Experiences with primary healthcare in Fuzhou, urban China, in the context of health sector reform: a mixed methods study.

China has recently placed increased emphasis on the provision of primary healthcare services through health sector reform, in response to inequitably distributed health services. With increasing funding for community level facilities, now is an opportune time to assess the quality of primary care delivery and identify areas in need of further improvement. A mixed methodology approach was adopted for this study. Quantitative data were collected using the Primary Care Assessment Tool-Chinese version (C-PCAT), a questionnaire previously adapted for use in China to assess the quality of care at each health facility, based on clients' experiences. In addition, qualitative data were gathered through eight semi-structured interviews exploring perceptions of primary care with health directors and a policy maker to place this issue in the context of health sector reform. The study found that patients attending community health and sub-community health centres are more likely to report better experiences with primary care attributes than patients attending hospital facilities. Generally low scores for community orientation, family centredness and coordination in all types of health facility indicate an urgent need for improvement in these areas. Healthcare directors and policy makers perceived the need for greater coordination between levels of health providers, better financial reimbursement, more formal government contracts and recognition/higher status for staff at the community level and more appropriate undergraduate and postgraduate training.

Assessing primary care in Austria: room for improvement.

BACKGROUND: There is emerging evidence that strong primary care achieves better health at lower costs. Although primary care can be measured, in many countries, including Austria, there is little understanding of primary care development. OBJECTIVE: Assessing the primary care development in Austria. METHODS: A primary care assessment tool developed by Barbara Starfield in 1998 was implemented in Austria. This tool defines 15 primary care characteristics and distinguishes between system and practice characteristics. Each characteristic was evaluated by six Austrian primary care experts and rated as 2 (high), 1 (intermediate) or 0 (low) points, respectively, to their primary care strength (maximum score: n = 30). RESULTS: Austria received 7 out of 30 points; no characteristic was rated as '2' but 8 were rated as '0'. Compared with the 13 previously assessed countries, Austria ranks 10th of 14 countries and is classified as a 'low primary care' country. CONCLUSION: This study provides the first evidence concerning primary care in Austria, benchmarking it as weak and in need of development. The practicable application of an existing assessment tool can be encouraging for other countries to generate evidence about their primary care system as well.

[Validity and reliability of the Argentine version of the PCAT-AE for the evaluation of primary health care]. / Validez y fiabilidad de la versión argentina del PCAT-AE para evaluar la atención primaria de salud.

OBJECTIVE: To determine the validity and reliability of the version of the Primary Care Assessment Tool for adult users, adapted for Argentina (known as AR-PCAT-AE). METHODS: Two cross-sectional pilot studies were conducted among people over age 17, largely through self-administered questionnaires. Items that were equivalent to the original version of the PCAT and 13 others proposed for the instruments were analyzed. The factorial validity and reliability of the scores for each dimension were studied. The validity indicators were: factors that had three or more items with a factorial load of > 0.35, item-total correlation > 0.30, and interpretation of the solution according to the theoretical model. RESULTS: The factorial analysis yielded nine factors that explained 57.4% of the variability. Considering the pre-established criteria for validity, two items were excluded from the dimensions of continuity and comprehensiveness and six were added to comprehensiveness and cultural competency. In the dimensions, the percentage of questions with an item-total correlation of greater than 0.30 ranged from 67% to 100% and the Chronbach's (alpha) coefficient of internal consistency ranged from 0.44 to 0.90. CONCLUSIONS: The validity and reliability of the AR-PCAT-AE questionnaire are adequate, maintaining high equivalence with the original version. The process presented could be adopted in other contexts to advance the evaluation of primary health care functions with quality tools.

Reliability and validity of the Spanish version of the Child Health and Illness Profile Child-Edition/Child Report Form (CHIP-CE/CRF).

OBJECTIVES: To assess the reliability and validity of the Spanish version of the CHIP-CE/CRF. METHODS: Cross-sectional study was conducted in a representative sample of primary school children in Spain. Children were administered the Spanish version of the CHIP-CE/CRF. The Achenbach Child Behavioral Checklist was given to parents. RESULTS: The overall response rate was 75% (n = 979). Internal consistency was >0.70 for 3 out of 5 domains, and the intraclass correlation coefficient for test-retest stability ranged from 0.69 to 0.80. Confirmatory factor analysis replicated the original model. Younger children scored higher in Satisfaction than older children. Girls scored lower in Comfort but higher in Risk Avoidance than boys. CONCLUSIONS: The Spanish version of the CHIP-CE/CRF has shown acceptable reliability and validity, similar to the properties of the original US version. Future studies should analyze the instrument's sensitivity to change.

