International Journal for Quality in Health Care Advance Access originally published online on May 20, 2008
International Journal for Quality in Health Care 2008 20(4):277-283; doi:10.1093/intqhc/mzn020
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The patient's view of the acceptability of the primary care in Poland
1 Department of Family Medicine and Community Nursing, Medical University of Bialystok, Mieszka I 4B, Bialystok 15054, Poland
2 Department of Pediatrics, Medical University of Bialystok, Bialystok 15274, Poland
Address reprint requests to: Ludmila Marcinowicz; Tel: +48-857-326-820; Fax: +48-857-327-848; E-mail: ludmila.marcinowicz{at}amb.edu.pl
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Abstract |
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Objective. The aim of the study was to determine how the time factor affected the patients' perception of the acceptability of the primary health care system and to assess their satisfaction with family physician care.
Design. A series of cross-sectional studies was conducted in 1998, 2002 and 2006, using face-to-face interviews with structured questionnaires.
Setting. The study was performed in Gi
ycko, Poland, where family physician services were introduced in 1995.
Study participants. Three surveys were conducted, each involving 1000 subjects. Every time, random sample was taken, after selecting a subgroup of patients using medical service within the previous week.
Main measures. Acceptability of the primary health care system (accessibility, the patient–practitioner relationship, the amenities of care, patient's preferences), perception of the changes in primary care and overall satisfaction with family physician care.
Results. Between 1998 and 2002, an improvement was noted, lasting till 2006, in such accessibility components as the possibility of making an appointment by phone or at a definite hour. Some aspects of the patient–doctor relationship indicate that family physician care is directed at illness rather than health-oriented. The level of patient satisfaction was high.
Conclusions. Generally, patients are satisfied with primary care reform and implementation of the family physician system. However, it is easier to improve accessibility of services than physician's personal qualities and the patient–practitioner relationship. Expressive functions of a physician (listening and reassuring) and activities regarding health promotion require special attention in the process of education of family physicians.
Keywords: acceptability of health care, Eastern Europe, family practice, primary health care, patient satisfaction
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Introduction |
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Poland is an Eastern European country in which the health care system was formerly highly centralized and financed from the state budget. Primary care was provided by multi-specialist teams of physicians trained in internal medicine, pediatrics, gynecology and obstetrics, and by dentists, nurses, midwives and ancillary support staff. All health care providers were state employees and were paid on a salary basis, but compensation levels were low [1]. Patients usually had difficulties with registration for the visit with a primary care physician, were dissatisfied with registration mode and had to queue for medical advice for a long time [2, 3].
Since the beginning of the 1990s, the government of Poland has introduced a number of reforms in the health care sector. One of the fields of change was the primary health care system. The aims of the reform were to strengthen primary care and introduce the family physician system. A capitation-based physician payment system was initiated in 1995, following the introduction of family medicine in Poland. Through implementation of the family physician system in Poland—based on the model operating in many Western European countries—an attempt was made to improve the quality of primary care (both in terms of the accessibility and effectiveness) [1, 4].
Acceptability is one of the quality components in health care, apart from efficiency, optimality, legitimacy and equity. It is defined as conformity to the wishes, desires and expectations of patients and responsible members of their families. Donabedian distinguished five elements of the concept of acceptability: accessibility, the patient–practitioner relationship, the amenities of care, patients' preferences regarding the effects, risks and cost of care, what patients consider to be fair and equitable [5]. Patients' views on the quality of care they receive should be a key part of any performance assessment system. In the twenty-first century, patients have an important role as evaluators of health care and potential change agents [6].
In most European countries that instituted health care reforms during the 1990s, numerous attempts are undertaken to assess these changes from the patient's perspective [7–12]. However, health care reform projects that have taken place in many of the former communist countries are rarely evaluated systematically, according to some reports [13]. New development facilities for family medicine appeared in Poland due to the access to the European Union as some practice guidelines, curriculums and new methods of the postgraduate continuous education were successfully implemented [14]. This may have been associated with an improvement of the attitudes, activities and capacity of Polish family physicians. On the other hand, a poor access to specialist services was noticed during this transition period [15]. All the above factors may have had an impact on patients' perception of primary care.
The aims of the study were first, to determine how time factor (8 years) affected patients' perception of the acceptability of the new primary health care system and, second, to assess patients' satisfaction with family physician care.
