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Research ArticleOriginal Research

Practice Features Associated With Patient-Reported Accessibility, Continuity, and Coordination of Primary Health Care

Jeannie L. Haggerty, Raynald Pineault, Marie-Dominique Beaulieu, Yvon Brunelle, Josée Gauthier, François Goulet and Jean Rodrigue
The Annals of Family Medicine March 2008, 6 (2) 116-123; DOI: https://doi.org/10.1370/afm.802
Jeannie L. Haggerty
PhD
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Raynald Pineault
MD, PhD
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Marie-Dominique Beaulieu
MD, MSc
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Yvon Brunelle
MA
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Josée Gauthier
MSc
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François Goulet
MD
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Jean Rodrigue
MD
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    Table 1.

    Definitions of Accessibility and Continuity of Primary Health Care

    Conceptual DefinitionOperational 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 problem20Patients 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 circumstances5Accumulated 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 patient5Patients should express confidence that their primary care physician and the specialistsa communicate and collaborate in their care. (Coordination PCAT subscale, 8 items)
    • View popup
    Table 2.

    Characteristics of the Study Clinics (N=100)

    CharacteristicPercent
    Type
        Private group practice57
        Private solo practice16
        Stand-alone, walk-in clinic10
        Community health center (CLSC)17
    Location
        Urban38
        Suburban22
        Rural24
        Remote16
    Have a nurse on site39
    Have an occupational or physical therapist on site25
    Offer 24/7 telephone access other than provincial nurse help-line7
    Offer walk-in services
        None26
        Daytime only36
        Daytime and evening11
        Daytime, evening, and weekends27
    Offer scheduled visits during
        Evenings48
        Weekends13
    No. of other health care establishments with which the clinic has formal, operational agreements
        053
        114
        215
        315
        43
    • View popup
    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
    DimensionMeanMinimum25th Percentile75th PercentileMaximum
    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 continuity36 (3.35)−13 (2.72)27 (3.26)48 (3.47)76 (3.76)
    Coordination continuity30 (3.30)−34 (2.31)15 (3.13)49 (3.49)100 (4.00)
    • View popup
    Table 4.

    Characteristics of Clinic Organization and Physician Practice That Influence Patients’ Confidence in First-Contact Accessibilitya

    CharacteristicMultivariate 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 clinics2.30 (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 line0.30 (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 services0.07 (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)
    • View popup
    Table 5.

    Characteristics of Clinic Organization and Physician Practice That Influence Patients’ Confidence in Relational Continuitya

    CharacteristicMultivariate 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 clinics3.35 (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 evening0.05 (−0.01 to 0.10)
        Availability of scheduled visits on weekends—
    Physician-level characteristicsc
    Physician orientation
        Attachment to the community served by the clinic0.05 (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)
    • View popup
    Table 6.

    Characteristics of Clinic Organization and Physician Practice That Influence Patients’ Confidence in Coordination Continuitya

    CharacteristicMultivariate 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 patients3.30 (2.28 to 3.39)
    Clinic-level characteristicsb
    Clinic structure
        Availability of 24/7 telephone access other than provincial nurse help line0.16 (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 therapists0.12 (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%—

Additional Files

  • Tables
  • 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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The Annals of Family Medicine: 6 (2)
The Annals of Family Medicine: 6 (2)
Vol. 6, Issue 2
1 Mar 2008
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Practice Features Associated With Patient-Reported Accessibility, Continuity, and Coordination of Primary Health Care
Jeannie L. Haggerty, Raynald Pineault, Marie-Dominique Beaulieu, Yvon Brunelle, Josée Gauthier, François Goulet, Jean Rodrigue
The Annals of Family Medicine Mar 2008, 6 (2) 116-123; DOI: 10.1370/afm.802

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Practice Features Associated With Patient-Reported Accessibility, Continuity, and Coordination of Primary Health Care
Jeannie L. Haggerty, Raynald Pineault, Marie-Dominique Beaulieu, Yvon Brunelle, Josée Gauthier, François Goulet, Jean Rodrigue
The Annals of Family Medicine Mar 2008, 6 (2) 116-123; DOI: 10.1370/afm.802
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