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Understanding British Columbians’ experiences with primary health care : developing a sector-specific… Wong, Sabrina T.; Peterson, Sandra; Regan, Sandra; Watson, Diane E.; Black, Charlyn, 1954- Sep 30, 2007

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UBC CENTRE FORHEALTH SERVICES ANDPOLICY RESEARCHUnderstanding British Columbians’  experiences with primary health careDeveloping a sector-specific surveySeptember 2007Sabrina T Wong RN, PhDSandra Peterson MScSandra Regan RN, MSNDiane E Watson MBA, PhDCharlyn Black MD, ScDU N D E R S T A N D I N G  B R I T I S H  C O L U M B I A N S ’  E X P E R I E N C E S  W I T H  P R I M A RY  H E A LT H  C A R E2Library and Archives Canada Cataloguing in Publication         Understanding British Columbians’ experiences with primary healthcare [electronic resource] / Sabrina T. Wong ... [et al.]. Includes bibliographical references. ISBN 978-1-897085-13-4         1. Primary health care--British Columbia--Evaluation.  I. Wong,Sabrina T.  II. University of British Columbia. Centre for Health Services and Policy Research. RA427.9.U54 2007                        362.109711              C2007-904408-5 UBC  C E N T R E  F O R  H E A LT H  S E R V I C E S  A ND  P O L I C Y  R E S E A R CHS E P T E M B E R  2 0 0 7  4   About CHSPR  5   Acknowledgements  6   Executive Summary  7   Introduction Project Background and Objectives10    Methods11    Results Content of the Survey Sample for the Survey Reliability and Validity of Survey Items20    Conclusion21    ReferencesContentsU N D E R S T A N D I N G  B R I T I S H  C O L U M B I A N S ’  E X P E R I E N C E S  W I T H  P R I M A RY  H E A LT H  C A R E4About CHSPRThe Centre for Health Services and Policy Research (CHSPR) is an independent research centre based at the University of British Columbia. CHSPR’s mission is to advance scientific enquiry into issues of health in popula-tion groups, and ways in which health services can best be organized, funded and delivered. Our researchers carry out a diverse program of applied health services and population health research under this agenda. The Centre’s work is:    •   Independent    •   Population based    •   Policy relevant    •   Interdisciplinary    •   Privacy sensitiveCHSPR aims to contribute to the improvement of population health by ensuring our research is relevant to contemporary health policy concerns and by working closely with decision makers to actively translate research findings into policy options. Our researchers are active participants in many policy-making forums and provide advice and assistance to both government and non-gov-ernment organizations in British Columbia (BC), Canada and abroad. Funding and SupportCHSPR receives core funding from the BC Ministry of Health, and ongoing support from the University of Brit-ish Columbia and the UBC College of Health Disciplines. This enables the Centre to focus on research that has a direct role in informing policy and health reform, and facilitates CHSPR’s continuing development of the BC Linked Health Database.Our researchers are also funded by competitive external grants from provincial, national and international fund-ing agencies. They include the Canadian Health Services Research Foundation, the Canadian Institutes of Health Research, the Commonwealth Fund, Health Canada, the Michael Smith Foundation for Health Research, and WorkSafeBC.Data Services: The BC Linked  Health DatabaseMuch of CHSPR’s research is made possible through the BC Linked Health Database, a valuable resource of data relating to the encounters of BC residents with various health care and other systems in the province. These data are used in a de-identified form for applied health services and population health research deemed to be in the public interest.CHSPR has developed strict policies and procedures to protect the confidentiality and security of these data holdings and fully complies with all legislative acts gov-erning the protection and use of sensitive information. CHSPR has over 30 years of experience in handling data from the BC Ministry of Health and other professional bodies, and acts as the access point for researchers wish-ing to use these data for research in the public interest.UBC  C E N T R E  F O R  H E A LT H  S E R V I C E S  A ND  P O L I C Y  R E S E A R CHS E P T E M B E R  2 0 0 7AcknowledgementsThe authors gratefully acknowledge the contributions of staff at the UBC Centre for Health Services and Policy  Research, including Ella Young (no longer with the Cen-tre), Dawn Mooney, and Chris Balma. We also thank contacts at the British Columbia Ministry of Health, including Valerie Tregillus, Executive Director, Primary Health Care, Heather Davidson, now Assistant Deputy Minister in the British Columbia Ministry of Employment and Income Assistance, and Carol Myron, Director, Strategic Planning and Liaison, Early Childhood Development, Child Care. Members of the 2004 Evalua-tion Working Group for Primary Health Care were also helpful in the conceptualization of this work.The British Columbia Ministry of Health provided funding to support this project under a contribution agreement between the Ministry and the UBC Centre for Health Services and Policy Research (CHSPR). Sabrina Wong is also funded by a Michael Smith Scholar Award and a Canadian Institutes of Health Research New Inves-tigator Award.The results and conclusions are those of the authors and no official endorsement by the Ministry is intended or should be inferred. All analysis and interpretation, and any errors, are the sole responsibility of the authors. The Behavioural Research Ethics Board of the University of British Columbia approved this study.   