Properties of a short questionnaire for assessing primary care experiences for children in a population survey.

BACKGROUND: The Primary Care Assessment Tool (PCAT) is an interesting set of tools for primary care research. A very short version could inform policy makers about consumer experiences with primary care (PC) through health surveys. This work aimed to investigate the validity and reliability of a selection of items from the child short edition (CS) of the PCAT. METHODS: A 24 item questionnaire permitted the identification of a regular source of care and the assessment of the key attributes of first contact, ongoing care over time, coordination, services available and services received (comprehensiveness), and cultural competence. Structural validity, reliability, and construct validity were assessed using responses from 2,200 parents of a representative sample of the population aged 0 to 14 years in Catalonia (Spain) who participated in the 2006 Health Survey. Structural validity was analyzed using exploratory and confirmatory factor analyses and reliability was assessed using Cronbach's alpha. Construct validity was assessed using linear regression analysis between PC experience scores and a measure of overall user satisfaction with healthcare services. RESULTS: A total of 2,095 (95.2%) parents provided useable responses on PC. After Confirmatory Factor Analysis (CFA), the best fitting model was a 5-factor model in which the original dimensions of first contact and ongoing care were collapsed into one. The CFA also showed a second order factor onto which all domains except services available loaded (root mean square error of approximation = 0.000; comparative fit index = 1.00). Cronbach's alpha values for one of the original scales (first-contact) was poor (alpha < 0.50), but improved using the modified factor structure (alpha > 0.70). Scores on the scales were correlated with satisfaction with healthcare services (p < 0.01), thereby providing some preliminary evidence of construct validity. CONCLUSIONS: This very short questionnaire obtained from the PCAT-CE yields information about five attributes of PC and a summary score. It has shown evidence of validity and reliability for judgments about experiences with primary care overall. If space on surveys is at a premium, the instrument could be useful as a measure of PC experiences.

Reliability and validity of the Spanish version of the Child Health and Illness Profile (CHIP) Child-Edition, Parent Report Form (CHIP-CE/PRF).

BACKGROUND: The objectives of the study were to assess the reliability, and the content, construct, and convergent validity of the Spanish version of the CHIP-CE/PRF, to analyze parent-child agreement, and compare the results with those of the original U.S. version. METHODS: Parents from a representative sample of children aged 6-12 years were selected from 9 primary schools in Barcelona. Test-retest reliability was assessed in a convenience subsample of parents from 2 schools. Parents completed the Spanish version of the CHIP-CE/PRF. The Achenbach Child Behavioural Checklist (CBCL) was administered to a convenience subsample. RESULTS: The overall response rate was 67% (n = 871). There was no floor effect. A ceiling effect was found in 4 subdomains. Reliability was acceptable at the domain level (internal consistency = 0.68-0.86; test-retest intraclass correlation coefficients = 0.69-0.85). Younger girls had better scores on Satisfaction and Achievement than older girls. Comfort domain score was lower (worse) in children with a probable mental health problem, with high effect size (ES = 1.45). The level of parent-child agreement was low (0.22-0.37). CONCLUSIONS: The results of this study suggest that the parent version of the Spanish CHIP-CE has acceptable psychometric properties although further research is needed to check reliability at sub-domain level. The CHIP-CE parent report form provides a comprehensive, psychometrically sound measure of health for Spanish children 6 to 12 years old. It can be a complementary perspective to the self-reported measure or an alternative when the child is unable to complete the questionnaire. In general, the results are similar to the original U.S. version.

Comparison of primary care experiences among adults in general outpatient clinics and private general practice clinics in Hong Kong.

BACKGROUND: The main goal of Hong Kong's publicly-funded general outpatient clinics (GOPCs) is to provide primary medical services for the financially vulnerable. The objective of the current study was to compare the primary care experiences of GOPC users and the users of care provided by private general practitioners (GPs) in Hong Kong via a territory-wide telephone survey. METHODS: One thousand adults in Hong Kong aged 18 and above were interviewed by a telephone survey. The modified Chinese translated Primary Care Assessment Tool was used to collect data on respondents' primary care experience. RESULTS: Our results indicated that services provided by GOPC were more often used by female, older, poorer, chronically-ill and less educated population. GOPC participants were also more likely to have visited a specialist or used specialist services (69.7% vs. 52.0%; p < 0.001), although this difference in utilization of specialist services disappeared after adjusting for age (55.7% vs. 52.0%, p = 0.198). Analyses were also performed to asses the relationship between healthcare settings (GOPCs versus private GPs) and primary care quality. Private GP patients achieved higher overall PCAT scores largely due to better accessibility (Mean: 6.88 vs. 8.41, p < 0.001) and person-focused care (Mean: 8.37 vs. 11.69, p < 0.001). CONCLUSIONS: Our results showed that patients primarily receiving care from private GPs in Hong Kong reported better primary care experiences than those primarily receiving care from GOPCs. This was largely due to the greater accessibility and better interpersonal relationships offered by the private GPs. As most patients use both GOPCs and private GPs, their overall primary care experiences may not be as different as the findings of this study imply.

