The health system in the Netherlands is organized on three levels: primary, secondary, and tertiary care. According to the Organization of Economic Co-operation and Development (OECD)'s Health Statistics 2015, the Dutch allocate about 11% of gross domestic product (equal to about $869.5 billion US) to health spending, well beyond the OECD average of 8.9%. In the Netherlands, healthcare is universal and oriented to primary care. Ambulatory patient visits begin with the general practitioner (GP). Generally patients cannot consult with medical specialists in the secondary care setting without a GP's referral.
About 8,700 GPs practice in the 5,500 GP offices in the Netherlands, or one GP per 1,972 patients. As of 2017, about 1,000 physician assistants (PAs) were employed in a wide variety of settings and specialties. Some GPs are solo clinicians and own a practice; others work in group practices. GP offices are open weekdays with office hours typically between 8 a.m. and 5 p.m. Care outside of these hours is considered out-of-office-hours or after-hours care.
GPs face crowded waiting rooms and struggle to handle patient flow, especially when requested to do home visits outside of office hours. Home visits are especially challenging in less-populated provincial areas because of travel time between the office and patients' homes. Out-of-office care has emerged in many areas to accommodate the demand for health services. GPs in a cooperative (an association of GPs that provides coordinated care in a geographic region) may organize this coverage and/or employ contract physicians to provide this care.
Because of pressure to meet the growing demand for out-of-office care, a GP cooperative in the Friesland province (northwest Netherlands) decided to use PAs to provide some of this care. Accredited master PA training programs were introduced into Dutch higher education in 2003. By now, PAs are widely dispersed in hospitals.1,2 However, increasingly PAs also are trained to practice family medicine in office settings and during out-of-office-hours care.3,4
Although the increase in the number of PAs is of interest to policymakers, little is known about patient satisfaction with this strategy. Quality of care in the Netherlands is measured by performance indicators, including effectiveness, safety, and patient satisfaction. These three aspects are defined from the perspectives of providers, insurers, and patients.5
The aim of this study was to examine whether patients are satisfied with the care delivered by a PA instead of a physician. The study also sought to determine if patient satisfaction is correlated with sociodemographic factors. The settings were GP medical centers available for patient visits outside of office hours.
A quantitative, cross-sectional, explorative, and comparative research design was selected. Patients were surveyed about the care they received from their GP or PA during out-of-office hours. Four GP out-of-office-hours posts were selected from the organization Dokterswacht Friesland (DWF), in the Frisian cities of Dokkum, Heerenveen, Drachten, and Leeuwarden (Figure 1). For reliable analysis, the number of respondents needed was 100 per type of provider (GP and PA), so 400 questionnaires were distributed. To control for confounding variables, seven exclusion criteria were imposed:
- patients who indicated they were not willing to participate in research
- patients who were terminally ill
- patients who visited the GP post for administrative purposes such as refilling a prescription or asking questions of a pharmacist
- patients with confidentiality concerns (for example, a 16-year-old who does not want her parents to know she requested emergency contraception)
- suspicion of domestic abuse or substance abuse
- patients who live outside the Netherlands
- patients who in the previous 12 months already were invited to complete a patient satisfaction questionnaire.
Patient satisfaction was surveyed by administering the Consumer Quality Index (CQI) questionnaire to patients who attended GP posts. The validated CQI questionnaire is considered the gold standard for measuring patient satisfaction and is granted support by the Netherlands Patient and Consumer Federation, the Dutch College of General Practitioners, and various health insurance companies. The CQI questionnaire was developed by IQ Healthcare, the Scientific Institute for Quality of Healthcare of the Radboud University Nijmegen Medical Centre. This paper-and-pencil questionnaire measures concrete experiences of patients' received care. The CQI also provides insight into what patients consider important and their experience with the care provided.6
The concept of patient satisfaction in this study was based on three composite scales derived from the CQI:
- Approach. Patients were asked “Did the provider show interest in your personal situation?”
- Professional practice. Questions included “Did the provider have enough time for you?”
- Customized care. Questions included “Have you been told the information you wanted to know about your health problem?”
All questions were answered on a Likert scale in which 1=not important and 4=of the utmost importance. For this study, the scores were calculated for the three composite scales to compare GPs and PAs. A total patient satisfaction score also was calculated. The scale scores were calculated by substracting the minimum scale score from the raw scale score, dividing this by the scale score range, and then multiplying by 100.6,7
Descriptive statistics were used to analyze patient characteristics. Patient responses from the GP and PA groups were compared on several characteristics to test for nonsignificant differences (Table 1). The dependent variables in this study were the three composite scales. The variables were analyzed for normality of distribution by the Kolmogorov-Smirnov test, a parameter-free test used to assess whether data complied with a normal distribution.
The difference in the degree of patient satisfaction between groups was examined anticipating a nonnormally distributed outcome measures by using the Mann Whitney U test. In addition, a simple linear regression analysis examined both age and educational level as prognostic factors. Other sociodemographic variables, such as sex, ethnicity, marital status, and family composition were examined as potential predictors of patient satisfaction. Because of a nonnormal distribution of the data, a Spearman correlation analysis was performed before the regression analyses to determine whether age and educational level correlated with any of the three composite scales. These analyses were carried out per type of medical care provider. In this study, the significance level was set at P<.5. To determine the internal consistency of the composite scales, Cronbach alphas and accompanying mean interitem correlations were computed. All statistical analyses were performed with the IBM SPSS Statistics for Windows, Version 21.
During July and August 2014, 800 questionnaires were distributed sequentially by postal mailing 2 weeks after a patient visit, to 400 patients seen by GPs and 400 seen by PAs. Ninety-nine patients (24.75%) seen by GPs and 115 patients (28.75%) seen by PAs responded. These response rates were considered sufficiently representative for reliable analysis. Both groups of patients were reviewed for comparability on a number of patient characteristics (Table 1).
