systematic review on primary health care

• Open access
• Published: 25 April 2023

Patients values regarding primary health care: a systematic review of qualitative and quantitative evidence

• Agnes Bhakti Pratiwi   ORCID: orcid.org/0000-0002-8567-1617 1 , 2 ,
• Retna Siwi Padmawati   ORCID: orcid.org/0000-0003-0744-5996 3 , 4 ,
• Joko Mulyanto   ORCID: orcid.org/0000-0002-4653-2470 5 , 6 &
• Dick L. Willems   ORCID: orcid.org/0000-0002-5587-2549 1  

BMC Health Services Research volume  23 , Article number:  400 ( 2023 ) Cite this article

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Accessible and high-quality primary health care (PHC) is fundamental to countries moving towards universal health coverage. In order to improve the quality of patient-centered care provided in PHC, a comprehensive understanding of patients’ values is crucial to address any gaps in the health care system. This systematic review aimed to identify patients’ values relevant to PHC.

We searched primary qualitative and quantitative studies about patients’ values related to primary care in PubMed and EMBASE (Ovid) from 2009 to 2020. The studies’ quality was assessed using Joanna Briggs Institute (JBI) Critical Appraisal Checklist for both quantitative and qualitative studies and Consolidated Criteria for Reporting Qualitative Studies (COREQ) for qualitative studies. A thematic approach was used in the data synthesis.

The database search resulted in 1,817 articles. A total of 68 articles were full-text screened. Data were extracted from nine quantitative and nine qualitative studies that met the inclusion criteria. The participants of the studies were mainly the general population in high-income countries. Four themes emerged from the analysis: patients’ values related to privacy and autonomy; values associated with the general practitioners including virtuous characteristics, knowledge and competence; values involving patient-doctor interactions such as shared decision-making and empowerment; and core values related to the primary care system such as continuity, referral, and accessibility.

Conclusions

This review reveals that the doctor’s personal characteristics and their interactions with the patients are critical considerations concerning the primary care services from the patients’ point of view. The inclusion of these values is essential to improve the quality of primary care.

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Introduction

Different countries are moving health systems resources towards universal health coverage, necessitating efficient health resources allocation, sustainable health financing, and a strong primary healthcare (PHC) system as the backbone [ 1 , 2 , 3 ]. The role of PHC has become indispensable because it serves as the initial and continuous contact for patients, acts as the gatekeeper to higher levels of care, and provides a coordinated and comprehensive care to the community [ 4 ]. The PHC principles are universal access, equitable care provision, accentuating prevention, health promotion, and community participation [ 1 ]. In the practice of PHC service provision, it is imperative to find the balance in social and medical aspects to meet the need of its users.

However, from the patients’ point of view, PHC may not fully satisfy their needs. Evidence suggest that even in the absence of major barriers such as costs and geography, some people would prefer other healthcare services, such as emergency departments, hospitals, or traditional healers [ 5 , 6 , 7 , 8 ]. A perception exists about low quality in primary care due to low confidence in the doctors’ knowledge and skills, or difficulties related to communication [ 9 ]. Other barriers include cost and time, low perceived need, and fears related to a patient’s medical condition or procedures [ 10 ].

The current advancement of medical technologies has placed patients’ views, values, and preferences as central considerations [ 11 ]. However, doctors’ or service providers’ values possibly differ from the patients’ values [ 11 ]. Hence, patient values should not be defined by other stakeholders in the PHC system, but by the patients’ voices themselves. Patients’ values can be identified in their satisfaction with care, their preferences and priorities, expectations, experiences, and aspects of care important to them [ 12 , 13 ]. These values can vary widely and are affected by various social, demography, cultural, and health system factors [ 12 , 14 ]. Taking into account patient values can positively impact healthcare access and delivery, better care continuity and treatment adherence, while minimizing the need for a higher level of care [ 3 , 15 ]. This qualitative approach in turn can improve health outcomes (decrease preventable morbidities and deaths), and save costs to individuals as well as the health system [ 13 ].

Understanding what people value from primary care has also become fundamental for a patient-oriented service provision. This information can help to identify which aspects of PHC are important to patients for further quality improvement. Previous systematic reviews about patient values by Bastemeijer et al. researched the definitions and concepts of patient values and preferences [ 16 ]. One study conducted by Mathioudakis et al. also reviewed patient values, but specifically to improve breast cancer screening [ 17 ]. There is a lack of information about patient values related to primary health care. This systematic review intended to fill this gap of evidence.

Eligibility criteria

Studies were eligible for inclusion if they:

• were about values from the perspective of and expressed by patients, that is, patients as the participants in the study.

• contained information on values, aspects that patients consider important [ 18 ] in primary care.

• used qualitative, quantitative, or mixed-method study designs.

Studies were excluded if they:

• described only views from other stakeholders, such as doctors or healthcare workers on patient values.

• described a context that was outpatient but not PHC, such as in the secondary or tertiary level of care.

• were conference abstracts and briefs since they often contain preliminary findings and insufficient information synthesis [ 19 ].

Search procedure

We sought evidence by systematically searching for original research articles in PubMed and EMBASE (Ovid) (Supplementary file 1 ) and additional searches in Google Scholar. Articles from January 2009 to May 2020 were included. We identified values and preferences important to patients related to PHC services. Considering values are a complex concept, the inclusion criteria were extended by identifying articles that might implicitly research and explain patient values . The search terms were selected from key terms often used in literature for describing patients' values such as satisfaction, important aspects or factors, expectations, priorities, preferences, and experiences [ 12 , 13 , 14 , 16 ]. We used MeSH terms, keywords, and synonyms to search the articles. The main search terms were "Primary health care", "Patient", "value", and "access" (Supplementary file 1 ). Search terms were kept broad to capture as many relevant articles within our study objectives.

Selection process, data extraction, analysis, and synthesis

ABP and JM performed the title, abstract, and full-text screening independently. Through online meetings with all team members, we discussed and resolved disagreements. Due to the variability in methods and data collected in the included studies, meta-analysis was not performed. The data extraction process was guided by the Joanna Briggs Institute (JBI) mixed methods data extraction form [ 20 ]. Extracted data were analyzed thematically and synthesized narratively by ABP, RSP, and DW, with input from JM. Firstly, we performed inductive coding to allow concepts and themes to emerge from the data. Coding and concepts were discussed, refined, and finalized with all authors. Secondly, a deductive phase was conducted to categorize the findings. The concepts developed by Bastemeijer et al. [ 16 ] were used as an initial guide to classify our findings. This systematic review was presented according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [ 21 ].

Quality and risk of bias assessment

The quantitative and qualitative studies' quality was assessed using the JBI Critical Appraisal Checklist for Analytical Cross-sectional Studies [ 17 ]. This checklist was developed collaboratively, approved by the JBI International Scientific committee, and used in previously published systematic reviews [ 18 , 19 , 20 ]. In addition, qualitative studies were assessed using Consolidated Criteria for Reporting Qualitative Studies (COREQ) [ 22 , 23 ] by ABP and JM. DW and RSP reviewed and gave input to the appraisal results.

Study description

After removing duplicates, a total of 1,819 articles were identified and screened for titles and abstracts, which resulted in 70 articles eligible for full-text screening (Fig.  1 ). Among them, six full texts were not available. The authors then performed full-text screening for the rest of the articles, resulting in 16 papers and two additional papers from reference searching that met the inclusion criteria. Articles were excluded because of the following reasons: twenty-two articles did not directly reveal patient values; eight papers were about specific aspects and values that had been pre-determined by investigators; six articles focused on other types of care such as emergency; five articles were about scoring and ratings; three studies did not meet the method inclusion criteria (such as using discrete choice experiment), and two studies were not clearly from the patients' point of view. Characteristics of the included studies are described in Tables  1 and 2 .

PRISMA flowchart for the included studies [ 21 ]

The selected qualitative studies met between 9 to 10 from 10 JBI criteria, and 18 to 27 from the 32 COREQ criteria (Supplementary file 2 ). Half of the qualitative studies explicitly explained the interviewers' characteristics, but only one study presented a discussion concerning non-participation. One study had a coding tree description, and the other studies may have put the coding tree directly into themes or subheadings in the main text. Most of the quantitative studies met the critical appraisal criteria checklist. However, the criteria on appropriate exposure measurement, confounding identification, and mitigation strategies did not apply for some of the studies (Supplementary file 2 ) . All authors (ABP, RSP, JM, DW) judged the included studies to be of sufficient quality.

Patient values of primary care services

Out of eighteen included studies, none came from low-income settings, thirteen originated from high-income countries, and the rest were from middle-income countries (country category according to The World bank) [ 24 ]. Nine studies were from European countries. Most respondents aged 18 and above. Vulnerable populations identified within the included studies were elderly, lesbian women, people with mental illness and substance abuse, and ethnic minority groups. No studies were about parent's or children's values.

To provide a clearer view at which level the values occur within the PHC system, we categorized the patient values into four groups, as illustrated in Figs.  2 and 3 :

1. Values related to attributes of the patients themselves (labelled as "patients").

2. Values related to their expectations from a primary care physician (labelled as "doctors").

3. Values related to the patient-physician interaction (labelled as "patient-physician interaction").

4. Values related to the system (labelled as "primary care system").

Mapping results from the data extraction. First author and year: (1) Berkelmans et al. (2010) [ 28 ], (2) Ekawati et al. (2017) [ 31 ], (3) Marcinowicz et al. (2014) [ 26 ], (4) Bjorkman et al. (2009) [ 29 ], (5) Chauhan et al. (2018), (6) Papp et al. (2014) [ 35 ], (7) Naidoo et al. (2019), (8) Ross et al. (2015) [ 27 ], (9) Artuso et al. (2013) [ 33 ], (10) Aldosari et al. (2017) [ 38 ], (11) Croker et al. (2013) [ 36 ], (12) Droz et al. (2019) [ 12 ], (13) Ofei-Dodoo et al. (2019) [ 34 ], (14) Kenny et al. (2015), (15) Sebo et al. (2015) [ 39 ], (16) Lionis et al. (2017) [ 13 ], (17) Mercado et al. (2012) [ 40 ], (18) Hirsch et al. (2016) [ 37 ]

Conceptual framework for patient values regarding primary care

Values and related quotations from the included qualitative studies are shown in Table 3 .

From our analysis, there are two values closely associated with the patient: autonomy and privacy.

We found that for patients, autonomy means being given choices. The study by Kenny et al. found that the opportunity to choose which General Practitioner (GP) to see was regarded as an essential aspect by more than 80% of Australian adults [ 32 ]. Vulnerable groups prioritized more autonomy, because they may feel the lack of it. Berkelmans et al. found that autonomy is a need for senior citizens in the Netherlands. In their study, some patients who got a home visit from doctors would prefer to be given a choice to visit the GP at the practice [ 28 ]. Indigenous respondents in Australia accentuate the need for autonomy. They were provided with less information, have inadequate ability to understand medically related information, and felt they were left without options [ 33 ]. An empowering respondent illustrated this value: "Giving people the power to be able to say, 'Well, we want this' and then resource those ideas….." [ 33 ] .

We could not find any explicit description about the specific aspects patients hold important about privacy. One recent survey found that patients’ experience that their privacy is protected during visits, increases their satisfaction by 1.34 (95% CI: 1.10 – 1.63) [ 34 ]. In this research, the question asked about privacy was “What was the way the health services ensured that you could talk privately to providers?”. Papp et al. (2014) found that patient privacy and information confidentiality during the PHC visit is essential but rarely expressed by patients from the EU nations [ 35 ]. This focus group discussion (FGD) study categorized privacy during the primary care visits and patients’ information as part of patient-centered care.

We found that patient values were predominantly associated with the values of the GP. Patients hold high expectations towards their GPs even though the system and regulation also contribute to patients’ experience. Some values related to the GP were especially crucial, to such an extent that it would be intolerable if violated by the physician. Some studies found that patients would rather change providers if their personal values are breached. However, in practice the GPs might not be fully aware of this situation.

Patient as a person

Eight studies revealed the value of treating patients as a person [ 12 , 13 , 25 , 26 , 27 , 30 , 33 , 35 ], and in complement, there were six studies that emphasized the importance of being taken seriously [ 12 , 13 , 26 , 28 , 31 , 36 , 37 ]. Patients would rather be seen and treated as a whole person, meaning as an individual with needs concerning their medical conditions, than to be merely seen as a medical case. Patients perceive that their complaints, illness, and medical situation often become the doctor's sole focus without adequately considering their psycho-social needs. To be seen as an individual also meant to be taken seriously by the doctor, being asked about feelings and concerns.

Studies in this review emphasized the value of being taken seriously [ 12 , 13 , 26 , 28 , 31 , 36 , 37 ]. One possible way to interpret this value would be that the patient wants to be seen as a person whose health problems should be dealt with by having their medical conditions assessed and treated holistically by the physician. In the findings from a United Kingdom (UK) study, the aspect "GP that takes patients problems seriously" was ranked as the most critical component in GP consultation, consistent across different genders, ethnicities, and age groups, but no further explanation was provided about what they meant. Having their problems seriously addressed increases patients' confidence and trust in their GP by three times [ 36 ].

Among specific population groups, elderly with chronic diseases in South Africa experienced an uncomfortable disease-centered form of care where the GPs focus only on providing medication [ 25 ]. An elderly patient visiting the geriatric section at primary care felt frustration and ignorance when they were immediately referred to another doctor without proper explanation [ 25 ]. Furthermore, individuals with mental illness or substance abuse often have complex and interrelated physical, medical, and psychosocial needs that are crucial to be seen as a whole person for their well-being [ 27 ].

Appropriate communication and information provision

The doctors’ excellence in communication and information provision was an important value by studies among Australians [ 32 ], elderly in Poland [ 26 ], dental patients in Brazil [ 38 ], UK patients [ 36 ], and patients in Switzerland [ 12 ]. Adequate doctors’ explanation was also ranked as the third most important aspect by UK patients, notably ranked more critical among the subgroup age 35–64 white people, but rated lower among elderly non-white [ 36 ]. A study conducted in Switzerland showed that communication is considered the most important value of family medicine. Getting a clear understanding of what their GP explains was regarded as very important by 70% of respondents [ 12 ]. In contrast, a small number of elderly patients in The Netherlands prefer less information or would instead obtain information independently from other sources such as the Internet [ 28 ].

Patients suggest that communication and information provision affect the quality of care they receive. The willingness of doctors to explain and provide information affects patients’ satisfaction with care [ 26 , 32 , 36 , 38 ]. For some patients, the value of communication and information provision is fundamental so that a patient may decide to go to another service if this value was not met. Inappropriate languages and expressions can be perceived as offensive by patients. For example, lesbian women who felt that the physician responded improperly to their situation decided to see another doctor [ 29 ]. The situation might occur due to the doctor’s limited understanding of the lesbian patients’ context. Sometimes, patients are left confused with the information provided by the GP or thinking that the doctor’s explanation is sometimes insufficient. Some patients have encountered doctors who barely explain their health conditions but instead jump directly to giving prescriptions [ 25 ].

Listening to patients is also highly valued as part of good communication skills [ 12 , 13 , 28 , 32 , 35 ]. Being listened to also meant being asked back about details, since patients may have difficulties even saying anything due to their limited understanding of diseases [ 26 ]. According to a survey in Greece, patients want to be given a chance to ask questions [ 13 ].

Knowledgeable and competent doctors

In eight of the studies, patients value the knowledge, skills, and competence of GPs [ 27 , 28 , 29 , 30 , 31 , 35 , 39 , 40 ]. Having sufficient knowledge and skills is perceived to determine the doctor's ability to treat patients adequately and deliver relevant information [ 28 ]. Knowledge does not only refer to medical comprehension but also about contextual features inseparable to the patients’ life and well-being. The certified doctor was also considered as a competent doctor as shown in two studies about preference for seeing a certified GP [ 39 , 40 ].

