Comparison of Patients' and General Practitioners' Evaluations of General Practice Care
Comparison of Patients' and General Practitioners' Evaluations of General Practice Care
Comparison of Patients' and General Practitioners' Evaluations of General Practice Care
ORIGINAL ARTICLE
Objectives: To compare patients’ and general practitioners’ (GPs’) evaluations of the quality of
general practice care.
Design: Written surveys among patients and GPs.
Setting: General practice in the Netherlands.
Subjects: 1772 patients (from 45 GPs) and a random sample of 315 GPs.
Main outcome measures: Patients’ and GPs’ evaluations of 23 aspects of general practice care and
GPs’ perceptions of patients’ evaluations using a 5 point scale.
Results: The response rate was 88% in the patient sample and 63% in the GP sample. The patients’
ratings of care were significantly more positive (mean 4.0) than those of the GPs (mean 3.7) as well as
GPs’ perceptions of patients’ evaluations (mean 3.5) (p<0.001). The overall rank order correlations
between the patients’ evaluations, GPs’ evaluations, and GPs’ perceptions of the patients’ evaluations
were 0.75 or higher (p<0.001). Patients and practitioners gave the most positive evaluations of spe-
cific aspects of the doctor-patient relationship (“keeping patients’ records and data confidential”, “lis-
See end of article for
authors’ affiliations tening to patients”, and “making patients feel they had enough time during consultations”) and aspects
....................... of the organisation of care (“provide quick service for urgent health problems” and “helpfulness of the
staff (other than the doctor)”). The aspects of care evaluated least positively by patients as well as by
Correspondence to:
Dr H P Jung, Veerweg 6,
GPs were other organisational aspects (“preparing patients for what to expect from specialist or hospi-
5851 AP Afferden, The tal care” and “getting through to practice on the telephone”).
Netherlands; Conclusions: GPs and patients have to some extent a shared perspective on general practice care.
HPJung@nlzorg.net However, GPs were more critical about the quality of care than patients and they underestimated how
Accepted for publication positive patients were about the care they provide. Furthermore, specific aspects of care were evalu-
9 May 2002 ated differently, so surveys and other consultations with patients are necessary to integrate their
....................... perspective into quality improvement activities.
P
ositive patient evaluations of health care are increasingly would like to improve. However, if they agree in their evalua-
seen as an important outcome.1 Although doubts have tions there is a higher chance that both parties are motivated
been raised as to whether patients have the capacity to to improve less positively evaluated aspects of care. If GPs are
evaluate all aspects of care,2 patients do, in fact, evaluate their poor estimators of patients’ evaluations and base the selection
care—for example, in the way they deal with treatment regi- of topics they want to improve on their perceptions of patients’
mens (compliance),3 re-attendance,4 choice of care provider,5 evaluations, they might choose the wrong ones.
and even health status.6 Negative patient evaluations are The following research questions were formulated:
therefore indicators for potential opportunities to improve the • Which aspects of general practice care are evaluated
quality of care. positively or negatively by patients and by GPs, and do these
Evaluations by general practitioners (GPs) of the care they evaluations differ?
provide and their perceptions of the patients’ evaluations may
be important factors in improving the quality of care. These • Can GPs adequately estimate their patients’ evaluations?
perceptions are likely to influence their willingness to actually
change something in their professional performance or METHODS
organisation of care. It is unclear how GPs’ perceptions relate Samples
to patients’ evaluations of care. Previous studies have shown a The study included a sample of GPs and a sample of patients.
