Patient satisfaction with primary care physician performance in a multicultural population

Patient satisfaction has emerged as an important measure in the evaluation of healthcare systems and in predicting health outcomes [1]. Healthcare systems are comprised of several complex and interrelated elements spanning multiple settings in which diverse patients seek care. This holds true in Israel, where Jews and Arabs make up the vast majority of residents. One of the many critical settings within the healthcare system is primary care where patients’ interactions may carry differences in perceived quality of healthcare or satisfaction [2, 3]. For example, an Israeli study found that Arabs reported a higher number of visits to primary care physician (PCP) compared to Jews, whereas the Jews utilize more specialists than the Arabs [4]. Further, Arabs have poorer health status compared to Jews, with higher rates of chronic diseases such as obesity [5], Diabetes [6], and poorer life expectancy [6]. Previous studies have examined the role of primary care in patient health and identified the high importance of the PCPs’ performance on health outcomes [3, 7], as well as on improved patient’s satisfaction [8]. Shi and colleagues found that primary care and income inequality were strong contributors to life expectancy [9]. Furthermore, patients who visited their PCP more often, and used them as the main source of information related to their health status, were more likely to be healthier (regardless of their initial health status and socio-demographic characteristics), hospitalized less, and spent less on annual healthcare expenditures [7]. In general, Israeli citizens report high satisfaction from the healthcare system; however, since 2009, the overall satisfaction level has not improved according to national surveys (across different ethnicities) [10, 11] In Israel, research in health care management and PCP performance field lacks evaluation of ethnic differences. Previous international studies have shown that racial and ethnic differences contribute to patients’ satisfaction levels with their PCP [12‐15]. For example, Asian-American patients rate primary care performance lower than do white, African-Americans, and Hispanic [13]. Further, a study by Gross and Colleagues found that non-white patients were less satisfied with time spent with their physicians compared to white patients [16]. Racial and ethnic minorities in the US rate the quality of interpersonal care with physicians and the healthcare system lower relative to their non-Hispanic white counterparts [17‐19].

Therefore, the purpose of this study was to explore whether patients’ satisfaction level regarding their PCPs’ performance differs across the two main population groups in Israel. The study may highlight performance domains that need to be improved in each population group in order to help meet the ethnicity-specific needs, which will hopefully lead to improved health outcomes of sub-populations in Israel.

This study is unique in examining perceptions of satisfaction with PCP across ethnic subgroups within a country with national health insurance. Given all citizens have access to healthcare based on the socialized structure of the system, and all the HMOs are required to provide all members with the full range of benefits prescribed by the National Health Insurance law, and assuming that there are no ethnic differences in training and knowledge of the PCP in Israel, these ethnicity-based perceptions might explain possible disparities based on the quality of care received and practical availability of the healthcare services (e.g. in different geographic regions). Overall, Arabs compared to Jews were less likely to be “very satisfied” than “satisfied on average” with their PCPs’ performance across multiple domains (i.e. communication skills, interpersonal manners, and time spent with doctor). However, overall and across all the domains, most of the participants (Jews and Arabs) reported being either “satisfied” or “very satisfied” regarding the performance of their PCP. These observed differences by ethnic groups have been described in previous literature [22‐25]. In our study, Arabs were younger, less educated and less employed compared to Jews participants. Previous studies have shown that personal characteristics may explain part of the ethnic differences in satisfaction from PCP, include age (younger ages report lower satisfaction), employment, income, and education [26]. Furthermore, previous data have shown that disparities in mental and physical health between minority groups in Israel could be explained, to a certain extent, by subjective and objective measures of SES [27]. Although, we adjusted for these variables in our multivariate analysis, there is still a possible residual confounding. Our results have shown that Arab participants reported a better-perceived health status than Jews. These results are consistent with previous data by Baron-Epel and colleagues, showing that Arabs tend to evaluate health better than Jews even though life expectancy is lower and morbidity is higher, concluding that subjective health status in Jews and Arabs does not necessarily have the same meaning in relation to objective measures of health [28]. We also assume that lower satisfaction from PCP performance can be due to differences between Arabs and Jews in the expectations from services received, but further studies are needed to explore disparities related to the expectations from PCP services and performance. For example, Arabs were less satisfied compared to Jews with the time spent with their PCP. This is a concern rising also from the PCP side. A previous study by Rosen and colleagues have shown that PCPs complain about patient visits being too short (averaging< 10 min), not having enough time to address mental and health promotion issues, the computer barriers between physician and the patient, and growing managerial monitoring/interference in their practice [29]. Interestingly, Arabs have reported receiving health promotion advice (e.g. physical activity, diet) from their PCP more commonly than Jews, which may be time-consuming and can explain the feeling of lack of sufficient visit time among Arab participants compared to Jews. However, there is no objective evidence to confirm that Arab patients receive less time compared to Jews patients and this should be explored in future studies.