Some patients in Indonesia go to PHC only for minor illness. They perceive the GP to have insufficient knowledge and skills to treat more serious illness [ 31 ]. A study on patients with mental disorders explained that the feeling of being offended and mistreated may make them decide to leave the GP and not come back [ 27 ]. Similarly, lesbian women noted that GPs commonly lack awareness of the lesbian context, and perceive patients generally as heterosexual. Hence, doctors may relate lesbian patients’ medical condition inappropriately to their relationship preference [ 29 ].

Virtuous characteristics

Physicians in PHC are expected to uphold and demonstrate virtues, including attitudes of non-discrimination, inclusivity. Six studies [ 27 , 29 , 30 , 33 , 35 , 36 , 37 ] emphasized the importance of non-discriminatory and non-judgmental treatment from GPs to facilitate a favorable care experience. In one European study, none of the participants reported being discriminated against in primary care [ 35 ]. However, in other parts of the world, patients feel that they did not receive satisfactory treatment because of racial, skin color, and socio-economic-status-related discrimination [ 27 , 30 ]. In addition, some individuals received privileged access due to pre-existing connections with PHC staff. Patients experiencing discrimination in Brazil were unwilling to see the same physician again [ 30 ].

Inclusiveness is considered an essential value, as reflected in studies among specific groups, including lesbian women, the elderly, indigenous communities, and patients with mental illness [ 27 , 29 , 39 ]. For mental health patients who have complex social circumstances, a non-inclusive service provision may increase the risk to forgo the care altogether [ 27 ]. An integrated and inclusive care provision is needed to fulfil their health needs.

The virtues were further expanded to attributes that have been commonly associated with ideal physicians such as being empathetic and respectful [ 29 , 30 , 34 ], open-minded [ 26 ], friendly [ 26 , 35 ], accepting [ 29 ], understanding [ 29 ], open [ 29 ], supportive [ 29 ], attentive [ 30 , 35 ], as well as comforting [ 30 ]. These attributes have been shown to contribute to increasing patient satisfaction, as found by a study from Ghana [ 34 ].

Patient doctor interaction during visit

Empowerment and shared-decision making emerged as essential features from the patient-doctor interaction.

Shared decision-making

Patients valued being asked and involved in decisions concerning their medical conditions and treatment [ 26 , 28 , 32 , 34 , 35 , 36 ]. Shared decision-making for patients meant having their views taken into deliberation, an open discussion, and avoiding paternalistic decisions. Shared decision-making was perceived to lead to better treatment adherence.

A shared decision is highly valued by patients in Europe [ 26 , 28 , 35 ]. Among the general population in the UK, shared decision-making is ranked as the fourth most important aspect of a primary care doctor. It is ranked the second most crucial aspect by the white elderly population aged above 65 years but ranked lower notably by non-white young people below 35 years old [ 36 ]. In this study, there was no difference in the rank of shared decision-making among different genders [ 36 ]. The study in Ghana found that the involvement of patients in the decision-making process increases their satisfaction with primary care by 1.34 times [ 34 ].

Empowerment

Patients emphasized the importance of being empowered by their GPs [ 12 , 27 , 35 , 38 ]. Patients who have a good relationship and support from their PHC provider will feel confident and empowered to care for their own well-being [ 27 ]. Although considered vital in care, patient activation as described by adherence to the agreed plan and fulfilling scheduled appointments are valued relatively less in Switzerland. Only half of the respondents regarded it as very important [ 12 ].

Primary care system

Time preference.

Having a visit to primary care services often means a trade-off to other activities, including work. People prefer shorter waiting times inside the clinic and brief queues to get appointments, yet patients also regarded sufficient consultation time as crucial [ 26 , 32 , 38 ]. Patients expected a longer consultation time with the PHC provider than the current allocated time, including sufficient time to get the explanation of their medical condition [ 35 ]. Among dental primary care users in Brazil, patients receiving enough time for treatment were more satisfied [ 38 ].

This situation causes a trade-off to choose specific patients values for the primary care system, where it is impossible to accommodate all. In European countries, concerns in queuing are more directed towards the waiting time from calling or getting in contact with the clinic until getting the appointment schedule. In middle-income countries such as Indonesia, Brazil, and South Africa, the time spent for queuing at primary care can be problematic, because the patients have to show up physically and wait.

The acceptable waiting time in clinics varies between studies. For the elderly and patients with addiction, waiting at the clinic for more than a half hour was considered to be long [ 27 , 28 ]. In Brazil, some primary care patients needed to show up early in the morning to queue [ 30 ]. Long waiting times also result in higher opportunity for community acquired infection as well as increased dissatisfaction and indirect costs. In Indonesia, lengthy waiting times increases the risk of patients leaving the PHC and changing to a private hospital because the opportunity costs for working people will be high [ 31 ]. Similarly, in South Africa, people can spend their whole day queuing or, worse, having to come back the next day, which entails additional costs on transportation [ 25 ].

Acceptable waiting time in terms of days to get appointments varies, ranging from zero days (getting appointment immediately at arrival) to two weeks [ 27 , 28 , 30 , 35 , 38 , 39 ]. In some countries, any waiting time that impedes access to care is unacceptable. Meanwhile in Finland, one week of waiting for an appointment schedule is considered acceptable [ 35 ]. A study from Brazil found that patients accepted for dental treatment upon arrival were more satisfied than those who were scheduled [ 38 ]. Getting immediate appointments was also preferred by patients with mental health conditions. In the usual situation in one study, they may have to wait two to three weeks [ 27 ].

In terms of age, young patients were reported to have less tolerance for lengthy waiting time at the clinic than waiting for an appointment, while the elderly were more demanding in expecting to meet the doctor on the same day [ 39 ]. Regardless of age, most respondents considered a waiting period of up to two weeks appropriate and tolerable [ 39 ].

Continuity of care

Patients value the continuity of care by seeing the same doctor [ 12 , 26 , 27 , 28 , 30 , 32 , 35 ]. The doctor is expected to know the patients’ personal as well as their medical history. This aspect makes the patients feel familiar and comfortable to visit the primary care since they do not have to explain their condition again for the subsequent visits. Seeing the same doctor also means that the patient and the doctor can build a more personal relationship, resulting in the patient's trust and confidence in the doctor. It is regarded as important by individuals in seven EU countries as reflected by one respondent [ 35 ]:

‘“It is important that one doctor sees the whole process of the illness. So, the patient should not tell another doctor the whole case history again and again”. (Hungarian patient)' [ 35 ]

Continuity of care was particularly valued by patients with medical conditions needing multiple visits. This value was described as knowing the GP that patients will meet which was regarded as very important by more than 50% of Swiss respondents, and more importantly, among patients with chronic disease [ 12 ]. The importance of continuity of care for people with mental health issues was also divulged from a study in Canada that indicated as many as 80% of participants who see the same GP regularly have a good relationship with their health care provider [ 27 ].

Adequate referral provision

Patients also valued referral provision [ 12 , 26 , 27 , 28 , 31 , 33 , 35 ] because sometimes they encountered difficulties in obtaining an appropriate referral. Some perceive the gatekeeping role of primary care, and practitioners’ reluctance hinder people from obtaining a referral. Others would expect the humility of the practitioners they see to offer a referral immediately if the medical condition is outside of their expertise [ 27 ]. Patients prefer direct access instead of going to the GP only to get the specialist's referral letter [ 35 ]. GPs’ decision to refer to a specialist is considered very important by almost 70%, and the second most substantial value of family medicine by respondents in Switzerland [ 12 ]. In a study from Poland, geriatric patients perceived that doctors were reluctant to provide a referral to a specialist [ 26 ], as illustrated by one respondent in the statement below:

‘‘‘Somehow doctor was not very eager to give a referral for tests’’ (Woman, aged 79).’

This issue that patients have to go back and forth between referrals is also seen in the back referral process (referral from a higher level of care back to the primary care). When patients are referred to the specialist and then back to primary care, the GP will convey that it is beyond their competence and capacity [ 35 ]. In one study, aboriginal patients with cardiac conditions were commonly left without follow-up care once they had finished with treatments at the hospital and returned to their community [ 33 ].

Accessibility

Ease of access is another important element that patients consider highly when choosing PHC that emerged from the data. Services that can be easily reached through phone calls and are closer in proximity are preferable [ 31 , 31 , 32 , 35 , 40 ]. Similarly, geographical access and time needed to reach PHC were influential aspects for patients in Europe [ 35 ].

In terms of financial accessibility, out-of-pocket payments may impede accessibility of PHC. Patients in Germany expect no charge for access to primary care, even for preventive care, because not everyone can pay [ 35 ]. Costs are closely linked to the primary care services that the health system implements, and they have been brought up as a significant factor in choosing GPs by patients in Australia [ 32 ].

Description of factors affecting values

Although the essential values of primary care arising from the included studies were mainly similar, different social determinants such as age, gender, ethnicity, disease, and rurality might influence patients' values regarding PHC. Findings from the studies varied, particularly appearing from the analysis in some quantitative studies. According to two studies, the most important values do not differ between gender, although women assigned higher values [ 12 , 32 ]. Specifically, for vulnerable groups, the value of non-discriminatory services should be seen as a top priority, because it could potentially influence their decision to visit a particular PHC [ 27 , 29 , 30 , 33 , 36 , 37 ]. In a survey in Switzerland, participants with chronic diseases valued the aspect of being seen as a person and continuity of care higher than people without chronic illness with OR 2.21 and 1.92, respectively [ 12 ]. In contrast, the study in Australia found that having a chronic disease and rurality do not differ in all their modelling in essential aspects of GP [ 32 ]. However, age and GP visit frequency did. According to Sebo et al., elderly and patients at large practices are more stringent [ 39 ].

Our review sought to understand the vital aspects of health care services that patients value regarding PHC. Our findings describe that values in primary care vary; some values influence outcome measures such as patient satisfaction, trust, and utilization. Concerning patients’ experience, privacy and autonomy are crucial. Related to the doctor, patients accentuate the importance of being seen as a whole person and expect doctors to have good knowledge and competence in medical and non-medical aspects. Patients also valued doctors’ virtuous traits. Shared decision-making and empowerment were critical in the interaction between doctor and patient. Other elements that patients value specifically related to the primary care system arrangement were waiting time, being able to see the same doctor, being given a referral, and accessible primary care.

Virtuous characteristic of doctors and patient as a person

Values related to the general practitioner were paramount and apparent in most studies from high- and middle-income countries. This may reflect that even in a good PHC system, patients place high expectations on their doctor's interpersonal skills. Patients value primary care doctors who have not only medical-related competence but also virtuous characteristics and can address their patients' as a person, as in findings from previous studies [ 41 , 42 , 43 ]. A study from the UK found the most critical component of general practitioner consultation was having their problems addressed seriously, which increases trust and confidence in GP. Findings from other countries also emphasized this value. The picture of an ideal physician may not always be realistic. However, it reflects the need for primary care providers to pay attention to tailored care to address patients' specific needs.

Value prioritized by vulnerable subgroups

In healthcare and daily life, vulnerable groups experience stigma and discrimination daily outside healthcare, from stigma related to the socio-economy, and criminalization, to unsettled housing, which can become notable barriers to accessing PHC. Our study highlights that vulnerable subgroups may prioritize a particular value regarding PHC differently than general adult patients. For example, the elderly and indigenous accentuated their need for autonomy. In contrast, lesbians and patients with mental disorders prioritized inclusivity and understanding their psycho-social context. In Europe, patients don't feel discriminated against in PHC [ 27 ]. However, this is not the case in other parts of the world, including studies from Brazil and Canada. Hence, it is crucial to operationalize an inclusive care provision at PHC with patients' views.

Continuity of care and referral

Seven studies from different countries valued the continuity of care, which is unique for PHC. For patients needing multiple visits or those with chronic illness, continuity of care is regarded as relatively more critical, similar to findings from previous studies [ 44 , 45 ]. Continuity of care impacts health outcomes and may lead to decreased mortality in primary and secondary care [ 45 ]. Through this continuity of care, patients experience the benefit in that the doctor remembers patients’ information, so they do not have to repeat the same story. This can save the uncomfortable process for the patient of explaining their medical condition and establish trust and a good relationship [ 12 , 27 , 32 ]. PHC may operationalize continuity of care differently, either at the healthcare facility or doctor level. In the findings, patients value the latter.

Furthermore, referral provision is also unique to PHC. Our findings highlight the importance of the PHC doctor's decision to provide a referral. However, some patients perceived reluctance and experienced difficulties related to the referral. Referral provision-related policies may restrict doctors from providing referrals [ 4 , 8 ]. Due to limited understanding of this gatekeeping system, patients may demand that GPs give referrals to a higher level of care [ 31 ]. Some patients perceive GP's gatekeeping role as a barrier to reaching specialist care [ 35 ], creating a dilemma for the doctor.

Privacy and autonomy

We noted that although privacy protection increased patient satisfaction [ 34 ], it is rarely explicitly framed. Privacy protection is closely related to patients' trust and care-seeking should be possible without any privacy infringement [ 46 , 47 , 48 , 49 ]. Attention to patient privacy should be reflected at least in two aspects: during the visit and on patients' information. Research on privacy in healthcare recently leaned towards discussing electronic patient records and online data protection [ 49 , 50 , 51 , 52 , 53 ]. Despite being equally important, there was little discussion of the other dimensions of privacy, such as how the patient felt and experienced their privacy. Privacy during PHC visits might not be an issue in some countries, but this gap suggests there is scarce evidence about how and which aspects of privacy patients value in primary care.

Autonomy in primary care can be particularly challenging for vulnerable groups. Respecting a patient's autonomy can be, at a certain point, challenging when in conflict with the value of evidence-based medicine [ 54 ], for example, for doctors to find the balance between their medical knowledge and patients' wishes. Research on patients with chronic illness found that autonomy is recognized as a value underlying patients' demand for quality services, while paternalism and ‘knowing better’ can reflect a lack of recognition of patients' autonomy [ 55 ]. Autonomy is also closely related to the second theme; doctor-patient interaction relates to the values of shared-decision making and empowerment.

According to the IOM and Picker institute, values should guide clinical decisions [ 56 , 57 ]. Patient values identified in our study can be used as a basis for PHC aiming at patient-centered care. This kind of patient-centered approach could be implemented, for example, into a guideline that incorporates patients' values [ 58 , 59 ].

Strengths and limitations

To our knowledge, this is the first systematic review on patient values regarding primary care. We used rigorous methods through the search steps and assessment of the articles. We used the most relevant studies, suggesting that the values reflected are related to the current situation. The studies included different populations, and countries, thus capturing various settings and circumstances.

A limitation of this study is that it only included studies published in English. Related to the included studies, elaboration and description of particular values were often unavailable. As a result, we could not compare possible different meanings concerning a specific value in different studies.

This study provides insight into aspects and values from the patients' perspective that may affect their decision towards seeking care at a PHC. Countries that want to set a primary care system as the basis for universal health coverage should prioritize and consider the aspects patients think are important about PHC. Patients value the interpersonal and virtuous characteristics of a PHC doctor, which demands particular attention. Patients values in primary care were mainly related to the doctor or interaction during clinical encounters, which is unique to PHC. Although we assumed that privacy might be an essential value, patients rarely expressed it in the studies. Different subgroups of patients may prioritize values differently. Further identification of priority values concerning patient characteristics can inform patient-centered service provision. Continuity of care, good referral provision, and accessibility were values related to the PHC system that need careful attention. There were no studies from low-income countries, nor about parents' or children's specific values. Further research may need to concentrate on these two blind spots.

Availability of data and materials

Data from included articles in this study are available in the reference for download. Data generated during the analysis are available in the main text and supplementary materials.

