Measuring Consumer Experiences With Primary Care Charlyn E. Cassady, PhD*; Barbara Starfield, MD, MPH*‡; Margarita P. Hurtado, PhD, MA, MHS§; Ronald A. Berk, PhDʈ; Joy P. Nanda, MS, MHS*; and Lori A. Friedenberg, BA* Abstract. Objective. To assess the adequacy of the care base achieve better health outcomes and Primary Care Assessment Tool-Child Edition (PCAT-CE) greater population satisfaction at lower costs than for evaluating the attainment of the key characteristics health systems more focused on specialty services.1 of primary care services for children and youth. Within the United States alone, areas with more Design. Community-based telephone survey. primary care physicians have lower rates of hospi- Setting. Specific political subdivision in Washing- talization for conditions that are sensitive to pri- ton, DC. 2 3 Participants. Four hundred fifty parents/guardians mary care, lower death rates from major causes, 3 of offspring 18 years of age or less. and better birth outcomes. A recent report by the Measures. Reliability, validity and principal com- Institute of Medicine (IOM)4 reinforces the impor- ponent analysis of 5 scales representing key aspects of tance of strong primary care as a critical feature of the 4 cardinal domains of primary care included in the the health services system. It also encouraged the PCAT-CE. In addition, 2 subdomains (first contact use development of appropriate tools to assess its at- and extent of affiliation with a primary care source) tainment. The challenge is further heightened by were included as indices to describe overall patterns of the development of new programs, such as the use and affiliation with the particular source of care. State Children’s Health Insurance Program Results. Most scales had adequate internal consis- tency, test-retest reliability, and construct validity. The (SCHIP), which has made federal funds available to principal components factor analysis yielded 5 separate states to provide health insurance for low-income factors. These corresponded to the subdomains of first children. contact accessibility; coordination of care; characteris- Characteristics of health services delivery that tics of the professional-patient relationship over-time; are unique to primary care are theoretically amena- and comprehensiveness (both services available and in- ble to measurement.5 As a result, it is now possible dicated services received). to assess health services delivery systems accord- Conclusions. Psychometric assessment supported ing to the characteristics of their approach to pro- the integrity and general adequacy of the PCAT-CE for viding primary care. Because primary care services assessing the characteristics and quality of primary care for children and youth. Testing of revised versions in a should be person-focused rather than illness- or variety of different settings is underway. A major com- problem-focused, the assessment of the quality of ponent of this testing is to explore the possibility of these services is appropriate to all individuals and reducing the number of items while retaining sufficient populations. detail about each component of primary care to make A previously described model of primary care,5 judgements about people’s experiences with that care. which applies to all ages, was used as the frame- Pediatrics 2000;105:998–1003; primary care, survey, work to guide the development of a Primary Care reliability, validity, scale development. Assessment Tool-Child Edition (PCAT-CE). Over the past 30 years, a succession of professional com- ABBREVIATIONS. IOM, Institute of Medicine; SCHIP, State mittees and experts have reaffirmed the important Children’s Health Insurance Program; PCAT-CE, Primary Care characteristics of primary care, although the terms Assessment Tool-Child Edition. that are used to describe these are not always the same. Taking direction from one of the first official 6 fforts to improve the accountability of health documents on the subject, we have designated service organizations are likely to increase these characteristics as: first-contact care (facilitat- Eover time. An accumulating literature docu- ing entry into care), longitudinality (ongoing per- ments the importance of a strong primary care in- son-focused care), comprehensiveness, and coordi- frastructure within a health services system. Health nation. All have been documented to be important systems that are better organized around a primary in primary care as a means of reducing the likeli- hood of unnecessary and potentially dangerous care as well as reducing overall costs of care.5 These From the Schools of *Hygiene and Public Health, ‡Medicine, and ʈNurs- ing, Johns Hopkins University, Baltimore, Maryland; and the §Institute of 4 domains, in combination, are