low correlation between patients’ and physicians’ evaluations The sample of 500 GPs was randomly selected from the
and physicians’ perceptions of patient evaluations.7 8 Physi- national register of GPs maintained by the Netherlands Insti-
cians evaluated care less positively than patients,9 10 and phy- tute of Primary Care (NIVEL). The GPs were mailed a
sicians thought that patients would evaluate their care less questionnaire in January 1998 and, after 3 weeks, a reminder
positively than they actually did.11 However, none of these was sent to those who had not responded. Each GP also
studies was based on a representative sample of patients and received an invitation to participate in a study in which
physicians. In addition, all studies were in one7–10 or two11 set- patients’ evaluations would be measured. If they were
tings with vocational trainees7 8 and with a small number of interested they had to send back a short form in which they
patients and physicians.7–10 For this reason, a national study of had to fill in the location of their practice, type of practice, and
the evaluations of both patients and GPs was undertaken. age and sex of physician. This form had to be sent back in a
The main objective of the study was to compare the views of different envelope from the anonymous questionnaire. Of
patients and GPs about general practice care and to find out those who responded, a stratified sample of 45 GPs from 45
the extent to which GPs are able to estimate their patients’ different practices were asked to give a questionnaire to 45
judgements. If patients and GPs differ considerably in their consecutive adult patients visiting their practice after a
evaluations of care, they might also differ in those aspects they specific starting point. The practice assistant registered all
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316 Jung, Wensing, Olesen, et al
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Comparison of patients’ and GPs’ evaluations of general practice care 317
Table 3 Patients’ and GPs’ evaluations of care and GPs’ perceptions of patients’ evaluations. Rank orders based on
valid percentages evaluating positively as 4 or 5 on a 5 point Likert scale
GPs’ perceptions of
Patients’ evaluations GPs’ evaluations patients’ evaluations
(n=1772) (n=315) (n=315)
What is your opinion of the GP and/or general practice over the last 12 Rank no Absolute Rank no Absolute Rank no Absolute
months with respect to . . .* (%) no (%) no (%) no
Keeping your records and data confidential? (I)** 1 (94.6) 1440 2 (88.9) 279 1 (85.8) 266
Listening to you? (I) 2 (88.5) 1546 4 (78.1) 246 7 (60.3) 190
Making you feel you had time during consultations? (I) 3 (87.8) 1540 5 (74.0) 223 12 (52.5) 165
Providing quick services for urgent health problems? (IV) 4 (85.2) 1137 1 (93.9) 295 2 (80.6) 253
Helpfulness of the staff (other than the doctor)? (IV) 5 (83.8) 1329 3 (79.2) 248 4 (64.4) 201
Explaining the purpose of tests and treatments? (II) 6 (83.3) 1331 11 (66.6) 209 11 (53.0) 166
Telling you what you wanted to know about your symptoms and/or illness? (II) 7 (82.7) 1399 10 (67.2) 211 13 (50.3) 158
Making it easy for you to tell him or her about your problems? (I) 8 (82.5) 1399 13 (63.8) 201 16 (46.8) 147
Physical examination of you? (III) 9 (82.4) 1328 6 (73.9) 232 3 (65.8) 206
Interest in your personal situation? (I) 10 (82.0) 1409 8 (70.8) 223 8 (56.5) 178
Thoroughness? (III) 11 (81.2) 1361 9 (68.4) 214 6 (61.2) 191
Involving you in decisions about your medical care? (I) 12 (81.0) 1323 7 (72.7) 229 5 (61.3) 193
Helping you to understand the importance of following his or her advice? (II) 13 (79.7) 1141 21 (47.9) 150 18 (36.5) 113
Helping you to feel well so that you can perform your normal daily activities?