Abbreviations

Primary Health Care

Joanna Briggs Institute

Focus group discussion

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Acknowledgements

We would like to thank Faridi S van Etten-Jamaludin for helping with and checking the literature search strategy, Nabila P Kesuma for valuable feedback on the manuscript, and Erik Hookom for proofreading the manuscript.

ABP received funding from Indonesia Endowment Fund for Education (LPDP) for her PhD study, number 201909222915503. The funder had no role in the design, data collection, analysis, and interpretation in the manuscript.

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ABP and DW designed the study with critical feedback from RSP and JM. ABP and JM performed the search, screening, and data extraction. All authors (ABP, RSP, JM, DW) collaborated in the article selection process, decision, and quality appraisal. ABP performed the initial analysis, RSP and DW provided substantial input and refined the analysis process. RSP, JM, DW reviewed and provided input to the analysis and interpretation of the data. ABP drafted the manuscript, RSP, JM, and DW revised the manuscript's structure, content, and flow. All authors reviewed and approved the final manuscript.

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Pratiwi, A.B., Padmawati, R.S., Mulyanto, J. et al. Patients values regarding primary health care: a systematic review of qualitative and quantitative evidence. BMC Health Serv Res 23 , 400 (2023). https://doi.org/10.1186/s12913-023-09394-8

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DOI : https://doi.org/10.1186/s12913-023-09394-8

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Systematic review of comprehensive primary health care models

Many countries are investing in primary health care (PHC) reform, with particular attention being paid to establishing local or regional organisational structures; implementing new funding arrangements and changing the PHC workforce skills mix. This review examines what is known about the implementation and effectiveness of the different system-wide models being developed in Australia, United Kingdom and New Zealand to achieve PHC reform.

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Jacobs R, Aylott L, Dare C, et al. The association between primary care quality and health-care use, costs and outcomes for people with serious mental illness: a retrospective observational study. Southampton (UK): NIHR Journals Library; 2020 Jun. (Health Services and Delivery Research, No. 8.25.)

The association between primary care quality and health-care use, costs and outcomes for people with serious mental illness: a retrospective observational study.

Chapter 2 systematic literature review of primary care quality.

This chapter is based on Kronenberg et al. 39 This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/ . This includes minor additions and formatting changes to the original text.

• Introduction

Quality and Outcomes Framework indicators are targeted at high-priority disease areas for which primary care has principal responsibility for ongoing care and when there is good evidence that improved primary care will have health benefits. However, as noted in Chapter 1 , Other measures of quality , the QOF may neglect important unmeasured aspects of quality of care 43 and the incentives may result in tunnel vision 44 or a focus on activities that are incentivised at the expense of other non-incentivised activities. 45 , 46

We therefore performed a systematic review of the literature and interrogated international databases to identify potential quality indicators that we could include in our study. We sought to include indicators identified in the literature into our analysis as additional measures of quality of care, rather than focusing only on QOF indicators. These additional measures could potentially supplement or even replace indicators included in the QOF for people with SMI and could potentially be incentivised in primary care. Identifying indicators of primary care quality for people with SMI could help shed light on neglected areas of care, as well as providing the basis for incentive schemes aimed at improving quality.

A major focus of our analysis was the source of the data on which the indicators were based. Those requiring primary data collection, for example via surveys of patients or health professionals, or retrospective auditing of patient records, would be very challenging to examine in routine data. This was an important consideration for inclusion in our analysis. Previous literature reviews on quality indicators have focused on SMI in secondary care, 47 , 48 whereas our review was the first to focus specifically on people with SMI treated in primary care.

A systematic review of primary care quality indicators for people with SMI was conducted 39 in February 2015, with the aim of identifying quality indicators in addition to those already included in the QOF.

The base search was constructed using MEDLINE and adapted to other resources. The following databases were searched: Applied Social Sciences Index and Abstracts (ASSIA); Cochrane Central Register of Controlled Trials (CENTRAL); Cochrane Database of Systematic Reviews; Conference Proceedings Citation Index – Science (CPCI-S); Database of Abstracts of Reviews of Effects (DARE); EMBASE; Ovid MEDLINE ® In-Process & Other Non-Indexed Citations and Ovid MEDLINE ® ; PsycINFO and MEDLINE. The full strategy for MEDLINE as a template is available in Appendix 1 .

Additionally, previous reviews with overlapping aims were searched and we contacted authors to ask for their indicators (most notably Stegbauer et al. 48 and Großimlinghaus et al. 49 ). The quality indicator database of the Agency for Healthcare Research and Quality 50 was also searched for indicators relevant to primary care. The final selection of indicators was informed by the views of our SSC.

Inclusion and exclusion criteria

We sought published examples of potential quality indicators that could readily be collected in primary care with reference to routine data. Search terms were identified by an information specialist, in conjunction with the research team. Included papers had the terms serious mental illness AND primary care AND quality indicator, including alternative spellings and synonyms. Studies on children, and on mental illnesses other than SMI, were excluded. All studies from January 1990 to February 2015 were considered for inclusion. No language restrictions were applied, although all search terms were in English, and all studies in English, German, Dutch and Afrikaans were considered due to the authors’ combined language knowledge.

Study selection

All titles were first reviewed by MG, TK, TD, RJ and Christoph Kronenberg (CK), a former member of the research team. All studies that two members of the research team indicated as potentially relevant were included in the abstract screening process. All abstracts were screened by LA, MG, TK, TD, RJ and CK, and full papers were obtained if two members of the team judged the abstract potentially relevant or in scope (i.e. covering SMI, primary care and quality indicators). Full papers were divided into four groups and independently reviewed by MG and CD, TD and LA, TK and SG, and RJ and CK. The focus of the selection was to identify papers that included relevant quality indicators that could be applied in primary care. It was evident that the definition of primary care varies between different countries, so we included indicators with elements of shared care between primary and specialist settings (e.g. prescribing and monitoring of antipsychotic medication), while acknowledging that, in some countries, those indicators may be more applicable to secondary care. Our search strategy complied with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist.

Data extraction and analysis

A short description of each indicator from each paper was extracted and the descriptions for similar indicators were merged. The indicators were grouped into six relevant domains [(1) continuity of care, (2) substance abuse, (3) access to care, (4) medication management, (5) mental health assessment and care and (6) physical health]. The domains were selected by the research team as representing broad areas that would encompass all the chosen indicators. Given the main focus of our study, we decided if each indicator could, in principle, be measured from routine data or if primary data collection would be necessary. Furthermore, we checked if the identified indicators had ever been included in the QOF. We also assessed the quality of the evidence of the included studies using an adaptation of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) guideline, 51 and rated the quality of the evidence as high [systematic reviews or randomised controlled trials (RCTs)], moderate (non-randomised control studies or unsystematic reviews), low (expert opinion or uncontrolled studies) or not applicable (measure was extracted from the grey literature).

Indicator selection

We presented the final list of indicators to our SSC and discussed the list within the research team, as well as with our PPI team members. Based on these discussions, the evidence from the literature review and how readily the indicators could be translated into appropriate quality measures from routine data, we decided to choose two quality indicators that were not already included in the QOF for analysis in this study. Although some of the remaining potential indicators were, in theory, measurable from routine data, they would be unable to be measured in the primary care data used for this study owing to limitations of the clinical coding (e.g. quality of the data, missingness).

In total, 1847 studies and further database sources were identified using the search. The split was ASSIA ( n  = 34), CENTRAL ( n  = 96), Cochrane ( n  = 12), CPCI-S ( n  = 125), DARE ( n  = 28), EMBASE ( n  = 738), Ovid MEDLINE ( n  = 537), PsycINFO ( n  = 271) and six further database sources (Agency for Healthcare Research and Quality 50 , Stegbauer et al. , 48 Großimlinghaus et al. , 49 Parameswaran et al. 52 and NICE 36 ). After removing duplicates using bibliographic software [EndNote X7.3 (Clarivate Analytics, Philadelphia, PA, USA) and Zotero 4.0 (Center for History and New Media, George Mason University, Fairfax, VA, USA)], 1303 records remained. Title screening reduced this to 356, excluding those that were not about quality indicators, primary care, mental illness or were not included in our definition of SMI (e.g. depression or substance abuse disorders). Abstract screening reduced the records to 113, with similar reasons for exclusion. Finally, from those 113 records, 86 were excluded and 27 records were included in the review ( Figure 1 ).

The PRISMA flow diagram for systematic review of quality-of-care indicators for patients with SMI. Reproduced from Kronenberg et al. This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) (more...)

Out of these 27 records, a final set of 59 different indicators was extracted. The final list of indicators are shown in Table 1 .

Quality-of-care indicators identified for people with SMI

Table 1 shows that of the 59 indicators, 52 could potentially be assessed using routine data and seven would require primary data collection from patients or professionals. Of these 59 indicators, 17 are, or have previously been, included in the QOF. A large proportion of the indicators relevant to primary care are in the physical health domain. Another large subset of indicators relate to the process of receiving care (e.g. continuity of care, access to services and frequency of contacts).

Table 2 shows the quality of evidence of the included studies from which the indicators were drawn. Two studies were rated as high quality (Cochrane or systematic review, RCT), three studies as moderate quality (non-randomised study or unsystematic review), 19 studies as low quality (expert opinion, uncontrolled studies) and three studies were of uncertain quality, having been identified from the ‘grey’ literature (e.g. non-government organisation documents or databases).

Quality of evidence of studies identifying quality-of-care indicators for people with SMI

Only a very few RCTs have evaluated quality indicators. Two RCTs were reviewed in Cimo et al. , 76 which produced evidence on the effectiveness of lifestyle interventions for people with type 2 diabetes and schizophrenia or schizoaffective disorder. However, more often, indicators were based on expert consensus or small cross-sectional studies.

Many of the indicators identified were derived from a database of indicators produced by the Agency for Healthcare Research and Quality, 50 and the strength of evidence underpinning the individual indicators is variable.

From the large set of quality indicators reviewed, we identified two indicators that could potentially be created and adapted from the routine data to which we had access: continuity of care (indicator 2) and polypharmacy (indicator 28). Our SSC, our PPI team members and the literature all suggested that these two areas were important aspects of quality of primary care for people with SMI. Although the quality of the evidence for these indicators was rated as weak in this review, we felt that there was sufficient interest to suggest that they would be worth exploring as important quality measures. The two indicators we constructed are described in Chapter 3 , Non-Quality and Outcomes Framework indicators .

Summary of findings

To our knowledge, this was the first attempt to identify potential indicators of quality of primary care for people with SMI in a systematic way. Although we identified > 50 indicators that could potentially be captured and monitored using routine data, crucially, we note that the quality of the available evidence underpinning many of the indicators is relatively weak. We identified two indicators for further analysis on their association with outcomes using routine data: (1) continuity of GP care and (2) antipsychotic polypharmacy.

Strengths and limitations

The feasibility of collecting data for any set of quality indicators will vary across different health-care systems. Many countries have insurance or other systems, which routinely collect activity data in primary care. Some indicators are likely to require more effort to collect (e.g. patient questionnaires for perceived continuity of care). Our study focused specifically on finding indicators that could be monitored at relatively low cost to the UK health-care system.

The list of quality indicators identified here is much broader and more encompassing than the current list of indicators contained in the QOF SMI domain. However, even if good-quality metrics were identified for use, criticisms would remain around their adoption. These include measuring only what can be measured (in routine data), instead of focusing on measuring what matters, and the risk of unintended consequences arising from prioritising some activities at the expense of other non-incentivised activities. Moreover, there are gaps in the literature and in the indicators identified, as the service user perspective is not well represented in the literature. There is also an absence of quality indicators around aspects of the social environment, such as the stability of housing for people with SMI. Although such factors are important and may well influence health outcomes, the extent to which primary care could influence these factors may be very limited and hence it may not be appropriate to hold primary care practitioners responsible for improving quality in these domains. Finally, our search excluded non-published indicators and those written in languages other than those listed earlier (see Inclusion and exclusion criteria ).

Implications for research and practice

Donabedian’s 27 conceptual framework of quality of care suggests that indicators can usually be divided into three subcategories: (1) structure, (2) process and (3) outcome measures. As noted above, the vast majority of indicators included in this review relate to processes of care and although aspects of process are highly relevant, especially to patients, it is important to establish whether or not quality indicators also promote improved health outcomes. If so, there is a case for their inclusion in the QOF and other initiatives aiming to improve the care of people with SMI. For physical conditions, improvements in processes of care in primary care settings have been found to be associated with modest improvements in intermediate outcomes (e.g. cholesterol levels 78 ) and quality of life, 79 but associations with patient outcomes, such as emergency hospital admission, are weaker. 80 For SMI, the evidence is much more limited and suggests that higher provider performance on processes may not be associated with better patient outcomes. 43

This evidence gap is something that this research report explicitly addresses. We chose two areas in which we could construct a range of indicators from routine data (continuity of care and polypharmacy) and examine their respective associations with outcomes in Chapters 4 – 6 .

• Cite this Page Jacobs R, Aylott L, Dare C, et al. The association between primary care quality and health-care use, costs and outcomes for people with serious mental illness: a retrospective observational study. Southampton (UK): NIHR Journals Library; 2020 Jun. (Health Services and Delivery Research, No. 8.25.) Chapter 2, Systematic literature review of primary care quality.
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Patient safety in primary health care: a systematic review

• PMID: 25317512
• DOI: 10.1590/0102-311x00114113

The aim of this study was to identify methodologies to evaluate incidents in primary health care, types of incidents, contributing factors, and solutions to make primary care safer. A systematic literature review was performed in the following databases: PubMed, Scopus, LILACS, SciELO, and Capes, from 2007 to 2012, in Portuguese, English, and Spanish. Thirty-three articles were selected: 26% on retrospective studies, 44% on prospective studies, including focus groups, questionnaires, and interviews, and 30% on cross-sectional studies. The most frequently used method was incident analysis from incident reporting systems (45%). The most frequent types of incidents in primary care were related to medication and diagnosis. The most relevant contributing factors were communication failures among member of the healthcare team. Research methods on patient safety in primary care are adequate and replicable, and they will likely be used more widely, thereby providing better knowledge on safety in this setting.

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• Volume 4, Issue Suppl 8
• Primary health care financing interventions: a systematic review and stakeholder-driven research agenda for the Asia-Pacific region
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• http://orcid.org/0000-0002-7188-7740 Blake Angell 1 ,
• http://orcid.org/0000-0003-3469-8999 Rebecca Dodd 1 ,
• http://orcid.org/0000-0002-8127-9351 Anna Palagyi 1 , 2 ,
• Thomas Gadsden 1 ,
• Seye Abimbola 1 , 2 ,
• Shankar Prinja 3 ,
• Stephen Jan 1 ,
• http://orcid.org/0000-0002-6898-3870 David Peiris 1
• 1 The George Institute for Global Health, University of New South Wales , Sydney , New South Wales , Australia
• 2 School of Public Health, Faculty of Medicine and Health , Sydney University , Sydney , New South Wales , Australia
• 3 School of Public Health, Post Graduate Institute of Medical Education and Research , Chandigarh , India
• Correspondence to Dr Blake Angell; bangell{at}georgeinstitute.org.au

Introduction Interventions targeting the financing of primary health care (PHC) systems could accelerate progress towards universal health coverage; however, there is limited evidence to guide best-practice implementation of these interventions. This study aimed to generate a stakeholder-led research agenda in the area of PHC financing interventions in the Asia-Pacific region.

Methods We adopted a two-stage process: (1) a systematic review of financing interventions targeting PHC service delivery in the Asia-Pacific region was conducted to develop an evidence gap map and (2) an electronic-Delphi (e-Delphi) exercise with key national PHC stakeholders was undertaken to prioritise these evidence needs.

