Article Figures & Data
Tables
Conceptual Definition Operational Definition of Minimal Expectation (PCAT Subscale) PCAT=Primary Care Assessment Tool. a In Canada, all physicians who are not general practitioners or family physicians are specialists. First-contact accessibility: the ability of a person to obtain needed care (including advice and support) from the practitioner of choice within a time frame appropriate to the urgency of the problem20 Patients should express confidence that they could probably get advice or be seen within 1 day by someone at their regular clinic if they suddenly get sick and need care. (First-Contact Access PCAT subscale, 4 items) Relational continuity: a therapeutic relationship with a practitioner that spans more than 1 episode of care and leads, in the practitioner, to a sense of clinical responsibility and an accumulated knowledge of the patient’s personal and medical circumstances5 Accumulated knowledge: patients should express confidence that their physician probably knows their medical history and personal situation. (Ongoing Care PCAT subscale, 8 items) Clinical responsibility: patients should express confidence that their physician’s clinical responsibility probably extends beyond the clinical encounter. (Ongoing Care PCAT subscale, 4 items) Coordination continuity: the delivery of services by different practitioners in a timely and complementary manner so that care is connected and cohesive for the patient5 Patients should express confidence that their primary care physician and the specialistsa communicate and collaborate in their care. (Coordination PCAT subscale, 8 items) Characteristic Percent Type Private group practice 57 Private solo practice 16 Stand-alone, walk-in clinic 10 Community health center (CLSC) 17 Location Urban 38 Suburban 22 Rural 24 Remote 16 Have a nurse on site 39 Have an occupational or physical therapist on site 25 Offer 24/7 telephone access other than provincial nurse help-line 7 Offer walk-in services None 26 Daytime only 36 Daytime and evening 11 Daytime, evening, and weekends 27 Offer scheduled visits during Evenings 48 Weekends 13 No. of other health care establishments with which the clinic has formal, operational agreements 0 53 1 14 2 15 3 15 4 3 - Table 3.
Percentage by Which PCAT Scores Were Above or Below the Minimal Expected Standard Score of 3 at Various Levels for Each Dimension (N = 100 Clinics)
Level Dimension Mean Minimum 25th Percentile 75th Percentile Maximum PCAT=Primary Care Assessment Tool. Note: Values are expressed as percentage above or below minimal PCAT score. A PCAT score of 3 (probably) is the minimal threshold; a score of 1 (definitely not) would be −100% below minimal expectation, and a score of 4 (definitely) would be +100% above minimal. For example, for first-contact accessibility, the mean score of 2.30 was 35% below the minimal expected standard of 3. First-contact accessibility −35 (2.30) −68 (1.63) −44 (2.11) −29 (2.41) 85 (3.85) Relational continuity 36 (3.35) −13 (2.72) 27 (3.26) 48 (3.47) 76 (3.76) Coordination continuity 30 (3.30) −34 (2.31) 15 (3.13) 49 (3.49) 100 (4.00) - Table 4.
Characteristics of Clinic Organization and Physician Practice That Influence Patients’ Confidence in First-Contact Accessibilitya
Characteristic Multivariate Regression Coefficient (95% CI) CI=confidence interval. Note: the overall adjusted R2=15.7%. a Results of hierarchical regression modeling showing the impact on achievement of optimal first-contact accessibility. The model controlled for patient age, education, and use of primary care. Only the clinic’s regular patients were included in the analysis (N = 2,725). b Some 20.3% of the variance in first-contact accessibility was attributed to between-clinic variance, of which 77.1% was explained by the final model. c Some 3.2% of the variance in first-contact accessibility was attributed to between-physician variance; physician-level characteristics decreased between-clinic variance but not between-physician variance. Mean first-contact accessibility for all clinics 2.30 (2.26 to 2.33) Clinic-level characteristicsb Practice culture Priority of rapid access (effect of 1-unit increase in the importance at the clinic on a 5-point scale centered on the average for all clinics) 0.07 (0.01 to 0.14) Clinic structure More than 10 family physicians (compared with =10) −0.21 (−0.33 to −0.09) Presence of a nurse in the clinic (compared with no nurse) 0.12 (0.05 to 0.19) Availability of 24/7 telephone access other than provincial nurse help line 0.30 (0.10 to 0.50) No. of other health care establishments with which the clinic has formal, operational agreements (effect of each additional establishment) 0.03 (0.00 to 0.06) Clinic services Availability of evening walk-in services 0.07 (0.00 to 0.14) Availability of weekend walk-in services – No. of hours open during the week above 55 hours (effect of each additional hour) 0.008 (0.006 to 0.010) Physician-level characteristicsc Next appointment in less than 1 week (compared with >1 week) 0.09 (0.01 to 0.17) No. of patients seen per hour (each additional patient above the mean of 3.4 patients per hour) 0.02 (−0.1 to 0.05) Manage urgent care by meeting patients at the hospital emergency department −0.17 (−0.25 to −0.09) - Table 5.
