Approaches to ensure and improve quality at primary healthcare centres - a study of the effects of a structured patient-sorting system and a healthcare reform

Sammanfattning: Background: Primary healthcare in Sweden meets increased demands from an aging population concerning quality and accessibility while dealing with a growing shortage of general practitioners and imperfect efficiency. Initiatives in the delivery and governance of primary care services attempt to improve quality and performance, but frequently do not attain the targeted results. Aim: The thesis studies the effects of i) an initiative for improved health service delivery – the structured patient-sorting system (PSS) – and ii) a healthcare reform aiming to strengthen the patient’s role and to improve access and responsiveness through freedom of choice and establishment. Methods: A Swedish primary healthcare centre (PHCC) developed and implemented the PSS using improvement science methods. Changes in access rates and questionnaires on patients’ and staff members’ perceptions were analyzed quantitatively (Paper I). In a qualitative study (phenomenography) 11 staff members’ conceptions of the PSS were analyzed (Paper II). In another qualitative study (content analysis) the perceptions of 24 managers of publicly owned PHCCs about the changes through the healthcare reform in Region Västra Götaland were analyzed (Paper III). In an observational study the differences between privately and publicly owned PHCCs in Region Västra Götaland were quantitatively analyzed concerning the listed populations, the patient perceived quality, the prescription rates of antibiotics and benzodiazepines, and the rate of follow-up for certain chronic conditions (Paper IV). Results: The introduction of the PSS resulted in a 13% increase in the access rate on average, mainly through improved accessibility to physiotherapists and psychologists. More than 90% of the surveyed patients (n=96) were satisfied with both accessibility and treatment. 92% of staff members (n=36) were satisfied with the working situation. Staff members conceptualized the PSS as an appropriate platform for the transformation into an effective patient-centred team. Improvement of health service delivery, professional development and team development took place concurrently. Managers perceived the healthcare reform as a rapid change, enforced through financial incentives and leading to prioritization conflicts between patient groups with different care needs. In comparison with publicly owned PHCCs (n=114), privately owned PHCCs (n=86) were characterized by: urban overrepresentation (54%); smaller population sizes (avg. 5932 vs. 9432 individuals); overrepresentation of individuals of working age (62% vs. 56%) and belonging to the second most affluent socioeconomic quintile (26% vs. 14%); better results in perceived patient quality (82.4 vs. 79.6 points); higher 3-month prescription rates of antibiotics per 100 individuals (6.0 vs. 5.1 prescriptions) with a larger variance (SD 2.78 vs. 1.50); lower prescription rates of benzodiazepines; lower rates for follow-ups of chronic disease. While antibiotic use decreased, the use of benzodiazepines increased on average for all PHCCs over time. Conclusions: The findings indicate a more efficient use of all competences at the PHCC and the transformation into an effective team through the PSS. Prioritization conflicts between patient groups emerged after the healthcare reform and the question of the effect of the ownership type on quality could not be answered unambiguously. Further research is necessary to improve health service delivery and health system governance.