Results Thirty-one peer-reviewed articles (including 10 systematic reviews) and 10 grey literature reports were included in the review. There was limited consistency in results across studies but there was evidence that some interventions (removal of user fees, ownership models of providers and contracting arrangements) could impact PHC service access, efficiency and out-of-pocket cost outcomes. The e-Delphi exercise highlighted the importance of contextual factors and prioritised research in the areas of: (1) interventions to limit out-of-pocket costs; (2) financing models to enhance health system performance and maintain PHC budgets; (3) the design of incentives to promote optimal care without unintended consequences and (4) the comparative effectiveness of different PHC service delivery strategies using local data.

Conclusion The research questions which were deemed most important by stakeholders are not addressed in the literature. There is a need for more research on how financing interventions can be implemented at scale across health systems. Such research needs to be pragmatic and balance academic rigour with practical considerations.

• primary health care
• health financing
• systematic review
• asia-pacific region
• health systems
• research priorities
• delphi process

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ .

http://dx.doi.org/10.1136/bmjgh-2019-001481

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Key questions

What is already known.

Effective and sustainable primary health care systems are essential if the low-income and middle-income nations of the Asia-Pacific region are to achieve universal health coverage.

Financing interventions have been used across the world to incentivise the demand for and delivery of quality healthcare.

The role that research plays in informing policy decisions is often limited by insufficient attention to context, policymakers’ priorities and the broader system-wide impacts of interventions.

What are the new findings?

While national primary health care stakeholders see an important role for financing interventions in the push to achieve universal health coverage in the Asia-Pacific region, there are key gaps in the evidence needed to inform policy decisions.

Evidence priorities for primary health care financing include the role of interventions at the: (1) community level, to improve access to services and financial protection of individuals; (2) provider level, to incentivise appropriate care and ensure appropriate management decisions and (3) system level, to improve performance of primary care systems.

What do the new findings imply?

Filling priority evidence gaps will require robust partnerships between researchers and policymakers and the development of pragmatic methods that balance academic rigour with the practical challenges of implementation.

Affordable, equitable and high-quality primary health care (PHC) is essential for achieving universal health coverage (UHC). Financing interventions to alter the incentives facing different health system actors, including those working in PHC systems, have been proposed as potential solutions to a range of challenges facing low-income and middle-income countries (LMICs). These challenges include improving the quality and appropriateness of care provided, 1–5 reducing wasteful expenditure 6 7 and overcoming workforce shortages and the maldistribution of health workers. 8 However, evidence supporting the effectiveness of financing interventions remains mixed, and many have pointed to the potential for such interventions to have negative, unintended consequences when scaled-up, highlighting the need for financing interventions to be carefully calibrated to the context in which they are implemented.

The Asia-Pacific region is home to two-thirds of the global population. 9 The LMICs of the region range from the most populous countries of the world in South and East Asia, to the least across the Pacific Island nations. While all countries in the region are pursuing UHC, the policy initiatives being implemented, and the context and challenges of each system vary dramatically. The more populous countries such as India, 10 China, 11 Vietnam 12 and Indonesia 13 are embarking on large programmes of reform to overcome historical underinvestment and provide health and financial protection for their citizens. High rates of economic growth in these countries in recent decades have stimulated an increase in the amount that payers (government, industry and consumers) are prepared to invest in health care. 14 15 The sustainability of this growth in health care investment, together with how and where such funds are allocated, will be strong determinants of how these nations progress towards UHC. Pacific Island nations face very different challenges: here, health expenditure has been historically high relative to their income levels, 15 but service delivery costs are also high due to small, remote, widely dispersed and expanding populations. 16–19

Across all nations of the region, the efficiency of existing health expenditure has been questioned 7 and the challenges facing these health systems have been magnified in recent years by the rising burden of non-communicable diseases. 20 This has stretched resources and challenged the adaptability of health systems that were historically oriented to episodic, curative care models rather than the long-term care needs of those with, or at risk of, chronic diseases. 21 The scope of reforms currently underway across the region provides a unique opportunity to understand optimal paths to UHC across these different contexts. There is limited evidence on how to best finance and incentivise PHC systems to encourage appropriate, cost-effective, equitable, high quality and sustainable care. 21 22 Identifying research questions that meet the needs of policymakers looking to accelerate progress towards UHC 23 24 is therefore a priority.

In this paper, we present an iterative process to develop a prioritised agenda to inform future PHC financing research in LMICs of the Asia-Pacific, incorporating the perspectives of researchers, policymakers and other national PHC system stakeholders across the region.

This study forms part of a larger project examining evidence gaps in the organisation of PHC service delivery in LMICs of the Asia-Pacific region. 25 26 We followed a two-phase process to identify and prioritise evidence gaps related to PHC financing interventions. Phase 1 was a systematic review of the peer-reviewed and grey literature to identify core knowledge gaps in the published research. Phase 2 involved an electronic-Delphi (e-Delphi) priority-setting exercise with key PHC stakeholders in Asia-Pacific LMICs to refine and prioritise research questions related to PHC financing interventions.

Patient and public involvement

No patients or members of the public were involved in this study.

Phase 1: systematic review

A systematic review of the peer-reviewed and grey literature was carried out to identify studies of the effectiveness of financing interventions implemented within PHC systems of LMICs in the Asia-Pacific region.

Inclusion criteria

The inclusion criteria for the review specified three criteria. First, studies had to evaluate financing interventions in relation to the key PHC outcomes of quality, coverage and accessibility, efficiency, responsiveness or equity. 26 Financing interventions were defined broadly to include any intervention that altered the incentives facing PHC providers or patients, changed the ownership structure of PHC services or altered the fees faced by patients. Health economic evaluations that assessed the cost-effectiveness of various PHC interventions were excluded if the interventions did not meet these criteria. Second, studies had to be published between 1 January 2008 and February 2018. Third, studies had to have been conducted in the LMICs of the World Bank regions of South Asia and East Asia and Pacific. Studies examining an intervention implemented in multiple countries were included if country-specific results were reported or if all included nations were located in these regions.

Search strategy

A search of the Medline, Global Health and Cochrane databases was conducted in February 2018 using variations of the search terms contained in online supplementary file 1A . We also hand-searched grey literature from 14 websites of organisations and agencies from the international development and global health sector. Reference lists of the final included publications were hand-searched for additional articles relevant to the review, and further relevant articles were identified through expert consultation.

Supplemental material

Data extraction.

Study review, selection and data extraction were jointly undertaken by two authors (AP and RD). Abstracts, titles and keywords of the studies returned from the search were screened for compatibility with the inclusion criteria. Once studies were identified for potential inclusion, full texts were reviewed to determine inclusion into the review. Due to the likely heterogeneity of the methods of included studies and the underlying purpose of the review to inform the e-Delphi phase of the study, no formal quality assessment was carried out of reviewed studies, nor were there any quality criteria for inclusion or exclusion. The full text of each included publication was reviewed to identify key study characteristics (context, geographical scope, research method, study population, disease focus) and the PHC system outcomes and inputs addressed. Each of these elements was populated in a predefined coding framework using EPPI-Reviewer 4 (EPPI-Centre, Social Science Research Unit, Institute of Education, University College London, UK) to generate an ‘evidence gap map’. Studies were grouped according to the following themes: resource allocation and budgeting; revenue collection; funding models; provider incentives and demand-side incentives. These were mapped against PHC outcomes of quality of care, efficiency, coverage and accessibility, responsiveness and equity.

Phase 2: modified e-Delphi expert panel

Following the systematic review, an e-Delphi expert panel was convened over April–June 2018 using a web-based data collection tool (Research Electronic Data Capture). Stakeholders were identified through the authors’ existing networks and snowball sampling. Despite the authors’ strong network of China stakeholders, we discovered prior to the initiation of the Delphi exercise that firewall restrictions precluded use of the online survey with China-based participants so no stakeholders from China were included in this study. In total, 179 email invitations to join the panel were sent to stakeholders from 15 Asia-Pacific LMICs and 15 regional bodies. While we endeavoured to achieve a diverse sample of professions in the e-Delphi process, the panel was based on the authors’ prior networks and, as such, we were unable to make further efforts to balance the countries and professions represented. The characteristics of the panel are summarised in table 1 . This process was part of a larger study that also examined the organisation of PHC. 25

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Country of work and professional background of the 22 Delphi expert panel members

The e-Delphi was an iterative prioritisation process involving three rounds of web-based surveys with the expert panel members. Panel members were asked to complete each Delphi round within 10 days and automated email reminders were sent to each prior to each round closing.

Round 1: topic suggestions

The first round of the e-Delphi process was based on the findings of the systematic review and evidence gap analysis. Participants were presented with a list of broad research gaps identified by the mapping exercise and asked to assign a priority score of 1–5, for each topic (where 1 is the lowest research priority and 5 the highest). Participants were also asked to identify specific research questions of interest that fit within their top two priority topics.

Round 2: prioritisation

The three highest scoring research topics from Round 1 were identified and the research questions generated thematically grouped within these. The questions were then fed back to panel members who were asked to prioritise the research questions according to the priority setting criteria established by the primary health care performance initiative (outlined in box 1 ). 27 These criteria aim to prioritise research most likely to impact on PHC system performance.

Priority setting criteria established by the primary health care performance initiative

Priority tiers:.

Tier 1: includes research gaps of high potential leverage, in which more evidence is likely to have a significant impact on strengthening PHC performance.

Tier 2: includes research gaps of moderate potential leverage, in which more evidence is somewhat likely to have an impact on strengthening PHC performance.

Tier 3: includes research gaps for which more evidence is unlikely to have an impact on strengthening PHC performance.

Priority setting criteria:

Available knowledge: What is the current level and quality of available knowledge? (Areas with lower available knowledge should be prioritised for further exploration.)

Leverage: What is the potential for improvements in this area to contribute to strengthening PHC performance? (Areas that are seen as key levers of improvement should be prioritised.)

Magnitude of need: How crosscutting is this problem in your setting?

Equity: How likely is research on improving the areas also likely to reduce disparities

Innovation: How likely is the research to stimulate innovation in how PHC is strengthened or innovation in how known interventions are implemented?

Can research address the gap?

Round 3: final selection of priority topics

Research questions that were ranked under the top two priority tiers were fed back to panel members, who were requested to assign each question a priority score of 1–5, as in Round 1. Responses of panel members were then collated and an overall median priority score (1–5) was calculated for each research question. Research gaps with a median priority score of 4 or 5 (ie, the two highest priority levels) were ranked to present a ‘top 10’ list of priority questions.

The initial search yielded 3001 articles. Once duplicates were removed, the titles and abstracts of 1919 articles were screened plus 14 more found through reference list searches and expert advice. In total, 155 full texts were reviewed and 31 met the inclusion criteria for this review ( figure 1 ). 28–58 In addition, the search returned 10 systematic reviews of relevance to our study. 1 8 59–66

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Flow chart of literature search and inclusion. LMIC, low-income and middle-income countries; PHC, primary health care.

Study characteristics

Twenty-one original research peer-reviewed publications and 10 grey literature reports were included in the review. A summary of these studies is presented in the online supplementary tables S1 and S2 and an overview of the systematic reviews found through our search is provided in supplementary table S3. Reflecting the broad nature of our inclusion criteria, studies examined a diverse set of financing interventions, across a number of nations and included evaluations using a range of methodologies. Included original research studies were conducted across a total of eight LMICs of the Asia-Pacific region: China (nine articles), Vietnam (three articles), Nepal (two articles), Afghanistan (two articles) and Pakistan, India, Bangladesh, American Samoa and Timor-Leste (one each). One grey literature study covered three nations (China, Indonesia and the Philippines); there were two grey literature reports from Indonesia, two from India and one each from China, the Philippines, Vietnam, Papua New Guinea and Lao PDR. No studies were found that linked financing interventions to improved health outcomes. Studies were coded against the predefined input and outcome categories as described above to identify gaps in the literature ( table 2 ) and are examined below based on the type of PHC financing intervention studied.

Evidence gap map showing primary health care financing studies in the Asia-Pacific region examining selected issues

Pay-for-performance interventions

Five peer-reviewed studies and one grey literature report investigated pay-for-performance interventions that aimed to incentivise health workers by paying for agreed indicators of service quality. 34 42 43 47 48 58 The specific design of each intervention differed across the studies. Engineer and colleagues examined the impact of a pay-for-performance scheme on maternal and child health services in Afghanistan using a cluster randomised controlled trial design. 34 They found no impact on coverage and equity measures but some impact on indicators of quality of care. The authors conclude that overall the programme had limited impact and attribute this to communication difficulties between policymakers and health workers and failure to consider demand-side factors. Two studies investigated pay-for-performance schemes in conjunction with capitation payment structures in China. 43 47 Sun used an interrupted time-series design and concluded that the combination of capitation and pay-for-performance (based on financial performance of the service) led to an increase in primary care visits, a reduction in inpatient admissions and a decreased cost of outpatient visits. However, performance payments had no impact on reducing inappropriate prescribing practices which was a key aim of the programme. 47 Powell-Jackson and colleagues attempted to separate out the impact of the pay-for-performance intervention from the capitation intervention also using an interrupted time series conducted across two policy changes. They found that performance payments had no additional impact on health service utilisation above that associated with the introduction of an insurance programme. 43 A World Bank study found paying doctors for appropriate prescribing had a positive effect, reporting a significant reduction in inappropriate prescribing using a cluster quasi-randomised controlled study. 48 Finally, Powell-Jackson and colleagues investigated the provision of incentives to both service providers and mothers to encourage use of skilled birth attendants. 42 Using an interrupted time series design, the authors found an improvement in skilled birth attendance, but only in areas where women’s groups disseminated information about the programme. There was no impact on neonatal mortality across any site.