considered to rep- Medicine–National Academy of Sciences, Washington, DC. resent the cardinal features of primary care. Each of Received for publication May 26, 1999; accepted Nov 12, 1999. these domains encompasses 2 subdomains: the ca- Address correspondence to Barbara Starfield, MD, MPH, Johns Hopkins pacity of the provider’s practice (structure) and the University, Department of Health Policy and Management, 624 N Broad- way, Baltimore, MD 21205. E-mail: [email protected] activities of the practice that pertain to the charac- 5 PEDIATRICS (ISSN 0031 4005). Copyright © 2000 by the American Acad- teristics of primary care (process). emy of Pediatrics. Our approach is intended to describe people’s 998 PEDIATRICS Vol.Downloaded 105 No. 4 from April www.aappublications.org/news 2000 by guest on September 25, 2021 actual experiences in interacting with the health MEASURES system, rather than their perceptions of its ade- Identification of Primary Care Source quacy (satisfaction). Because experiences have (Longitudinality: Extent of Affiliation) 7 been shown to relate to satisfaction, a focus on the Three questions were developed to identify the child’s most respondent’s experiences should also reflect satis- likely or usual source of primary care, rather than the “regular” faction. Thus, the research sought to determine if source of care, which might be a specialist consulted frequently the PCAT-CE is a potentially useful tool for assess- for care of some particular problem. The respondent was asked: ing the adequacy of key characteristics of primary 1) if there was a particular place or doctor that the child usually goes to if sick or when advice about health is needed, and its care services for children and youth, and to explore identity (“usual source”); 2) the identity of the place/doctor that the psychometric properties of the pilot instru- knows the child best as a person (“knows best”); and 3) the ment. identity of the place/doctor where the child would be taken in the event of a completely new health problem, aside from an emergency (“new problem”). An algorithm based on responses PARTICIPANTS AND METHODS to these 3 questions identified the most likely source of primary care: 1) If all 3 places/doctors were the same, that site was used as Participants the focus of the interview questions; 2) if the response to “usual The city of Washington, DC was chosen as the site for testing source” was the same as for either of the other 2 questions, then the the instrument because the health department’s strategic plan “usual source” site was used; 3) if the response for “usual source” included an assessment of primary care. The city was particu- was different, but the responses to the 2 other questions were the larly interested in health services for children and youth and same, then the place/doctor where both are the same was used; and requested that the survey be targeted at primary care and be 4) if all 3 responses were different, then the site identified for conducted in a political subdivision that represented a cross- “usual source” was used. All subsequent questions in the inter- section of the city’s population. The selected ward had a popu- view asked about this specific place or person. lation of 72 118, with 12 961, or 18%, Ͻ18 years old.8 A national survey company assisted in the development of a sampling Cardinal Domains of Primary Care frame using random digit dialing and telephone listings. A target As noted in the preceding paragraph, the structural charac- sample size of 450 respondents was defined to achieve 90% teristic of actually having a primary care source (Longitudinal- power to detect differences between relatively deprived and ity: Extent of Affiliation) was assessed by means of 3 questions. nondeprived population subgroups with an overall expected Four subsequent questions concerned the nature of the relation- proportion of 50%, assuming a binomial distribution, a signifi- ship with this source (Longitudinality: Relationship). To assess cance level of .05 and a 20% nonresponse rate.9 The survey the structural characteristics that facilitate First-Contact: Acces- instrument and procedures were approved by the Johns Hopkins sibility of that regular source of care, 11 questions common in University Office for Research Subjects and the District of Co- previous studies of accessibility to health care5 were used. The lumbia Institutional Review Board for Public Health. subdomain of First-Contact: Use concerned the consistency of use of that source when care was last needed for each of 3 different types of needs. The Comprehensiveness: Services Survey Procedures Available subdomain addressed the structural characteristic of Cost considerations dictated administration by telephone availability