(III) 14 (78.7) 1172 19 (53.8) 161 17 (37.9) 113
Getting an appointment to suit you? (IV) 15 (78.1) 1335 14 (60.8) 191 20 (34.4) 108
Knowing what s/he had done or told you during contacts? (IV) 16 (76.2) 1135 20 (52.7) 164 10 (54.4) 168
Offering you services for preventing diseases (eg screening, health checks,
immunisations)? (III) 17 (76.1) 953 16 (59.2) 184 9 (54.9) 168
Helping you deal with emotional problems related to your health status? (II) 18 (75.5) 873 17 (57.6) 181 15 (47.3) 148
Quick relief of your symptoms? (III) 19 (74.8) 1239 22 (41.4) 126 23 (24.8) 75
Preparing you for what to expect from specialist or hospital care? (IV) 20 (74.7) 818 23 (40.4) 127 21 (31.2) 97
Being able to speak to the GP on the telephone? (IV) 21 (71.9) 1051 12 (65.3) 205 19 (34.7) 109
Getting through to the practice on the phone? (IV) 22 (71.3) 1247 18 (55.1) 173 22 (28.3) 89
Waiting time in the waiting room? (IV) 23 (61.2) 1066 15 (60.5) 190 14 (48.6) 152
*Stem in the questionnaire for GPs: “What is your own opinion of yourself and/or your general practice over the last 12 months with respect to . . .” and
“What is your perception of the opinion of your patients of you and/or your general practice over the last 12 months with respect to . . .”. The word “you”
was replaced by “patients” in all 23 items for general practitioners, e.g. “making patients feel they had time during consultations”, so the words “him or
her”, “s/he”, “his or her” were replaced by “you” or “your”.
**Dimensions of general practice care: I=doctor-patient relationship (6 items); II=information and support (4 items); III=medical-–technical care (5 items);
IV=organisation of services (8 items).
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318 Jung, Wensing, Olesen, et al
problems related to their health status” (rank number 17, “getting an appointment to suit you” (78.1% (n=1335) of
57.6% (n=181)). patients, 34.4% (n=108) of GPs’ perceptions) and “preparing
patients for what to expect from specialist or hospital care”
Did patients’ and GPs’ evaluations differ? (74.7% (n=818) of patients, 31.2% (n=97) of GPs’ percep-
The absolute ratings differed systematically between the tions).
patients and the GPs. The patient sample had a mean overall
rating of 4.0, while the GP sample had a mean overall rating of DISCUSSION
3.7 (own evaluations) and 3.5 (perception of patients’ evalua- GPs were more critical about the care they provided than
tions) (p<0.001). GPs were thus more critical of their care patients and GPs underestimated how positive patients actu-
than patients and underestimated just how positive patients ally were about general practice care. However, patients’ and
actually were about the care they provided. GPs’ views on what was relatively best or worst in general
The Spearman rank order correlation between the patients’ practice care were remarkably similar. Both patients and GPs
and the GPs’ evaluations was 0.76 (p<0.001)—that is, the evaluated the doctor-patient relationship and the organisa-
rank orders for the 23 different aspects of general practice care tional aspects “providing quick services for urgent health
were very similar. The five aspects ranked highest (most posi- problems” and “helpfulness of staff” most positively. The other
tively) by the patients were also ranked highest by the GPs: organisational aspects were among the least evaluated aspects
“keep data confidential”, “listen to you”, “enough time during of care.
consultation”, “provide quick service for urgent problems”, This study has some limitations. Despite the stratified sam-
and “helpfulness of staff”. pling procedure, the 45 GPs who handed out the question-
However, there were also some differences in rank order of naires may not be representative of the total group of GPs. It
evaluations. The largest differences were found for the organi- is, however, reassuring that there was no difference between
sational aspects “waiting time in the waiting room” and the 45 GPs and the remaining GPs with respect to their evalu-
“being able to speak to the GP on the telephone”. GPs ranked ations of the care provided or their estimations of patients’
these aspects 12 and 9 places higher, respectively, than evaluations of care. Furthermore, almost half the GPs worked
patients. However, the patients’ ranking of the aspect related in solo practices. This might limit the generalisability of the
to information and support (“helping to understand the results to other healthcare settings such as in the UK.
