doi: 10.1111/hex.12326
Community preferences in general practice: important factors for choosing a general practitioner Patricia Kenny MPH,* Richard De Abreu Lourenco MEc,† Chun Yee Wong PhD,† Marion Haas PhD‡ and Stephen Goodall PhD§ *Senior Research Fellow, †Research Fellow, ‡Professor of Health Economics and §Associate Professor of Health Economics, Centre for Health Economics Research & Evaluation, University of Technology Sydney, Sydney, NSW, Australia
Abstract Correspondence Patricia Kenny Senior Research Fellow Centre for Health Economics Research & Evaluation University of Technology Sydney PO Box 123 Broadway Sydney NSW 2007 Australia E-mail: [email protected]. Accepted for publication 28 November 2014 Keywords: consumers, general practice, preferences
Background Understanding the important factors for choosing a general practitioner (GP) can inform the provision of consumer information and contribute to the design of primary care services. Objective To identify the factors considered important when choosing a GP and to explore subgroup differences. Design An online survey asked about the respondent’s experience of GP care and included 36 questions on characteristics important to the choice of GP. Participants An Australian population sample (n = 2481) of adults aged 16 or more. Methods Principal components analysis identified dimensions for the creation of summated scales, and regression analysis was used to identify patient characteristics associated with each scale. Results The 36 questions were combined into five scales (score range 1–5) labelled: care quality, types of services, availability, cost and practice characteristics. Care quality was the most important factor (mean = 4.4, SD = 0.6) which included questions about technical care, interpersonal care and continuity. Cost (including financial and time cost) was also important (mean = 4.1, SD = 0.6). The least important factor was types of services (mean = 3.3, SD = 0.9), which covered the range of different services provided by or co-located with the practice. Frequent GP users and females had higher scores across all 5 scales, while the importance of care quality increased with age. Conclusions When choosing a GP, information about the quality of care would be most useful to consumers. Respondents varied in the importance given to some factors including types of services, suggesting the need for a range of alternative primary care services.
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ª 2015 John Wiley & Sons Ltd Health Expectations, 19, pp.26–38
Important factors for choosing a GP, P Kenny et al.
Introduction Understanding the factors consumers regard as important when choosing a general practitioner (GP) or primary health-care provider can be important for ensuring the availability of relevant and useable information for consumer decision making. Identification of the practitioner and practice attributes regarded as important can also inform health-care policy by contributing to the design of primary care services which reflect the priorities of the users of those services. This study aimed to identify the factors people in Australia consider important when choosing a GP and to examine the extent to which this varies by health and demographic characteristics. Through an examination of conceptual reviews and empirical studies, Cheraghi-Sohi1 developed a ‘conceptual map’ of the key attributes of primary care that were important to patients. They identified seven attribute categories: access (to care and to preferred services), technical care quality, interpersonal care (including communication and explanation), patient-centredness, continuity (of information, care and provider), outcomes (including health status, quality of life and satisfaction) and hotel aspects (such as waiting room).1 This wide-ranging list was found to be too large to be comprehensively addressed by most patient assessment instruments. A number of survey methods have been used for measuring preferences in relation to primary care including direct rating of the importance of a range of attributes of care and discrete choice experiments (DCE). Direct questions rating the extent of preference for each attribute allow for the inclusion of a large number of different attributes but do not force respondents to weigh up the relative importance of different attributes and so may lack sensitivity to differences between attributes, for example where many respondents identify all or most attributes as important. Discrete choice experiments offer respondents a series of choices where attribute levels vary between choice options and across choices. This approach has the advantage of being able to quantify the
ª 2015 John Wiley & Sons Ltd Health Expectations, 19, pp.26–38
extent to which respondents would trade attributes of care against each other but is constrained by the number of different attributes that can be feasibly considered at one time. Discrete choice experiment surveys investigating preferences for GP services have originated mainly in Europe (predominantly the UK) and have generally found technical quality of care,2,3 doctor communication,4–7 information provided,4,6,8 continuity of care2,3,9,10 and choice of provider9–13 to be the most important attributes for GP care among those included in the relevant experiments. In the Australian context, Haas14 found that trust in the doctor was more important than other interpersonal aspects for choosing to remain with a GP. In many of the DCE studies, respondents were willing to trade off speed of access for a GP appointment with the preferred attributes. Not surprisingly, preferences varied according to respondent characteristics such as age, gender and health status. Results from studies using direct questions about the respondent’s preference or strength of preference for individual attributes of care have varied somewhat according to the question and attributes included. Razzouk et al.15 asked respondents to rate the usefulness of 22 different information items (including patient satisfaction ratings) for choosing a new primary care physician. They found that respondents most frequently identified ratings of patient satisfaction with care quality, access and interpersonal skills as useful information for choosing a physician. Fung et al.16 asked respondents to choose between hypothetical primary care physicians described in terms of six attributes (three related to technical care and three related to interpersonal care). They found that physicians who were rated highly on technical aspects of care were selected more frequently than those rated highly on interpersonal aspects, and this did not differ by age, gender or ethnicity. This study used a task similar to DCE studies but a simpler design and analytic approach. Little et al.17 asked patients attending a GP appointment what they wanted from their medical encounter and using factor
