What Constitutes Quality Primary Care?

Rebecca S. Etz, PhD

A novel patient-centered primary care measure has targeted a comprehensive list of aspects of care considered to represent the greatest value among themselves, their physicians, and payers.

The Person-Centered Primary Care Measure (PCPCM), from the Larry A. Green Center for the Advancement of Primary Health Care for the Public Good, has established 11 domains that each represent a single item representing the broad scope of primary care. As lead author Rebecca S. Etz, PhD, explained to MD Magazine®, the team has created a measure that “actually aligns with the work of primary care physicians, and what matters to patients.”

Etz and colleagues used a multistep approach to identify and establish a parsimonious item set which assesses the related processes that comprise high-value primary care. They sought a measure so as to help proceeding research concentrate its material resources, and to help influence the structure of proven medical practice.

Previous primary care-based measures have proven to be research-focused, investigators wrote, while primary care clinicians often use patient experience survey to guide feedback.

“Patient experience measures focus important attention on the consumer experience of care delivery and receipt of services, but fall short of focused attention on the broad scope of primary care,” they wrote.

Investigators gauged 412 patients, 525 primary care clinicians, and 85 healthcare payers to define value in primary care. Additional insights were gathered from another 70 primary care and health services experts over 3 days at an international medicine meeting. The team then conducted a qualitative analysis to develop a parsimonious set of patient-reported items.

Their evaluation included factor analysis, Rasch modeling, and association analyses. Their final 11-domain measure consisted of the following items:

• Accessibility
• Advocacy
• Community context
• Comprehensiveness
• Continuity
• Coordination
• Family context
• Goaloriented care
• Health promotion
• Integration
• Relationship

Results from the crowd-sourced analyses showed strong patient and clinician agreement around the significance of care delivery relationships, while payers emphasized the importance of transactions in care.

Results from the medicine meeting lent to the idea that primary care is a relationship-based field, with emphases on dynamic work and adaptability. The domains of care are so interrelated, investigators noted, that they should be measured as a whole.

Etz noted to MD Mag that the “truncated conversation” that burdens primary care visits—with each taking 7-8 minutes on average—is counterintuitive to the findings that a relationship-dependent dynamic constitutes quality care. Some of that blame may be on the interests of payers, who have become a “third party in the room.”

“Time spent on data collection doesn’t serve physicians’ or patients’ needs,” Etz said. “The time we have could be enough, if we didn’t have a third party in the room.”

Though the PCPCM shows promising psychometric properties, investigators noted it may require further reliability testing—as well as further assessment of its concurrent and predictive validity. In the meantime, it could serve as a useful measure in investigations and clinical efforts to improve the mechanisms of primary care, health care system, and population health.

“Future research should compare PCPCM to other measures used to predict health and health care use outcomes,” investigators wrote. “Pending these comparisons, the conciseness of the PCPCM has potential to reduce the current large measurement burden by replacing measures that are longer or that do not as squarely represent core domains that have been identified as important by patients, clinicians, and policy makers.”

Etz anticipated hope it’s greatly received in the primary care clinician community—which should also correlate to positive reception with patients.

“Primary care is founded on relationships,” she said. “It’s not just a presentation of symptoms, it’s not just a concern expressed—it’s concerns expressed in a lifespan.”

The study, "A New Comprehensive Measure of High-Value Aspects of Primary Care," was published online in the Annals of Family Medicine.