Expectations, values, preferences and experiences of Hungarian primary care population when accessing services: Evaluation of the patient’s questionnaires of the international QUALICOPC study

Background: Preferences and wishes of patients is an important indicator of primary health care provision, although there are differences between national primary care systems. Aim: The aim of this paper is to describe and evaluate the preferences and values of Hungarian primary care (PC) patients before accessing and to analyse their experiences after attending PC services. Methods: In the Hungarian arm of the European QUALICOPC Study, in 2013–2014, information was collected with questionnaires; the Patient Values contained 19 and the Patient Experiences had 41 multiple-choice questions. Findings: The questionnaires were filled by 2149 (840 men, 1309 women) using PC services, aged 49.1 (SD ± 16.7) years, 73% of them having chronic morbidities. Women preferred to be accompanied and rated their own health better. Patients in the lowest educational category and women visited their GPs more often, and they are consulted more frequently by other doctors as well. Men, older and secondary educated people reported more frequently chronic morbidities. Longer opening hours were preferred by patients with higher education. The most preferred expectations were availability and polite communication of doctors, not pressures on consultation time, clear instructions provided during consultations, shared decisions about treatments and options for consultations, the knowledge of the doctors concerning the living conditions, social and cultural backgrounds of patients, updated medical records, short waiting times, options for home visits, wide scope of professional competences and trust in the doctor. Conclusion: Wishes, preferences of patients and fulfilment were similar than described in other participating countries of the study. Although there are room to improve PC services, most of the questioned population were satisfied with the provision.


Introduction
Many studies proved that in countries where primary care (PC) system is stronger, the healthcare system performs better (Macinko et al., 2003). Strong PC has to response to the patients' needs, expectations and preferences as well (Schäfer et al., 2011). There is a big variation between individuals, therefore at the patients' level as well. What do patients expect the general practitioners (GPs) to take within the consultation and to what extent are these expectations fulfilled? What factors influence the expectations of the patients and the actions of GPs? (Webb and Lloyd, 1994). Why and when do patients visit doctors? They could have been different influence on daily activities and symptom burden, such as the total number of symptoms experienced by each person (Elnegaard et al., 2017).
In 2010, the three-year Quality and Costs of Primary Care in Europe (QUALICOPC) study was planned, aiming to compare and analyse how the primary health care systems of 35 countries perform in terms of quality, cost and equity. The study analysed three levels of PC. The service provision level, covering characteristics of the GP practice, organisation and the type of services that are delivered and the patient level, where the users of services experience whether the care provided responds to their needs and expectations (Schäfer et al., 2013).
Family physicians/GPs were chosen as one of the survey subjects. Beside GPs, their patients were also approached and questioned using 2 other questionnaires, to explore their expectations before and their experiences after using the services.
The aim of this paper was to describe and evaluate the expectations, personal values and experiences of Hungarian people who attended to PC services, based on the information collected within the Hungarian arm of the QUALICOPC Study, using two questionnaires. Two questionnaires, developed by the QUALICOPC researchers, were used. In each participating country, the response target was 220 GPs and 2200 patients (10 per each).
The questionnaires were translated in the respective national language(s) via an official forward-and back-translation procedure. The Patient Values questionnaire contained 19 questions (statements with multiple choice answers), four questions focused on communication between GPs and patients. Both questionnaires were previously tested and validated (Schäfer et al., 2013).
The Patient Experiences questionnaire included 41 multiple choice questions, asking to what extent the patient agrees with the statement given. There were questions on the patient's background and socio-economic status, perceived constructed for patients.

Method
Structuring the questionnaires, study design Health, reason for visiting the GP, and visits to medical specialists and hospitals, experiences with 'continuity of care', use of medical records and time slot, available for patient. Quality of care as experienced by patients, accessibility of care, divided into physical and financial access. There were inquiries on home visits and waiting times, towards equity in access and equity in treatment, experiences of coordination in the case of referral, on treatment by a practice nurse, about patient's involvement in decision making and referrals, beside their adherence to the treatment plan. Comprehensiveness of services offered by the GP was also probed in a question about patients' views on the breadth of the clinical task profile of services.

Distributing questionnaires, settings
The study centre of the Hungarian arm of QUALICOPC project was established at the University of Debrecen, with close cooperation with the other Departments of Family Medicine (Budapest, Pécs, Szeged). An advertisement was issued to recruit participating GPs in the whole country. Two hundred-twenty two GPs who wanted to participate were selected randomly, based on the order of application. Population density and expected geographically representativeness were also considered (Rurik et al., 2012).
During the study period (2012)(2013)(2014), the questionnaires were transported to the practices by educated fieldworkers, who were usually medical students. They gave one questionnaire per practice, to the nearest patients in the waiting room (Patients' value) and contacted nine other patients consecutively, who left the surgery to summarise (Patients Experiences).

