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Quality of Primary Care from the Patient Perspective in Saudi Arabia : a Multi-Level Study

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Quality of Primary Care from the Patient Perspective in Saudi Arabia : a Multi-Level Study University of Louisville ThinkIR: The University of Louisville's Institutional Repository Electronic Theses and Dissertations 5-2014 Quality of primary care from the patient perspective in Saudi Arabia : a multi-level study. Khalid Awad Alahmary University of Louisville Follow this and additional works at: https://ir.library.louisville.edu/etd Part of the Health and Medical Administration Commons Recommended Citation Alahmary, Khalid Awad, "Quality of primary care from the patient perspective in Saudi Arabia : a multi-level study." (2014). Electronic Theses and Dissertations. Paper 22. https://doi.org/10.18297/etd/22 This Doctoral Dissertation is brought to you for free and open access by ThinkIR: The University of Louisville's Institutional Repository. It has been accepted for inclusion in Electronic Theses and Dissertations by an authorized administrator of ThinkIR: The University of Louisville's Institutional Repository. This title appears here courtesy of the author, who has retained all other copyrights. For more information, please contact [email protected]. QUALITY OF PRIMARY CARE FROM THE PATIENT PERSPECTIVE IN SAUDI ARABIA: A MULTI-LEVEL STUDY By Khalid Awad Alahmary B.S., King Saud University, 2000 B.S.N., George Mason University, 2003 M.S.N., University of Pittsburgh, 2008 A Dissertation Submitted to the Faculty of the School of Public Health and Information Sciences of the University of Louisville in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy Department of Health Management and Systems Sciences University of Louisville Louisville, Kentucky May, 2014 Copyright © 2014 by Khalid Awad Alahmary All Rights Reserved QUALITY OF PRIMARY CARE FROM THE PATIENT PERSPECTIVE IN SAUDI ARABIA: A MULTI-LEVEL STUDY By Khalid Awad Alahmary B.S., King Saud University, 2000 B.S.N., George Mason University, 2003 M.S.N., University of Pittsburgh, 2008 A Dissertation Approved on March 31, 2014 by the following Dissertation Committee: _________________________________ Dissertation Director Robert Steiner, M.D., M.P.H., Ph.D. __________________________________ Robert Esterhay, M.D. __________________________________ Raymond Austin, Ph.D. __________________________________ Karunarathna Kulasekera, Ph.D. ii DEDICATION This dissertation is dedicated to my loving parents, Awad and Salihah Alahmary who have surrounded me with their eternal love, support, and sincere prayers; to my loving wife Eman Alahmary who has encouraged me to pursue my dreams and has been supportive and patient throughout my doctoral studies; and to my wonderful daughters, Maiar and Ala who have given my life new meaning. I thank you all from the bottom of my heart. I love you all. iii ACKNOWLEDGMENTS First of all, I thank Allah, He is the Mighty and the Majestic, who has blessed me with his willing and grace to pursue my dreams and to earn the PhD degree. I would like to express my sincere gratitude and deepest appreciation to my Committee Chair and mentor, Professor Robert W. Steiner for his continued support, mentorship, and leadership. His encouragement, methodological advice, and interpersonal skills are largely responsible of the quality of my experience and the completion of my journey to obtain the PhD degree. Without his support, guidance, and consistent advice this work could not have been completed. Dr. Steiner has inspired me to become a life-long learner, a good scientist, and a change agent to lead a social change toward health and social justice. I would also like express my deepest thanks and appreciation to Dr. Robert Esterhay for providing me with his support and pearls of wisdom, especially during my most difficult times. Dr. Esterhay is a true motivational leader who taught me to be persistent and goal-oriented person, which enabled me to achieve my academic goal to obtain the PhD degree. I would also like to express my deepest thanks and appreciation to Dr. Raymond Austin for his time and expertise in teaching me to think more broadly about my dissertation work in the context of policy development and evaluation, which has helped me to improve the quality of my dissertation. My sincere gratitude and thanks also go to Dr. Karunarathna Kulasekera for teaching me iv and guiding me to select and apply the appropriate statistical methods, which made my dissertation meaningful and worthwhile. I would like to thank all of my friends who have kept me in their thoughts and encouraged me during my eight years of graduate studies in the U.S. since I began pursuing my master degree in May of 2006. Special thanks go to my friend Dr. Adel Bashatah for his support and encouragement and for his constant international phone calls to cheer me up and to ask about my progress. I would also like to thank all the staff at the Ministry of Health and the Ministry of National Guard who facilitated the approval and access to data for