of growing populations with chronic conditions, many countries are redesigning their health systems. However, little information is available about how health systems perform from the perspective of people living with chronic conditions. The Organisation for Economic Co-operation and Development (OECD) Member States therefore mandated the OECD to initiate the International Survey of People Living with Chronic Conditions (PaRIS survey), which aims to provide insight in outcomes and experiences of care as reported by people living with chronic conditions. The PaRIS-SUR consortium has been tasked by the OECD to support the development and implementation of the survey. METHODS AND ANALYSIS: As primary care services play a pivotal role in the management of chronic conditions, the PaRIS survey will be implemented in the primary care setting. Data will be collected with a survey among users of primary care services aged 45 years or older, of whom many have chronic conditions. An additional survey is conducted among their primary care providers. The nested study design will allow analysis of the patient-reported data in relation to characteristics of and care provided by primary care providers within and across countries. In 2022, the survey will be tested in a Field Trial in participating countries. Data for cross-country comparison will be collected by the Main Survey in 2023. ETHICS AND DISSEMINATION: Informed consent will be obtained from primary care providers and service users. National Project Managers search ethical approval of the survey in their country, if required. Reporting by the OECD will focus on questions for international comparison. A secured information technology platform will be developed for participants and stakeholders in countries to receive feedback and answer their own questions. Findings will also be disseminated through an international OECD flagship report, conferences, scientific papers and policy briefs, to inform strategies to improve care for people living with chronic conditions throughout the world.

A snapshot of the organization and provision of primary care in Turkey.

BACKGROUND: This WHO study aimed to support Turkey in its efforts to strengthen the primary care (PC) system by implementing the WHO Primary Care Evaluation Tool (PCET). This article provides an overview of the organization and provision of primary care in Turkey. METHODS: The WHO Primary Care Evaluation Tool was implemented in two provinces (Bolu and Eskisehir) in Turkey in 2007/08. The Tool consists of three parts: a national questionnaire concerning the organisation and financing of primary care; a questionnaire for family doctors; and a questionnaire for patients who visit a family health centre. RESULTS: Primary care has just recently become an official health policy priority with the introduction of a family medicine scheme. Although the supply of family doctors (FDs) has improved, they are geographically uneven distributed, and nationwide shortages of primary care staff remain. Coordination of care could be improved and quality control mechanisms were lacking. However, patients were very satisfied with the treatment by FDs. CONCLUSIONS: The study provides an overview of the current state of PC in Turkey for two provinces with newly introduced family medicine, by using a structured approach to evaluate the essential functions of PC, including governance, financing, resource generation, as well as the characteristics of a "good" service delivery system (as being accessible, comprehensive, coordinated and continuous).

Home care in Europe: a systematic literature review.

BACKGROUND: Health and social services provided at home are becoming increasingly important. Hence, there is a need for information on home care in Europe. The objective of this literature review was to respond to this need by systematically describing what has been reported on home care in Europe in the scientific literature over the past decade. METHODS: A systematic literature search was performed for papers on home care published in English, using the following data bases: Cinahl, the Cochrane Library, Embase, Medline, PsycINFO, Sociological Abstracts, Social Services Abstracts, and Social Care Online. Studies were only included if they complied with the definition of home care, were published between January 1998 and October 2009, and dealt with at least one of the 31 specified countries. Clinical interventions, instrument developments, local projects and reviews were excluded. The data extracted included: the characteristics of the study and aspects of home care 'policy & regulation', 'financing', 'organisation & service delivery', and 'clients & informal carers'. RESULTS: Seventy-four out of 5,133 potentially relevant studies met the inclusion criteria, providing information on 18 countries. Many focused on the characteristics of home care recipients and on the organisation of home care. Geographical inequalities, market forces, quality and integration of services were also among the issues frequently discussed. CONCLUSIONS: Home care systems appeared to differ both between and within countries. The papers included, however, provided only a limited picture of home care. Many studies only focused on one aspect of the home care system and international comparative studies were rare. Furthermore, little information emerged on home care financing and on home care in general in Eastern Europe. This review clearly shows the need for more scientific publications on home care, especially studies comparing countries. A comprehensive and more complete insight into the state of home care in Europe requires the gathering of information using a uniform framework and methodology.

QUALICOPC, a multi-country study evaluating quality, costs and equity in primary care.