An international perspective on the basis for payment for performance.

This discussion paper reflects on the pay-for-performance system in UK general practice - the Quality and Outcomes Framework (QOF) - from an international viewpoint. The QOF intends to bring the best scientific evidence to bear on primary care practice. However, the QOF and patient-centred medicine are often at odds. Inadequacies and commercial bias in the creation of evidence make the scientific basis of the QOF questionable. The framework for the QOF does not align well with the scope of primary care, making its basis as a tool for quality measurement questionable. The extent of impact of the QOF on health outcomes and on equity of health outcomes needs examination. Attention to resolution of patients' problems is an important aim of quality improvement activities. Alternative modes of improving patient care may be better than the QOF.

Transforming medical professionalism to fit changing health needs.

BACKGROUND: The professional organization of medical work no longer reflects the changing health needs caused by the growing number of complex and chronically ill patients. Key stakeholders enforce coordination and remove power from the medical professions in order allow for these changes. However, it may also be necessary to initiate basic changes to way in which the medical professionals work in order to adapt to the changing health needs. DISCUSSION: Medical leaders, supported by health policy makers, can consciously activate the self-regulatory capacity of medical professionalism in order to transform the medical profession and the related professional processes of care so that it can adapt to the changing health needs. In doing so, they would open up additional routes to the improvement of the health services system and to health improvement. This involves three consecutive steps: (1) defining and categorizing the health needs of the population; (2) reorganizing the specialty domains around the needs of population groups; (3) reorganizing the specialty domains by eliminating work that could be done by less educated personnel or by the patients themselves. We suggest seven strategies that are required in order to achieve this transformation. SUMMARY: Changing medical professionalism to fit the changing health needs will not be easy. It will need strong leadership. But, if the medical world does not embark on this endeavour, good doctoring will become merely a bureaucratic and/or marketing exercise that obscures the ultimate goal of medicine which is to optimize the health of both individuals and the entire population.

Ambulatory care provided by office-based specialists in the United States.

PURPOSE: Increasing use of specialist services in the United States is leading to a perception of a specialist shortage. Little is known, however, about the nature of care provided by this secondary level of services. The aim of this study was to examine the content of care provided by specialists in community settings, including visits for which the patient had been referred by another physician. METHODS: Nationally representative visit data were obtained from the National Ambulatory Medical Care Survey (NAMCS) for the years 2002 through 2004. To describe the nature of care, we developed a taxonomy of office-based visit types and constructed logistic regression models allowing for adjusted comparisons of specialty types. RESULTS: Overall, 46.3% of visits were for routine follow-up and preventive care of patients already known to the specialist. Referrals accounted for only 30.4% of all visits. Specialists were more likely to report sharing care with other physicians for referred, compared with not referred, patients (odds ratio [OR] = 2.99; 95% confidence interval [CI], 2.52-3.55). Overall, 73.6% of all visits resulted in a return appointment with the same physician, in more than one-half of all cases as a result of a routine or preventive care visit. CONCLUSIONS: Ambulatory office-based activity of specialists includes a large share of routine and preventive care for patients already known, not referred, to the physician. It is likely that many of these services could be managed in primary care settings, lessening demand for specialists and improving coordination of care.

Defining comorbidity: implications for understanding health and health services.

Comorbidity is associated with worse health outcomes, more complex clinical management, and increased health care costs. There is no agreement, however, on the meaning of the term, and related constructs, such as multimorbidity, morbidity burden, and patient complexity, are not well conceptualized. In this article, we review definitions of comorbidity and their relationship to related constructs. We show that the value of a given construct lies in its ability to explain a particular phenomenon of interest within the domains of (1) clinical care, (2) epidemiology, or (3) health services planning and financing. Mechanisms that may underlie the coexistence of 2 or more conditions in a patient (direct causation, associated risk factors, heterogeneity, independence) are examined, and the implications for clinical care considered. We conclude that the more precise use of constructs, as proposed in this article, would lead to improved research into the phenomenon of ill health in clinical care, epidemiology, and health services.

Policy characteristics facilitating primary health care in Thailand: A pilot study in transitional country.