U N D E R S T A N D I N G  B R I T I S H  C O L U M B I A N S ’  E X P E R I E N C E S  W I T H  P R I M A RY  H E A LT H  C A R E6Executive SummaryIn 2005, the British Columbia Ministry of Health identified the development and validation of a survey regarding adults’ experiences with primary health care (PHC) as an important step toward monitoring, evalu-ating and reporting on this sector in the province.This report describes Ministry-responsive work un-derway at CHSPR to develop and validate items and scales for just such a survey. The resulting instrument is unique in that it is designed to measure dimensions (or aspects) of PHC identified as priorities through focus groups held with patients across the province, a review of relevant scientific literature, and input from government stakeholders.More specifically, this report outlines work to: (a) evaluate the reliability and validity of an index, items and scales derived from publicly available PHC survey instruments that were developed but not previously validated in British Columbia; (b) evaluate the reli-ability and validity of new items and scales intended to measure important dimensions of PHC; and (c) as-sess the effects of sociodemographic factors on scales in order to examine whether the measures can be used reliably across different groups. The report lays out broad findings based on the survey development and validation—a more detailed analysis of the items, index and scales is available upon request.The pilot survey was administered to a random sample of 500 adult British Columbians—stratified by gender and community size—using computer as-sisted telephone interviews. The average age of survey participants was 54. The vast majority (89%) were Caucasian, 50 per cent were male, 50 per cent lived in large communities, and nearly half had at least one chronic health condition. We examined variability, including item-scale cor-relations and normality of distributions, and assessed internal consistency reliability and construct validity. Psychometric analysis was completed across the total sample, and by gender, age group (19-39, 40-64, > 65 years) and community population (regions with more than 50,000 people, and regions with less than 50,000 people). The majority of items and scales tested revealed ac-ceptable reliability, variability and validity in the total sample, and by gender, age group and community size. Items measuring five of six dimensions (technical ef-fectiveness, the degree to which medical interventions are delivered in accordance with guidelines, was not included in the survey) important to focus group par-ticipants can be reliably used for future surveys. With some exceptions, most of the single items and scales measuring other important dimensions of PHC can also be used in future surveys. All items measuring confidence in PHC, and two single items measuring confidence in the health care system, can also be used in future surveys.More work is required to improve the usability of the survey and to provide more comprehensive mea-surement of PHC dimensions such as continuity, interpersonal communication and chronic disease management. These results suggest that most of the survey content, with additional refinement, is robust enough to be administered through future telephone survey work in the province. Two Canadian Institutes of Health Research-funded projects are underway at CHSPR to advance this work.  UBC  C E N T R E  F O R  H E A LT H  S E R V I C E S  A ND  P O L I C Y  R E S E A R CHS E P T E M B E R  2 0 0 7The development and validation of a public-domain survey regarding adult’s experiences with primary health care (PHC) was identified in 2005 by the British Columbia Ministry of Health as an important step toward monitoring, evaluating, and reporting on, this sector. This report describes the development and validation of survey items and scales relevant to adults’ experiences with PHC in British Columbia. The result-ing survey items were designed to measure dimensions of PHC that are:    •   important to British Columbians, as identified through focus groups held across the province. These dimensions include accessibility, continuity, respon-siveness, interpersonal communication, technical effectiveness and whole-person care;   •   considered to be important to quality of care and pa-tient outcomes, including: utilization of medical care; utilization of other services; general health; presence of a chronic disease; chronic disease management; patient activation; patient empowerment; and satis-faction with PHC; and    •   deemed important by the British Columbia Minis-try of Health–namely, confidence in the health care system. This work is part of a series of activities that re-searchers at CHSPR undertook to support the British Columbia Ministry of Health and the province’s health authorities in renewing PHC. At the time this work received funding, it was recognized that a PHC sector survey would be designed to reflect the features of PHC that are important to British Columbians, and be validated for use in the province. IntroductionProject Background and ObjectivesThis report describes work completed on the latest stage of a research program designed to gain a better understanding of British Columbians’ experience with