27
28 Important factors for choosing a GP, P Kenny et al.
analysis identified three domains of patient preference (communication, partnership and health promotion) among the 21 questions (which were focused on patient-centred care). They found communication aspects reported more frequently than other aspects, and this varied by health, employment and frequency of GP visits.17 In addition to the above approaches, a number of studies have inferred preferences from the analysis of associations between patient evaluation of different aspects of their care and satisfaction with that care. Among these, aspects of care quality have dominated. Paddison et al.18 found that doctor communication was more strongly associated with patient satisfaction with primary care than other measures of patient experience including helpfulness of staff and measures of care availability. There were statistically significant but small differences in the effect sizes by ethnicity, health status and age.18 Tung and Chang19 found that patient evaluation of the doctor’s technical skill was the most important driver of satisfaction followed by interpersonal skill. In a study from the USA,20,21 both waiting time in the doctor’s office and time spent with the doctor were found to be important to satisfaction with a primary care physician, although the improvement in satisfaction associated with an additional minute spent with the doctor (3.78) was substantially greater than the decrement for an additional minute waiting (0.39). Fan et al.22 (also from the USA) found continuity was associated with satisfaction and this was the case for satisfaction with both the provider and the organizational aspects of care. This study also found that satisfaction increased with age and was higher for females, people with higher incomes and those reporting better mental health.22 A small Australian study23 also found associations between waiting time in the doctor’s office and satisfaction with primary care. Although the important factors for choosing a GP have been examined by a number of quantitative studies using a variety of methods, all have limitations. DCE studies can be cognitively
challenging and are limited by the number of attributes that can be included in the experiment. To date, most DCEs have only included between three and nine attributes. Inferring preference for factors from the associations between satisfaction with components of services and general satisfaction with the service is limited by the components of the service assessed and interpretation of satisfaction, which has previously been found to be attributable to patient factors to a much greater extent than differences in services or satisfaction with components of services (see, e.g. Salisbury et al.24). Few studies (other than DCEs) have directly measured preferences for attributes of GP care, and only one of these examined the dimensions of care underlying preferences; this study included a limited range of attributes because its focus was patientcentred care rather than GP care more broadly. In addition, few studies have examined preferences for GP care in the context of the Australian health-care system. This article reports a study investigating the important attributes for choosing a GP in Australia. It extends the existing literature by examining a comprehensive range of attributes of GP care and by assessing the extent to which these attributes can be grouped into underlying dimensions. It also explores the extent to which preferences are associated with individual health and demographic characteristics.
Methods A survey of Australian adults aged 16 or more was completed online in July 2013 by members of a panel hosted by Pureprofile (http:// www.pureprofile.com/au). The panel has a large number of account holders who have registered online to participate in surveys. Respondents are paid for each completed survey, according to the length of the survey. Information about the payment amount is included in the survey invitation, and the respondent chooses which surveys to complete. There are no inclusion/exclusion criteria for joining the panel except that panel members must be over 13 years of age. The invitation
ª 2015 John Wiley & Sons Ltd Health Expectations, 19, pp.26–38
Important factors for choosing a GP, P Kenny et al.
