Bmc Family Practice a Qualitative Study of Patients' Views on Quality of Primary Care Consultations in Hong Kong and Comparison with the Uk Care Measure

Background: Patients' priorities and views on quality care are well-documented in Western countries but there is a dearth of research in this area in the East. The aim of the present study was to explore Chinese patients' views on quality of primary care consultations in Hong Kong and to compare these with the items in the CARE measure (a process measure of consultation quality widely used in the UK) in order to assess the potential utility of the CARE measure in a Chinese population.


Background
The consultation between doctor and patient is the core of clinical medicine and has been particularly emphasized in general practice and primary care [1][2][3][4]. Quality can be conceptualized as a combination of access to care and effectiveness of care, with effectiveness depending on both technical and interpersonal aspects [5]. Research on interpersonal effectiveness suggests that empathic, patient-centred consultations improve patient satisfaction [6,7] and enablement [8], and may improve health outcomes [9][10][11].
Although patient-centred care is becoming widely advocated, there is no single, globally accepted definition. Research on patient-centred care has predominantly been carried out in the West, especially the UK and North America [12,13]. Recently however, there has been a growing interest in people and patient-centred care in Eastern countries [14][15][16][17]. Additionally there is now a renewed focus on primary care globally, including countries such as China and Japan [18]. In seeking to develop effective primary care services in such countries, it is important that patients' views on what constitutes 'good' consultations are collected and fed into policy and health services developments in primary care. Hong Kong is one such region which is currently embarked on health care reforms with a strong emphasis on strengthening primary care services [19].
In the present qualitative study we have explored patients' views on what constitutes quality at consultation in different primary care settings in Hong Kong. We have then compared these views with the ten-item CARE measure, which is a widely used measure of consultation quality in the UK, developed by one of the authors [20][21][22]. The UK CARE Measure captures key aspects of the process of the clinical encounter, rather than outcome, and was developed from the views of patients of differing socio-economic status, as well as having a theoretical and empirical base. In a study of over 3,000 patients over 95% of patients felt the items were applicable to their consultation in primary care [22]. The CARE measure is currently accredited for appraisal of General Practitioners (GPs) and is a compulsory component of work place -based assessment in the training of all GPs in the UK.