primary health care.Objective 1: Identify the features of PHC that are most important to British ColumbiansIn 2005, 11 focus groups were conducted across the province to gain a better understanding of British Co-lumbians’ experiences with PHC, as well as to identify the features of care, or dimensions*, that they con-sider important and relevant to their satisfaction with PHC services. This work identified six dimensions that adults in the province considered important (in decreasing order of importance): accessibility, con-tinuity (informational, relational and management), responsiveness, interpersonal communication, techni-cal quality, and whole-person care. The focus groups also described these concepts in a manner relevant to British Columbians, providing insight about how best to measure them. These dimensions represent areas on which provincial PHC survey tools should focus in order to capture aspects of care important to patients. The findings outlined in this report are under review by a peer-reviewed journal. A copy of that paper, What is Important About Primary Health Care? Public Priori-ties, was submitted to the British Columbia Ministry of Health in the spring of 2006.  *  A dimension is defined as one aspect of a construct. U N D E R S T A N D I N G  B R I T I S H  C O L U M B I A N S ’  E X P E R I E N C E S  W I T H  P R I M A RY  H E A LT H  C A R E8Objective 2. Identify publicly available survey items that measure features of PHC that are important to British Columbians Peer reviewed scientific literature regarding the di-mensions identified in focus groups was reviewed. In collaboration with Dr Jeannie Haggerty (University of Sherbrooke) and Dr Jean-Frédéric Levesque (University of Montreal), relevant items from publicly available sur-veys were identified to create a pool of potential items. Additional items related to capturing quality of care and patient outcomes, as well as other items deemed important by the British Columbia Ministry of Health, were also identified.Objective 3. Identify new survey items that need to be developed to ensure dimensions important to British Columbians are measuredNo publicly available items or scales regarding responsiveness and technical effectiveness—two dimensions identified by British Columbians dur-ing focus groups—could be identified through the project’s literature review or work previously done in Quebec.To measure responsiveness, seven new survey items were developed. Of these, one item (How often did you feel that you had enough time to tell your doc-tor about your feelings, fears or issues related to your health problem?) was created to specifically address patient feedback that emerged during focus groups. The other six items were created to reflect information generated from a concurrent Canadian Institute for Health Information process to develop PHC per-formance indicators—these indicators were used to develop survey questions. Items designed to measure technical effectiveness (the degree to which medical care is delivered in accor-dance with guidelines) were not included because this dimension of PHC is not usually measured in patient self-report surveys. Patients may not recall or under-stand technical features of the care they receive1 or may not be able to judge what constitutes acceptable levels of technical quality2. We are also aware that the Public Health Agency of Canada and the Canadian Institute for Health Information are conducting exten-sive survey development work in this area. Objective 4. Evaluate the suitability of existing Canadian survey and administrative data to measure dimensions of PHCA separate CHSPR report3 assessed existing Canadian population-based survey and administrative data for their suitability in measuring key constructs of PHC4. This report confirmed that survey and administra-tive data tools are available to measure some aspects of the PHC system, but found that we lack basic tools to measure important system outputs, qualities of these outputs (e.g., coordination), and interpersonal effectiveness (communication). This work confirmed that the areas being developed and tested in the cur-rent PHC survey fill an important gap and represent important areas for evaluation and ongoing monitor-ing of the sector. UBC  C E N T R E  F O R  H E A LT H  S E R V I C E S  A ND  P O L I C Y  R E S E A R CHS E P T E M B E R  2 0 0 7Objective 5. Develop and validate a public-domain survey regarding patient experiences with primary health careBased on the project’s literature review and the devel-opment of new items, a prototype survey was devel-oped. It contained: 1)  questions related to five dimensions of PHC identi-fied in focus groups held across the province;2)  questions important to evaluating PHC (e.g., utiliza-tion) identified in a literature review;3)  questions identified by the Ministry (e.g., confidence in the Canadian health care system); and4)  additional questions required for reliability and validity testing. In order to evaluate the reliability and validity of the resulting prototype survey, it was tested in the fall of 2006 on a random sample of 500 adult British Colum-bians. As part of reliability and validity testing, the survey had a sufficient sample size to test its utility for person-specific (age and sex) and contextual (large and small community) differences. This work is the main focus of this report, and is described in more detail in the sections that follow.U N D E R S T A N D I N G  B R I T I S H  C O L U M B I A N