BACKGROUND: In contrast to the considerable evidence of inequitable distribution of health, little is known about how health services (particularly primary care services) are distributed in less developed countries. Using a version of primary health care system questionnaire, this pilot study in Thailand assessed policies related to the provision of primary care, particularly with regard to attempts to distribute resources equitably, adequacy of resources, comprehensiveness of services, and co-payment requirement. Information on other main attributes of primary health care policy was also ascertained. METHODS: Questionnaire survey of 5 policymakers, 5 academicians, and 77 primary care practitioners who were attending a workshop on primary care. Descriptive statistics with Fischer's exact test were used for data analysis. RESULTS: All policymakers and academicians completed the mailed questionnaire; the response rate among the practitioners was 53.25% (41 out of 77). However, the responses from all three groups were consistent in reporting that (1) financial resources were allocated based on different health needs and special efforts were made to assure primary care services to the needy or underserved population, (2) the supply of essential drugs was adequate, (3) clinical services were distributed equitably, (4) out-of-pocket payment was low, and that some primary health care attributes, particularly longitudinality (patients are seen by same doctor or team each time they make a visit), coordination, and family- and community-orientation were satisfactory. Geographical variations were present, suggesting inequitable distribution of primary care across regions. The questionnaire was robust across key stakeholders and feasible for use in a transitional country. CONCLUSION: A primary care systems questionnaire administered to different types of health professionals was able to show that resource distribution was equitable at a national level but some aspects of primary care practice across regions is still of concern, in at least in this transitional country.

The impact of primary healthcare on population health in low- and middle-income countries.

This article assesses 36 peer-reviewed studies of the impact of primary healthcare (PHC) on health outcomes in low- and middle-income countries. Studies were abstracted and assessed according to where they took place, the research design used, target population, primary care measures, and overall conclusions. Results indicate that the bulk of evidence for PHC effectiveness is focused on infant and child health, but there is also evidence of the positive role PHC has on population health over time. Although the peer-reviewed literature is lacking in rigorous experimental studies, a small number of relatively well-designed observational studies and the consistency of findings generally support the contention that an integrated approach to primary care can improve health. A few large-scale experiences also help identify elements of good practice. The review concludes with several recommendations for future studies, including a focus on better conceptualizing and measuring PHC, further investigation into the advantages of comprehensive over selective PHC, need for experimental or quasi-experimental research designs that allow testing of the independent effect of primary care on outcomes over time, and a more detailed conceptual framework guiding overall evaluation design that places limits on the parameters under consideration and describes relationships among different levels and types of data likely to be collected in the evaluation process.

Ambulatory specialist use by nonhospitalized patients in us health plans: correlates and consequences.

Approximately 7 of 10 (and 95% of the elderly) people in US health plans see one or more specialists in a year. Controlling for extent of morbidity, discontinuity of primary care physician visits is associated with seeing more different specialists. Having a general internist as the primary care physician is associated with more different specialists seen. Controlling for differences in the degree of morbidity, receiving care from multiple specialists is associated with higher costs, more procedures, and more medications, independent of the number of visits and age of the patient.

Routine care provided by specialists to children and adolescents in the United States (2002-2006).

BACKGROUND: Specialist physicians provide a large share of outpatient health care for children and adolescents in the United States, but little is known about the nature and content of these services in the ambulatory setting. Our objective was to quantify and characterize routine and co-managed pediatric healthcare as provided by specialists in community settings. METHODS: Nationally representative data were obtained from the National Ambulatory Medical Care Survey for the years 2002-2006. We included office based physicians (excluding family physicians, general internists and general pediatricians), and a representative sample of their patients aged 18 or less. Visits were classified into mutually exclusive categories based on the major reason for the visit, previous knowledge of the health problem, and whether the visit was the result of a referral. Primary diagnoses were classified using Expanded Diagnostic Clusters. Physician report of sharing care for the patient with another physician and frequency of reappointments were also collected. RESULTS: Overall, 41.3% out of about 174 million visits were for routine follow up and preventive care of patients already known to the specialist. Psychiatry, immunology and allergy, and dermatology accounted for 54.5% of all routine and preventive care visits. Attention deficit disorder, allergic rhinitis and disorders of the sebaceous glands accounted for about a third of these visits. Overall, 73.2% of all visits resulted in a return appointment with the same physician, in half of all cases as a result of a routine or preventive care visit. CONCLUSION: Ambulatory office-based pediatric care provided by specialists includes a large share of non referred routine and preventive care for common problems for patients already known to the physician. It is likely that many of these services could be managed in primary care settings, lessening demand for specialists and improving coordination of care.

Evaluating the tools used to assess the medical home.

