Experiences of adult patients using primary care services in Poland – a cross-sectional study in QUALICOPC study framework

To describe patients experiences we developed a satisfaction index (SI) for all seven studied PC areas: “Accessibility” (ACCS), “Continuity” (CONT), “Comprehensiveness” (COMP), “Coordination” (COOR), “Quality of care” (QUAL), “Equity” (EQ), and “Efficiency” (EFF). All the variables (questionnaire items) from the “Patient Experience” questionnaire were assigned to areas of care, according to the key provided by the international study coordinator of QUALICOPC [16]. We rescaled all variables to a uniform scale ranging from −1 (extremely negative) to +1 (extremely positive). We assigned positive values to good experiences and negative values to poor experiences. In case of dichotomous variables and two possible answers (Yes/No), the values (+1) or (−1) were assigned respectively. For variables measured on ordinal scale, for questions with more than two answers, values from (−1) (for extremely negative) to (+1) (extremely positive) were given, the other were given intermediate values (−0.5), (0), (+0.5). The satisfaction indexes were calculated as an arithmetic mean (μ) of variables representing particular PC areas.

In the final analysis, we used three approaches to the satisfaction indexes. First, we analyzed them as interval dependent variables ranging from −1 to +1. Second, we categorized the interval variables in 5 categories: “extremely negative experience” when the SI equaled −1, “negative experience” for the SI (−1, −0.2), “neutral experience” for the SI [−0.2, 0.2], “positive experience” for the SI (0.2, 1) and “extremely positive experience” when SI equaled 1. Third, from the interval variables we derived dichotomous variables: “negative experience”, for the SI below 0 and “positive experience”, for SI 0 to +1.

As independent variables, we used 9 socio-demographic characteristics of patients from the “Patient Experience” questionnaire, including age, gender, education, employment status, the presence of children in the household, the presence of other adults in the household, declared income, self-estimated health status, and presence of chronic medical conditions. The PC physicians’ characteristics were obtained from the “PC physician” questionnaire. The following 7 independent variables were used: age, gender, medical specialties, years of work in PC, physicians’ involvement in pre- and postgraduate medical education, PC practice location, declared the average time of consultation. Additionally, the analysis employed 8 variables, retrieved from “the Fieldworker” questionnaire, characterizing the infrastructure of the facility: handicap adjustment (parking place, physical barriers in the access to the practice building, location of the practice on the ground floor or presence of an elevator, accessible toilet); reception and waiting room confidentiality; information about opening hours and out-of-hours PHC services.

In the studied primary care areas, the mean values of the satisfaction index were as follows: “Accessibility” 0.64 (SD = 0.33); “Continuity” 0.60 (SD = 0.52); “Comprehensiveness” 0.30 (SD = 0.40); “Coordination” 0.44 (SD = 0.48); “Quality” 0.77 (SD = 0,.9); “Equity” 0.8 (SD = 0.34); and “Efficiency” 0.55 (SD = 0.29). Figure 2 presents distributions of satisfaction indexes in particular areas of primary care.

The determinants of patients’ negative experiences with a particular PC area were analyzed in logistic regression are presented in Figs. 4, 5, 6, 7, 8, 9, 10.

The strongest predictors of negative experience with primary care were: location of the practice (town vs. city) in the area of “Accessibility of care” (p < 0.01); diagnosis of a chronic condition in the area of “Continuity of care” (p < 0.01); location of the practice in rural area in comparison to the location in a city in the area of “Comprehensiveness of care”, “Coordination of care” and “Efficiency of care” (p = 0.001, p < 0.001 and p < 0,.5 respectively); declared household incomes above average in comparison to below average in the area “Quality of services” and “Equity of care” (p < 0.05 and p < 0.05, respectively).