S ’  E X P E R I E N C E S  W I T H  P R I M A RY  H E A LT H  C A R E1 0Methods: Developing the SurveySurvey content was developed to reflect dimensions of PHC: a) identified by British Columbians in focus groups held across the province; b) cited as important by the scientific literature; and c) identified by the British Columbia Ministry of Health. Additional items were included in order to gather sociodemographic characteristics required to test the validity of the instrument.ProcedureNordic Research Group (NRG), a telephone survey company based in Vancouver, was engaged to develop a computer assisted telephone interview (CATI) pro-gram and administer the survey. A random sample of telephone numbers5 was pulled from British Colum-bia’s 28 census divisions, based on relative population. For example, the Greater Vancouver Regional District (GVRD) contains 51 per cent of British Columbia’s population, thus 51 per cent of the sample was drawn from the GVRD. The sample was stratified by gender and community size.* To avoid sample bias, the sample consisted of both directory-listed (DL) numbers and directory-not-listed (DNL) numbers. For every five DL numbers in the sample, one DNL number was included. Initial contact was made with prospective participants using a standard telephone script that described the study and screened participants for eligibility. In order to be eligible, participants had to: (a) be aged 19 to 90, (b) be English-speaking, (c) suffer from no cognitive impairments**, and (d) have visited a family doctor or nurse practitioner in the past 24 months. All data were collected between September 8 and October 22, 2006. Interviewers entered telephone survey data directly into the CATI program. Verbal consent was obtained from all participants and the University of British Columbia’s Behavioral Research Ethics Board approved all procedures.Data analysisSingle item response distributions were examined to assess response patterns and ensure variability across responses. If items were part of a scale, internal con-sistency reliability was examined. Cronbach’s alpha coefficient was used to assess the internal consistency of each scale, using a standard of 0.70 or higher6. For both single items and scales, variability (range, frequency distribution, degree of skew***, floor and ceiling effects) and item-to-scale correlations were examined. Construct validity was assessed by examin-ing whether the subscales correlated as expected with related subscales. For example, there was evidence of construct validity if the interpersonal communica-tion subscales (communication, decision-making and interpersonal style) correlated more highly with each other than with other scales.  Descriptive statistics, including frequencies and percent-ages for categorical data and means, standard deviations and ranges for continuous data, were calculated to char-acterize the study population. All analyses were rerun stratified by person-specific and contextual differences and assessed for variation. This allowed the examination of variable distributions, reliability and validity, if rel-evant, of items and scales by gender (male, female), age group (19-39, 40-64, > 65 years), and community size for each category. Based on variable and scale performance, recommendations are made about the utility of items and scales for inclusion in PHC surveys.* Community size was based on census sub-division popula-tion. Large communities were regions that had more than 50,000 people, and small communities were regions that had less than 50,000 people.** Participants aged 75 years and older were administered a brief cognitive test to assess for any cognitive impairment. Those with cognitive impairments were excluded (n=2).*** The skewness statistic was used to indicate the degree of skew, from negative to positive infinity. The closer the score to zero, the more normal is the distribution; scores over two may require transformation.  UBC  C E N T R E  F O R  H E A LT H  S E R V I C E S  A ND  P O L I C Y  R E S E A R CHS E P T E M B E R  2 0 0 7Content of the SurveyFocus group participants reported that accessibility, continuity (information, relationship and manage-ment), responsiveness, interpersonal communica-tion, technical effectiveness and whole-person care were some of the most important aspects of care they receive in the primary health care system.   •   Accessibility was defined by participants as being able to obtain PHC services in a timely fashion, regard-less of geographic barriers (e.g., great distances) or environmental conditions (e.g., poor weather).   •    Continuity contains three dimensions: informa-tional (ongoing relevant information exchanged between providers regardless of the site of care), relationship (continuous long-term patient-pro-vider relationship) and management (ongoing management of a health condition)7.    •   Responsiveness, or accommodation,8 was defined as the ability of the system and provider to meet patients’ health care needs (e.g., minimizing in-office waits and receiving enough time with the provider).    •   Interpersonal communication consists of three over-arching areas: communication, shared decision-making, and the provider’s interpersonal style9.    •   Technical effectiveness was defined as patients’ perceptions of providers’ technical competence in performing diagnostic and therapeutic proce-dures10.   •   Whole-person care was defined as being treated as a person and not a disease or bodily system, regardless of having a long-term relationship with a provider.Additional dimensions deemed important to PHC based on a literature review included: utilization of medical care, utilization of other services, presence and type of chronic conditions, chronic disease man-agement, goal setting/tailoring, problem solving/con-textual, patient activation, patient empowerment, use of telephone advice lines, and overall satisfaction with Results PHC. Additional dimensions deemed important by the British Columbia Ministry of Health included confi-dence in the PHC sector and confidence in the overall health care system.The final PHC survey contained single items, scales and one index. Items are specific questions designed to measure dimensions of PHC. Scales include sev-eral items whose content is based on an underlying construct (e.g., PHC) whereas indices include items that determine the level of a construct11 (e.g., strength of affiliation with a usual source of care). Specific publicly available scales used in this survey included the Strength of Affiliation scale,12 the Patient Assess-ment of Chronic Illness Care measure,13 Interpersonal Processes of Care measure,14 Whole-Person Orienta-tion scale,15 and the Patient Activation measure.16Sample for the SurveyA total of 9,382 telephone numbers were randomly gen-erated, of which 1,322 were eligible residential telephone numbers. Five-hundred-and-four adults completed interviews. On average, the survey took 23 minutes to complete. Sociodemographic characteristics of those who completed interviews are outlined in Table 1.The average age of survey participants was 54. The majority identified their ethnicity as white, Caucasian or European (89%) and most were married (69%). The vast majority reported having a grade 12 education or higher (89%), and fewer than 15 per cent reported a household income less than $20,000 a year. Seventeen per cent of participants reported their health as being either fair or poor, and almost half (49%) reported having at least one chronic health condition. Hypertension (4%), arthritis (14%) and depression (8%) were the most commonly reported conditions. Participants were purposefully sampled by gender (50% male) and community size (50% large community).U N D E R S T A N D I N G  B R I T I S H  C O L U M B I A N S ’  E X P E R I E N C E S  W I T H  P R I M A RY  H E A LT H  C A R E1 2Characteristic Total Sample  (N=504)Demographics Age, Mean (standard deviation) 54 (15)Male 50%Large community size 50%Married or cohabitating 69%Ethnocultural group    Caucasian 89%   Aboriginal 5%   Chinese 2%   South Asian 2%   Other 3%Education   Less than grade 12 11%   Grade 12 graduate or GED 22%   Some post secondary, college or university 24%   Post secondary diploma or degree obtained 43%Income   Less than $20,000 13%   $20,000 to $49,999 34%   $50,000 to $79,999 25%   $80,000 or greater 28%Employed outside of home 52%HealthGeneral health   Poor or fair 16%   Good, very good or excellent 84%Chronic conditions 49%   Heart disease 7%   Arthritis 14%   High blood pressure or hypertension 14%   Depression 8%   Diabetes 5%   Other chronic health problem 30%Table 1: Demographic characteristics of the total sample.UBC  C E N T R E  F O R  H E A LT H  S E R V I C E S  A ND  P O L I C Y  R E S E A R CHS E P T E M B E R  2 0 0 7Reliability and Validity of Survey ItemsTable 2 summarizes the analysis of the items, scales and index used in the survey. Rows at the bottom of each section indicate whether an item, scale or index could be used, without modification, in future sur-veys. Items and scales were considered useful if they had adequate variability and met internal consistency reliability and construct validity criteria. For those items or scales identified as being less robust, the table summaries whether they require minor (e.g., wording changes) or major (e.g., dropping items from a scale) modification. Six of ten single items used to measure accessibility were found to be robust enough for use in future survey work. The index, strength of affiliation, which is made up of six related items, was also found to be useful in understand-ing the degree to which a person has a usual source of care. Response categories were developed for four single items that inquire about the types of difficulty experi-enced while getting care. These response categories need further testing and modification before being used in future surveys.Continuity has three sub-dimensions: information, relationship and management. One item was used to measure information continuity and one item was used to measure relationship continuity. Both can be used in future survey work. Two subscales were used to measure management continuity, both of which would require major revisions before being used in future surveys.Six of eight single items used to measure responsiveness could be used in future surveys. Two single items need additional work to response categories before being used in future survey work. Of the five scales used to measure the sub-dimensions (communication, shared decision-making and interpersonal style) of interpersonal com-munication, three subscales can be used in future surveys and two require additional work. The whole-person care scale can also be used.With some exceptions, most of the single items and scales measuring other important dimensions of PHC could be used in future surveys. Two identical sets of nine items examine other medical services received (e.g., nutrition-ist, pharmacy). These items, except for