PURPOSE: The patient-centered medical home is evolving as an approach to providing primary care. Primary care is defined by four main characteristics: comprehensive, coordinated, continuous, and accessible care, all of which are measurable. This analysis identifies tools for determining whether a patient-centered medical home achieves high level primary care. DESIGN: Instruments for measuring primary care were reviewed. METHOD: Tools were reviewed for population coverage, format, testing of validity and reliability, and inclusion of the attributes of primary care. PRINCIPAL FINDINGS: Only one tool, the Primary Care Assessment Tool (PCAT), scored highly on primary care features, as it was designed to assess both structural and process features of primary care and is available in multiple user formats. CONCLUSION: Based on the evidence supporting the relationship between primary care, improved population health, and reduced health care costs, measurement of primary care transformation approaches such as the medical home can and should include specific measurement of the services associated with the four core attributes of primary care.

Validity of the health profile-types of the Spanish Child Health and Illness Profile-Adolescent Edition (CHIP-AE).

OBJECTIVE: To develop and validate a simplified, easy to interpret scoring system based on the health profile-types taxonomy for the Spanish version of the Child Health and Illness Profile-Adolescent Edition (CHIP-AE). METHODS: The CHIP-AE was administered to a 1453 Spanish adolescents. Hierarchic and nonhierarchical cluster analyses, as well as conceptual considerations, were used to identify exhaustive, mutually exclusive health profile-types based in four CHIP-AE domain scores: Satisfaction, Discomfort, Resilience, and Risks. Validity of the health profile-types was assessed by testing expected differences among adolescents according to sex, age, socioeconomic status, and self-reported conditions. Logistic models were built. RESULTS: A total of 13 health profile-types (10 that best fitted the data and three additional considered conceptually necessary) were identified. The largest group of adolescents was in the "Excellent health" or "Good health" types (43.4%), although 11.2% were in the "Worst health" profile. According to a priori hypotheses, being a girl (OR = 1.81; 95% CI = 1.26-2.60), older age (OR = 1.80; 1.26-2.57), and self-reported recurrent (OR = 2.49; 1.72-3.60) and psychosocial disorders (OR = 4.38; 2.92-6.56) were associated to the likelihood of a "Worst health" profile-type. CONCLUSIONS: The Spanish CHIP-AE health profile-types offer a simplified method to describe adolescents' patterns of health, which is valid and similar to the original US taxonomy. This can facilitate interpreting the instrument scores and using it for needs assessment, although additional research is required.

Primary care in Canada: coming or going?

Despite an early start in the transformation of its health system toward a primary care infrastructure, Canada has not kept pace in the production of knowledge that is needed to support forward momentum. Having achieved the three key system features needed for primary care practice (attempted distribution of resources equitably; government control or heavy regulation of insurance; and low or no copayments), Canada now needs to take bold steps to address at least two interrelated challenges: (1) to shift from a disease orientation to a population orientation toward multi-morbidity and (2) to better understand the delineation of the relative roles of primary care physicians and specialists. The Canadian commitment to primary care research has been very weak. Its strengthening would help Canada to move ahead and could contribute greatly to the advancement of primary care as a worldwide imperative of the 21st century.

Income redistribution is not enough: income inequality, social welfare programs, and achieving equity in health.

Income inequality is widely assumed to be a major contributor to poorer health at national and subnational levels. According to this assumption, the most appropriate policy strategy to improve equity in health is income redistribution. This paper considers reasons why tackling income inequality alone could be an inadequate approach to reducing differences in health across social classes and other population subgroups, and makes the case that universal social programs are critical to reducing inequities in health. A health system oriented around a strong primary care base is an example of such a strategy.

The primary care physician workforce: ethical and policy implications.

PURPOSE: We undertook a study to examine the characteristics of countries exporting physicians to the United States according to their relative contribution to the primary care supply in the United States. METHODS: We used data from the World Health Organization and from the American Medical Association Physician Masterfile to gather sociodemographic, health system, and health characteristics of countries and the number of international medical graduates (IMGs) for the countries, according to the specialty of their practice in the United States. RESULTS: Countries whose medical school graduates added a relatively greater percentage of the primary care physicians than the overall percentage of primary care physicians in the United States (31%) were poor countries with relatively extreme physician shortages, high infant mortality rates, lower life expectancies, and lower immunization rates than countries contributing relatively more specialists to the US physician workforce. CONCLUSION: The United States disproportionately uses graduates of foreign medical schools from the poorest and most deprived countries to maintain its primary care physician supply. The ethical aspects of depending on foreign medical graduates is an important issue, especially when it deprives disadvantaged countries of their graduates to buttress a declining US primary care physician supply.