Patient perspective on task shifting from general practitioners to medical practice assistants – a quantitative survey in Germany

As part of the practice-based research network “RESPoNsE” (RESearch Practice Network East: https://​forschungspraxen​netz.​charite.​de/​) funded by the German Federal Ministry of Education and Research (BMBF), a project on attitudes towards the assignment of medical tasks to MPAs from the perspective of GPs, MPAs and patients was carried out. The planning of the project and the development of the questionnaires was conducted with the involvement of the practice advisory board of the RESPoNsE network. The results of the questionnaire survey conducted in summer 2021 among all Statutory Health Insurance-accredited GPs in Berlin, Brandenburg, and Thuringia (n = 5516, Fig. 1) and their employed MPAs are reported elsewhere [38]. Participating practices were asked to also take part in the subsequent explorative and anonymous cross-sectional survey among patients of GP practices. Due to the explorative nature of the study, no sample size calculation or power calculation was performed. The feasible number of questionnaires to be completed within the given time of two week was discussed with our practice advisory board. Fifty questionnaires were sent to each practice accordingly. In order to participate in the study it was not requested to provide a minimum number of completed questionnaires.

The self-designed, double-sided printed German-language questionnaire was developed based on literature research of comparable studies and on the GP/MPA questionnaire [38]. The piloting of the questionnaire was carried out in two steps: First GPs (n = 7) and non-physician colleagues (n = 7) as well as two medical layperson were asked to test the questionnaire. As a result, changes were made to the questionnaire. Secondly, the survey procedure (handing out, assigning patients, answering, and returning of the questionnaires) as well as the handling and comprehensibility of all study documents were piloted in one general practice. At this, questionnaire items were piloted again, this time by patients of the practice. No further changes were necessary.

Data collection among participating practices was performed during a two-week survey period in September 2021. The practice teams were informed that they should distribute the questionnaires randomly to the patients during the survey period and not favour certain subgroups of patients or individuals.

The key patient inclusion criteria were sufficient knowledge of the German language and a minimum age of 18 years.

The questionnaire consisted of 18 questions. In addition to the collection of sociodemographic patient data (six questions: age, gender, federal state, region of residence, employment status, educational level), information was collected on the practice visit (four questions: visit with appointment or not, current reason for consultation, urgency and complexity of the issue) and on patients’ state of health (three questions: presence of a chronic disease, state of health in the last two weeks and compared to six months ago). Patients were also asked how long they had been receiving treatment at the practice, how often they had visited the practice in the last twelve months, and to what extent the Corona pandemic had had an influence on the frequency of their practice visits (three questions). Regarding the attitude towards delegation of medical tasks (acceptance of task delegation), the patients were able to mark whether it was absolutely necessary for them to consult their GP for their current problem/request or whether they could also be cared exclusively by MPAs (one question). This assignment could only be made once regarding the current problem/request, even if the patients had more than one problem. Furthermore, the willingness of the patients to be treated by MPAs was asked based on five predefined theoretical reasons for treatment (1. Repeat/follow-up prescription, 2. Sick leave due to a slight cold, 3. Referral, 4. Routine health check, 5. Uncomplicated problem, e.g. a slight cold or vaccination against influenza), each with three possible answers (yes/maybe/no). In general we avoided using the term “delegation” as it is probably not familiar to many patients. Instead, we described the process with easier words (“For my present concern, do I absolutely have to speak to the GP, or could the MPAs help without me talking to the GP?”). The questionnaires were pseudonymised at practice level to provide each practice with the results of their patients compared to the total sample of the study. This possibility of comparison was intended to be an additional incentive for participating practices.

Positive ethics votes were available from all three federal states before the start of the study (Berlin: EA1/025/21, Brandenburg: AS34(bB)/2021, Thuringia: 2021–2176-Bef).

Of the contacted GPs (n = 5516) 235 showed interest (response rate 4.3%, Fig. 1) in the patient survey. A total of 101 GPs (Thuringia n = 19, Berlin n = 44, Brandenburg n = 38) signed the consent form for study participation (Fig. 1). A total of 5.050 questionnaires (50 per practice) were sent to these practices. A total of 61 GPs with 1861 valid patient questionnaires participated (Fig. 1). Referring to all GPs who had the opportunity to participate and who were contacted, 1.1% participated. On average, participating practices returned 31 questionnaires (SD 17, min/max 2/50). Of the questionnaires received (n = 1888), 27 were excluded due to the age of the participants (younger than 18 years) (Fig. 1).

More than half of the study participants were female (58.0%) with an average age of 55 years (Table 1). Overall, 50.3% rated their health status as good or very good (Table 1). The detailed characteristics of the study participants are shown in Table 1. At the time of the survey, 61.0% of the patients came to the practice with an appointment (Table 2). More than half of the respondents considered their problem/request to be very or rather urgent (58.3%), 23.8% of the respondents considered their problem/request to be very or rather complicated (Table 2). The most frequently cited reasons for consulting the practice were (multiple responses were possible): acute complaints (34.1%), known problem (28.0%), prescription (28.2%), and routine health check (24.5%) (Table 2). The most frequently mentioned free text answers to the question about other reasons could be categorised as “routine health check” (e.g., blood sampling, control/preventive examinations) and “existing or new problem” (e.g., evaluation of findings, health complaints).

Patients’ acceptance of speaking exclusively with MPAs and not consulting GPs regarding their current problem/request varied at the level of the federal states between 25.3% in Thuringia and 32.3% in Berlin (Table 2). For the entire data set, this applied to 29.6% of respondents (Table 2). When asked about the current reason for visiting the practice, multiple answers were possible. Patients mainly wanted to see a GP for acute complaints, known or new problems, sick leave, and other medical certificates (Fig. 2). Respondents were most likely to imagine receiving help from MPAs exclusively for vaccination/vaccination advice (40.2%) and prescription (33.4%) (Fig. 2).

The willingness to be treated exclusively by MPAs was also surveyed in relation to five theoretical reasons for care. For all five scenarios, over 54% of respondents expressed their agreement with care being provided by MPAs (Fig. 3). The highest level of agreement was obtained for the scenarios “repeat prescription/follow-up prescription” (85.6%) and “referral” (69.9%) (Fig. 3). The most frequent free-text responses on other reasons could be categorised as “discussion of medical findings”, “vaccination/vaccination consultation”, “examinations” and “health complaints”.

Multivariable analysis was used to adjust for possible confounding. For the present model, the ICC was 12.7%, which corresponded to substantial differences in task delegation acceptance responses between practices. The model showed an effect of age (10-year-OR 0.84, 95%-CI [0.75, 0.93]) and subjectively perceived complexity (OR = 0.44, 95%-CI [0.26, 0.8]) of the current concern on delegation acceptance (Fig. 4). Younger age and reporting a less complicated problem/request were associated with a higher willingness to seek care exclusively from MPAs instead of GPs. Furthermore, patients were more likely to seek care from GPs with the following problems/requests: “acute complaints” (OR = 0.27, 95%-CI [0.17, 0.45]), “routine health check” (OR = 0.48, 95%-CI [0.30, 0.79]), “new problem” (OR = 0.13, 95%-CI [0.06, 0.28]) and “known problem” (OR = 0.16, 95%-CI [0.10, 0.27]) (Fig. 4).