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(Department of General Practice, Pingshan District People's Hospital, Shenzhen, Guangdong, 518118)

ABSTRACT: Objective To investigate the patients experience in community health centers (CHCs) and explore its associated factors. Methods A cross-sectional study was conducted among 330 patients who visited CHCs in Shenzhen, China from January to March 2018. Dependent variable was patient experience. Key descriptive variables were age, gender, marital status, working status groups, visits frequency for the past 6 months, whether patients had signed a family doctor, whether trusted in family doctor, whether had chronic diseases. Results Questionnaires for 300 patients were assessed. In the univariate analysis, patients experience total score was significantly associated with marital status (P<0.1),working status groups (P<0.1), frequency of visit for the past 6 months(P<0.05), whether had signed a family doctor(P<0.05), whether trusted in family doctor(P<0.05), whether had chronic diseases(P<0.05). The multivariate analysis showed that unmarried patients (P=0.011, OR=2.96, 95% CI: 1.24-5.43) and had signed a family doctor (P=0.023, OR=0.44, 95% CI: 0.22-0.85) were more likely to get a higher score. Conclusions Findings of this study showed a medium-level score of patients experience in the community. Patients had a quite good experience and more interventions should be focused upon the influence factors to improve patients experience.

KEY WORDS: patients experience; influencing factors; community health centers; family doctor; chronic disease

Introduction

Primary health care is an integral part in the health care systems of both high-and low-income countries, and there is ample evidence that primary health care is closely related to the improvement of health outcomes[1]. International evidence has shown that perfect primary health care system can lead to better population health outcomes and more equitable distribution of healthcare resources[2-3]. China as a transforming country in East Asia has gradually expedited the process of reshaping a primary care-oriented health care system underpinned by community health centers (CHCs)[4]. CHCs are the major primary care providers in urban areas. The Institute of Medicine (IOM) proposed that patient experience is a measure of patient centeredness, one of six health care quality aims[5]. Research has consistently demonstrated that patient experience is related to clinical processes of prevention and management of disease and with better health outcomes[6-9]. Patients experience has a strong relationship to care regimens and patients adherence to medication particularly in the case of chronic conditions[10-13]. Patients experience is also positively correlated with some significant financial indicators, such as patient loyalty and retention, increased employee satisfaction and reduced medical malpractice risk. Despite the growing body of studies with patient experience in mainland China, most researches are related to tertiary hospitals and there is limited evidence about CHCs.

In this paper, a cross-sectional study was conducted on a population of patients who attended CHCs in Shenzhen, a city in mainland China. This paper aims to investigate what factors associated with patient experience in CHCs. Identification of such factors can provide suitable targets for tailored CHCs interventions.

Methods

Thestudydesignandsamples

A cross-sectional study was performed in patients from CHCs of Pingshan district, Shenzhen, China. The paper questionnaires were distributed to 330 patients in 22 CHCs of Pingshan district from March to June 2018. The authors distributed the questionnaires among participants and told them the objectives of the study and instructed them to fill out the questionnaires. Their consent was implied from their agreement to complete the questionnaires. Sample size was calculated based on the previous literature. Patients who visited the CHCs and who had a normal mental health status and could cooperate with the investigators were included in the study. Given the need of the study, criteria were set to exclude patients having difficulty in understanding or communicating with the investigators, and patients with severe acute diseases, patients weak to participate.

Questionnairesandscales

PrimaryCareAssessmentTool(PCAT)

PCAT was proposed and validated in the USA by Cassady et al[14]. There are several versions in different countries and they have been used in china before[15-16]. The CR-PCAT validated by Mei J[17]in Shenzhen and Dongguan was adopted in this study. The CR-PCAT comprises 15 items with 5 scales measuring 4 core dimensions of primary care, and it reflects patients experience. Five scales include first-contact utilization, access, continuity, coordination, and comprehensiveness. Each item uses a 5-point scale ranging from 1 to 5. The higher the score, the better the patient experience. The total score are 100, less than 50 points represents poor experience, and more than 50 points represents good experience while the influencing factors of patients experience are analyzed.