one that requires minor modifications, could be used in a future survey. Given the redundancy between the two sets of items, one set should be removed. We tested two patient activation scales and recommend using the Hibbard measure. The patient empowerment and overall satisfaction with PHC scale could also be used in future surveys. Given that there are a number of revisions needed to many of the Patient Assessment of Chronic Illness Care (PACIC) scales, we recommend not using this instrument until further testing and measurement work has been completed. All seven single items measuring confidence in PHC and two single items about confidence in the Canadian health care system (dimensions deemed important by the Brit-ish Columbia Ministry of Health) can be used in future surveys, with some minor wording changes recommend-ed. The seven single items measuring confidence in PHC can be aggregated into a single summary scale.As part of reliability and validity testing, the effects of person-specific (e.g., gender and age) and contextual (e.g., community size) factors was examined on all scales. These sub-analyses by person-specific and contextual factors generated results consistent with the total data set. When the scales displayed adequate reliability and validity in the total sample, sub-analyses of the scale by gender, age or community size also displayed adequate reliability and validity. When scales displayed inadequate reliability and validity in the total sample, sub-analyses by these factors also displayed inadequate reliability and validity. The one exception were the PACIC goal setting and tailoring scales, which showed adequate reliability and validity over the entire sample, but inadequate reliability in males and two age groups (19 to 39 years and 40 to 64 years).U N D E R S T A N D I N G  B R I T I S H  C O L U M B I A N S ’  E X P E R I E N C E S  W I T H  P R I M A RY  H E A LT H  C A R E1 4AccessibilityThe ability to obtain PHC services in a timely fashionItems ReviewedReceived routine care, experienced difficulties getting routine care, types of difficulties experienced while getting routine care, required immediate health care services, experienced difficulties getting immediate health care services, experienced difficulties getting immediate health care during regular office hours, types of difficulties experienced getting immediate health care during regular office hours, experienced difficulties getting im-mediate care during evenings and weekends, types of difficulties experienced getting immediate health care during evenings and weekends, types of difficulties experienced getting immediate health care.Total items reviewed Useful itemsItems requiring minor revisionItems requiring major  revision10 6 4 0Indices Reviewed Strength of affiliation.Total indices reviewed Useful indicesIndices requiring  minor revisionIndices requiring major revision1 1 0 0NotesContains eight items that are subject to use of a specific service.Table 2(a): Summary of reliability and validity of single items, indices and scales in the PHC survey of British Columbians: Items, indices and scales measuring dimensions (aspects) of PHC important to focus group participants.Information continuityOngoing relevant information exchanged between providers, regardless of site of careItems ReviewedPatient’s confidence that the primary health care they receive from different providers is coordinated.Total items reviewed Useful itemsItems requiring minor revisionItems requiring major  revision1 1 0 0Relationship continuityContinuous long-term patient-provider relationshipItems ReviewedContinuity.Total items reviewed Useful itemsItems requiring minor revisionItems requiring major  revision1 1 0 0UBC  C E N T R E  F O R  H E A LT H  S E R V I C E S  A ND  P O L I C Y  R E S E A R CHS E P T E M B E R  2 0 0 7Management continuityOngoing management of a health conditionScales ReviewedPACIC Delivery System/Practice Design, PACIC Follow-Up/Coordination.Total scales reviewed Useful scalesScales requiring minor revisionScales requiring major  revision2 0 0 2NotesBoth scales are subject to use only by those with chronic disease.ResponsivenessThe ability of the system and usual provider to meet patient’s health care needsItems ReviewedTime with doctor, enough time with doctor, average wait in waiting room to see doctor, requested health information in past 12 months, expe-rienced difficulty getting health information, types of difficulties experienced getting health information, satisfaction with usual place of care, satisfaction with care received from family doctor.Total items reviewed Useful itemsItems requiring minor revisionItems requiring major  revision8 6 2 0NotesContains two items that are subject to use of a specific service.Interpersonal communicationCommunication, shared decision-making and a provider’s interpersonal styleScales ReviewedIPC II-Communication: hurried communication or lack of clarity, IPC II-Communication: physician elicited and responded to concerns, IPC II-Communication: physician explained results, IPC II-Decision-making: physician encouraged patient-centred decision-making, IPC II-Interpersonal Style: physician was compassionate and respectful.Total scales reviewed Useful scalesScales requiring minor revisionScales requiring major  revision5 3 0 2Whole-person carePatient viewed by the provider as a ‘whole person’Scales ReviewedWhole-person orientation.Total scales reviewed Useful scalesScales requiring minor revisionScales requiring