Associations between primary care practice type and patient-reported access

Adequate, timely access to high-quality care is a cornerstone of primary care (PC) [1]. PC is meant to be where people have their “first contact care, health promotion and basic treatment”, and their PC physician (PCP) is meant to facilitate “adequate access to other health care and related services for those who need this” [1]. Decreased access to PC has been associated with increased use of more expensive services such as the emergency room or medical specialists [2], while improved access to PC may increase the use of preventive services [3]. Access to PC is a complex concept that involves multiple health system, practice and patient factors [4]. Previous research of patient factors has found that younger patients and those from ethnic minorities report worse access [5‐7]. Access is variably measured by patient reported outcomes measures or by attempts to find more ‘objective’ measures such as the next available appointment, but no consensus appears to exist [8].

Traditional determinants of PC access at the practice-level have frequently been identified using practice size and reimbursement models for physicians [9, 10]. Associations between PC practices grouped by organization or services offered and access are particularly important to guide organizational changes in primary care to improve access. Health systems can also use incentives to encourage certain practice types associated with improved patient access [11]. From previous literature, patients seem to report easier access to smaller practices [7, 9, 12], and access and continuity may be in opposition to each other, where practices with improved access have worse continuity [9, 10]. One limitation of this previous literature has been difficulty integrating the many aspects of PC practice organization into analyses of the determinants of access. Typically, a small number of predefined PC characteristics are used as independent variables to assess patient access, leading to only a partial view.

Our team recently employed a novel methodology to create a typology of PC practices that integrates many variables simultaneously using a multiple factorial analysis [13]. We inputted 74 PC features from the QUALICOPC questionnaire integrating multiple organizational features of PC practices that were then summarized with two axes, thus creating an empirical typology. We found this approach helpful for describing Swiss PC as it is made up of a heterogeneous mix of general practitioners and general internists with the liberty to define their scope of practice [14]. Pre-defined models commonly used in other countries (like for example community health centres), do not readily apply.

The first of the two composite axes contained variables related to the range of clinical and technical procedures provided, and was named “comprehensiveness of services” score [13], while the second axis contained variables related to the workforce available in each practice. The comprehensiveness of services axis is of particular interest as there appears to be a gradual narrowing of the PCP scope of practice in Switzerland [15].

Using the defined latent variables, the current study aimed to investigate the relationship between access and PC practice type, using data from a large, practice-based network of PCPs and their patients in Switzerland. We hypothesized that PC practice type, as characterized by a practice’s score on the comprehensiveness axis, would be a predictor of patient-perceived access.

Of the 200 PCPs of the SPAM network, 199 completed the questionnaire. Characteristics of the 1791 patients recruited after a visit in each of these practices are shown in Table 1. The mean age was 57 years, 56% were female, 45% reported having a longstanding disease or condition, and 33% described their own health as fair or poor. The majority (91%) had a visit with their usual PCP, and the most common reasons for a visit were illness (37%) and a check-up (33%).

The overall access results are shown in Table 2. Ninety-two percent of patients had made an appointment for their visit, though 42% had made the appointment the same day or the day before. Of those who had made an appointment, 31% responded that it was not easy to get the appointment. Few patients reported having had to miss or postpone a visit in the past 12 months (10%), and only 5% because of lack of insurance or other financial reasons.

In univariate analyses, few associations were observed between the difficulty to obtain an appointment and patient- and practice-level variables, except for a higher level of education and the French linguistic area (Table 3). However, education level and language area did not remain statistically significant in the multivariate final model (Table 3).

For the second primary outcome (“opening hours too restricted”), the univariate regressions were significant for several patient characteristics, such as level of education, income and linguistic area. Moreover, higher practice comprehensiveness scores were moderately associated with more patients reporting that the opening hours are too restricted (OR 1.07, 95% CI 1.00–1.14, p = 0.04). This association remained in the multivariate regression OR 1.07, 95% CI 1.00–1.14, p = 0.05), but totally disappears when the variable linguistic area is included in the final model (Table 4).