for the current study was only extended to panel members aged 16 or older. The survey asked respondents to rate the importance of a range of doctor and practice attributes to their choice of GP. There were 36 attributes, each with the same 5-point numeric response scale anchored at 1 = ‘not at all important’ and 5 = ‘extremely important’. The 36 questions are given in Table 1. Using the framework devised by Cheraghi-Sohi et al.,1 the 36 questions covered access to care in general, access to preferred services, technical care, interpersonal care in terms of communication, continuity (informational and relational/interpersonal) and hotel aspects (such as waiting room and parking). Although some of the questions we have identified as interpersonal care may also be seen as relating to patientcentredness (such as ‘the GP involves me in discussions about my treatment’), this aspect of the framework was not explicitly covered separately from the interpersonal care aspect. The survey also asked respondents about their experiences of GP care and usage, and included questions about health and sociodemographic characteristics. The questionnaire was devised for this survey and drew on existing questionnaires such as the Australian Bureau of Statistics Patient Experiences in Australia Survey.25 The doctor and practice attributes were identified from the literature on consumer preferences in general practice, particularly studies using DCE methods, and modified for the Australian context. The questionnaire was pilot-tested (n = 26) for clarity of language and interpretability and revised in response to respondent feedback. Principal components analysis (PCA) was used to identify dimensions among the 36 importance items and to facilitate reduction to a smaller number of summated scales. PCA assesses the existence of underlying latent variables or domains. It examines the extent to which some variables form a coherent subset by correlating with one another while being largely independent of other subsets.26 PCA was conducted using SAS version 9.3: SAS Institute Inc., Cary, NC, USA. Oblimin
ª 2015 John Wiley & Sons Ltd Health Expectations, 19, pp.26–38
rotation26 was used as some correlation among factors was expected, and it provided small improvements in interpretability of factors relative to varimax rotation. Items loading onto the same factor were interpreted as part of the same dimension, using factor loadings of 0.40 or greater. A five-factor solution explained 57.7% of the variance in the 36 items and was selected based on the scree plot and interpretability of factors. The factor loadings are given in Table 1. One item loaded onto two factors; ‘The doctor sees me promptly at the appointed time’ loaded onto Factor 3 (0.41) and Factor 4 (0.46) and was interpreted with the latter. As expected, there was some correlation between factors; Factor 1 correlated with Factor 4 (0.46), and Factor 2 correlated with Factor 3 (0.37) and Factor 5 (0.42). Dimension scores were estimated as the mean of items loading onto the same factor (possible range 1–5). The data were initially analysed to identify the individual items most frequently reported as important and unimportant and to examine the relative importance of the dimensions by comparing the mean dimension scores and their 95% confidence intervals (CI). Multiple regression analyses were then used to identify the respondent characteristics associated with each dimension score. The characteristics of primary interest were those relating to health, health-care access and GP utilization; therefore, all models included age, an indicator for the existence of at least one chronic condition, self-reported health status, GP visits in the past year, area of residence and concession status. The Australian government provides a range of concession cards linked to its various income support programmes some of which can also be accessed by low-income families and retirees. Concession status was included because it can be an important determinant of access to free primary health-care services. Other demographic characteristics were initially entered into the models but only retained if statistically significant; these included gender, education, income, marital status, having children aged
Community preferences in general practice: important factors for choosing a general practitioner Patricia Kenny MPH,* Richard De Abreu Lourenco MEc,† Chun Yee Wong PhD,† Marion Haas PhD‡ and Stephen Goodall PhD§ *Senior Research Fellow, †Research Fellow, ‡Professor of Health Economics and §Associate Professor of Health Economics, Centre for Health Economics Research & Evaluation, University of Technology Sydney, Sydney, NSW, Australia
Abstract Correspondence Patricia Kenny Senior Research Fellow Centre for Health Economics Research & Evaluation University of Technology Sydney PO Box 123 Broadway Sydney NSW 2007 Australia E-mail: [email protected]. Accepted for publication 28 November 2014 Keywords: consumers, general practice, preferences
Background Understanding the important factors for choosing a general practitioner (GP) can inform the provision of consumer information and contribute to the design of primary care services. Objective To identify the factors considered important when choosing a GP and to explore subgroup differences. Design An online survey asked about the respondent’s experience of GP care and included 36 questions on characteristics important to the choice of GP. Participants An Australian population sample (n = 2481) of adults aged 16 or more. Methods Principal components analysis identified dimensions for the creation of summated scales, and regression analysis was used to identify patient characteristics associated with each scale. Results The 36 questions were combined into five scales (score range 1–5) labelled: care quality, types of services, availability, cost and practice characteristics. Care quality was the most important factor (mean = 4.4, SD = 0.6) which included questions about technical care, interpersonal care and continuity. Cost (including financial and time cost) was also important (mean = 4.1, SD = 0.6). The least important factor was types of services (mean = 3.3, SD = 0.9), which covered the range of different services provided by or co-located with the practice. Frequent GP users and females had higher scores across all 5 scales, while the importance of care quality increased with age. Conclusions When choosing a GP, information about the quality of care would be most useful to consumers. Respondents varied in the importance given to some factors including types of services, suggesting the need for a range of alternative primary care services.
26
ª 2015 John Wiley & Sons Ltd Health Expectations, 19, pp.26–38
Important factors for choosing a GP, P Kenny et al.