major  revision1 1 0 0U N D E R S T A N D I N G  B R I T I S H  C O L U M B I A N S ’  E X P E R I E N C E S  W I T H  P R I M A RY  H E A LT H  C A R E1 6Utilization of medical careFrequency of use of medical services relevant to PHCItems ReviewedVisits to doctor in past year, walk-in visits in past year, ER visits in past year.Total items reviewed Useful itemsItems requiring minor revisionItems requiring major  revision3 3 0 0Utilization of other servicesFrequency of use of other health services relevant to PHCItems ReviewedFrequency of primary health care services received during routine check-up or during care for a minor health problem (nutrition/dietary, physical therapy, pharmacy, laboratory services, resources for self-management of chronic conditions, education about health, specialist services, other PHC services).Total items reviewed Useful itemsItems requiring minor revisionItems requiring major  revision18 8 1 9NotesAll 18 items are subject to use of a specific service.General healthSelf-reported level of healthItems ReviewedGeneral health.Total items reviewed Useful itemsItems requiring minor revisionItems requiring major  revision1 1 0 0Chronic diseasePresence of a chronic diseaseItems ReviewedPresence of chronic health condition, heart disease, arthritis, high blood pressure or hypertension, depression, diabetes, other chronic condition.Total items reviewed Useful itemsItems requiring minor revisionItems requiring major  revision7 7 0 0NotesContains six items that are subject to use only by those with chronic disease.Table 2(b): Summary of reliability and validity of single items and scales in the PHC survey of British Columbians: Items and scales measuring dimensions (aspects) of PHC important to the research community.UBC  C E N T R E  F O R  H E A LT H  S E R V I C E S  A ND  P O L I C Y  R E S E A R CHS E P T E M B E R  2 0 0 7Chronic disease managementNurse involvement in chronic disease managementItems ReviewedNurse involved in management of condition.Total items reviewed Useful itemsItems requiring minor revisionItems requiring major  revision1 1 0 0NotesItem is subject to use only by those with chronic disease.Goal setting and tailoringDegree to which provider encourages and assists patient to set goals, improve health habits and seek information or supportScales ReviewedPACIC Goal Setting/Tailoring.Total scales reviewed Useful scalesScales requiring minor revisionScales requiring major  revision1 0 0 1NotesScale is subject to use only by those with chronic disease.Problem solving/contextualDegree to which provider considers patient’s social and cultural needs when making a treatment planScales ReviewedPACIC Problem Solving/Contextual.Total scales reviewed Useful scalesScales requiring minor revisionScales requiring major  revision1 1 0 0NotesScale is subject to use only by those with chronic disease.Patient activationDegree to which provider seeks patient input and allows patient to participate in decision-makingPa-tient’s interest and reported ability to manage their own careScales ReviewedPACIC Patient Activation, Patient Activation Measure.Total scales reviewed Useful scalesScales requiring minor revisionScales requiring major  revision2 1 0 1NotesContains one scale that is subject to use only by those with chronic disease.U N D E R S T A N D I N G  B R I T I S H  C O L U M B I A N S ’  E X P E R I E N C E S  W I T H  P R I M A RY  H E A LT H  C A R E1 8Patient empowermentDegree to which provider seeks information regarding patient’s lifestyle and supports their under-standing that positive lifestyle changes could increase their control over their own healthScales ReviewedIPC Empowerment.Total scales reviewed Useful scalesScales requiring minor revisionScales requiring major  revision1 1 0 0Overall satisfaction with PHCPatient’s overall satisfaction with PHC services over the past 12 monthsScales ReviewedPatient’s satisfaction with usual place of care and satisfaction with care received from family doctor.Total scales reviewed Useful scalesScales requiring minor revisionScales requiring major  revision1 1 0 0Satisfaction with telephone advice line servicesPatient’s use of, and satisfaction with, telephone advice line servicesItems ReviewedPatient’s use of telephone-based health advice line services, and satisfaction with telephone advice line services.Total items reviewed Useful itemsItems requiring minor revisionItems requiring major  revision2 2 0 0NotesContains one item that is subject to use of this service.Table 2(b)(cont.): Summary of reliability and validity of single items and scales in the PHC survey of British Columbians: Items and scales measuring dimensions (aspects) of PHC important to the research community.UBC  C E N T R E  F O R  H E A LT H  S E R V I C E S  A ND  P O L I C Y  R E S E A R CHS E P T E M B E R  2 0 0 7Confidence in the health care systemPatient’s certainty and trust in the PHC sector and in the overall health care systemItems ReviewedConfidence in the Canadian health care system, confidence in ability to get required primary care services, confidence in ability to get prescrip-tion drugs without financial hardship, confidence in ability to get PHC without financial hardship, confidence in their PHC being coordinated, confidence in PHC including early detection and screening, confidence in PHC including health promotion, degree of improvement that Canada’s health care system requires, confidence in the Canadian health system.Total items reviewed Useful itemsItems requiring minor