Self-designedquestionnaire

The self-designed questionnaire was used to collect data of risk factors for patients experience. It was developed based upon a panel of literature review and was assessed by a group of general practice. The questionnaire contains 18 items, which could be divided into 2 categories: socio-demographic details of the participants and family doctor services utilization that might influence patients experience.

Procedure

The investigator distributed the paper questionnaires according to inclusion and exclusion criteria. A standard consent form approved by the Research Ethics Committee of Pingshan Hospital was provided if patients agreed to participate in the study. Patients experience was measured using the PCAT. A total of 330 questionnaires were distributed among 22 CHCs, and 300 copies were finally returned. Data loss less than 5% of the questionnaires used mean instead of missing data and more than 20% were eliminated.

Dataanalysis

The data was analyzed by SPSS 20.0 using descriptive statistics (frequency, percentage, mean and standard deviation) and inferential statistics (independent samples t-test, analysis of variance and multivariate logistic regression. Level of significance was considered asP<0.1

Results

Socio-demographicfactorsofpatientsexperience

In this study, 300 out of 330 respondents replied to the questionnaires (90.90% response rate). The majority of participants were female, 65.70% in total, aged between 18 and 44 years, 70.50% in total, 81.00% of the participants were married, 69.33% were employed, 54.85% participants with high school and higher education level, 77.78% of the participants with the average income more than 3 000 RMB per person, 68.33% of the respondents did not have Labor Medical Insurance, 44.80% with insurance grade one, 29.40% with insurance grade two, 25.80% with insurance grade three. The proportion of registered residents of Shenzhen was 17.67%.

Table 1 showed the univariate analysis of the socio-demographic factors of patients experience. Significant differences were found between marital status groups regarding mean scores of patients experience total score (t=-1.97,P<0.1) and working status groups (t=-1.71,P<0.1).

Table 1. Univariate analysis of the socio-demographic factors of patients' experience (n=300)

Note: * Indicates that the data is missing

Familydoctorfactorsofpatientsexperience

Table 2 showed the univariate analysis of the family doctor factors of patients experience. A total of 4 family doctor factors had P-value of less than 0.05, including frequency of visit for the past 6 months, whether patients had signed a family doctor, whether trusted in family doctor, and whether had chronic diseases.

Chronicdisease-relatedfactorsofpatientsexperience

Participants were divided into 2groups (n=237 without chronic diseases,n=58 with chronic diseases). Table 3 showed scores of each dimension and total scores of participants with chronic diseases and without chronic diseases. The dimension of first-contact utilization (P<0.05), ongoing care (P<0.01), comprehensiveness (CM) (P<0.01) and total scores (P<0.01) were significantly different between 2 groups.

Table 2. Univariate analysis of the family doctor factors of Patients experience (n=300)

Note: * indicates that the data is missing

Table 3. Comparison of two groups patients' experience scores (n=300)

Binarylogisticregressionanalysis

Table 4 showed the results of binary logistic regression analysis. The total score of patients experience were divided into less than 50 points and more than 50 points. A total of 6 factors withP<0.10 were included in the analysis, of which 2 were identified to be independently associated with patients experience total score. Those unmarried patients (P=0.011, OR=2.96, 95% CI: 1.24-5.43), and had signed a family doctor (P=0.023, OR=0.44, 95% CI: 0.22-0.85) were more likely to have higher patients experience score.

Table 4. Binary logistic regression analysis of patients experience total score (n=300)

Discussion

Patientshopingforfamilydoctor

In more and more countries, family practices are adopting quality indicators to demonstrate levels of practices performance and to improve the quality of patients experience and patients' care.