Characteristics of Clinic Organization and Physician Practice That Influence Patients’ Confidence in Relational Continuitya
Characteristic Multivariate Regression Coefficient (95% CI) CI=confidence interval. Note: the overall adjusted R2=15.9%. a Results of hierarchical regression modeling showing impact on achievement of optimal relational continuity. The model controlled for patient age, education, and use of primary care. Only the physician’s regular patients were included (N = 2,725). b Some 8.8% of the variance in relational continuity was attributed to between-clinic variance, of which 73.9% was explained by the final model. c Some 6.7% of the variance in relational continuity was attributed to between-physician variance, of which 40% was explained by the final model. Mean relational continuity for all clinics 3.35 (3.34 to 3.39) Clinic-level characteristicsb Clinic structure No. of other health care establishments with which the clinic has formal, operational agreements (effect of each additional establishment) 0.03 (0.00 to 0.04) Clinic services Availability of scheduled visits in the evening 0.05 (−0.01 to 0.10) Availability of scheduled visits on weekends — Physician-level characteristicsc Physician orientation Attachment to the community served by the clinic 0.05 (0.02 to 0.08) Physician intentions for informational continuity (communication of visit results to patient’s responsible physician) 0.09 (0.06 to 0.13) Physician practice Percentage of clinic hours spent on walk-in care =70% (compared with <50%) −0.14 (−0.24 to 0.05) No. of patients seen per hour (each additional patient above the mean of 3.4 patients per hour) −0.03 (−0.05 to 0.00) - Table 6.
Characteristics of Clinic Organization and Physician Practice That Influence Patients’ Confidence in Coordination Continuitya
Characteristic Multivariate Regression Coefficient (95% CI) CI=confidence interval. Note: the overall adjusted R2=7.8%. a Results of hierarchical regression modeling showing impact on achievement of optimal coordination continuity. The model controlled for patient age, education, and use of primary care. Only the physician’s regular patients who had seen a specialist in the last 2 years were included (n = 1,682). b Some 2.4% of the total variance in coordination continuity was explained by between-clinic variance, almost all of which (98%) was explained by the final model. c Some 6.3% of the total variance in coordination continuity was explained by between-physician variance, of which 79.6% was explained by the final model. Mean coordination continuity for all patients 3.30 (2.28 to 3.39) Clinic-level characteristicsb Clinic structure Availability of 24/7 telephone access other than provincial nurse help line 0.16 (0.04 to 0.28) No. of other health care establishments with which the clinic has formal, operational agreements (effect of each additional establishment) 0.04 (0.04 to 0.07) Presence of occupational and physical therapists 0.12 (0.03 to 0.21) Physician-level characteristicsc No. of medical procedures performed on site by the physician (effect of each additional procedure above the mean of 3.8) 0.02 (0.00 to 0.04) Percentage of time spent in clinic is <50% — Percentage of time spent in clinic is 50%–70% 0.09 (−0.02 to 0.23) Percentage of time spent in clinic is 70%–90% —
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The Article in Brief
Practice Features Associated With Patient-Reported Accessibility, Continuity, and Coordination of Primary Health Care
Jeannie L. Haggerty, PhD , and colleagues
Background In this study in Quebec, Canada, researchers measure the organizational and professional characteristics of primary care practice that are associated with accessible care, continuity (an ongoing patient-doctor relationship), and coordination of care between different clinicians.
What This Study Found The way the medical practice is organized influences both continuity and accessible care. This includes offering care in the evenings, access to telephone advice, and establishing operational agreements with other health care establishments. Patients in this study have little confidence that they can get needed care from the clinician of their choice in a time frame that is appropriate to the urgency of the problem, but they have positive assessments of continuity and coordination between their family physician and specialists.
Implications
- The study suggests ways to organize and deliver primary health care for better accessibility and continuity, especially in the Canadian health care system.
- Telephone access for patients is an important feature.
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