Differences in patient satisfaction
In this study, the difference in perceived patient satisfaction between GPs and PAs was measured by three composite scales (Table 2). No statistically significant difference emerged in patient satisfaction with the care provided by a GP compared with that of a PA for the items and composite scores in the professional practice and approach scales. However, two items in the customized care scale, as well as the related scale score showed a statistically significant difference between the two provider types, and favoring PAs. The total patient satisfaction score also did not show a statistically significant difference between the two provider types.
Correlations between patient satisfaction and sociodemographic variables
A meta-analysis by Hall and Dornan that examined many sociodemographic variables found that respondents' age and education level were the only predictive factors on the degree of patient satisfaction.8 In this study, correlation analyses were performed on the three composite scales versus the variables age and education. Patient sex was included in a correlation analysis. PAs in the Netherlands are predominantly female; in this study, all the PAs were female but the GPs consisted of both sexes. Accordingly, a one-tailed Point Bi-serial correlation analysis was conducted (Table 3).
The correlation analyses revealed that female patients seen by GPs appear to be less satisfied (rpb (94)= -.230, P=.013) with aspects of customized care. This also is reflected in a lower degree of total patient satisfaction (rpb (94)=-.182, P=.039). In the same group of patients seen by GPs, an increasing age correlates statistically significant with the composite scale of customized care (rs (92)=.247, P=.018); with an explained variance (R2) of 6.1%. For patients seen by PAs, no statistically significant correlations emerged with respect to patient sex. However, when this group of patients was analyzed by age, taking into account the composite (aggregated) scales professional practice, approach, customized care, and total patient satisfaction, all demonstrated positive statistically significant correlations, with explained variances of 4.4%, 3.5%, 5%, and 5.3%, respectively. Correlation analyses for PAs and GPs in regards to total patient satisfaction and educational level did not reach statistical significance.
Age, sex, and patient satisfaction
Based on the results of the correlation analyses in the GP group, age and sex were correlated with the composite scale customized care and with total patient satisfaction. To investigate whether age is a predictive factor for these scales, a simple linear regression was undertaken. The regression showed that for the scale customized care, age is a statistically significant predictor (beta=.247, P=.018) and significantly explained the variance (F=5.857, P=.018) to 6.1%. Despite a positive correlation between age and total patient satisfaction, in the GP group, patient age was not a significant predictor (beta=.131, P=.213). On the other hand, sex of patients treated by GPs was a predictor for the scale customized care (beta=-.23, P=.026) and explained variance accounted for 5.3% (F=5.133, P=.026).
For the patients seen by PAs, all composite scales, as well as total patient satisfaction, were positively correlated and statistically significant (Table 4). In this analysis, age is a predictor for all composite scales.
This study found that Dutch patients appear to be as satisfied with the care received by PAs as GPs. This work also supports similar studies that suggest that patients usually are satisfied with their care when their needs are met, regardless of who provides it. Not surprisingly, these findings of patient satisfaction with PAs appear to be worldwide.9-12
For the Netherlands, the evidence on patient satisfaction in relation to the PA workforce is scarce. This foray into consumer assessment of PA-delivered care must be viewed as an exploratory study that drew on an established Dutch patient satisfaction instrument. A study comparing Dutch NPs with GPs found that patients were not always clear if the NPs consulted with the GP.13 In the United States, research has probed the degree of patient satisfaction in relation to the sex of the attending physician. A study at Harbor-UCLA Medical Center interviewed 852 patients after they had visited the ED.14 Compared with men, women were more satisfied with the care provided when they had a female physician.14 In male patients, patient satisfaction did not depend on the sex of the attending provider.14
Budzi and colleagues examined patient satisfaction in the Veterans Health Administration and found that patient satisfaction levels between physicians, PAs, and NPs were very similar.15 In one of the earliest studies on patient satisfaction with PAs and NPs, Hooker and colleagues found no discernable difference in patient satisfaction between these two providers and physicians across a spectrum of specialities.11 Their conclusion was that satisfaction occurs when patients' needs are met, regardless of who delivers the care.11 In this Dutch study on patient satisfaction, the number of female patients who visited GPs was 66 versus 70 for PAs. However, most respondents were female as were all of the PAs; at the time of data collection, no male PAs were working at the Dokterswacht Friesland out-of-office-hours GP posts. Therefore, the test for the hypothesis of sex being a potentially significant variable in satisfaction, as examined in the study by Derose and colleagues, remains to be reported (and a variable to be included in planned studies).14
This study has some methodologic limitations. One is that the consultation duration was not charted during the data collection. The hypothesis is that the high degree of patient satisfaction of PAs could be explained by the fact that PAs took more time for a consultation, an area for additional study as noted by Morgan and colleagues.12 Another limitation is that evening and weekend care may differ from weekday care—an important hypothesis in need of testing. Provider recognition may be another issue—although GPs and PAs tend to introduce themselves to patients by name and type of medical provider, the average urgency of the visit and sparse dissemination of PAs means that patients may not be aware of which type of provider they saw. Finally, the characteristics of the patients and providers were not fully noted. Further research into the correlation between the sex of the practitioner in relation to the sex of the patient is needed.
In the Netherlands, patients are at least as satisfied with the care they receive from PAs as with GPs. This study found little differences in patient perception of care when delivered by PAs compared with GPs. Such findings are consistent with findings in other countries, and in different time periods under different circumstances and in different settings. What has emerged is that one of the most important aspects of quality is the patient's perception of care. The prevailing theory is that when patients' needs are met, the type of provider delivering that care is less important.
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