Presentation of data
The original order of questions was followed. There were 12 identical questions in the questionnaires; therefore, the overlapped answers were presented together. Distributions are always presented and statistical correlations, when found. In some columns, similar answers were merged. Options, with only a few number of responses were missed.
Statistical analyses were performed with STATA software.

Results
The Patient Values questionnaire was filled by 214 persons (139 men, 75 women). Their mean age was 47.2 years (SD ± 17.6). Younger, more educated persons and women were satisfied better with their health status, when describing their own health in general. Men, older and secondary educated people reported more frequently chronic morbidities.
Answers options important and very important were merged into one column in Table 1.
Almost all participants of the two surveys (97.2%) and their mothers (96.3%) were born in Hungary. In the same household, 77.2% lived with adult family members and 33.4% with children under 18 years of age.
Regarding employment status, 37% worked in civil service, 8% as self-employed, 29% retired and 7% student, 8-8% were disabled and unemployed, 52 % estimated their income around and 42.6% below the average. Women patients preferred significantly (P = 0.007) better to be accompanied by family members to the consultation, and according to their reports, they could cope better with health problems after the visit (P = 0.071). Longer opening was preferred better (P = 0.035) by patients with higher education.
Majority of patients (84.1%) visited their own, registered family physician. Presence of chronic or longstanding conditions (high blood pressure, diabetes, depression, asthma, etc.), description of own health in general, frequency of consultation with GPs in the last 6 months and consultations with specialist in the previous year are presented in the figures of Table 2.
Patients in the lowest educational category visited more often their GPs, females consulted more frequently, proved by logistic regression analysis. For gender, correlation coefficient: 0.13, standard error: 0.04, P < 0.001 and 95% confidence interval: [0.06; 0.20].
Experiences regarding the actual visit, content of consultation and agreement about the listed statements are described in Table 3. Doctors dealing with not medical problems only, giving more attention to personal problems and worries, were preferred better by patients with higher education (P = 0.01) and by women (P = 0.002). Listening carefully to the patients was requested better 2 Anna Nánási et al. by women as well (P = 0.08). In 71.8% of the cases, the time of travel between the home and the GP's office was less than 20 minutes. Twenty one percent of patients made an appointment, 85% of them got it easy, 29% made it the same day, 37% a day before, while 19% had to wait for 2-7 days. One third of patients had to wait less than 15 minutes, 29 % waited 15-30 minutes.  This doctor doesn't just deal with medical problems but can also help with personal problems and worries 42.9 After this visit, I feel I can cope better with my health problem/ illness than before 62.7 In the past 12 months, has a GP from this practice talked to you about how to stay healthy? (For instance about diet, alcohol or smoking) 65.9 In past 2 years, has a GP from this practice ever asked you about all the medications you take (also those prescribed by other doctors)? 79.5 If I need a home visit I can get one 79.0 I know how to get evening, night and weekend services 73.0 People were polite and helpful at the reception desk 91.9 n = 1935.

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Anna Nánási et al. Table 4. Most of the patients were informed that there is an option to change their doctors, if not satisfied with manner or services.

Negative experiences of patients were listed in
Within the whole study population, 507 persons did postpone or abstain from a visit to the GP in the past 12 months, despite they needed it. Forty four percent of the patients had to cancel their planned visits because she/he was too busy, 11.6% could not get there (physically). Financial reasons were mentioned by 12.8% and only 2.8% did not have insurance. Other reasons for missed visits were 34.7%.
In the case of consultations, 84% of patients believed that their GP was informed about the finding, 61% stated that specialist was informed by the GP appropriately and only 7% experienced difficulties during referral.
Six hundred fifty of the interviewed persons had personal experiences about using out of hour services or emergency departments. The most frequent reasons for encounter were morbidities or complain out of the scope of GP (46.5%), out of the opening time of GPs (21.7%), 5.5% expected a shorter waiting time, 6.8% mentioned that emergency department is more convenient to reach.
The preferences and expectations of patients with complaints, in the case of the listed symptoms are described in Table 5.
Only 22.8% of patients were examined or treated by a nurse in the GP's practice. Patients have a great confidence to their GPs. The statement 'In general, doctors can be trusted' were strongly agree by 33.5%, simple agree by 61.3% of the questioned persons

Main findings
Patients' expectations are mainly focusing on professionalism, comfort and accessibility of services.
In professional term: updated knowledge and good manners of doctors, wide scope of complaints to be able to solve, easy to get prescriptions, no barriers to referrals, common decision making about treatment, in respect of the clinical outcomes and also the emotional and human features of the consultation are the highlights of the patient's expectations.
Preferences regarding circumstances, facilities, courteous communication, clear instructions, adequate information about living circumstances, social and cultural background of the patients were mentioned as well.
Easy access to services, availability and short waiting time, option for home visit, not pressured by time during consultations are also expected. Primary Health Care Research & Development

