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      Patients’ experience and satisfaction in primary care: secondary analysis using multilevel modelling

      research-article

      , 1 , 2 , 1

      BMJ : British Medical Journal

      BMJ Publishing Group Ltd.

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          Abstract

          Objective To explore whether responses to questions in surveys of patients that purport to assess the performance of general practices or doctors reflect differences between practices, doctors, or the patients themselves.

          Design Secondary analysis of data from a study of access to general practice, combining data from a survey of patients with information about practice organisation and doctors consulted, and using multilevel modelling at practice, doctor, and patient level.

          Setting Nine primary care trusts in England.

          Participants 4573 patients who consulted 150 different doctors in 27 practices.

          Main outcome measures Overall satisfaction; experience of wait for an appointment; reported access to care; satisfaction with communication skills.

          Results The experience based measure of wait for an appointment was more discriminating between practices (practice level accounted for 20.2% (95% confidence interval 9.1% to 31.3%) of variance) than was the overall satisfaction measure (practice level accounted for 4.6% (1.6% to 7.6%) of variance). Only 6.3% (3.8% to 8.9%) of the variance in the doctors’ communication skills measure was due to differences between doctors; 92.4% (88.5% to 96.4%) of the variance occurred at the level of the patient (including differences between patients’ perceptions and random variation). At least 79% of the variance on all measures occurred at the level of the patient, and patients’ age, sex, ethnicity, and housing and employment status explained some of this variation. However, adjustment for patients’ characteristics made very little difference to practices’ scores or the ranking of individual practices.

          Conclusions Analyses of surveys of patients should take account of the hierarchical nature of the data by using multilevel models. Measures related to patients’ experience discriminate more effectively between practices than do measures of general satisfaction. Surveys of patients’ satisfaction fail to distinguish effectively between individual doctors because most of the variation in doctors’ reported performance is due to differences between patients and random error rather than differences between doctors. Although patients’ reports of satisfaction and experience are systematically related to patients’ characteristics such as age and sex, the effect of adjusting practices’ scores for the characteristics of their patients is small.

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          Most cited references 20

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          Patients' experiences and satisfaction with health care: results of a questionnaire study of specific aspects of care.

          To determine what aspects of healthcare provision are most likely to influence satisfaction with care and willingness to recommend hospital services to others and, secondly, to explore the extent to which satisfaction is a meaningful indicator of patient experience of healthcare services. Postal survey of a sample of patients who underwent a period of inpatient care. Patients were asked to evaluate their overall experience of this episode of care and to complete the Picker Inpatient Survey questionnaire on specific aspects of their care. Patients aged 18 and over presenting at five hospitals within one NHS trust in Scotland. 3592 questionnaires were mailed to patients' homes within 1 month of discharge from hospital during a 12 month period. Two reminders were sent to non-responders; 2249 (65%) questionnaires were returned. Almost 90% of respondents indicated that they were satisfied with their period of inpatient care. Age and overall self-assessed health were only weakly associated with satisfaction. A multiple linear regression indicated that the major determinants of patient satisfaction were physical comfort, emotional support, and respect for patient preferences. However, many patients who reported their satisfaction with the care they received also indicated problems with their inpatient care as measured on the Picker Inpatient Survey; 55% of respondents who rated their inpatient episode as "excellent" indicated problems on 10% of the issues measured on the Picker questionnaire. The evidence suggests that patient satisfaction scores present a limited and optimistic picture. Detailed questions about specific aspects of patients' experiences are likely to be more useful for monitoring the performance of various hospital departments and wards and could point to ways in which delivery of health care could be improved.
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            Age, gender, socioeconomic, and ethnic differences in patients' assessments of primary health care.

            Patients' evaluations are an important means of measuring aspects of primary care quality such as communication and interpersonal care. This study aims to examine variations in assessments of primary care according to age, gender, socioeconomic, and ethnicity variables. A cross sectional survey of consecutive patients attending 55 inner London practices was performed over a 2 week period using the General Practice Assessment Survey (GPAS) instrument which assesses 13 important dimensions of primary care provision. Variations in scale scores were investigated for differences relating to age, gender, socioeconomic, and ethnic status as reported by respondents. A total of 7692 questionnaires were returned (71% response rate). Valid information on age, gender, socioeconomic status, and ethnicity was available for 4819 out of 5496 adult respondents. Approximately half the respondents reported their ethnic group as "white" and most of the remaining respondents reported belonging to "black" or South Asian groups. Significant differences existed between groups of patients defined by age or ethnicity for most of the scale scores examined. Black, South Asian, and Chinese respondents reported lower scores (representing less favourable assessments) than white respondents; older respondents reported more favourable evaluations of care than younger respondents; and less affluent groups reported lower scores than more affluent groups for two of the 13 dimensions. There was no significant difference between gender groups with respect to assessment of primary care. Age and ethnicity were independent predictors of respondents' assessments of primary care. Differences exist between identifiable subgroups of the population in their assessments of primary health care measured using the GPAS instrument. This work adds to the literature on variation in healthcare experience and the potential for patient assessment of primary care. Further work is required to investigate these differences in more detail and to relate them to differences in the nature and process of primary care provision. Primary care providers need to ensure that services provided are appropriate for all patient groups within their communities.
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              Patient sociodemographic characteristics as predictors of satisfaction with medical care: a meta-analysis.

              A meta-analysis was performed to examine the relation of patients' sociodemographic characteristics to their satisfaction with medical care. The sociodemographic characteristics were age, ethnicity, sex, socioeconomic status (three indices), marital status, and family size. Greater satisfaction was significantly associated with greater age and less education, and marginally significantly associated with being married and having higher social status (scored as a composite variable emphasizing occupational status). The average magnitudes of relations were very small, with age being the strongest correlate of satisfaction (mean r = 0.13). No overall relationship was found for ethnicity, sex, income, or family size. For all sociodemographic variables, the distribution of correlations was significantly heterogeneous, and statistical contrasts revealed the operation of several moderating variables. The meaning of the overall results and their relation to earlier reviews is discussed.
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                Author and article information

                Contributors
                Role: professor of primary health care
                Role: ST2 core medical doctor
                Role: reader in health services research
                Journal
                BMJ
                bmj
                BMJ : British Medical Journal
                BMJ Publishing Group Ltd.
                0959-8138
                1468-5833
                2010
                2010
                12 October 2010
                : 341
                Affiliations
                [1 ]University of Bristol, Bristol BS8 2AA, UK
                [2 ]Royal Berkshire Hospital, Reading RG1 5AN, UK
                Author notes
                Correspondence to: C Salisbury  c.salisbury@ 123456bristol.ac.uk
                Article
                salc748202
                10.1136/bmj.c5004
                2954274
                20940212
                © Salisbury et al 2010

                This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/2.0/ and http://creativecommons.org/licenses/by-nc/2.0/legalcode.

                Product
                Categories
                Research
                Patients
                General Practice / Family Medicine
                Communication
                Ethnic Studies

                Medicine

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