Regarding the last outcome, there was an association between increasing comprehensiveness of services offered and patients reporting that they had to postpone their visit in univariate analysis (OR 0.91, 95% CI 0.86–0.96, p = 0.001) and in the multivariate final model (OR 0.92, 95% CI 0.87–0.97, p = 0.002), even after including the linguistic area variable (Table 5). The other predictive variables were patients’ age (OR 1.38, 95% CI 1.15–1.65, p < 0.001), the number of visits during the last 6 months (OR 1.23, 95% CI 1.03–1.46, p = 0.02) and a fair or poor perceived health (OR 2.28, 95% CI 1.06–4.91, p = 0.03).

In this cross-sectional, nationally representative survey of Swiss PCPs and their patients, we found limited evidence of associations between a novel typology of PC practices defined by the comprehensiveness of services offered and patient-reported access. There was a slight trend of patients seen at offices with more comprehensive services being less likely to have postponed an appointment within the last 12 months.

It is unclear why organizational differences between PC practices, as described by the comprehensiveness axis from the new typology, would have a limited impact on patient-reported access in Switzerland. One possibility is that patient access is generally quite good in Switzerland, creating a ceiling effect that makes it difficult to differentiate between practices. The fact that we only interviewed patients after an appointment, who by definition got access to a PCP, may add to that effect. A 2014 telephone survey of older adults conducted by the Commonwealth Fund found that Switzerland did quite well on overall indicators of access to primary care [23]. However, direct comparisons with Canada and Greece, who also participated in QUALICOPC, show that a higher proportion of patients in both say it was easy to make an appointment (94% in Canada, 86% in Greece and 61% in the current study) [24, 25]. Research from other countries focusing on first-contact accessibility has shown that access appears to be better in small clinics [9] and with fee-for-service [26], which are the norm in Swiss PC. American community health centres appear to do less well with first-contact accessibility than other models [27]. However, Switzerland does not perform well on all aspects of patient access, in particular with regards to weekend access [28]. It is equally possible that while the comprehensiveness access best describes variability between Swiss PC practices, other aspects of the practices not included in the comprehensiveness score are more important for patient access. Finally, it is possible that differences between practices are in fact relatively minor, as supported by our previous study showing that one single model is predominant in Switzerland [13]. More important differences in primary care access might be seen when comparing internationally, a direction of future collaboration with the IMPACT (Innovative Models Promoting Access-to-Care Transformation) program [29].

Differences between Swiss linguistic regions appear to have a strong effect on patient-reported access, which could be both due to differences between PC practices and cultural differences between patients. Many of the differences between services offered that are included in the composite score are heavily influenced by regional differences that follow linguistic lines. We presented models both with and without language area as the introduction of the language area along with the comprehensiveness score may cause over-adjustment bias. Multiple previous reports have underlined the importance of patient factors, including worse access for various groups (linguistic or racial minorities, younger patients, etc.) [5, 6, 30], and a British study finding that the primary predictor of variations in patient satisfaction was unmeasured patient factors [31]. Several predictors of access that are important in other countries did not have significant associations in our study, such as financial status or insurance [32].

It is unclear why patients at practices offering more comprehensive services were less likely to have postponed an appointment within the last twelve months. In our sample, very few patients reported having to forego care for financial reasons (Table 2). Switzerland has universal coverage with private insurance, but the highest out-of-pocket medical expenses in the world [23]. Nonetheless, previous studies support the finding that inadequate finances are rarely an issue [33]. Practices with high comprehensiveness scores are more oriented towards somatic complaints and may be more flexible in their accommodation of urgent complaints. Reasons for postponing may be more often linked to lack of time or a lack of availability on nights and weekends. This may explain why age and education level have an important impact on patient answers to the statement that “the visiting hours are too restricted.”

More comprehensive offering of services in PC in the United States was recently linked to lower overall costs, suggesting that the scope of services offered could be linked to important patient outcomes [34]. Our study found only limited associations between comprehensive services and patient access. It is important to understand the impact of practice differences on access, as in both Switzerland and the United States, PCPs report a gradual narrowing of their scope of care, decreasing the comprehensiveness of services offered in individual practices [35].

In conclusion, there WAS limited evidence for an association between the typology of practices created by our group using a multiple factorial analysis and patient-reported access. This work is an important proof of concept that a global typology capturing variance between PC practices can be applied to patient-reported measures such as access. Future studies could employ the current methods to explore associations between practice type and access across countries.