BACKGROUND: The QUALICOPC (Quality and Costs of Primary Care in Europe) study aims to evaluate the performance of primary care systems in Europe in terms of quality, equity and costs. The study will provide an answer to the question what strong primary care systems entail and which effects primary care systems have on the performance of health care systems. QUALICOPC is funded by the European Commission under the "Seventh Framework Programme". In this article the background and design of the QUALICOPC study is described. METHODS/DESIGN: QUALICOPC started in 2010 and will run until 2013. Data will be collected in 31 European countries (27 EU countries, Iceland, Norway, Switzerland and Turkey) and in Australia, Israel and New Zealand. This study uses a three level approach of data collection: the system, practice and patient. Surveys will be held among general practitioners (GPs) and their patients, providing evidence at the process and outcome level of primary care. These surveys aim to gain insight in the professional behaviour of GPs and the expectations and actions of their patients. An important aspect of this study is that each patient's questionnaire can be linked to their own GP's questionnaire. To gather data at the structure or national level, the study will use existing data sources such as the System of Health Accounts and the Primary Health Care Activity Monitor Europe (PHAMEU) database. Analyses of the data will be performed using multilevel models. DISCUSSION: By its design, in which different data sources are combined for comprehensive analyses, QUALICOPC will advance the state of the art in primary care research and contribute to the discussion on the merit of strengthening primary care systems and to evidence based health policy development.

Task shifting from general practitioners to practice assistants and nurses in primary care: a cross-sectional survey in 34 countries.

AIM: To describe variation in task shifting from general practitioners (GPs) to practice assistants/nurses in 34 countries, and to explain differences by analysing associations with characteristics of the GPs, their practices and features of the health care systems. BACKGROUND: Redistribution of tasks and responsibilities in primary care are driven by changes in demand for care, such as the growing number of patients with chronic conditions, and workforce developments, including staff shortage. The need to manage an expanding range of services has led to adaptations in the skill mix of primary care teams. However, these developments are hampered by barriers between professional domains, which can be rigid as a result of strict regulation, traditional attitudes and lack of trust. METHODS: Data were collected between 2011 and 2013 through a cross-sectional survey among approximately 7200 GPs in 34 countries. The dependent variable 'task shifting' is measured through a composite score of GPs' self-reported shifting of tasks. Independent variables at GP and practice level are: innovativeness; part-time working; availability of staff; location and population of the practice. Country-level independent variables are: institutional development of primary care; demand for and supply of care; nurse prescribing as an indicator for professional boundaries; professionalisation of practice assistants/nurses (indicated by professional training, professional associations and journals). Multilevel analysis is used to account for the clustering of GPs in countries. FINDINGS: Countries vary in the degree of task shifting by GPs. Regarding GP and practice characteristics, use of electronic health record applications (as an indicator for innovativeness) and age of the GPs are significantly related to task shifting. These variables explain only little variance at the level of GPs. Two country variables are positively related to task shifting: nurse prescribing and professionalisation of primary care nursing. Professionalisation has the strongest relationship, explaining 21% of the country variation.

The breadth of primary care: a systematic literature review of its core dimensions.

BACKGROUND: Even though there is general agreement that primary care is the linchpin of effective health care delivery, to date no efforts have been made to systematically review the scientific evidence supporting this supposition. The aim of this study was to examine the breadth of primary care by identifying its core dimensions and to assess the evidence for their interrelations and their relevance to outcomes at (primary) health system level. METHODS: A systematic review of the primary care literature was carried out, restricted to English language journals reporting original research or systematic reviews. Studies published between 2003 and July 2008 were searched in MEDLINE, Embase, Cochrane Library, CINAHL, King's Fund Database, IDEAS Database, and EconLit. RESULTS: Eighty-five studies were identified. This review was able to provide insight in the complexity of primary care as a multidimensional system, by identifying ten core dimensions that constitute a primary care system. The structure of a primary care system consists of three dimensions: 1. governance; 2. economic conditions; and 3. workforce development. The primary care process is determined by four dimensions: 4. access; 5. continuity of care; 6. coordination of care; and 7. comprehensiveness of care. The outcome of a primary care system includes three dimensions: 8. quality of care; 9. efficiency care; and 10. equity in health. There is a considerable evidence base showing that primary care contributes through its dimensions to overall health system performance and health. CONCLUSIONS: A primary care system can be defined and approached as a multidimensional system contributing to overall health system performance and health.