Removal of user fees and public insurance

Seven peer reviewed studies and four grey literature reports examined the impact of removing user fees for care or the provision of publicly funded insurance (on top of the interventions combined with pay-for-performance described above). 28 30 32 33 39 41 45 49 52 53 57 The context and form of these interventions differed greatly across the included studies; however, there were relatively consistent results that these schemes reduced costs for users and increased PHC utilisation. Two studies from China showed that removing fees (while also compensating providers by increasing their reimbursement) led to significant increases in the use of outpatient care. 43 47 Similarly, Thanh and colleagues conducted an assessment of the impact of removing user fees in Vietnam through propensity-matched cohort study using household panel data and also found that the removal of user fees for the poor led to an increased utilisation of PHC services and reduced out-of-pocket health care expenditure. 52

The other included studies, however, reported challenges in implementing or expanding similar interventions that often diluted their overall impact. A study in Nepal examining the removal of user fees using paired case studies and qualitative research found beneficial, pro-poor impacts on utilisation in some facilities but no impact in others. The authors argued that this was a result of weak organisational capacity (in some facilities) to implement the reform. 45 Nguyen found that a poverty reduction policy that made basic curative and preventative health services free of charge did not impact healthcare utilisation in remote regions of Vietnam. 41 Rather, even for the poor, uptake was dependent on the perceived quality of care regardless of cost. Similarly, four World Bank studies examined the impact of expanded insurance programme and all found contextual factors had a large impact on their effectiveness. In Indonesia, a pre–post study found that Jampersal, an insurance programme to cover maternal services, was effective in reaching women particularly those who were least educated, poor and resided in rural areas. 28 Barroy and colleagues found that while the Vietnamese national insurance programme had reached relatively high coverage (60%) and there had been accompanying quality and equity improvements, out-of-pocket expenditures remained high and the programme was limited by ineffective risk-pooling and capitation. 30

Weak governance arrangements between central and provincial governments in Papua New Guinea were found to limit frontline PHC service provision in the expenditure analysis conducted by Cairns and Hou. 33 While noting that public programmes had increased coverage across the Philippines, Bredenkamp and Buisman highlighted the challenges that remained with regard to the financial protection of the population, noting that the poor still experienced significantly higher levels of catastrophic expenditure. 32 Finally, Mahmood highlighted shortcomings in a social insurance scheme in rural China, finding that the scheme’s gap payment acted as a significant barrier to care. 39

Contracting out PHC services

Six studies assessed the impact of contracting out PHC service provision to private and non-government providers or alterations to the ownership structure of PHC services. 29 36–38 55 56 A number of these found positive impacts in terms of coverage, efficiency and equity outcomes. In Afghanistan, Alonge and colleagues found that contracts that allowed providers freedom to allocate a fixed lump sum payment, combined with non-negotiable deliverables, were effective in improving equity of health services provision. 29 In Bangladesh, Heard and colleagues found that contracting out urban PHC services to a non-government organisation (NGO) led to improvements in the coverage of basic services, equity, quality of care and efficiency. 36 In Pakistan, it was found that contracting out PHC services in one poor and rural district to a local NGO resulted in increased coverage, community satisfaction and efficiency. 38

Potential negative impacts of contracting services were related to quality control, highlighted by two studies in China comparing different models of ownership of healthcare centres. One study found that private providers had the lowest quality of care and the least educated staff. 54 Similarly, another study found that government and hospital managed centres provided better quality care in terms of appropriate prescribing practices and optimal blood pressure control for patients with hypertension. 61 A report by the WHO found that expanding social health insurance via outsourcing services can impact negatively on equity outcomes, especially when schemes are rapidly scaled up. 37

Incentives for patients

Three peer reviewed studies and two grey literature reports examined the impact of incentives for to encourage patients’ use of PHC services. 35 40 42 46 53 Once again contextual factors were often found to play a vital role in the impact of such programmes. As highlighted above, patient incentives (as well as provider incentives) were only effective in improving skilled birth attendance in places with women’s groups, suggesting social networks are critical to the success of such programmes. In addition, the authors found that benefits accrued disproportionately to wealthier households. In American Samoa, a slight improvement in the attendance of adequate prenatal care services was found following the introduction of an incentive programme for expectant mothers; however, these effects were not able to overcome system limitations that made care inaccessible for many women in the study. 35

Using a randomised controlled trial, Martins and colleagues found limited impact in terms of adherence or the outcome of treatment from providing food incentives to patients with tuberculosis in East Timor. 40 By contrast, a study in India found the greatest reduction in inequities from social insurance occurred in states with a concurrent programme of conditional cash transfers to encourage attendance at maternal health services. 53 Similarly, a study in Lao PDR examined the impact of a community nutrition programme, comprising community education and conditional cash transfers, to determine impact on health-seeking behaviours among mothers who were pregnant or had a child under 2 years. 51 The intervention was found to improve the rate of diphtheria, pertussis and tetanus vaccinations and child-caring practices such as breastfeeding within 3 hours of birth and treatment-seeking for diarrhoea. Finally, an Indonesian study found that child healthcards (which entitled them to a price subsidy) had a protective effect during the Asian financial crisis, with public outpatient service utilisation declining less steeply compared with non-subsidised services. 46

Key evidence gaps

The systematic review and mapping exercise identified a number of key gaps in the existing literature. Notably, there were very few studies from Pacific Island countries and, conversely, much of the literature was dominated by studies from China. No studies examined the impact of financing interventions on health outcomes and there was limited work examining the efficiency and responsiveness of PHC systems, pointing to the need for further research on the appropriate role that health system incentives can play in these areas. This reflects the findings of reviews in similar areas across other LMICs as summarised in the online supplementary table S3 . Further, the generalisability of the literature that was found for this review was hampered by the diversity of interventions studied, health systems and methodologies used. One of the most consistent results of included studies was the importance of contextual factors that were found to impede or otherwise affect implementation or scale-up of these interventions and subsequently impact on the outcomes of policy interventions. These identified evidence gaps were used to formulate five broad areas for potential further research, which were presented to the Delphi panel in the first round of the e-Delphi process, as described below:

Mobilising resources to pay for PHC.

Contracting models to ‘purchase’ PHC.

Optimising efficiency and cost-effectiveness of PHC.

Financial incentives to improve demand for PHC services.

Financial management at PHC level.

Phase 2: e-Delphi results

In Round 1 of the e-Delphi exercise, 22 panel members (n=22) ranked the five topics above and identified 34 related research questions relevant to PHC financing in the countries in which they worked. Following the removal of duplicate questions and the thematic analysis outlined above, a final set of 18 research questions were derived for presentation in Round 2. Fourteen of the original 22 expert panel members completed Round 2 of the e-Delphi exercise. Non-respondents included panel members from Fiji and Bangladesh (one from each country), two panel members representing regional programmes of the aid/development sector and two stakeholders from India (from academic and aid/development sectors). Of these 18 research questions, 14 received an aggregate ranking within the top two priority tiers (ie, Tiers 1 and 2) and were collated for final prioritisation in Round 3.

Fourteen expert panel members completed Round 3. Eight questions received a median priority score of 4 or 5 (ie, two highest priority levels). We aimed to achieve a minimum of 80% agreement for those research questions of highest priority; however, we achieved 60% for six of the top questions only. Reasons for this might include the small panel size (only 14 of 22 (64%) original panel members completed Rounds 2 and 3 of the e-Delphi exercise), evidence priorities differing between countries within the region and the less obvious link between some of the evidence gaps and implementation research (eg, use of essential medicines and technologies to improve responsiveness).

The final list of priority questions are presented in table 3 . They represent an array of evidence needs that overlap in some areas with those identified through the literature but differ in others. Research questions focussed on interventions targeting different actors in the system—the community, service providers and policymakers themselves. The top-ranked question identified by the panel was: how can the poor be protected from impoverishing payments for catastrophic health expenditure, including the purchase of medicines? Interest coalesced around a set of questions related to efficiency and cost-effectiveness, with five of the top 10 research questions prioritised by this panel relating to these issues. Another key area of interest prioritised by the e-Delphi panel related to mobilising resources for PHC.

Consensus on Asia-Pacific research priorities in financing of primary health care, in rank order

Notably, the financial management of PHC resources was identified as a key knowledge gap, with research questions on the organisational capacity of health centres to manage PHC finances, and the optimal use of financial resources emerging as priorities. This issue is a critical element of PHC governance and relates to the capacity of health systems to manage, distribute and account for financial resources. No peer-reviewed study (and only one piece of grey literature) was identified on this issue, suggesting a major gap in evidence.

This evidence review and stakeholder consultation process identified the need for more research on the optimal design(s) of PHC financing interventions at the system, provider or community level in LMICS of the Asia-Pacific region. We also identified the need for research into how to best implement these interventions and the critical need to understand contextual constraints and opportunities.

In order to be of use to policymakers in the UHC era, health systems research needs to answer questions that matter for population health, offer contextually appropriate results in a form that can be used by policymakers and be methodologically innovative to balance rigorous assessment of causality of outcomes with practical considerations of policy implementation. 23 This study suggests that the current evidence base may not meet these requirements. There is a need for more research across a broader number of LMICs. Developmental and impact evaluations are needed that report on service utilisation, efficiency, provider and patient behaviour, financial risk protection and the health outcomes of populations. Where feasible, comparative effectiveness studies that examine the relative impacts of different financing models on different outcomes are likely to be of interest to policymakers.

To help address these issues, we have proposed a list of priorities for research to drive progress towards UHC in the Asia-Pacific region. Although there were studies that partially address some of the gaps raised by the e-Delphi participants (eg, patient incentives to improve PHC utilisation), most of the questions deemed most important by stakeholders could not be adequately addressed by existing evidence and did not align with the gaps we initially identified. At the community level, the top priority area was the need for more research around models that promote financial protection for the poor. While a growing body of global literature has documented the economic burden and impoverishment associated with healthcare costs, 67–69 the literature examining interventions to overcome these is not well developed. While there was existing evidence that removing or reducing user fees or expansion of publicly funded services increased PHC utilisation, there was limited focus on specific interventions to limit out-of-pocket payments, catastrophic health expenditure and medical-related impoverishment. Further, there was variation across the results of included studies reflecting the complexity of interventions, the context in which they were implemented and the scale at which they were implemented.

Across included studies, interventions often resulted in diluted impacts when rapidly scaled, casting more doubt on the usefulness of such research for policymakers and highlighting the need for pragmatic methods to assess the impact of financing interventions. Studies using methods such as natural experiments in a wide range of countries and contexts, at different scales of implementation and altering different levers in the design of financing interventions will be vital to tease out the best strategies for protecting populations from financial stress.

Stakeholders highlighted a range of provider-level research questions around factors such as managing budgets and identifying inefficient expenditure that were not considered in the studies included in the review. Provider-level issues such as how to best incentivise quality services (both financially and non-financially) were the second major category for future research highlighted in this study. There are opportunities for considerable innovation in both developing these incentives and the research methodologies needed to assess them. 70–72 Consideration of the trade-offs within health systems, for example, between patient choice, quality of care, efficiency and the relative investment in primary as opposed to other levels of care, and how to appropriately incentivise provider behaviours in light of these needs to form the basis for future research in the area. To be applicable to the different contexts of the LMICs of the Asia-Pacific region, such work needs to account for local preferences and community values, again opening up avenues for methodological innovation.

Research on system-wide policy reforms were also identified as a priority area. Interaction between primary and other levels of the healthcare systems was consistently highlighted as an issue for financing reform. Ensuring that resources could be directed to primary care and not diverted to latter stage care, using incentives to encourage patients to make greater use of primary care services, and removing barriers to care were key priorities to emerge from this study. Traditional ‘gold-standard’ approaches such as randomised controlled trials may be unsuitable to assess the impact of such interventions. Included studies show that while all health systems are complex, they are complex in different ways, and this context determines the impacts of interventions and the likely success of scale-up. This suggests the need for research and evaluation methods that address the channels through which financing interventions impact on actor behaviour and health system performance. Some promising developments have been identified in the existing literature based on methods such as difference in difference, time series analyses and propensity score matching often using routinely collected data. 73 74 Other pragmatic designs such as stepped-wedge randomised controlled trials may be needed to tease out the impacts of system-wide interventions across complex health systems. 75

There were some limitations to this study. Our focus was PHC; it is possible that in some studies PHC is described in different ways to the search strategy laid out in the online supplementary appendix A , which may have led to them not being included in our review. Our search was limited to English language studies, which may again miss some work that has been done in the field. Further, our search of the grey literature focused on specific preidentified websites and as such was not comprehensive. We were limited by the small Delphi panel size (only 22/179 (13%) invited participants agreed to join and 14/22 (64%) original panel members completed rounds 2 and 3). While the initial response rate is reflective of response rates previously achieved by web-based Delphi research, 76 it is a notable drawback of this virtual method of engagement that needs to be considered alongside benefits of efficiency and geographical reach. The panel did not reach a clear consensus on the research priorities and we were unable to analyse regional variation in priority evidence needs. Because of the limited panel sample size, we urge caution in interpreting the degree of concordance between the literature-informed evidence gaps and stakeholder research priorities. The exclusion of China stakeholders, in particular, was a limitation given the predominance of research evidence from China PHC systems. Alternative approaches to engaging China PHC stakeholders in priority setting activities, including roundtable discussions or the face-to-face nominal group technique, are recommended in future. Lack of expert panel representation from Pacific Island countries in the latter stages of the Delphi process also restricts the geographic relevance of identified research priorities. Further work involving both deeper engagement with panel members (perhaps through in-depth interviews) and broader engagement with a larger number of stakeholders from across the region could corroborate the findings presented here.

In addition, the inability to include China stakeholders, in particular, represents a significant limitation given the predominance of evidence from China PHC systems. Alternative approaches to engaging China PHC stakeholders in priority setting activities, including roundtable discussions or the face-to-face nominal group technique, are recommended in future. Lack of expert panel representation from Pacific Island countries in the latter stages of the Delphi process also weakens the geographic relevance of identified research priorities. Clearly, the findings would need to be corroborated with both deeper engagement with panel members (perhaps through in-depth interviews) and broader engagement with a larger number of stakeholders from across the region. Future studies may wish to use this work to develop similar prioritised research agendas at subregional, national or subnational level.

The impact of research on policy implementation and progress towards global targets such as UHC is too often limited by a lack of consideration of policymaker’s perspectives and local context. By involving policymakers and other key stakeholders, we have produced a prioritised research agenda that provides insights into the key needs of policymakers as they implement policies pursuant to UHC. The key priorities to emerge covered three levels of intervention: (1) community-level interventions to promote access and financial protection; (2) service-level financing models and (3) system-level funding policies. More research is needed which examines PHC systems and providers through an economic lens and there is substantial room for methodological innovation in health systems research across the Asia-Pacific region.

Acknowledgments

Preliminary results of this work were presented at the 5th Global Symposium on Health Systems Research in Liverpool in October 2018 at a satellite session entitled ‘Understanding and addressing knowledge gaps in improving primary health care systems and delivery in LMICs from governance through quality: findings from an emerging research consortium’.

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Handling editor Valery Ridde

Contributors This work was conducted as part of an international consortium examining primary health care systems in low-income and middle-income countries led by Ariadne Labs. DP and other members of the consortium developed the broad concept for this work. DP, RD, AP, SJ and BA developed the specific question answered in this paper. RD and AP reviewed the literature for study inclusion and extracted data from included studies. BA and TG wrote the initial version the manuscript. All authors provided input into the analysis and rewriting of the manuscript. All authors approved submission of this work.

Funding This publication is based on research funded by Ariadne Labs through Brigham and Women’s Hospital, which is the recipient of a Bill and Melinda Gates Foundation grant. The findings and conclusions contained within are those of the authors and do not necessarily reflect positions or policies of the Bill and Melinda Gates Foundation.

Competing interests SA is the editor in chief of BMJ Global Health but was not involved in the evaluation or peer-review process of this article. The other authors declare no competing interests for this work.

Patient consent for publication Not required.

Ethics approval Ethics approval for the e-Delphi process was granted by the University of New South Wales Human Research Ethics Advisory Panel Executive (Ref HC180135).

Provenance and peer review Not commissioned; externally peer reviewed.

Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.

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Peer-reviewed

Research Article

Primary health care quality indicators: An umbrella review

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliations MEDCIDS–Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal, CINTESIS–Centre for Health Technology and Services Research, Porto, Portugal

Roles Data curation, Formal analysis, Investigation, Writing – original draft, Writing – review & editing

Affiliation USF Camélias, ACeS Grande Porto VII (ARS Norte)–Vila Nova de Gaia, Portugal

Roles Data curation, Formal analysis, Investigation, Writing – review & editing

Roles Data curation, Formal analysis, Investigation

Affiliation MEDCIDS–Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal

Roles Conceptualization, Formal analysis, Methodology, Writing – review & editing

Affiliations MEDCIDS–Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal, CINTESIS–Centre for Health Technology and Services Research, Porto, Portugal, Public Health Unit, ACeS Grande Porto VIII (ARS Norte)–Espinho/Gaia, Portugal

Roles Conceptualization, Writing – review & editing

Roles Formal analysis, Validation, Writing – review & editing

Roles Conceptualization, Formal analysis, Methodology, Resources, Validation, Visualization

Roles Conceptualization, Funding acquisition, Project administration, Resources, Supervision, Validation, Visualization, Writing – review & editing

• André Ramalho, 
• Pedro Castro, 
• Manuel Gonçalves-Pinho, 
• Juliana Teixeira, 
• João Vasco Santos, 
• João Viana, 
• Mariana Lobo, 
• Paulo Santos, 
• Alberto Freitas

• Published: August 16, 2019
• https://doi.org/10.1371/journal.pone.0220888
• Reader Comments

Nowadays, evaluating the quality of health services, especially in primary health care (PHC), is increasingly important. In a historical perspective, the Department of Health (United Kingdom) developed and proposed a range of indicators in 1998, and lately several health, social and political organizations have defined and implemented different sets of PHC quality indicators. Some systematic reviews in PHC quality indicators are reported but only in specific contexts and conditions. The aim of this study is to characterize and provide a list of indicators discussed in the literature to support managers and clinicians in decision-making processes, through an umbrella review on PHC quality indicators. The methodology was performed according to PRISMA Statement. Indicators from 33 eligible systematic reviews were categorized according to the dimensions of care, function, type of care, domains and condition contexts. Of a total of 727 indicators or groups of indicators, 74.5% (n = 542) were classified in process category and 89.5% (n = 537) with chronic type of care (n = 428; 58.8%) and effective domain (n = 423; 58.1%) with the most frequent values in categorizations by dimensions. The results of this overview of reviews are valuable and imply the need for future research and practice regarding primary health care quality indicators in the most varied conditions and contexts to generate new discussions about their use, comparison and implementation.