Introduction Understanding the factors consumers regard as important when choosing a general practitioner (GP) or primary health-care provider can be important for ensuring the availability of relevant and useable information for consumer decision making. Identification of the practitioner and practice attributes regarded as important can also inform health-care policy by contributing to the design of primary care services which reflect the priorities of the users of those services. This study aimed to identify the factors people in Australia consider important when choosing a GP and to examine the extent to which this varies by health and demographic characteristics. Through an examination of conceptual reviews and empirical studies, Cheraghi-Sohi1 developed a ‘conceptual map’ of the key attributes of primary care that were important to patients. They identified seven attribute categories: access (to care and to preferred services), technical care quality, interpersonal care (including communication and explanation), patient-centredness, continuity (of information, care and provider), outcomes (including health status, quality of life and satisfaction) and hotel aspects (such as waiting room).1 This wide-ranging list was found to be too large to be comprehensively addressed by most patient assessment instruments. A number of survey methods have been used for measuring preferences in relation to primary care including direct rating of the importance of a range of attributes of care and discrete choice experiments (DCE). Direct questions rating the extent of preference for each attribute allow for the inclusion of a large number of different attributes but do not force respondents to weigh up the relative importance of different attributes and so may lack sensitivity to differences between attributes, for example where many respondents identify all or most attributes as important. Discrete choice experiments offer respondents a series of choices where attribute levels vary between choice options and across choices. This approach has the advantage of being able to quantify the
ª 2015 John Wiley & Sons Ltd Health Expectations, 19, pp.26–38
extent to which respondents would trade attributes of care against each other but is constrained by the number of different attributes that can be feasibly considered at one time. Discrete choice experiment surveys investigating preferences for GP services have originated mainly in Europe (predominantly the UK) and have generally found technical quality of care,2,3 doctor communication,4–7 information provided,4,6,8 continuity of care2,3,9,10 and choice of provider9–13 to be the most important attributes for GP care among those included in the relevant experiments. In the Australian context, Haas14 found that trust in the doctor was more important than other interpersonal aspects for choosing to remain with a GP. In many of the DCE studies, respondents were willing to trade off speed of access for a GP appointment with the preferred attributes. Not surprisingly, preferences varied according to respondent characteristics such as age, gender and health status. Results from studies using direct questions about the respondent’s preference or strength of preference for individual attributes of care have varied somewhat according to the question and attributes included. Razzouk et al.15 asked respondents to rate the usefulness of 22 different information items (including patient satisfaction ratings) for choosing a new primary care physician. They found that respondents most frequently identified ratings of patient satisfaction with care quality, access and interpersonal skills as useful information for choosing a physician. Fung et al.16 asked respondents to choose between hypothetical primary care physicians described in terms of six attributes (three related to technical care and three related to interpersonal care). They found that physicians who were rated highly on technical aspects of care were selected more frequently than those rated highly on interpersonal aspects, and this did not differ by age, gender or ethnicity. This study used a task similar to DCE studies but a simpler design and analytic approach. Little et al.17 asked patients attending a GP appointment what they wanted from their medical encounter and using factor
27
28 Important factors for choosing a GP, P Kenny et al.
analysis identified three domains of patient preference (communication, partnership and health promotion) among the 21 questions (which were focused on patient-centred care). They found communication aspects reported more frequently than other aspects, and this varied by health, employment and frequency of GP visits.17 In addition to the above approaches, a number of studies have inferred preferences from the analysis of associations between patient evaluation of different aspects of their care and satisfaction with that care. Among these, aspects of care quality have dominated. Paddison et al.18 found that doctor communication was more strongly associated with patient satisfaction with primary care than other measures of patient experience including helpfulness of staff and measures of care availability. There were statistically significant but small differences in the effect sizes by ethnicity, health status and age.18 Tung and Chang19 found that patient evaluation of the doctor’s technical skill was the most important driver of satisfaction followed by interpersonal skill. In a study from the USA,20,21 both waiting time in the doctor’s office and time spent with the doctor were found to be important to satisfaction with a primary care physician, although the improvement in satisfaction associated with an additional minute spent with the doctor (3.78) was substantially greater than the decrement for an additional minute waiting (0.39). Fan et al.22 (also from the USA) found continuity was associated with satisfaction and this was the case for satisfaction with both the provider and the organizational aspects of care. This study also found that satisfaction increased with age and was higher for females, people with higher incomes and those reporting better mental health.22 A small Australian study23 also found associations between waiting time in the doctor’s office and satisfaction with primary care. Although the important factors for choosing a GP have been examined by a number of quantitative studies using a variety of methods, all have limitations. DCE studies can be cognitively
challenging and are limited by the number of attributes that can be included in the experiment. To date, most DCEs have only included between three and nine attributes. Inferring preference for factors from the associations between satisfaction with components of services and general satisfaction with the service is limited by the components of the service assessed and interpretation of satisfaction, which has previously been found to be attributable to patient factors to a much greater extent than differences in services or satisfaction with components of services (see, e.g. Salisbury et al.24). Few studies (other than DCEs) have directly measured preferences for attributes of GP care, and only one of these examined the dimensions of care underlying preferences; this study included a limited range of attributes because its focus was patientcentred care rather than GP care more broadly. In addition, few studies have examined preferences for GP care in the context of the Australian health-care system. This article reports a study investigating the important attributes for choosing a GP in Australia. It extends the existing literature by examining a comprehensive range of attributes of GP care and by assessing the extent to which these attributes can be grouped into underlying dimensions. It also explores the extent to which preferences are associated with individual health and demographic characteristics.