Although not examined in this study, satisfaction may have been influenced by factors including physician-patient concordance (e.g., age, sex, ethnicity, and preferred language), the complexity of the patient’s health status and the perceived urgency of the patients’ health condition(s). The satisfaction level is often influenced by frustrations with the healthcare system and also reflect the disease profile or health status and sociodemographic characteristics of the patient [30], and ability to manage their conditions [31]. Disparities in patients’ satisfaction is an important component for measuring health care services and is associated with clinical outcomes, patient’s retention and treatment adherence. For example, a previous study among ambulatory patients has shown that the quality of interpersonal skills affects patient outcomes, and the patient adherence to treatment is mediated by patient satisfaction from their physicians [32]. Non-Adherence to treatment is a major public health concern and is associated with disease deterioration, poor prognosis, increase health care costs, and death [33]. This might further worsen the disparities in health status between Jews and Arabs, where Arabs have higher rates of obesity [5, 34], diabetes, [35, 36] sedentary behavior [37], smoking [38], and shorter life expectancy [6].

The current study has several strengths, such as having a large sample size and using a random selection from a large population. However, this study is also subject to several limitations. First, the use of random digit dialing restricted the results of the surveys to those with landlines, which may have resulted in selection bias. This does not seem to be a factor that would substantially affect the generalizability of the findings for the target population, supported also by the fact that our results are consistent with previous studies [11, 27, 28, 39]. Also, this study is subject to selection bias is given people that tend to answer telephone surveys may be different than people who refuse to answer telephone surveys. Further, our study is misrepresentative to the general Israeli populations in terms of age, over-representing people aged 65–74 years old, and under-presenting people aged 25–44 years old (Please see Supplementary Table 1). Recall bias was another limitation, given the use of self-reported surveys. However, this is a common practice in large national studies in other countries such as the US (e.g., Behavioral Risk Factor Surveillance System or BRFSS). Lastly, the health status of the participants, social support at home and health literacy were not collected and may be confounding factors.

The findings in the current study also hold insights for global stakeholders interested in understanding health disparities across socio-demographics, namely ethnicity. Key theoretical frameworks (e.g., the World Health Organization’s Framework for Action on the Social Determinants of Health) [40], have identified race and ethnicity, among other factors such as public policy (e.g., health policy), socioeconomic position, and education as critical in identifying health inequities. In terms of racial or ethnic disparities in patient satisfaction, early reports from the US such as the Institute of Medicine’s report, Unequal Treatment, highlighted several gaps in the quality of care received across race and ethnicity even with similar health care coverage [41]. Our results are also consistent with other studies in that ethnic minority groups rate the interpersonal care by physicians (and within the healthcare system) lower compared to their counterparts within majority sub-groups [18, 19]. For example, our finding that Arabs reported lower satisfaction with their PCPs’ interpersonal manners compared to Jews mirrors findings from Johnson and colleagues examining patient-physician communication differences between African-American and non-Hispanic white patients [17]. While this study provides a glimpse into healthcare satisfaction and possible underlying inequities among patient sub-groups in Israel, findings point to the need for future studies and specific recommendations for improving patient-provider interactions.

In summary, for both Jews and Arabs, the satisfaction level from the PCPs’ performance is above the average. However, the current study found that there are significant differences between Jews and Arabs in the extent of satisfaction level from the PCPs’ performance and from the healthcare system; Jews are more very satisfied with their PCPs’ performance compared to Arabs. Our findings show that ethnic differences are evident with the communication domains, interpersonal manners, and time spent with the doctor. These differences might contribute to ethnic differences in health outcomes.