This study showed that there were 39.00% of the participants believed the technique as the most important value of family doctors, followed by the communication ability (14.33%), attitude(29.67%) and education(14.67%). In addition, the service mode that patients were most looking forward to was door-to-door service(42.00%), followed by institution consultation(27.33%), telephone consultation(15.67%) and network online service(13.00%). As we all know, the first-time contact with doctors indicates a trusted relationship between family doctors and patients, and family doctors can use medical techniques to reduce the pain of patients, so most of patients in this study believed that the medical techniques ranked the first. Continuous efforts should be made to enhance family doctor's techniques, which, in turn, attract more patients to sign a family doctor.

A study conducted in Shanghai showed that patients had the highest demands of door-to-door service[18], which was consistent with our findings. This may be due to the long-standing misunderstanding of patients to current family doctor service system, and insufficient publicity on concept of family doctor. However, previous studies indicated that more patients preferred institution consultation than other service forms[19]. It suggested that the general practice developed differently in various cities of China, and people have different perceptions and expectations for family medicine. In the study, findings showed that people had less demand for network online service model, which was similar to the following study[20]. This may be attributed to the continuous development of online medical consulting service in our country. It suggests that medical institutions should make online medical service more advanced, accessible and patient-centered.

Maritalstatusandpatientsexperience

Patients experience is increasingly recognized as one of the three pillars of quality of healthcare alongside clinical effectiveness and patients' safety[5]. There was a significant difference (P<0.1) in patients experience score between married and unmarried patients, unmarried patients were more likely to get a higher score. At present, there has been less evidence about association between marital and patients experience. The relationship between 2 issues may be indirect. A related study indicated that the health status of married people was better than that of unmarried people, which indicated a potentially positive effect of marriage on health[20]. The most likely explanation is that unmarried patients have a poor health status, and their need for health guidance from community doctors is helping to establish a good relationship.

Whetherhadsignedfamilydoctorandpatientsexperience

Patients who had signed a family doctor had a higher score and had a better patients experience than those who had not signed a family doctor. Signing the contact with a family doctor may be a contributing factor of better patient experience. Individuals without signing the contract with family doctors were also more likely to experience difficulties in accessing routine care than those with a family doctor. Meanwhile, having a regular family doctor can reduce the probability of reporting problems and improve access to healthcare services, indicating that family doctors can promote better patients experience. A study showed a strong positive association between the quality of doctor-patient communication and treatment adherence[21]. First of all, good communication with patients is able to offer information for accurate diagnosis and effective treatment. Patients who have signed a family doctor can communicate with a doctor regularly and effectively, family doctors then adjust the treatment plan for the patient's condition in time and enhance treatment adherence. Secondly, it can meet the needs and expectations of the patients, which results in an improved level of patients experiences. As showed in the study[22], frequent visits to family doctors and constantly visiting the same family doctor were associated with good experience. Family doctors can improve patients' subjective initiative, provide disease-related knowledge, improve the patient's ability to manage the disease and quality of life. Furthermore, patient gain a good health status and have good experience.

Whetherhadchronicdiseasesandpatientsexperience

Given the age distribution of population, management of chronic diseases becomes an important part of improving patients experience for policy makers[23-24]. Patients experience is also justified on utilitarian grounds as a mean of improving health status of patients, particularly those with chronic diseases[25-26]. Findings of this study revealed that patients with chronic diseases have higher scores than those without chronic diseases in first-contact utilization, ongoing care, comprehensiveness and total scores. Consistent with previous study, it has been suggested that health status is a major influencing factor on patients' satisfaction and patients experience. Patients who reported their health as poor had the average problem scores that were almost twice as high as those of patients who reported excellent health. Patients who had chronic diseases and high average problem scores would choose to share details of their health problems with family doctors, thereby benefiting the continuity of care. In line with findings of one study[27], patients with chronic diseases were more likely to obtain higher scores in first-contact utilization. Also another study revealed that patients with chronic conditions were in general more satisfied with medical care[28]. Possible explanation might be that such patients, in comparison to healthy subjects who visit family doctors occasionally, may receive more continuous, active and focused care from doctors.

Conclusions

As a result of the study, it was determined that the total score of patient experience in the community is on average. The marital status and signing a contact with family doctors will affect community patient experience, whether have a chronic disease be associated with five scales of patient experience.