Methods A survey of Australian adults aged 16 or more was completed online in July 2013 by members of a panel hosted by Pureprofile (http:// www.pureprofile.com/au). The panel has a large number of account holders who have registered online to participate in surveys. Respondents are paid for each completed survey, according to the length of the survey. Information about the payment amount is included in the survey invitation, and the respondent chooses which surveys to complete. There are no inclusion/exclusion criteria for joining the panel except that panel members must be over 13 years of age. The invitation
ª 2015 John Wiley & Sons Ltd Health Expectations, 19, pp.26–38
Important factors for choosing a GP, P Kenny et al.
for the current study was only extended to panel members aged 16 or older. The survey asked respondents to rate the importance of a range of doctor and practice attributes to their choice of GP. There were 36 attributes, each with the same 5-point numeric response scale anchored at 1 = ‘not at all important’ and 5 = ‘extremely important’. The 36 questions are given in Table 1. Using the framework devised by Cheraghi-Sohi et al.,1 the 36 questions covered access to care in general, access to preferred services, technical care, interpersonal care in terms of communication, continuity (informational and relational/interpersonal) and hotel aspects (such as waiting room and parking). Although some of the questions we have identified as interpersonal care may also be seen as relating to patientcentredness (such as ‘the GP involves me in discussions about my treatment’), this aspect of the framework was not explicitly covered separately from the interpersonal care aspect. The survey also asked respondents about their experiences of GP care and usage, and included questions about health and sociodemographic characteristics. The questionnaire was devised for this survey and drew on existing questionnaires such as the Australian Bureau of Statistics Patient Experiences in Australia Survey.25 The doctor and practice attributes were identified from the literature on consumer preferences in general practice, particularly studies using DCE methods, and modified for the Australian context. The questionnaire was pilot-tested (n = 26) for clarity of language and interpretability and revised in response to respondent feedback. Principal components analysis (PCA) was used to identify dimensions among the 36 importance items and to facilitate reduction to a smaller number of summated scales. PCA assesses the existence of underlying latent variables or domains. It examines the extent to which some variables form a coherent subset by correlating with one another while being largely independent of other subsets.26 PCA was conducted using SAS version 9.3: SAS Institute Inc., Cary, NC, USA. Oblimin
ª 2015 John Wiley & Sons Ltd Health Expectations, 19, pp.26–38
rotation26 was used as some correlation among factors was expected, and it provided small improvements in interpretability of factors relative to varimax rotation. Items loading onto the same factor were interpreted as part of the same dimension, using factor loadings of 0.40 or greater. A five-factor solution explained 57.7% of the variance in the 36 items and was selected based on the scree plot and interpretability of factors. The factor loadings are given in Table 1. One item loaded onto two factors; ‘The doctor sees me promptly at the appointed time’ loaded onto Factor 3 (0.41) and Factor 4 (0.46) and was interpreted with the latter. As expected, there was some correlation between factors; Factor 1 correlated with Factor 4 (0.46), and Factor 2 correlated with Factor 3 (0.37) and Factor 5 (0.42). Dimension scores were estimated as the mean of items loading onto the same factor (possible range 1–5). The data were initially analysed to identify the individual items most frequently reported as important and unimportant and to examine the relative importance of the dimensions by comparing the mean dimension scores and their 95% confidence intervals (CI). Multiple regression analyses were then used to identify the respondent characteristics associated with each dimension score. The characteristics of primary interest were those relating to health, health-care access and GP utilization; therefore, all models included age, an indicator for the existence of at least one chronic condition, self-reported health status, GP visits in the past year, area of residence and concession status. The Australian government provides a range of concession cards linked to its various income support programmes some of which can also be accessed by low-income families and retirees. Concession status was included because it can be an important determinant of access to free primary health-care services. Other demographic characteristics were initially entered into the models but only retained if statistically significant; these included gender, education, income, marital status, having children aged