my research study. Special thanks go Dr. Ali Al-Farhan, Deputy Executive Director of Primary Healthcare at NGHA for his warm reception and immediate assistance in giving me access to the NGHA Primary Care System. I also thank the team of data collectors who helped me to collect primary survey data from 612 patients in 16 primary care centers in Riyadh. I would like to acknowledge King Saud bin Abdulaziz University for Health Sciences for supporting my PhD scholarship. Special thanks go to His Excellency Dr. Bandar Al Knawy, President of KSAU-HS and his Executive Assistance Mr. Fareed Bahnas for approving the final extension of my scholarship, which enabled me to complete my PhD studies. I would also like to acknowledge and thank Dr. Ahmad Al Amry, Dean of the College of Public Health and Health Informatics who has put his trust in me to become a member of the new and growing college. v ABSTRACT QUALITY OF PRIMARY CARE FROM THE PATIENT PERSPECTIVE IN SAUDI ARABIA: A MULTI-LEVEL STUDY Khalid A. Alahmary May 10, 2014 Objectives: To assess primary care performance for measures of patients’ experience in Community-based Primary Care (CPC) and Employer-based Primary Care (EPC) systems in Saudi Arabia, to examine variations in performance across the two systems, and to explore factors at both the individual-level and the organizational-level that explain variations in primary care performance. Design and Methods: This is an observational and cross-sectional study, using comparative design and survey research methods. The newly revised and re-translated Arabic version of the Primary Care Assessment Survey (PCAS) was used to measure patients’ experience of primary care. PCAS operationalizes the IOM definition of primary care, which identified core domains of primary care as accessibility of care, continuity of care, comprehensiveness of care, coordination of care, interpersonal treatment, communication, and community orientation. A two-stage cluster, matched sampling was employed to select 16 primary care centers (eight CPC and eight EPC centers) in Riyadh, the capital and largest city (population > 5.5 million) in Saudi Arabia. A systematic random sampling was employed to collect primary survey data from 612 adult patients visiting the selected primary care centers. Results: After adjusting for differences in the patient-mix and taking into account the multi-level structure of data by means of multi-level modeling, EPC performed vi statistically significantly better than CPC in interpersonal care (Mean EPC = 68.3, 95% CI [± 6.3] vs. Mean CPC = 59.5, 95% CI [± 5.9], p = 0.024, Effect Size (d) = 0.36) and communication (Mean EPC = 69.8, 95% CI [± 4.9] vs. Mean CPC = 64.4, 95% CI [± 5.5], p = 0.035, d =0.22), in addition to the total quality score (Total PCAS EPC = 60.4, 95% CI [± 2.9 ] vs. Total PCAS CPC = 56.1, 95% [± 3.3], p = 0.009, d =0.31). CPC performed statistically significantly better than EPC in community orientation (Mean CPC = 47.8, 95% [± 5.7] vs. Mean EPC = 35.5, 95% [± 6.2], p = 0.003, d =0.50) and accessibility of care (Mean CPC = 67.4, 95% [± 5.7] vs. Mean EPC = 63.5, 95% [± 4.5], p = 0.025, d=0.23). There were no significant differences between CPC and EPC in coordination of care (p= 0.098), comprehensiveness of care (p = 0.208), and visit-based continuity of care (p = 0.354). Patient-level (compositional) variables explained a significant proportion (R2 = 0.14) of the observed level-one (within-centers) variations in measures of patients’ experience. Those variables include gender, self-perceived health status, and patient- reported co-morbidity. Female patients, reporting poor health, and reporting chronic conditions are each statistically significantly associated with lower ratings of patients’ experience of care. Organizational-level (contextual) variables explained a significant proportion (R2 = 0.78) of the observed level-two (between-centers) variations in measures of patients’ experience. Those organizational variables include practice type and proportions of family physicians in a center. EPC centers and those centers with higher proportions of family physicians are each statistically significantly associated with better patients’ experience. Finally, aspects of care that were statistically significantly associated with better patients’ experience include knowing the name of the physician and being with the same physician for longer durations. Conclusion: Enhancing continuity and quality of patient-physician relationships may improve the overall patients’ experience of care. Healthcare systems in Saudi Arabia might embrace the Bio-Psycho-Social model to foster a culture of health and caring. Effective, community-oriented primary care systems have the potential to re-orient health systems’ from a sole focus on sickness and disease, to include additional approaches for prevention and wellness at the societal level. Positive indicators of health, at both the individual and community levels, are needed to better align existing healthcare systems with this goal, mission and vision to improve population health.
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