Citation: Ramalho A, Castro P, Gonçalves-Pinho M, Teixeira J, Santos JV, Viana J, et al. (2019) Primary health care quality indicators: An umbrella review. PLoS ONE 14(8): e0220888. https://doi.org/10.1371/journal.pone.0220888

Editor: Wisit Cheungpasitporn, University of Mississippi Medical Center, UNITED STATES

Received: March 18, 2019; Accepted: July 22, 2019; Published: August 16, 2019

Copyright: © 2019 Ramalho et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting Information files, and are from studies indexed and available in four databases (Medline, Scopus, ISI-WOS and CINAHL via Ebsco Host).

Funding: The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was financed by FEDER - Fundo Europeu de Desenvolvimento Regional funds through the COMPETE 2020 - Operacional Programme for Competitiveness and Internationalisation (POCI), and by Portuguese funds through FCT - Fundação para a Ciência e a Tecnologia in the framework of the project POCI-01-0145-FEDER-030766 (“1st.IndiQare - Quality indicators in primary health care: validation and implementation of quality indicators as an assessment and comparison tool”).

Competing interests: The authors have declared that no competing interests exist.

Introduction

Primary health care (PHC) is defined by the World Health Organization (WHO) as the “essential health care based on scientifically sound and socially acceptable methods and technology, which make universal health care accessible to all individuals and families in a community. It is through their full participation and at a cost that the community and the country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination" [ 1 ]. Some studies suggest that health systems with better financial and clinical results are those with a greater focus on PHC, thus enhancing the sustainability of the entire health system [ 2 – 4 ]. This depends on providing high quality primary health care, hence raising the need to develop methods for quality assessment and monitoring [ 5 ]. One of these methods is the use of quality indicators—a quantitative measure of the activities, that can assist as a guideline for quality monitoring and evaluation of relevant patient care and support services [ 6 , 7 , 8 ].

Quality of care was defined by the Institute of Medicine (IOM) in 1999 as the degree to which health services increase the likelihood of desired outcomes and are consistent with current professional knowledge [ 9 ]. The evaluation of the degree of quality of care is done through indicators, a set of measures that assist health care quality monitoring and evaluation in several areas, such as governance, management, assistance and support [ 10 , 11 ]. The importance of indicators is given by the fact that they allow for signalling opportunities of improvement, and controlling compliance with the best existing clinical practices, through quantitative parameters (planning, organizational, clinical) aiming better processes and outcomes [ 12 , 13 ].

Studies of how quality can be assessed were conducted by Donabedian and Fleming, who categorized the information from which inferences can be drawn on the topic, in three categories: structure, process and outcome [ 14 ]. The “three-part” assessment approach performed by the authors is only possible because a good structure increases the probability of a good health care processes, and good processes increase the probability of good outcomes [ 14 ]. Importantly, for a process to be a valid measure of quality, it must be closely related to a result that people care about [ 12 ]. It is also worth remembering that we often find factors that interfere with patients' survival and health-disease dynamics, and in these cases, it may be useful for outcome measures to be adjusted for other factors (such as lifestyle, disease) to control confounders that may affect the analysis of outcome indicators [ 10 ]. The development and selection of indicators must meet requirements for use, such as validity, reliability, relevance, pertinence, applicability, data availability, minimum bias, and moreover based on the best evidence available [ 15 , 16 ].

For historical contextualization only, the National Health Service Executive and the Department of Health in United Kingdom (UK)—pioneers in this area—proposed a range of indicators in 1998, many of which would apply to primary health care groups [ 17 ]. The interest in assessing the quality of primary health care services has increased, especially after 2004, when the Quality and Outcomes Framework (QOF) was introduced in the UK [ 18 – 20 ]. After the development of the QOF, some pay-for-performance systems have been developed over the years. These were based on the concept of allocative efficiency: “the optimal use of resources to achieve the intended outcomes” [ 21 ]. As such, financial incentive schemes are being used for PHC units worldwide and professionals, representing a way of rewarding improvements in productivity and/or adaptation to better quality healthcare provision [ 22 ].

Lately, several health, social and political organizations such as World Health Organization (WHO), Organization for Economic Cooperation and Development (OECD), European Commission and the Agency for Research and Quality of Health Care (AHRQ), have defined and implemented different sets of quality indicators for primary care [ 23 – 25 ]. There are several studies proposing PHC quality indicators in different countries, which have led to some systematic reviews revealing substantial geographical variability regarding quality of primary care services [ 26 ]. Identifying papers referring to PHC quality assessment projects, these systematic reviews reported that the number and content of indicators and their domains varied among studies. Moreover, they demonstrated that the lack of standardization of collection tools across projects would lead to invalid comparisons [ 27 – 31 ].

Considering the importance of understanding the PHC context, identifying and measuring quality indicators are essential factors for the achievement of high-quality care [ 32 ]. Some systematic reviews related to the topic are available in the literature but with focus on specific contexts, making it necessary to synthesize and understand the reality of these indicators in a broader scope. The aim of this umbrella review is not an exercise for a meta-review, but rather to identify systematic reviews of studies on quality indicators (QI) for PHC to provide a list of selected indicators considered in systematic reviews.

An umbrella review was conducted, to collect and extract data from all systematic review studies uncovering PHC quality indicators. The methodology was performed according to PRISMA Statement [ 33 ] ( Fig 1 and S1 File ). All the phases were performed by two independent reviewers with a third as a tie-breaker, considering the eligibility criteria. Composing PICO, participants were the primary care systems and the intervention to be analysed is the implementation of quality indicators. The comparator was the categories such as context, dimension, type and domain of care, and the main outcome was the primary health care quality indicators to present a summary list of the indicators used in PHC. The protocol was registered at PROSPERO [ 34 , 35 ] with number CRD42019124170 ( S2 File ).

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https://doi.org/10.1371/journal.pone.0220888.g001

Search strategy

Identification phase..

From an initial set of studies, a search expression was defined and calibrated [ 36 , 37 ] through test rounds for each and combined terms in electronic databases. The search database eligible for calibration was MEDLINE. There were no restrictions on publication period or language. We considered studies from inception until 20 th December 2018, the date when the search was performed. After the calibration, the most relevant search expression ( S3 File ) was used in four databases (MEDLINE, Web of Science, Scopus and CINAHL plus via EBSCOhost). The terms related to systematic reviews were chosen using information of balance between sensitivity and specificity terms, available in the literature [ 38 – 42 ].

Study selection

Eligibility criteria..

Included studies 1) are systematic reviews regardless of their objective or nature (including studies that have used a formal systematic review as their starting point) 2) have a primary health care scope and 3) aim at quality indicators assessment or development. We excluded studies that 1) did not have an abstract in the screening phase or 2) which, in the eligibility phase, did not have the full-text version available, even after direct contact with the author.

Screening phase.

Once we obtained all the articles, duplicate between databases were identified and excluded using Endnote. From 2817 articles, a total of 1480 remained after removing the duplicates and were evaluated in the screening phase (reading of title and abstracts) by two independent reviewers and a third as a tie-breaker.

Eligibility phase.

Full-texts of all the included articles were extracted (n = 33). As it was planned to contact the corresponding author if the full text of the article was not available, we used the ResearchGate website to extract full text articles, or to contact the authors for the articles that were not available. All eligible articles were assessed in full text format. The eligibility criteria were reapplied by two independent reviewers and a third as a tie-breaker, and the reference lists of each eligible article were scrutinized for any omitted studies.

Quality assessment and risk of bias.

The evaluation of the quality and risk of bias of the eligible systematic reviews was carried out by evaluation through AMSTAR-2 tool [ 43 ]. The disagreement between the reviewers was solved by consensus in an agreement meeting by three reviewers. The AMSTAR-2 tool was considered for the definition of quality classification, fulfilling the systematic review research model. Articles that meet AMSTAR-2 requirements have been classified as "HIGH"; those that did not meet up to 2 relevant requirements were classified as "MODERATE", and those with more than 2 requirements not appraised were classified as "LOW". This quality assessment was carried out in order to understand how the studies were conducted and how the indicators were selected. However, none of the selected articles were excluded based on this assessment because the objective of this umbrella review does not include results from implementation of indicators, only a list of indicators implemented. The AMSTAR-2 items #11 and #12 were not applicable to the studies.

Data collection process.

In first stage, a standard data extraction form was created, and general data extracted from each study included the following characteristics: article title, name of first author, publication type, country of origin, year of publication and indicators identified in the studies. Three reviewers independently extracted the data. Differences in data extracted was resolved by consensus method.

A second stage consisted in abstracting information regarding quality indicators using the primary studies in the systematic reviews included. This was necessary since some indicators identified in the systematic reviews lacked a proper description. Finally, indicators duplicated were identified by the reviewers involved in the first and second stage of data extraction and excluded through consensus.

Synthesis analysis.

Analysis of the indicators were carried independently by two reviewers and third as a tie-breaker, who categorized the indicators presented in the systematic reviews included, according to five classifications frameworks: Context reflects the WHO ICPC-2 chapters categorization (General and Unspecified; Blood, Blood Forming Organs and Immune Mechanism; Digestive; Eye; Ear; Cardiovascular; Musculoskeletal; Neurological; Psychological; Respiratory; Skin; Endocrine/Metabolic and Nutritional; Urological; Pregnancy, Childbearing, Family Planning; Female Genital; Male Genital; Social Problems) [ 44 ]; the dimensions of care was defined based on the framework proposed by Donabedian to assess quality of healthcare (structure, process and outcome)[ 10 , 14 ], type of care reflects whether an indicator is associated with acute, chronic, or preventive care [ 10 , 45 ]; function of care conveys information about the purpose of health care (screening and prevention, diagnosis, treatment, follow up and continuity) [ 10 , 45 ] and domains and domain of health care quality was defined based on the framework proposed by National Academy of Medicine (NAM)(former Institute of Medicine) in 2001 (safe, effective, efficient, timely, patient-centred, equitable)[ 9 ].

Frequencies were computed based on these frameworks to analyse and summarize the information extracted, in two perspectives: Indicators by Context and Dimensions of care; and Type, Function and Domain by Dimensions of care.

Search and study selection

The identification phase results returned 2817 articles (being 419 MEDLINE, 1452 Scopus, 567 ISI-WOS, 379 CINAHL via EBSCOhost). After removal of duplicate articles our research started with 1480 articles. Title and abstract were scrutinized for relevance based on inclusion and exclusion criteria. From a total of 1401 excluded articles, 1332 did not meet the eligibility criteria and 69 had no abstract available. The eligibility phase started with 79 articles that were read in their full-text versions, checking for the eligibility criteria. The studies identified by that involved RAND methodology, their inclusion in the umbrella review was justified since the methods included an initial systematic review prior the implementation of a panel discussion for validating appropriateness of indicators. Since the goal was to be as inclusive/comprehensive as possible, these studies were also included. In the perspective of the authors, the exclusion of these studies could compromise comprehensiveness of the umbrella review. The excluded studies (n = 46) did not have a full text version available or did not meet the eligibility criteria. Thirty-three articles were selected [ 29 , 30 , 46 – 77 ], for qualitative analysis and for the quality and risk of bias assessment. ( Fig 1 )

The Quality and Risk of Bias Assessment was carried out using the AMSTAR-2 assessment tool [ 45 ]. This assessment performed by the reviewers classified the confidence rate of each review as "low" (n = 14), “moderate” (n = 17) or “high” (n = 3) ( S4 File ).

Among the studies with low overall confidence rate, the main points of non-compliance with the requirements were, the non-performance of adequate studies selection with no extraction in duplicate (at least two independent reviewers); studies presented the quantity of excluded articles but without proper justification; not considering risk of bias (RoB) in individual studies when interpreting / discussing the results of the review; not using a satisfactory technique to assess RoB in individual studies that were included in the review and did not provide a satisfactory explanation for, or discussion of any heterogeneity observed in the results.

Study characteristics.

The 33 articles in this umbrella review included articles from Canada (n = 5), Spain (n = 5) and the United Kingdom (n = 5), among other countries ( Fig 2 ).

https://doi.org/10.1371/journal.pone.0220888.g002

Although the diversity of countries where the systematic reviews were performed, all articles were evaluated in the English version, except article #16 (Spanish).

The reviews comprised a total of 1406 included primary studies and 21 national guidelines, The databases used to search for these articles were the most varied, with the most used databases: MEDLINE (100%) and EMBASE (70%) ( Table 1 ). Seven hundred and twenty seven (n = 727) indicators were extracted from the systematic reviews and primary studies in the reviews (Supplementary Material S1 Appendix ) .

https://doi.org/10.1371/journal.pone.0220888.t001

The dimension of care with the highest number of indicators by context was process (n = 548, 74.5%), followed by outcome (n = 146, 20.0%) and structure (n = 46, 6.0%). The frequency of indicators among the classification by dimension of care and condition contexts is shown in Table 2 . When analysed by dimension of care and condition context, the indicator totals within each dimension (columns) could not be added up because there were indicators (n = 13) that participate in more than one context category within each dimension of care. The total number of indicators analysed was the denominator of the percentage in parentheses and refers to the total number of indicators in the extraction list (n = 727) indicated in the heading. The same is observed in context totals (lines). The ranking of the highest number of indicators found were classified in the categories A—general and non-specific followed by the K—Circulatory System categories specific, P–Psychological and R—Respiratory System. The categories B—Blood, hematopoietic and lymphatic organs, H—Ears and Z—Social Issues, had no indicators presented in the included studies.

https://doi.org/10.1371/journal.pone.0220888.t002

Among the indicators of structure (n = 45), the indicators with the most frequent type of care were those classified in all three categories—Acute, Chronic and Preventive (n = 34, 45.3%), e.g. Professional profiles; Primary care expenditures; Availability of primary care services. Those of specific category of type of care were less frequent ( Table 3 ).

https://doi.org/10.1371/journal.pone.0220888.t003

Structure indicators were more commonly assigned to more than three functions of care (n = 35, 77.7%) (Diagnosis, Screening and Prevention, Follow-up and continuity, Treatment), eg Availability: Number of physicians per unit of population; Availability: Number of hospital beds per unit of population; Technical efficiency.

Most structure indicators were associated with the effective domain of health care quality (n = 22, 48.8%) e.g. Governance: (From) centralization of primary care management and service development; Integration of primary care in the health care system; Appropriate technology in primary care. No structure indicators was associated with the safe domain of health care quality.