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Methods |
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Setting
The surveys were performed in Gi
ycko (a town in northern Poland), where physicians with specialist training in family medicine were introduced in 1995. The setting in this study was chosen for two reasons. First, this was one of the first places in Poland where the family physician system was introduced. Second, both family physicians and local government were interested in obtaining patients' opinions concerning the quality of the services provided. Since 1995, family physicians have been contracted with the financial institution (currently National Health Fund). Within the study period, 16 family physicians worked in this area. In 2006, the population of patients using the service was 33 500, of which approximately 75% lived in the urban area and 25% in the rural area.
Sample and study design
Three surveys were performed at 4-year-intervals (1998, 2002 and 2006), each involving a randomly selected sample of 1000 subjects. Patients were recruited from those who were using medical services within one week (family physician's surgery, nurse or doctor/nurse home visits).
In 1998 (survey I), a total of 1032 subjects were selected from the list of 4092 eligible patients. Because 991 interviews were completed (response rate was 96%), additional 9 subjects were selected in order to achieve 1000 valid questionnaires. In 2002 (survey II), a group of 1016 was chosen from the list of 4065 eligible patients. As only 988 interviews were obtained (response rate was 97.2%), additional 12 subjects were randomly selected from the list in order to achieve a similar sample size as in survey I. In 2006 (survey III), 1030 were chosen from the list of 3733 eligible patients. Because only 910 interviews were completed (response rate was 88.3%), they were supplemented later with additional 90 interviews.
Prior to the study and during the study duration, comprehensive information was provided, and announcements were widespread to all waiting rooms (booklets and posters). The participation was optional; however, patients were actively encouraged by family physicians to participate and were given information about the purpose, possible benefits and anonymity of the study.
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Questionnaire |
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A structured questionnaire was developed for the survey. The final questions were literature-based and referred mainly to the aspects of the quality of primary care that had been frequently criticized by patients in the previous system [2, 3]. Some questions concerning new aspects of family medicine in Poland were also included [16]. The questionnaire contained 39 items on various aspects related to family physicians' and family nurses' care. It also included demographic data (sex, age, place of residence, education, marital status), and questions which related to self-evaluation of health condition, chronic illness or the use of medical services. In the present study, we analysed patients' responses to the questions concerning acceptability of primary health care (accessibility, patient–practitioner relationship, amenities of care) (see Appendix). The information was collected by means of face-to-face interviews. The respondents were interviewed in their homes by trained social workers and had the possibility to see response options. Patients who either refused the participation or were hospitalized were never interviewed. When a patient was too sick and/or was unable to answer, the required information was obtained from the nearest caregivers (e.g. family members). The Ethics Committee of Medical University of Bia
ystok approved the study.
Analysis
Analysis was conducted using a packet Statistica PL, v. 7.1. Descriptive statistics are presented for demographic data and general opinion on accessibility. Means and standard deviations (SD) are presented for the assessment of data referring to the functioning of the family practice.
Results obtained from survey III were compared with those found in surveys I and II. The chi-square test was used to compare the background characteristics. The U-test for two frequencies was applied to assess the significance of differences between the percentages of patients' responses concerning accessibility. Mann-Whitney test was used for comparisons between values obtained from the assessment of functioning of the family practice expressed on an ordinal scale [17]. Level of statistical significance was set at P < 0.05.
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Results |
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Characteristics of the respondents
The sample characteristics in the three surveys were similar. There were no differences between the groups related to sex, education, self-reported chronic conditions or place of residence. Significant differences referred to the age of the respondents in the subsequent surveys. The proportion of subjects aged <44 decreased, while in the age groups of 45–64 years and 65 and over increased. Differences were also observed in the frequency of visits during previous 12 months (Table 1).
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Accessibility
As shown in Table 2, the percentage of patients making an appointment by phone to see their family physician increased significantly in survey II—from 8.8% to 41.7%—and remained the same in survey III. Similarly, the percentage of the respondents who made an appointment at a definite hour increased from 7.8% to 50.3%, with a slight decrease in survey III. Those who waited for a visit in the waiting room less than 15 min accounted for 32.2% in survey I and 58.6% in survey II. In survey III, however, a drop was noted as compared to survey II (53.1%).
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Visit duration was satisfactory for the majority of the respondents in each survey; however, the lowest percentage was found in survey I (82.9%), and the highest in survey II (91.1%).
An increase was noted in survey II regarding the percentage of the respondents confirming the possibility of phone consultation in the family practice, and a drop in survey III. However, the percentage of patients phoning their family physicians for medical advice increased only slightly in survey II, and then decreased in survey III. The percentage of patients who were refused home visits also consecutively decreased within the observation period.