Methods
The study involved in-depth, semi-structured interviews with 21 Chinese patients recruited from 3 different types of primary care clinics in Hong Kong: (1) a Family Medicine Integrated Clinic (FMIC), part of the public healthcare system run by the Hospital Authority, (2) the University health centre (UHC) of the Chinese University of Hong Kong (CUHK), and (3) a private family medicine (FM) clinic run by a Family Physician specialist. The three settings were chosen in order to sample patients with a range of ages, conditions, and socio-economic status. The patients at FMIC mainly attend for chronic disease management such as hypertension or diabetes mellitus. Nine patients (5 males and 4 females), with age group ranged from 41-45 to 81-85, were recruited. UHC was selected because it was the health centre of CUHK and any student or staff and their family members can have access to it and many patients consult for acute problems. Six patients (1 males and 5 females), with age group ranged from <20 to 56-60, were recruited. The private FM clinic was selected because it was run by a family physician (a Fellow of the Hong Kong College of Family Physicians) and patients with either acute and/or chronic diseases commonly attend the clinic. Six patients (3 males and 3 females), with age group ranged from 26-30 to 76-80, were recruited. Ethics approval was obtained before the start of the study from the Survey and Behavioural Research Ethics Committee of the Chinese University of Hong Kong. The doctor-in-charge of each clinic consented to the study after receiving full details, and specific nursing staff at each clinic were assigned to facilitate the recruitment of patients in order to reduce the disturbance to the smooth running of the clinic. The nursing staff approached attending patients to see if they were interested in participating in an interview. After verbal agreedment, the first author approached the patient, explain the study in detail and obtained written consent. Keeping strict confidentiality and anonymity was emphasized to every interviewee. Although we were not able to purposively select the interviewees, recruiting from the 3 separate clinics helped to ensure that a maximum variation sample was obtained. Table 1 shows the characteristics of the 21 patients recruited.
Patients were encouraged to talk freely and openly on their views on the quality of the primary care consultation in Hong Kong. Open-ended prompting questions included asking about their expectations, their experience of good or bad consultations, and their definitions of good or bad doctors/consultations. All the 21 interviews were conducted by the first author (CF), and a research assistant also helped to conduct the interviews on the six patients recruited from the private FM clinic. The interviews were conducted between May and August 2007 and averaged around 30 minutes (ranging from 15 minutes to 60 minutes).
The interviews were audio-taped and typed verbatim by a research assistant, and 4 student helpers (year 4 medical students of the Chinese University of Hong Kong). All transcripts were translated into English (all transcribers were native Cantonese speakers, fluently bilingual in written and spoken English). Accuracy of translation was checked by CF who read all transcripts in both English and Cantonese. Translation into English was necessary to enable SWM to assist in the analysis of the data.
A thematic approach was taken to identify key issues [23]. involving systematic identification, charting and sorting of the data. Analysis was iterative, with broad themes identified initially, then further broken down into subthemes [24]. The constant comparative method was used throughout [25] by initially comparing data sets between individual transcripts, and later comparing data with emergent hypotheses. Regular meetings between the two authors over the duration of the project allowed categorisation and classification, and the development of typologies and explanatory accounts to be pursued.
Preliminary coding of the raw data was undertaken independently by CF and SWM and agreement reached on the initial main codes. Initially 16 categories were identified, which were then rearranged/re-coded under three major themes: patients' definitions of good doctors and consultations, bad doctors and consultations, and expectations/ outcomes of the consultations. At this stage some 109 codes were generated in total. At the end of this process, the 109 codes were compared with the ten main items within the UK CARE measure ( Figure 1). We then used the CARE Measure items as a framework for categorizing the codes identified regarding the consultation process, and assessed how many of the codes could or could not be categorized within one or more of the CARE Measure items. Categories not fitting within the CARE Measure framework were also identified. Both CF and SWM carried out this comparison with the CARE measure independently, and then compared notes; mainly there was good agreement, and areas of differences in if and where codes fitted within the framework were discussed until consensus was reached.
We found that all of the codes relating to the interpersonal aspects of the consultation (76 out of 109) fitted within one or more of the ten-item CARE Measure framework; Additional themes which did not fit (33 out of 109) related to physical examination, the context of care (access The CARE Measure Figure 1 The CARE Measure. and time) and outcomes of care. Financial issues were also an important contextual issue, but will be reported in a separate paper. Rather than presenting our findings on interpersonal aspects of consultations under separate headings for all ten the CARE measure items, we have condensed these into 4 CARE Framework headings in order to present the findings in a more succinct manner; Patients valued doctors who allowed or encouraged them to 'tell their story' and actively listened in the consultation, as it enabled them to describe their symptoms and problems in detail, and the effects these were having on their life. Some patients described such encounters as like 'chatting to a friend' and such a relationship enhanced disclosure of issues that were of importance to the patient. Assessing holistically (CARE measure item 4) 'Whole person' care was seldom explicitly mentioned by patients as a key aspect of high quality interpersonal care, but many of their comments were integral to a holistic, bio-psycho-social approach. A few patients actually stated that they wanted doctors to spend more time understanding the possible psychological and/or social reasons behind their symptoms. For many patients, rather than 'volunteering' such issues, they felt a 'good' doctor would ask probing questions that would help uncover or 'digout' the underlying issues. This expectation that a wholeperson approach should be 'doctor-led' reflected a widely held general view that a more assertive approach on the part of the patient would be impolite or rude. 19 out of 21 patients had codes under this overall theme (CARE item 7 = 11/21, CARE item 8 = 18/21, CARE item 9 = 10/21, CARE item 10 = 5/21). For items 7, 9, 10, patients attending the public clinic (FMIC) were in the main those who did not mention these themes.

Physical examination
Apart from those domains within a consultation that patients had mentioned above, it was interesting to note that almost one-third of patients from each type of clinic pointed out that they valued the act of physical examination. They perceived physical examination as an attribute of a caring and thorough doctor, and an important part of diagnosis, and hence getting a 'full-picture' of the problem.
" Continuity Continuity of care was not overtly discussed in the interviews, but lack of relational continuity was apparent in the accounts of the patients attending the public healthcare system, where it is unusual for patients to be seen by the same doctors. Similarly, 'doctor-shopping' in the private sector is a common phenomenon in Hong Kong. However, when patients felt they had a good 'match' with a doctor, they were keen to continue seeing that doctor if at all possible.
Outcomes Two-thirds of the patients linked a good consultation with the doctor making a correct diagnosis leading to a rapid "cure" of his/her disease or illness. Thus judgments about quality of consultation and doctor were retrospective based on outcomes; if the patient recovered rapidly then they perceived the consultation, the doctor, and the treatment, as effective and thus of high quality.