Among the indicators of process (n = 542), Chronic care was the most frequent type of care observed (n = 355, 65.5%), e.g. Comorbid psychiatric conditions and response to treatment; Follow-up contacts during treatment episode after initial evaluation; Comprehensive diabetes care: HbA1c testing. Preventive care (n = 88, 16.2%) and all types of care (n = 80, 14.7%) shared similar frequencies ( Table 4 ).

https://doi.org/10.1371/journal.pone.0220888.t004

Treatment was the most frequent function of care of the process indicators (n = 254, 46.8%), e.g Tranquilisers prescribed: % of the recommended; Possible contraindications should be taken into account when antibiotics are prescribed; Co-prescription of itraconazole with simvastatin, or with atorvastatin at a dose ≥80mg. Screening and prevention and Follow up and continuity were also common, associated with 111 indicators each. Examples of Screening and Prevention indicators are: Pap smear rate; Urinary incontinence during initial dementia evaluation; Preventive care Immunizable conditions; Medical attention for nephropathy; and of Follow up and Continuity: Follow up by the same clinician; Plan for follow up care explained and scheduled; Extra pyramidal effects monitoring; Percentage of patients with asthma and measures of variability or reversibility recorded. Most process indicators were also associated with the effective domain of health care quality (n = 310, 57.2%) e.g. Follow-up contacts during treatment episode after initial evaluation; Coordinated care; Asthma: Percentage of children with follow-up from the same doctor for at least 80% of their visits. Also a common domain of health care quality in the listing was Safe (n = 152, 28%), e.g. Detection of Falls; Polyfarmacy; Systemic Lupus Erythematosus: Discussion about teratogenic risks of medication.

Among the indicators of Outcome (n = 140), Chronic care was the most frequent type of care observed (n = 67, 47.8%), e.g. Absenteeism from Work/School for Asthma; Proportion with increased BMI / abdominal waist line; Prevention of pressure ulcers in patients included in the chronic dependent patients care program; Duration of untreated psychosis. The frequency of indicators regarding acute care only (n = 51, 36.4%) and preventive care (n = 44, 31.4%) were similar ( Table 5 ).

https://doi.org/10.1371/journal.pone.0220888.t005

Treatment was the most frequent function of care within outcome indicators (n = 57, 40.7%), e.g Sedation side effects; Number of deaths in seven days between those whose calls were handled by doctors or nurses. Screening and Prevention (n = 25, 17.8%) and Diagnosis (n = 22, 15.7%) followed with similar number of outcome indicators. Examples of Screening and Prevention indicators are: Quality of maternal and child health care: maternal mortality rates; Quality of health promotion: Smoking rate; Preventive care: Low birth weight rate.

Finally, most outcome indicators were associated with the effective domain of health care quality (n = 91, 65%) e.g. Potentially preventable hospitalisation clinical indicator of Chronic Obstructive Pulmonary Disease; Comorbid psychiatric conditions and response to treatment. Also, a common health care quality domain in the listing was Patient-centered (n = 26, 18.5%), e.g. Patients with multiple chronic conditions and medications attended in primary care; Patient Quality of Life; Patient satisfaction with the family physician/specialist coordination of care.

Primary health care (PHC) is where the patient's first contact with the health system occurs and comprises a range of actions which includes many dimensions, domains, and contexts [ 14 ]. Due to these characteristics, it becomes important to evaluate and monitor the quality of primary care [ 78 – 80 ]. It is established that primary care can lead to better health outcomes, lower costs, and greater equity in health [ 81 ] and this can be achieved by using QIs, a set of objective measures with clinical evidence [ 6 , 82 – 83 ] that can represent an acceptable standard of care across a specific patient population [ 84 ].

As the aim of this umbrella review of systematic reviews was to search indexed literature, in order to find a setlist of QI useful for monitoring quality in PHC, our study shows interesting answers to what was proposed, identifying 33 systematic reviews of studies on quality indicators in primary health care and providing a list of selected indicators considered in the included reviews. The study resulted in 727 quality indicators, which were later categorized by context, dimension, type of care, function and domain.

Context of care was classified according to the International Classification of Primary Care (ICPC-2), which is recommended by the World Organization of Family Doctors (WONCA) for codification in this level of care.[ 44 ]. Although practical and useful for primary care, this classification represents a simplification and attempt at uniformization with other classification systems such as the International Classification of Diseases (ICD-11), which is not achieved completely [ 85 ]. Furthermore, since ICPC-2 is a classification based primarily in the location of the symptoms or disease, the authors could not define the context for 100 indicators, since they relate mostly to organizational measures not contemplated in adopted system. “Not defined” was the fourth most common context, representing 13.8% of the total of indicators found.

The majority of the indicators belong to the context category “A–General and Unspecified” (n = 112, 15.4%), which may reflect an attempt at creating indicators applicable to a wide range of procedures and contexts. Circulatory, psychological, respiratory, musculoskeletal and endocrine/metabolic diseases are the next most frequent contexts, indicating also a bigger concern for areas which are more prevalent in primary care (see Table 2 ) .

Most of the indicators found by the authors were related to the dimension of Process (n = 542, 74.5% of total). As defined by Donabedian, this dimension focuses in what is actually done, such as patient’s procedures in seeking care and practitioner’s activities while providing it [ 14 ]. Since QIs represent an opportunity for improvement in areas where quality standards are not met, process indicators may help implementing better procedures and guidelines, resulting in better health care. Outcome dimension was the second most frequent dimension (n = 140, 19.2%); since healthcare outcomes depend on the care provided, these indicators evaluate the result of the course of action of PHC professionals, unlike process indicators which evaluate a single aspect of care.

Type of care

Type of care was classified as acute, chronic or preventive, with “Chronic” being the most frequent. Indicators focused on chronic care are very helpful, since family doctors follow their patients longitudinally for many years, monitoring and managing the chronic diseases they develop throughout their lives [ 79 ]. The management and control of chronic conditions/diseases in the population is one of the main focuses of the activities of primary health care, being also the most studied and evaluated by the QIs, as our study demonstrates. Indicators such as control of prescriptions and monitoring of diseases such as asthma, COPD, hypertension and diabetes, as well as indicators of ambulatory care sensitive conditions that can generate avoidable hospitalizations are part of the list of indicators presented [ 30 ].

Indicators relating to “Treatment” were the most frequent, followed by “Screening and Prevention” and “Follow-up and Continuity”. Once again, the results mirror important aspects of PHC. The consideration of the patient as a whole and the approach of disease in a holistic perspective imply that the healthcare provider must consider indications, potential adverse effects and comorbidities of each patient before elaborating a treatment plan [ 79 ]. Within outcome indicators, most these were focused on treatment, contributing to the evaluation of its complications and preventable hospitalizations, once again alerting providers to re-evaluate their patients and review therapeutic options.

Regarding “Screening and Prevention”, the prevention of disease as well as early diagnosis are the main focus of this level of care [ 1 ]; the development of screening programs for oncological conditions and adequate follow-up for prevention of complications contribute to better health care in this aspect.

“Effective” was the most common domain among the three dimensions of care. Indicators under this domain focus on the capacitation of PHC providers and their articulation with secondary care. Since the effectiveness of a health system depends on the quality of its primary care [ 29 , 86 ], it would be expected that this would be an area of interest.

Other domains such as “Patient-centered” or “Safety” were also commonly evaluated through QIs, demonstrating once again the concern for a holistic approach of PHC.

Limitations

Although there is a significant amount of literature on health quality indicators, some of them are not directly linked to PHC, making it difficult to extrapolate the conclusions of the QI that are applied mainly to the secondary and tertiary levels of attention. Most articles published on QIs in PHC tend to choose very limited and specific areas of health care, without a generic approach to PHC as a whole. The uniqueness and heterogeneity found in these studies show the importance of comprehensive systematic reviews on PHC.

Systematic reviews included in this paper selected primary studies using slightly different methodological assessment and statistical pooling; some of these articles did not discriminate how many primary studies were included in the analysis. The use of different databases in each systematic review and different methods for choosing search terms, calibration and specificity of the search expressions must be considered when interpreting the results.

The authors of this article have searched the primary studies included in each systematic review in order to obtain a list of PHC quality indicators. The lack of a uniform method to collect and present the QIs among the included reviews limited the ability to withdraw complete information from every paper. As an example, most studies were missing information regarding the numerator, denominator and calculation method for each QI.

Conclusions

This is, to the best of our knowledge, the first umbrella review focusing on QIs for primary healthcare in a border scope. We present a final list of indicators ( S1 Appendix supplementary material ) from eligible systematic reviews summarizing the indicators available in the literature, allowing us to understand which areas of primary care are better covered by these measures. The results of our umbrella review are valuable and imply the need for future research and practice regarding quality indicators, as a great opportunity for further studies to test the acceptability, feasibility, reliability, comparison tools and validity of those indicators, while also checking for problems with their implementation to PHC, with adequate information and registration systems. It also provides a ready way for clinicians, managers and health decision makers to gain a clear understanding of the most evidence-based publications related to PHC quality indicators.

Supporting information

S1 file. prisma statement checklist..

https://doi.org/10.1371/journal.pone.0220888.s001

S2 File. PROSPERO protocol register.

https://doi.org/10.1371/journal.pone.0220888.s002

S3 File. Search expression query.

https://doi.org/10.1371/journal.pone.0220888.s003

S4 File. Quality and risk of bias assessment.

https://doi.org/10.1371/journal.pone.0220888.s004

S1 Appendix. Supplementary material–indicators list.

https://doi.org/10.1371/journal.pone.0220888.s005

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Literature review on patient experience in primary health care

Patients, consumers and carers provide a unique perspective of the care provided. Evidence suggests that improving patient experience can improve clinical outcomes. Primary health care (PHC) sector provides a range of services for the prevention and management of acute and chronic conditions. Gathering patient feedback is imperative for continuously improving the quality of care in PHC.

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Literature review to understand the current approaches, tools and use of patient experience in the primary care sector.

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Primary health care assessment tools: a literature review and metasynthesis

This study comprises a systematic review and metasynthesis of qualitative literature on national and international databases to identify the main tools used to assess Primary Health Care (PHC). A total of 3,048 results were returned for literature written in Portuguese, Spanish and English published between 1979 and 2013. Thirty-three articles/studies were selected after thorough reading and analysis. Eight of these studies addressed the use of one or more of the following validated PHC assessment tools: the WHO Primary Care Assessment Tool (PCET); the ADHD Questionnaire for Primary Care Providers (AQ-PCP); the General Practice Assessment Questionnaire (GPAQ), PACOTAPS (primary health care software); and the PCAT (Primary Care Assessment Tool). The study showed that the majority of these tools were used internationally. The PCAT and EUROPEP were used in Brazil and the most commonly used tool in this country was the PCAT. The results show that the use of research tools to assess PHC may assist in the creation of new proposals to improve family healthcare and that PCAT is the most adequate tool for this purpose.

Health assessment; Primary health care; Public health; Health services

Trata-se de uma revisão de literatura qualitativa seguida de metassíntese que procurou identificar nas bases de dados nacionais e internacionais os instrumentos que estão sendo utilizados para avaliar a Atenção Primária à Saúde (APS). Foram encontrados 3048 resultados em português, espanhol e inglês, publicados entre 1979 e 2013. Após leitura e análise minuciosa foram selecionados 33 artigos/pesquisas, destes, 8 estudos tratavam de instrumentos validados que avaliam a APS. Sendo eles: WHO Primary Care Evaluation Tool (PCET); ADHD Questionnaire for Primary Care Providers (AQ-PCP) e General Practice Assessment Questionnaire (GPAQ), PACOTAPS (Aplicativo para Atenção Primária em Saúde); e PCATools (Primary Care Assessment Tool). Observou-se que a maior parte dos instrumentos são utilizados internacionalmente. Ressalta-se que o PCATools e o EUROPEP são instrumentos que vêm sendo utilizados no Brasil para avaliar a APS, sendo o primeiro o que mais prevalece. Os resultados mostraram que a aplicação de um instrumento de pesquisa que visa avaliar a APS deve dar subsídios para a criação de novas propostas que possam contribuir para a qualificação da Saúde da Família e o instrumento que mais se aproxima desta proposta é o PCATool.

Avaliação em saúde; Atenção Primária à Saúde; Saúde pública; Serviços de saúde

Introduction

The worldwide debate about Primary Health Care (PHC) strategies has intensified over recent decades and measures to strengthen primary care are an integral part of the reorganisation of healthcare in various European and Latin American countries 1 1  Giovanella L. Atenção Primária à Saúde seletiva ou abrangente? Cad Saude Publica. 2008; 24(Supl. 1):21-23. .

The International Conference on Primary Health Care (the Alma - Ata Conference) held in 1978 marked a major milestone in the development of the concept of PHC by calling for "Health for all by 2000"and a broader vision of healthcare that encompassed the sectoral dimensions of health and participation of the population 2 2  Brasil. Ministério da Saúde (MS). Promoção da saúde: carta de Ottawa, declaração de Adelaide, Sundsvall e Santa Fé de Bogotá. Brasília: MS; 1996. .

According to the Alma-Ata Declaration, PHC is the central function of national health systems and forms an integral part of a permanent process of sanitary assistance that includes prevention, promotion, cure and rehabilitation, and of the overall social and economic development of the community, involving cooperation with other sectors to promote social development and confront the social determinants of health 2 2  Brasil. Ministério da Saúde (MS). Promoção da saúde: carta de Ottawa, declaração de Adelaide, Sundsvall e Santa Fé de Bogotá. Brasília: MS; 1996. .

In Brazil, PHC is called basic health care and is characterised by a series of actions and sanitary practices in both the individual and collective spheres that encompass health promotion and protection, prevention of problems, diagnosis, treatment, rehabilitation and maintenance. The approach to basic health care is based on democratic and participative management and actions are focused on populations of well defined geographical region staking into account the specific characteristics of each area 3 3  Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Política Nacional de Atenção Básica. Brasília: MS; 2012. .

Studies show that a given country's PHC framework depends on its approach to social health protection. In most European countries, outpatient services form an integral part of a universal health care system where the right to health is guaranteed at all levels through publically funded comprehensive universal systems in which PHC is seen as a gateway to the wider system.

However, in periphery countries, such as those in Latin America, PHC is selective and narrowly focussed on particular health problems. The expansion of health coverage depends on the private health insurance market that attends specific groups such as maternal and infant health. Health coverage in the majority of countries in Latin America is therefore segmented, with the coexistence of different schemes for different social groups. Primary care is incorporated only in the public sector through the implementation of selective programs, thus resulting in significant inequalities in access to health care 1 1  Giovanella L. Atenção Primária à Saúde seletiva ou abrangente? Cad Saude Publica. 2008; 24(Supl. 1):21-23. .

The context of the Brazilian health system is rather complex when it comes to approaches to primary care. Although the technically universal health system offers a diverse range of services and has expanded coverage to a large portion of the population previously without access, it coexists with private health schemes for the middle class thus creating a segmented and effectively dual system of healthcare which still remains insufficient. Although the population covered by the Unified Health System (SUS) is by no means small, the reach of services that should be guaranteed by the public system is questionable 1 1  Giovanella L. Atenção Primária à Saúde seletiva ou abrangente? Cad Saude Publica. 2008; 24(Supl. 1):21-23. .

The existence of different concepts of PHC shows that there are no set national or international standards, but rather a number of diverse models adapted to the social, economic and political context of a given country within a generalised tendency to embody a managed care approach under different politico-institutional contexts 1 1  Giovanella L. Atenção Primária à Saúde seletiva ou abrangente? Cad Saude Publica. 2008; 24(Supl. 1):21-23. .

According to Ibañez et al. 4 4  Ibañez N, Rocha JSY, Castro PC, Ribeiro MCSA, Forster AC, Novaes MHD, Viana ALD. Avaliação do desempenho da atenção básica no Estado de São Paulo. Cien Saude Colet 2006; 11(3):683-703. , research that focuses on organisational evaluations and care performance assessments of primary health care services and provides a critical insight into institutional mechanisms for monitoring and assessing primary health care is rare.

Given the nuanced understanding of the concept of PHC and the lack of research addressing primary care assessment, are view of literature on the current use of primary care assessment tools across health systems in different countries is considered of utmost importance.