Perception of various aspects of patient–doctor relationships during visits
One-half of the respondents admitted that during the visits, the family physician always listened to them carefully, although a significant decrease was noted in the subsequent surveys (Table 3). In the opinion of most respondents, the physician always provided information about disease and treatment, but the proportion of patients who claimed that their physicians advised on healthy lifestyle (nutrition, coping with stress, etc.) systematically decreased. Physicians very rarely talked to patients about their home and work conditions during visit.
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Overall assessment of functioning of the family practice
Patients assessed various aspects of functioning of the family practice in the 1–5 scale (Table 4). Significant differences were detected regarding family physician care, family nurse care, doctor–patient relationship, room cleanliness and aesthetics. The mean efficiency of family physician care increased across surveys. Professionalism and thoroughness of nurses were assessed higher in survey II as compared to I and remained at the same level in survey III, whereas room cleanliness and aesthetics, according to the respondents, decreased systematically. Rating of the remaining elements (nurse–patient relationship and housing conditions) did not differ between the surveys.
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Perception of the changes in primary health care, overall satisfaction and willingness to change the family physician
The percentage of patients who expressed the opinion that at present it is easier to get advice than it was previously from a district physician increased between survey I and II (72.1% and 83.6%, respectively; P < 0.001) and showed a rising tendency in survey III (84.7%). The same trend was also observed in patients' preferences about the form of medical care (present-day family physician vs district physician in the past). The percentages of patients preferring family physician were 70.2%, 81.3% (P < 0.001) and 84%, respectively. Also, the percentage of satisfied patients (‘very much’ and ‘rather’) with their family physician increased between surveys I and II (from 81.2% to 85.1%; P = 0.02) and remained stable in survey III (86.4%). Within the study duration, a decreasing proportion of patients declared an intention to change their family physician (survey I, 7.9%; II, 3.8%; and III, 2.3%; P < 0.001).
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Discussion |
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This study focused on the patients' opinions concerning the acceptability of the primary health care system in Gi
ycko, Poland, at 4-year intervals. The opinions received in 1998, 2002 and 2006 were compared. The limitation of our study is the fact that it was conducted in a relatively small district of Poland and may not necessarily represent the total population. Nevertheless, using the same method over consecutive cross-sectional surveys in the same population may guarantee a good reliability of the study. A considerable improvement was observed between 1998 and 2002, which still lasted in 2006, in such accessibility elements as possibility of making an appointment by phone or at a definite hour. Patients' opinions concerning the analysed elements of accessibility that improved between survey I and II showed a falling tendency in survey III. This referred to satisfactory visit duration, possibility of phone consultation and the percentage of patients calling their physician for advice. Phone consultation is a new form of providing medical service in Poland and, as shown in our study, not very popular with patients. Estonian authors reported that about 72% of patients in this country had good possibilities of contacting their family physician by phone [11]. The patients we studied occasionally called their family physicians to receive medical advice, although for the majority of the interviewees, telephone consultations were a well-known form of medical service.
Some of the aspects of patient–doctor relationship indicate that family physician care is more disease-oriented than health-oriented. Thus, family physicians had only a slight, and even decreasing (in subsequent surveys) contribution to health promotion (advising on nutrition, physical activity, coping with stress). Another of our studies seems to confirm the slight involvement of family physicians in health promotion among their patients [18]. Studies conducted by other authors partly explain the possible causal link: there is a common acceptance of the need for health promotion by the Polish family physicians who see, however, possible difficulties in implementing health promotion into their daily practice in terms of financial aspects, lack of motivation or lack of time [19]. We also found a modest interest of family physicians in family and work conditions of their patients, though a comprehensive approach is regarded as one of the core competencies of family physician [16].
Positive opinions of patients concerning some elements of communication (active listening, reassuring, comforting) also showed a downward trend in our study. International comparisons originating from various countries suggest that the aspects of doctor–patient communication are crucial from the patients' perspective [20].
In general, patients highly estimated the respective elements of functioning of the family practice. The mean level of satisfaction increased in the subsequent surveys. There was a possibility that having a regular physician and nurse, and long attendance with them had an effect on this increase. According to Hulka et al., having a regular physician is highly correlated with patient satisfaction [21]. In our study, the level of overall satisfaction with family physician care was relatively high and similar to that found in Poland [22] and in other European countries [9, 12]. However, one should be aware that patients tend to express over estimated opinions because patient satisfaction surveys usually produce high level of satisfaction [23]. Our study supports the above association.