Discussion
In the present study we assessed patients' views on the quality of the primary care consultation in Hong Kong by means of qualitative interviews of 21 patients attending three different types of primary care clinics (public clinic, University clinic, and private family medicine clinic) and tested whether these views are similar or different from patients views in the UK, by comparing the themes identified from the present study with the themes that comprise the UK CARE Measure. Patients judged doctors in terms of both the process of the consultation and the perceived outcomes. Themes identified that related to the interpersonal process of the consultation fitted well under the four theme CARE framework that we devised to incorporate the ten CARE Measure items; connecting and communicating (CARE items 1-3), assessing holistically (CARE item 4), responding with understanding and compassion (CARE items 5,6) and empowering (CARE items 7-10).
As far as we are aware, this is the first qualitative study of patients' views on consultation quality among Chinese patients attending a variety of different primary care providers in Hong Kong. Although international differences in patient and physician perceptions of "high quality" healthcare have been reported [26] and despite the many cultural differences between the East and the West, the core aspects of consultation quality in primary care as expressed by Hong Kong patients in the present study appear to be broadly similar to studies in Caucasian subjects in the West [27,28].
However, there did appear to be some differences in the way Chinese patients in the present study 'accessed' high quality consultations compared with studies in the West. Directly asking for information and advice was uncommon; rather patients waited for such advice and information to be 'offered' by the doctor. Similarly, with respect to a holistic approach to care, patients wanted doctors to 'dig-out' their problems, rather than assert them themselves. Similarly, patients had a low expectation, and apparent desire for, shared decision making in the consultation. These differences, which at face value suggest that Chinese patients are somewhat passive in medical consultations may relate to cultural factors and/or to a significant hierarchy and power differential between patients and doctors in Hong Kong. On the other hand, many of the patients in the present study were elderly and of lower socio-economic status. In the UK, although shared-decision making is a key policy and educational objective in medicine, several studies have reported low expectation of/desire for shared-decision making in older patients and patients of lower socio-economic status [29,30]. Similarly, another European study reported that elderly patients define involvement in care more in terms of the caring relationship and information receiving rather than on active participation in decision making [31].
Patients from the public clinic, who were generally of lower socio-economic status, were least likely to expect holistic care or empowerment in the present study. Further work is required to explore this, but it may relate to a more biomedical approach in these clinics, which deal mainly with chronic diseases. In the UK patients of lower socioeconomic status gain less enablement from consultations [32] especially if the clinical issues are complex [33] and in the USA greater dissatisfaction with health care amongst low-income patients has been reported with such patients feeling not listened to and 'brushed off by physicians [34].
In addition to these interpersonal aspects of care, these Hong Kong Chinese patients placed a high regard of receiving a physical examination. One reason for this may be that in Traditional Chinese Medicine (which is very commonly used by the Hong Kong population), physical examination such as looking at the tongue, face, and palpating the peripheral pulses is an integral part of a consultation and diagnosis. Given that TCM is still commonly used by people in Hong Kong.
Contextual issues of access to care, continuity, and consultation length interacted with opinions of 'good consultations'. Such judgements perhaps need to be seen within the general context of primary care in Hong Kong and the 'doctor-shopping behaviour' that is common place, at least in the private sector [35]. The fact that patients judged 'good consultations' not just on interpersonal aspects but also retrospectively according to outcome (and hence perceived effectiveness of treatment) has also been reported in the UK [29] but may be of greater importance to patients in Hong Kong given that most primary care is private requiring out-of-pocket payment.
The present study also had limitations. Because of time constraints we limited the number of interviews to 21 and thus we cannot be sure that data saturation was reached regarding all themes. The three clinics selected to recruit patients for interviews were not randomly selected and were geographically situated in the New Territories of Hong Kong, which is generally a less affluent area than Hong Kong Island. Nonetheless, our sampling frame did include a range of patients of differing ages, gender, socioeconomic status, and disease states. The aim of this study (and indeed of all qualitative studies) was not to generate findings that can be said to be representative of the general population, but to identify themes relating to consultation quality that can be tested in larger, quantitative studies. In this respect, we feel the present study has been successful, and the fact that the key interpersonal aspects of the consultations identified matched the items contained in the CARE Measure paves the way for further work on translation of the CARE measure into Chinese and validation studies. If the Chinese-CARE Measure proves to be a feasible, acceptable, and robust tool it may have wide-spread utility in the formative and/or summative assessment of medical students and primary care doctors in Hong Kong and mainland China, as well as in future research on consultation quality.

Conclusion
In conclusion, the results of the present qualitative study on patients' views on consultation quality in primary care suggest that Chinese patients in Hong Kong value engaged, empathic primary care doctors and judge the quality of consultations largely on these human skills and the attitudes and values that underpin them, as well as on the perceived outcomes of treatment.