revisionItems requiring major  revision9 6 3 0Scales Reviewed Overall confidence scale (new scale based on confidence items from the health survey by the Employee Benefit Research Institute).Total scales reviewed Useful scalesScales requiring minor revisionScales requiring major  revision1 0 1 0NotesOne item needs modification if used for people aged over 65.Table 2(c): Summary of reliability and validity of single items and scales in the PHC survey of British Columbians: Items and scales measuring dimensions (aspects) of PHC important to the British Columbia Ministry of Health.U N D E R S T A N D I N G  B R I T I S H  C O L U M B I A N S ’  E X P E R I E N C E S  W I T H  P R I M A RY  H E A LT H  C A R E2 0The survey described in this report is unique in that it combines items that measure dimensions of PHC impor-tant to British Columbians, to the PHC research commu-nity, and to government stakeholders. Validation results suggest that most items, indices and scales tested in the pilot survey can be readily used in future work. However, more work is required to improve the usability of certain items (e.g., modifying response categories) and scales (e.g., goal setting and tailoring). More work is also required to create and test additional items or scales in order to provide better coverage of certain dimensions (or aspects) of PHC: relationship, management and in-formation continuity, interpersonal communication (e.g., lack of clarity), and chronic disease management. It should also be noted that the survey sample was lim-ited to individuals with telephone access and who spoke English. However, the study does use a random sample of British Columbians, and assesses the impact of person-specific and contextual factors on the measurement properties of survey items and scales. This survey is a pilot that could benefit from further refinement before it is applied provincially or nationally. It can be used to develop the next iteration of a PHC sec-tor survey, and also outlines administration methods that are feasible for future surveys. Two Canadian Institutes of Health Research-funded projects, Chinese and South Asian Patients’ Perceptions and Expectations of Primary Health Care and Canadians’ Perspectives on the Quality of Primary Health Care are underway at CHSPR to advance this work. ConclusionUBC  C E N T R E  F O R  H E A LT H  S E R V I C E S  A ND  P O L I C Y  R E S E A R CHS E P T E M B E R  2 0 0 7References1 Gerbert B, Hargreaves W. Measuring physician behavior. Medical Care. 1986;24(9):838-847.2 Davies A, Ware J, Jr., Brook R, Peterson J, New-house J. Consumer acceptance of prepaid and fee-for-service medical care: results from a random-ized controlled trial. Health Services Research. 1986;21(3):429-452.3 Broemeling A, Watson D, Black C, Reid R. Mea-suring the performance of primary health care: existing capacity and future information needs. Vancouver, BC: Centre for Health Services and Policy Research; 2006.4 Watson D, Broemeling A, Reid R, Black C. A Results-Based Logic Model for Primary Health Care: Laying an Evidence-Based Foundation to Guide Performance Measurement, Monitoring, and Evaluation. Vancouver, BC: Centre for Health Services and Policy Research; 2004.5 ASDE. ASDE Survey Sampler.  http://www.surveysampler.com/en/company/team.html. Ac-cessed Sept 13, 2006.6 Nunnally JC, Bernstein IH. Psychometric Theory. 3rd ed. New York, NY: McGraw-Hill; 1994.7 Haggerty J, Reid R, Freeman G, Starfield B, Adair C, McKendry R. Continuity of care: a multidisciplinary review. British Medical Journal. 2003;327(7425):1219-1221.8 Haggerty J, Burge F, Gass D, et al. Operational definitions of attributes of primary health care to be evaluated: consensus among Canadian experts. Annals of Family Medicine. 2007;5:336-344.9 Stewart A, Napoles-Springer A, Perez-Stable E. Interpersonal processes of care in diverse popula-tions. Milbank Quarterly. 1999;77(3):305-339.10 Donabedian A. Quality assurance in health care: consumers’ role. Quality in Health Care. 1992;1:247-251.11 DeVellis R. Scale development: theory and applica-tions. Vol 26. Newbury Park, CA: Sage; 1991.12 Shi L, Starfield B, Xu J. Validating the adult primary care assessment tool. Journal of Family Practice. 2001;50:n161w-n171w.13 Glasgow R, Whitesides H, Nelson C, King D. Use of the patient assessment of chronic illness care (PACIC) with diabetic patients. Diabetes Care. 2005;28(11):26552661.14 Stewart A, Napoles-Springer A, Gregorich S, Santoyo-Olsson J. Interpersonal processes of care survey: patient-reported measures for diverse groups. Health Services Research. 2007;43(3 Pt 1):1235-1256.15 Safran DG, Karp M, Coltin K, et al. Measuring patients’ experiences with individual primary care physicians: results of a statewide demonstra-tion project. Journal of General Internal Medicine. 2006;21:13-21.16 Hibbard J, Mahoney E, Stockard J, Tusler M. De-velopment and testing of a short form of the pa-tient activation measure. Health Services Research. 2005;40(6):1918-1930.U N D E R S T A N D I N G  B R I T I S H  C O L U M B I A N S ’  E X P E R I E N C E S  W I T H  P R I M A RY  H E A LT H  C A R E2 2UBC Centre for Health Services and Policy ResearchThe University of British Columbia201-2206 East MallVancouver, B.C. Canada  V6T 1Z3Tel:  604.822.4969Fax:  604.822.5690Email: enquire@chspr.ubc.cawww.chspr.ubc.caAdvancing world-class health services and policy research, training and data resources on issues that matter to Canadians

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