Josephine Barbiere

BACKGROUND: Ethnic minorities and some other patient groups consistently report lower scores on patient surveys, but the reasons for this are unclear. This study examined whether low scores of ethnic minority and other socio-demographic groups reflect their concentration in poorly performing primary care practices, and whether any remaining differences are consistent across practices. METHODS: Using data from the 2009 English General Practice Patient Survey (2 163 456 respondents from 8267 general practices) this study examined associations between patient socio-demographic characteristics and 11 measures of patient-reported experience. FINDINGS: South Asian and Chinese patients, younger patients, and those in poor health reported a less positive primary care experience than White patients, older patients and those in better health. For doctor communication, about half of the overall difference associated with South Asian patients (ranging from -6 to -9 percentage points) could be explained by their concentration in practices with low scores, but the other half arose because they reported less positive experiences than White patients in the same practices. Practices varied considerably in the direction and extent of ethnic differences. In some practices ethnic minority patients reported better experience than White patients. Differences associated with gender, Black ethnicity and deprivation were small and inconsistent. CONCLUSION: Substantial ethnic differences in patient experience exist in a national healthcare system providing universal coverage. Improving the experience of patients in low-scoring practices would not only improve the quality of care provided to their White patients but it would also substantially reduce ethnic group differences in patient experience. There were large variations in the experiences reported by ethnic minority patients in different practices: practices with high patient experience scores from ethnic minority patients could be studied as models for quality improvement.

OBJECTIVE: To assess the robustness of patient responses to a new national survey of patient experience as a basis for providing financial incentives to doctors. DESIGN: Analysis of the representativeness of the respondents to the GP Patient Survey compared with those who were sampled (5.5 million patients registered with 8273 general practices in England in January 2009) and with the general population. Analysis of non-response bias looked at the relation between practice response rates and scores on the survey. Analysis of the reliability of the survey estimated the proportion of the variance of practice scores attributable to true differences between practices. RESULTS: The overall response rate was 38.2% (2.2 million responses), which is comparable to that in surveys using similar methodology in the UK. Men, young adults, and people living in deprived areas were under-represented among respondents. However, for questions related to pay for performance, there was no systematic association between response rates and questionnaire scores. Two questions which triggered payments to general practitioners were reliable measures of practice performance, with average practice-level reliability coefficients of 93.2% and 95.0%. Less than 3% and 0.5% of practices had fewer than the number of responses required to achieve conventional reliability levels of 90% and 70%. A change to the payment formula in 2009 resulted in an increase in the average impact of random variation in patient scores on payments to general practitioners compared with payments made in 2007 and 2008. CONCLUSIONS: There is little evidence to support the concern of some general practitioners that low response rates and selective non-response bias have led to systematic unfairness in payments attached to questionnaire scores. The study raises issues relating to the validity and reliability of payments based on patient surveys and provides lessons for the UK and for other countries considering the use of patient experience as part of pay for performance schemes.

OBJECTIVE: To examine variation in the management of prostate cancer in patients with different socioeconomic status. DESIGN: Survey using UK regional cancer registry data. SETTING: Regional population based cancer registry. PARTICIPANTS: 35 171 patients aged >or=51 with a diagnosis of prostate cancer, 1995-2006. MAIN OUTCOME MEASURES: Use of radiotherapy and radical surgery. Socioeconomic status according to fifths of small area deprivation index. RESULTS: Over the nine years of the study, information on stage at diagnosis was available for 15 916 of 27 970 patients (57%). During the study period, the proportion of patients treated with radiotherapy remained at about 25%, while use of radical surgery increased significantly (from 2.9% (212/7201) during 1995-7 to 8.4% (854/10 211) during 2004-6, P<0.001). Both treatments were more commonly used in least deprived compared with most deprived patients (28.5% v 21.0% for radiotherapy and 8.4% v 4.0% for surgery). In multivariable analysis, increasing deprivation remained strongly associated with lower odds of radiotherapy or surgery (odds ratio 0.92 (95% confidence interval 0.90 to 0.94), P<0.001, and 0.91 (0.87 to 0.94), P<0.001, respectively, per incremental deprivation group). There were consistently concordant findings with multilevel models for clustering of observations by hospital of diagnosis, with restriction of the analysis to patients with information on stage, and with sequential restriction of the analysis to different age, stage, diagnosis period, and morphology groups. CONCLUSIONS: After a diagnosis of prostate cancer, men from lower socioeconomic groups were substantially less likely to be treated with radical surgery or radiotherapy. The causes and impact on survival of such differences remain uncertain.

BACKGROUND: Patient experience is increasingly used to assess organizational performance, for example in public reporting or pay-for-performance schemes. Conventional approaches using 95% confidence intervals are commonly used to determine required survey samples or to report performance but these may result in unreliable organizational comparisons. METHODS: We analyzed data from 2.2 million patients who responded to the English 2009 General Practice Patient Survey, which included 45 patient experience questions nested within 6 different care domains (access, continuity of care, communication, anticipatory care planning, out-of-hours care, and overall care satisfaction). For each question, unadjusted and case-mix adjusted (for age, sex, and ethnicity) organization-level reliability, and intraclass correlation coefficients were calculated. RESULTS: Mean responses per organization ranged from 23 to 256 for questions evaluating primary care practices, and from 1454 to 2758 for questions evaluating out-of-hours care organizations. Adjusted and unadjusted reliability values were similar. Twenty-six questions had excellent reliability (≥0.90). Seven nurse communication questions had very good reliability (≥0.85), but 3 anticipatory care planning questions had lower reliability (<0.70). Reliability was typically <0.70 for questions with <100 mean responses per practice, usually indicating questions which only a subset of patients were eligible to answer. Nine questions had both excellent reliability and high intraclass correlation coefficients (≥0.10) indicating both reliable measurement and substantial performance variability. CONCLUSIONS: High reliability is a necessary property of indicators used to compare health care organizations. Using the English General Practice Patient Survey as a case study, we show how reliability and intraclass correlation coefficients can be used to select measures to support robust organizational comparisons, and to design surveys that will both provide high-quality measurement and optimize survey costs.