The acceptance of the primary health care system based on family physicians is expressed by the general opinion that accessibility to medical advice is higher as compared to the previous system and that family physician care is more satisfactory than district physician care. A similar situation has been reported in other countries of this European region; a recent well-designed and conducted study from Lithuania showed that over three-fourths of the respondents had an easy access to their primary health care institution [8].
Our results could be used for improvement of primary care system and, indeed, a new approach to the family medicine based on these data may be implemented in Poland. There is certainly a need of further development of communication skills and practical activities associated with health promotion among family physicians. Furthermore, primary health care providers should pay more attention on those areas of the system which are negatively assessed by patients. An implementation of motivating mechanisms, such as an additional remuneration of family physicians, may improve effectiveness of their activities related to health promotion.
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Conclusions |
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Patients are generally satisfied with the reform of primary health care and the implementation of the family physician system. However, it is easier to improve the accessibility of services than personal attitudes and the patient–practitioner relationship. Some accessibility elements, including phone consultations, require legal regulations and detailed guidelines in the practice of family physicians. The principles of family medicine appear particularly difficult in the context of family conditions, health promotion and expressive functions of physicians (listening and reassuring). These elements should receive special attention in the process of education of family physicians.
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Funding |
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The current study was conducted at the Medical University of Bialystok; Grant No. 4-04719
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Appendix |
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The following questions were asked in the survey:
- –How did you register at family physician for your last visit? (Answers: by phone; reported in person; upon prior setting of an appointment date).
- –When you saw your physician last time, was your appointment arranged for a precisely defined hour? (Answers: yes; no)
- –How long did you wait in the waiting room till the physician saw you during the last visit? (Answers: >15 min; 15–30 min; 30–60 min; <60 min)
- –How long was your last visit at family physician's surgery? (Answers: definitely too long; rather too long; sufficiently long; rather too short; definitely too short)
- –Is there a possibility to contact your physician by phone to get the consultation? (Answers: yes; no; I do not know)
- –Did you contact your family physician by phone within the last month to obtain an advice regarding your health problems? (Answers: yes; no)
- –Have you ever met with a refusal to make home visit by family physician? (Answers: yes, one time; yes, several times; never)
- –When you saw your physician last time, was your appointment arranged for a precisely defined hour? (Answers: yes; no)
Perception of various aspects of patient–doctor relationships during visits
- –How often did you experience the following situations during your visits at family physician's surgery:
- –physician listened carefully (Answers: always; often; seldom; never; difficult to say);
- –physician informed about the disease (Answers: always; often; seldom; never; difficult to say);
- –physician advised on healthy living (Answers: always; often; seldom; never; difficult to say);
- –physician reassured and comforted (Answers: always; often; seldom; never; difficult to say);
- –physician talked about family conditions (Answers: always; often; seldom; never; difficult to say);
- –physician was interested in work conditions (Answers: always; often; seldom; never; difficult to say)
- –physician listened carefully (Answers: always; often; seldom; never; difficult to say);
Overall assessment of functioning of the family physician practice
- –How do you assess functioning of the family practice? Please use the scale from 1 to 5, where 1 is the lowest grade and 5 the highest grade, regarding the categories specified below:
- efficiency of physician's care (scale from 1 to 5);
- nurse's care—professionalism and thoroughness of nurses (scale from 1 to 5);
- attitude of physician towards patient (scale from 1 to 5);
- attitude of nurse towards patient (scale from 1 to 5);
- housing conditions (scale from 1 to 5);
- room cleanliness and esthetics (scale from 1 to 5)
- efficiency of physician's care (scale from 1 to 5);
Perception of the changes in primary health care, overall satisfaction and willingness to change the family physician
- –Do you think that it is easier to get an advice at present than it was earlier from a district physician? (Answers: definitely easier; rather easier; unchanged; rather difficult; definitely more difficult).
- –Which of the primary care modes you prefer? (Answers: current—family physician; previous—district physician; do not have a personal opinion)
- –Are you satisfied with family physician care? (Answers: very satisfied; rather satisfied; rather dissatisfied; very dissatisfied; difficult to say).
- –Are you going to change your family physician? (Answers: yes; no)
- –Which of the primary care modes you prefer? (Answers: current—family physician; previous—district physician; do not have a personal opinion)
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