importance of following advice”) was 8 places higher than However, the results of a consultation related study in the UK
GPs’ ranking. which compared patients’ and doctors’ satisfaction in a group
When looking at absolute percentages of positive evalua- practice of five GPs were remarkably similar to our findings.10
tions (ratings), patients and GPs differed substantially. The The differences between the ranking and ratings between
largest differences were found for the organisational aspect the different groups are difficult to interpret. For example, the
“preparing for what to expect from specialist or hospital care” aspect “getting an appointment to suit you” was ranked
(rated positive by 74.7% (n=818) of patients and by only almost as high (15th) for patients as for GPs (14th). However,
40.4% (n=127) of GPs), the medical-technical aspect of care the percentage of GPs who rated this aspect positively was
“quick relief of symptoms” (74.8% (n=1239) of patients, 61%, which is as low as the lowest ranked item for patients
41.4% (n=126) of GPs), and for the aspect related to (waiting time). Similarly, the aspect “getting through to the
information and support “helping to understand the import- practice on the telephone” was ranked higher for GPs (18th)
ance of following the GPs’ advice” (79.7% (n=1141) of than for patients (22nd). However, the percentage of GPs who
patients, 47.9% (n=150) of GPs). rated this aspect positively was 55%, which is lower than the
rating of patients (71%) and even lower than the lowest
How did GPs perceive patients’ evaluations? ranked item for patients (waiting time 61%). It is unclear
The Spearman rank order correlation between the patients’ whether these figures reflect answering tendencies (GPs were
and the GPs’ perceptions of the patients’ evaluations was 0.75 more critical than patients), sampling variability, or real
(p<0.001)—that is, these two rank orders for the 23 different differences in opinions. It should be kept in mind that there is
aspects of general practice care were also very similar. Four of only a 10% difference between the items ranked 4th and 20th
the five aspects ranked lowest by the patients were also ranked in the patient sample, so there is considerable scope for sam-
lowest by the GPs when asked about their perceptions of their pling variability.
patients’ evaluations: “quick relief of symptoms”, “prepares If the results of the rankings and ratings are combined, the
you for what to expect from hospital care”, “able to speak to following picture emerges. Aspects of the doctor-patient rela-
GP on telephone”, and “getting through to practice on the tionship and provision of information were rated and ranked
telephone”. higher by patients than by GPs. This includes the aspects “lis-
The greatest differences in rank order of evaluations were tening to patients”, “making patients feel they had time dur-
found for the aspects of the doctor-patient relationship “mak- ing consultations”, “explaining the purpose of tests and treat-
ing the patient feel s/he had enough time during consultation” ments”, “telling patients what they wanted to know about
and “making it easy for patients to tell you about their prob- their symptoms and/or illness”, “making it easy for patients to
lems”. Patients’ rankings of these aspects were 9 and 8 places talk about their problems”, and “helping patients to under-
higher, respectively, than the ranking of GPs’ perceptions of stand the importance of following advice”. This has also been
these evaluations. Patients’ rankings of the organisational found in other studies.10 Furthermore, the two medical-
aspect “waiting time in the waiting room” and the medical- technical aspects “helping the patient to feel well so that
technical aspect “offering the patient services for preventing patients can perform their normal daily activities” and “quick
diseases (eg screening, health checks, immunisations)” were 9 relief of patients’ symptoms” were rated and ranked higher by
and 8 places lower, respectively, than the rankings of GPs’ per- patients than GPs’ ratings and ranking and GPs’ perception
ceptions of these evaluations. about patients’ rating and ranking. Only the aspect “providing
However, when looking at absolute percentages of positive quick services for urgent health problems” was rated and
evaluations (ratings), patients and GPs’ perceptions of ranked higher by GPs than by patients. GPs and patients may
patients differed substantially. The greatest differences were have different ideas about what is an urgent health problem.
found for the medical-technical aspect of care “quick relief of Viewed from the patients’ perspective, those aspects of care
patients’ symptoms” (rated positive by 74.8% (n=1239) of least positively evaluated are potential candidates for improve-
patients while only 24.8% (n=75) of GPs thought this would ment, as all aspects of care included in the EUROPEP
be rated positive by patients) and the organisational aspects questionnaire reflect patients’ priorities. GPs must therefore
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Comparison of patients’ and GPs’ evaluations of general practice care 319
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