Furthermore, the use of assessment tools to take a closer look at health systems allows a greater understanding of the following aspects of PHC in Brazil and other countries: perceptions of health service users, health professionals and managers; different health care frameworks; individual and collective care practices; and management practices.

The objective of this study is to therefore to carry out a review of literature on national and international databases to identify the tools currently used to assess Primary Health Care.

Methodology

A systematic search for qualitative research papers was undertaken followed by a metasynthesis of the literature. A systematic literature review is a research method which allows the researcher to group primary studies and extract the best scientific evidence 5 5  Lopes ANM, Fracolli LA. Revisão sistemática de literatura e metassíntese qualitativa: considerações sobre sua aplicação na pesquisa em enfermagem. Texto contexto - enferm. 2008; 17(4):771-778. .

Since it synthesises all high quality research on a given question, the method provides the highest possible level of evidence for decision-making related to issues of therapy or treatment 5 5  Lopes ANM, Fracolli LA. Revisão sistemática de literatura e metassíntese qualitativa: considerações sobre sua aplicação na pesquisa em enfermagem. Texto contexto - enferm. 2008; 17(4):771-778. . Furthermore, metasynthesis allows the researcher to interpret primary data and deepen his/her understanding of the phenomenon, thus facilitating the use of knowledge and research in decision making, to help set health policies and to define practices 6 6  Atallah AN. Revisão sistemática da literatura e metanálise. Diagnóstico e Tratamento 1997; 2(2):12-15. .

The following research question was formulated using the PICO method which is used to select a specific intervention or phenomenon of interest: "What are the main validated data collection tools used to evaluate Primary Health Care?"

The identification and selection of articles/studies was carried out in the following stages detailed in Figure 1 7 7  Sandelowski M, Barroso J. Handbook for synthesizing qualitative research. New York: Springer; 2007. :

Figure 1 Stages in the identification and selection of articles/studies for metasynthesis. Source: produced by the authors (2014).

Identification of the theme and formulation of research question;

Definition of data sources;

Establishment of study inclusion and exclusion criteria;

Data selection and processing;

Data analysis: evaluation of the quality of studies and interpretation of results.

This study used the following inclusion criteria: selected articles/studies must have used a validated data collection tool to evaluate PHC. The following exclusion criteria were also used: all articles/studies which did not use a validated data collection tool; articles/studies which addresses PHC but which evaluated quality of life of the population rather than the quality of PHC services; duplicated articles/studies; articles/studies that evaluated training and capacity building of PHC professionals.

The study considered articles/studies written in Portuguese, Spanish and English published between 1979 and 2013and indexed on the LILACS, CidSaúde, BDENF, IBECS, MEDCARIB, PAHO, MEDLINE databases and Cochrane and SciELO digital libraries as shown in Table 1 .

The following keywords were used for the search of the LILACS (Latin American and Caribbean Health Sciences Literature) database: "Evaluation of Health", "Primary Health Care Evaluation", "Public Health", and "Health Service". After meticulous reading of the eight selected studies, six were excluded because they used unvalidated data collection tools.

The following key words were used for the search of the CidSaúde database (Literature about Healthy Cities/Municipalities): "Evaluation of Health", "Primary Health Care Evaluation", and "Health Service". The only article found was read and it was found that the study used a validated data collection tool to evaluate PHC.

The following keywords were used for the search of the BDENF database (Nursing Data): "Evaluation of Health" and "Primary Health Care Evaluation". Two articles were found which were excluded after reading because neither used a validated data collection tool to evaluate PHC.

The following keywords were used for the search of the IBECS database (the Spanish Bibliographic Index of the Health Sciences): "Health Evaluation" and "Primary Health Care". The four studies found did not use a validated data collection tool to evaluate PHC.

The following keywords were used for the search of the MEDCARIB database: "Health Evaluation" and "Primary Health Care". Only one of the 40 results used a validated data collection tool to evaluate PHC. However, this study was not included in the metasynthesis because its direct focus was not PHC, but an evaluation of the severity of symptoms of diabetes within a PHC scenario.

The following key words were used for the search of the PAHO database: "Health Evaluation" and "Primary Health Care". After reading the summaries, none of the 90 studies found used a validated data collection tool to evaluate PHC.

The following MeSH terms were used for the search of the MEDLINE database (Medical Literature Analysis and Retrieval System Online): "health evaluation", "primary health care", "health services", "public health" and "questionnaires". Twenty-two of the 2,761 search results used a data collection tool to evaluate PHC. Meticulous reading of the 22 studies resulted in the selection of four articles/studies. Seventeen articles/studies were excluded because they did not deal directly with PHC, but rather evaluated quality of life among groups of people with different morbidities such as neoplasm, arterial hypertension and mental health disorders.

The term "evaluation" was used for the search of the Cochrane Library, resulting in 75 articles, which were all excluded because none dealt with PHC assessment tools.

The key words "Evaluation of Health", "Primary Health Care Evaluation", "Public Health" and "Health Service" were used for the search of SciELO (Scientific Electronic Library Online). After meticulous reading of the eight studies found by this search, two were found to use a validated data collection tool to evaluate PHC. However, these studies were duplicated because they had been found through the search of the LILACS database.

The eight studies selected for the metasynthesis were published in national and international journals. Study participants were either PHC professionals or PHC service users and research used secondary data obtained from primary health centres.

The main methods used by the studies were interviews with the use of validated tools, as well as self-administered questionnaires as detailed in Chart 1 .

Chart 1 Main characteristics of the studies selected for metasynthesis (1979 to 2013). Source: produced by the authors (2014).

The search identified the use of five main assessment tools: the WHO Primary Care Assessment Tool (PCET); the ADHD Questionnaire for Primary Care Providers (AQ-PCP); the General Practice Assessment Questionnaire (GPAQ); PACOTAPS (primary health care software); and the PCAT (Primary Care Assessment Tool).

The WHO Primary Care Assessment tool (PCET) has been used in a number of countries that are undergoing deep and wide-ranging health reforms related to the social function and essential values that underpin healthcare provision. Reforms in primary health care are not always based on evidence, and progress may be driven by political arguments or the interests of specific professional groups.

However, health policy-makers today demand scientific evidence that health reforms are really making progress. The WHO therefore created the PCET with the aim of providing a structured approach to assessment based on specific aspects of the health system, such as governance, funding and resource generation, as well as factors that characterise good primary health care, including access, comprehensiveness, coordination and continuity 8 8  Kringos DS, Boerma WG, Spaan E, Pellny M. A snapshot of the organization and provision of primary care in Turkey. BMC Health Services Research 2011; 11:90. .

The PCET has three components: a national questionnaire regarding organisation and funding of primary health care; a questionnaire for family doctors; and a questionnaire for service users 8 8  Kringos DS, Boerma WG, Spaan E, Pellny M. A snapshot of the organization and provision of primary care in Turkey. BMC Health Services Research 2011; 11:90. .

The ADHD Questionnaire for Primary Care Providers (AQ-PCP) was developed to evaluate the perceptions of primary care providers regarding their role, the challenges associated with diagnosis of attention deficit hyperactivity disorder (ADHD), and clinical activities specific to the care of children with ADHD. The items of this questionnaire were developed based on the following criteria: a careful revision of the recommendations for performing an evaluation of the disorder contained in the American Academy of Paediatrics Guidelines for treatment of ADHD; a revision of the role of primary health care providers; and focus groups of primary health care providers 9 9  Poder TJ, Mautone JÁ, Manz PH, Frye L, Blum NJ. Managing attention-deficit/hyperactivity disorder in primary care: a systematic analysis of roles and challenges. Pediatrics 2008; 121(1):65-72. .

PACOTAPS is a primary health care software developed using the programming language Visual Basic 5.0. The secondary data and outpatient care demand modules of this program were tested in a primary health centre in Pelotas in the State of Rio Grande do Sul. The tool proposes an interface between two fields of knowledge: epidemiology and information technology. By processing the information contained on patient forms, PACOTAPS provides secondary data on the age and sex distribution of a specific population, outpatient care demand, and all patient attendances at a given primary health centre 10 10  Tomasi E, Facchini LA, Osorio A, Fassa AG. Aplicativo para sistematizar informações no planejamento de ações de saúde pública. Rev Saude Publica 2003; 37(6):800-806. .

The General Practice Assessment Questionnaire (GPAQ) was developed by the National Primary Care Research and Development Centre at the University of Manchester for the 2003 GP contract. The GPAQ helps practices find out what patients think about the care provided by doctors and focuses on specific features of general practice, such as access, the interpersonal aspects of care, and continuity of care 14 14  Jaturapatporn D, Hathirat S, Manataweewat B, Dellow AC, Leelaharattanarak S, Sirimothya S, Dellow J, Udomsubpayakul U. Reliability and validity of a Thai version of the General Practice Assessment Questionnaire (CPAQ). J Med Assoc Thai 2006; 89(9):1491-1496. .

This study observed that the PCAT (Primary Care Assessment Tool) and European Task Force on Patient Evaluation of General Practice Care (EUROPEP) are tools currently used in Brazil. The most commonly used tool in Brazil is the PCAT, since it is widely accepted and validated in the United States, Spain and other countries.

O PCAT was developed by Starfield et al . 15 15  Starfield B, Xu J, Shi L. Validating the Adult Primary Care Assessment Tool. The Journal of Family Practice 2001; 50(2):161-175. at the Johns Hopkins Populations Care Policy Center for the Underserved Populations in Baltimore, Maryland based on a theoretical framework of primary care domains and characteristics. It measures the presence and extent of four cardinal domains and three related domains of primary care and user affiliation with the care source 15 15  Starfield B, Xu J, Shi L. Validating the Adult Primary Care Assessment Tool. The Journal of Family Practice 2001; 50(2):161-175. .

Starfield et al . 15 15  Starfield B, Xu J, Shi L. Validating the Adult Primary Care Assessment Tool. The Journal of Family Practice 2001; 50(2):161-175. defined four cardinal primary care domains: first-contact access, longitudinality, comprehensiveness, and coordination. The same authors also proposed three related domains: family centeredness, community orientation, and cultural competence.

The PCAT, originally made up of 77 questions (items) about the seven primary care domains, was created based on a health service quality assessment model proposed by Donabedian 17 17  Donabedian, A. The Quality of Care: How Can It Be Assessed? JAMA 1988; 260(12):1743-1748. which uses a structure, process and outcome framework 17 17  Donabedian, A. The Quality of Care: How Can It Be Assessed? JAMA 1988; 260(12):1743-1748. . Based on a Likert-type response scale, each domain is scored on a scale of one to four. The final score for each domain is represented by the average of the scores assigned to each of the items related to each domain. Some of the domains are made up of subdomains, for example: first-contact access (first contact and use), comprehensiveness (services received and services available) and coordination (information system and flow of service users). The essential primary health score is represented by the sum of the final average score assigned to each of the four cardinal primary care domains and their subdomains and the average extent of affiliation score. The overall primary health score is represented by the sum of the final average score assigned to each of the four cardinal primary care domains and the final average scores assigned to each of the three related domains 16 16  Harzheim E, Starfield B, Rajmil L, Alvarez-Dardet C, Stein AT. Internal consistency and reliability of Primary Care Assessment Tool (PCATool-Brasil) for child health services. Cad Saude Publica 2006; 22(8):1649-1659. .

This tool also has a child version (PCAT-CE with 55 items), adult version used only with individuals aged over 18 years (PCAT-AE with 87 items), and provider version (PCAT-PE with 77 items) 18 18  Brasil. Ministério da Saúde (MS). Secretaria de Atenção em Saúde. Departamento de Atenção Básica. Manual do Instrumento de avaliação da atenção primária à saúde: primary care assessment tool pcatool - Brasil. Brasília: MS; 2010. .

The EUROPEP was developed to provide feedback on practice, performance and organization of care among family health professionals. The EUROPEP has three components: 1) Key indicators (relationship and communication, medical care, information and support, continuity and cooperation, and service organisation); 2) indicators of specific areas of satisfaction (consultations, appointments and accessibility, characteristics of doctors, conditions at the health centre, and the services provided); 3) user information (socioeconomic and health data, and post-questionnaire attitudes) 19 19  Brandao ALRBS, Giovanella L, Campos CEA. Avaliação da atenção básica pela perspectiva dos usuários: adaptação do instrumento EUROPEP para grandes centros urbanos brasileiros. Cien Saude Colet 2013; 18(1):103-114. .

The PCAT and EUROPEP are used in Brazil along with another tool for assessing PHC called the Program for Improvement in Access and Quality of Primary Care ( Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica - PMAQ-AB). Although the search did not return any results mentioning the PMAQ-AB, it is important to describe the development of this tool in the Brazilian context.

The aim of the PMAQ is to widen the capacity of health managers, at the federal, state and municipal level, and primary healthcare teams to deliver services that ensure greater access to quality healthcare that meets the concrete needs of the population. The tool also aims to promote greater access to quality PHC that guarantees minimum standards of service at national, regional and local level, and greater transparency and effectiveness in government actions focussed on PHC across the country 20 20  Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Departamento de Atenção Básica. PMAQ: Manual instrutivo para as equipes de Atenção Básica. Brasília: MS; 2013. .

The PMAQ comprises four complementary phases that form a continuous cycle of improvements in the accessibility and quality of primary care (adhesion and contractualisation; development, external assessment, and recontractualisation) 20 20  Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Departamento de Atenção Básica. PMAQ: Manual instrutivo para as equipes de Atenção Básica. Brasília: MS; 2013. .

The analysis of the data collection tools used by the studies selected by our search shows that the most adequate tool for assessing essential aspects of primary health care service provision is the PCAT. This tool measures the presence and extent of the essential characteristics of primary care and at the same time assess indicators which address aspects related to the care process, such as the performance of family health teams. The tool is particularly appropriate to the Brazilian context and the work of family health teams because it enables the researcher to address family centeredness, community orientation, and cultural competence. These additional aspects of primary care are in line with Brazil's National Primary Health Care Policy whose main strategy for expanding and strengthening PHC is family health 2 2  Brasil. Ministério da Saúde (MS). Promoção da saúde: carta de Ottawa, declaração de Adelaide, Sundsvall e Santa Fé de Bogotá. Brasília: MS; 1996. .

The search for the "most adequate" tool for assessing PHC reveals that the fundamental aim of developing such instruments is the production of reliable scientific knowledge to support decision making 21 21  Novaes HMD. Avaliação de programas, serviços e tecnologias em saúde. Rev Saude Publica 2000; 34(5):547-559. .

The choice of an adequate assessment tool should therefore consider aspects of PHC that need to be revised and improved by health managers and the results of assessments of PHC using these tools should provide concrete information to support the creation of new proposals that contribute to improvements in family health.

The analysis of the five validated tools found by the literature review undertaken by this study shows that the PCAT is the tool that is most aligned with the family health strategy as proposed by Brazil's National Primary Health Care Policy and is therefore the most adequate tool for assessing primary care in this country.

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Publication Dates

• Publication in this collection Dec 2014
• Received 05 Mar 2014
• Accepted 27 May 2014

• Collaborations LA Fracolli, MFP Gomes and FRZ Nabão carried out the literature review and data analysis, produced the tables, and helped draft the final version of this article. MS Santos, VK Capellini and ACC Almeida were responsible for data interpretation and drafting and revising the final version of this article.

SCIMAGO INSTITUTIONS RANKINGS

Figures | tables.

• Figures (2)

Figure 1   Stages in the identification and selection of articles/studies for metasynthesis. Source: produced by the authors (2014).

Chart 1   Main characteristics of the studies selected for metasynthesis (1979 to 2013). Source: produced by the authors (2014).

Table1   Studies selected by data source (1979 to 2013).

• Source: produced by the authors (2014).

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