In the PHAMEU study, Poland was classified as a country with medium PHC strength, characterized by good accessibility and coordination and poorly developed comprehensiveness [9]. The QUALICOPC survey conducted among primary care physicians in Poland showed that doctors were very critical of the areas of care in process and outcomes of PHC services. Coordination, quality of care and equity were evaluated negatively by PC physicians, while accessibility, continuity, and comprehensiveness received neutral scores [18]. Contrary to poor evaluations of PC on the system level, patients (users of PC services) in our study had predominantly positive experiences with primary care in Poland. These findings are consistent with several previously published Polish studies on patient satisfaction with primary care. Marcinowicz et al. reported high satisfaction with communication skills of GPs (with scores around 4.5 on 1 to 5 scale) and length of consultation (88% satisfied) [11]. Kurpas et al. conclude in their paper on satisfaction with PHC of chronically ill patients, that they were at most satisfied with GP consultation (interview and physical examination) and their empathetic attitude, kindness and willingness to help [21]. In another national survey on patient’s satisfaction, 78% of participants evaluated positively accessibility of PHC with mean satisfaction value +0.32 (range:-1.0 to 1.0), which was the highest score of all areas of care. [22]. In our study, we found that the length of a doctor’s professional experience was a noticeable predictor of positive PC evaluation. The years of physician’s experience in primary care may be associated with the duration of the relationship and shared experiences with patients and their physician. Although the therapeutic alliance and the long-term patient-doctor relationship are important and beneficial for both of them, it seems to be essential for the patient’s satisfaction. According to Noyes et al., having a primary care physician and duration of that relationship is a key element determining the quality of care perceived by family medicine patients [23]. Interpersonal continuity with a regular provider is the most important predictor of patient satisfaction, as reported in Balkan populations by Gajovic et al. and in the USA by Nutting et al. [24, 25]. The findings of Mainous et al. showed that the patients place value on continuity with their regular physician [26]. According to Plomodon et al., PHC providers turnover was associated with worse patient satisfaction of care [27].

The difference between patients’ (overall good) and physicians’ (overall skeptical) evaluation of PHC was very likely to be linked to the negative evaluation of economic conditions and the structure of PHC in Poland by physicians. On the other hand, GPs might be more aware of their limitations or diagnostic uncertainty and less optimistic in the evaluation of their abilities to help patients [18, 28].

Exploring the positive PC experience predictors, we found a positive relationship between increasing age and patient satisfaction in all studied primary care areas. These results are compatible with other literature on patient evaluations of care [21, 29‐31]. Kontopantelis et al. suggested that differences in satisfaction by age group could be due to differences in actual care received or to different response tendencies of individual population groups [31].

Our findings indicate that specialty training in family medicine is one of the desired PC physicians’ characteristics associated with higher patient satisfaction, especially if the physician has more than one specialty. The introduction of family medicine into the primary health care system in Turkey resulted in an increase of patient satisfaction [32]. Similar observations were found in studies by Gavran et al. [33]. However, the study conducted by Chu-Weiniger et al. showed that giving patients the possibility of free choice of physician is more important than the doctor’s specialty. The free choice of PC provider helped to establish a trusting relationship [34].

The American research by Ly and Glied showed that patient satisfaction is not influenced by the number of PC physicians per inhabitant. Unexpectedly, longer waiting times for appointment were observed in practices with a higher physician-to-population ratio [35]. It may explain at least partially the observed discrepancies in satisfaction between patients from rural PC practices and those visiting PC physicians in big cities. In a national patient survey in Sweden, the higher satisfaction of care was observed among patients from smaller practices and practices where a high proportion of all visits were with a doctor [36]. According to Tung et al., the doctor’s technical skill was the most important determinant of satisfaction, followed by the doctor’s interpersonal skill. Staff care, access and providing patient education during the visit on prevention and prophylaxis were associated with improved patient satisfaction [37].

In our study, the infrastructure of facilities did not influence quality assessment. The literature review by Rozenblum et al. reported that the expansion of health information technologies did not significantly improve patient satisfaction [38]. These results may indicate that investments only in infrastructure and new technologies do not necessarily increase satisfaction.