Limitations
Our study was focused only to the Hungarian characteristics; answers of the patients about their preferences and experiences should be evaluated by taking into consideration specific national traits and a variety of PC provision depending strongly from the personality and available infrastructure of the physicians. It is not sure that questioned persons are representative in social and economic points of view.
After translating and launching the questionnaire, there was no option to clarify questions having different meanings in different countries.
Being part of an international study, we had to follow the original protocol, recruitments and presentations of the findings.
Before and after this study no such a survey was performed in Hungary. Since structure and utilisation of PC did no change in the past years, these findings could be valid nowadays as well.
There are no financial or administrative restrictions on the availability of PC services in Hungary. It can be used by all citizens, although a social insurance ID card is required before enrolment into a practice.
Hungary is relatively a closed country, hence almost all of the participants (also their mothers) were native Hungarians, and only small percent belonged to ethnic minority. According to the effective legislations in Hungary, it is strictly forbidden to register ethnic or national origin in any medical or official files. In the neighbouring Slovenia, where 6.5% of the PC population are migrants, often experiencing negative attitude from GPs (Jakič and Rotar Pavlič, 2016).
Walk-in accident and emergency services have been established in the Hungarian hospitals only in the last two decades; patients tend to visit them only if PC services are not available.
In the Hungarian primary care, there are no traditions of appointments; patients were served by the order of arrival. The ratio of appointments is continuously increasing due to the order of the Minister of Health. These scheduled services are becoming increasingly popular.
The time waiting for appointment is usually longer in Canada (Premji et al., 2018) and in the Nordic countries (Tolvanen et al., 2018), especially for older patients.
There were only small differences between expectations of different age groups; older patients were more satisfied with the care, perhaps their expectations were lower (Bowling et al., 2013). Higher scores of experience may not illustrate better consultations as such; it is the lower levels of initial expectations that determine the level of patient satisfaction (Ogden and Jain, 2005). The results revealed that patients with greater numbers of their expectations met reported significantly higher satisfaction with the consultation than those with lower numbers met (Williams et al., 1995). Generally, GP patients reported higher pre-visit expectations and post-visit met expectations, reflecting chiefly doctor-patient communication style and the doctor's approach to providing detailed information (Bowling et al., 2012).
Referrals of patients from the primary to specialist care are important in all health care system. Patients were most positive if the physician had initiated the referral, which supports the gate-keeper role of the GP (Rosemann et al., 2006). As gatekeeping is very weak in Hungary, the preferences of patients are mostly respected. Some specialists could be accessed without referral. Obtaining a letter of referral is often the reason why GPs are contacted; the referrals to specialist are often requested by patients, mainly in the bigger cities. The preferences and expectations of Hungarian patients were not always in agreement with their experiences and values. Findings in the literature regarding the relationship between strong PC and the responsiveness to patient expectations and needs are inconclusive (Ashworth and Armstrong, 2006). Patient satisfaction was found to be lower in countries where the access to specialist services was regulated through gate-keeping (Bensing et al., 2011;De Maeseneer et al., 2003;Schellevis et al., 2005).
Not all of the PC patients need a medical check-up, regular prescriptions and some consultations are done by practice nurses (Cockburn and Pit, 1997). However, 'nurse practitioners' are not yet involved in the Hungarian primary care.
In Hungary, smaller surgical procedures are routinely performed in rural or remote GP's offices, while in cities, GPs usually prefer referring to the surgeons. The available equipment are less advanced than in Nordic countries (Eide et al., 2017).
Most of the professional reasons for encounters are expected to be managed by the GPs. Patients prefer to visit their own GPs because all of their health-related information is available there, while computerised data are not always available in other countries (Lionis et al., 2017).
Group practices do not yet exist in Hungary. The patient has a right to choose a GP, and GPs are obliged to accept all enrollers in the geographical area they cover. Patients usually visit their own GP in a single-handed practice. Differences in access between different practice models, like in Canada, do not exist in Hungary (Miedema et al., 2016).
In bigger villages and cities, PC offices are easy to approach. Positive behaviour of doctors is well accepted, including consultation's skills and manner. Like in other countries, majority of patients felt better able to cope with their health-related problem after an appointment with GP, reflecting patients' enablement (Tolvanen et al., 2017). Regarding communication between doctors and patients, no difference was proved, while it could be better in medium-sized practices (Eide et al., 2016).
Unfortunately, preventive services are not appropriately implemented in the Hungarian primary care; the visits to doctors are mostly caused by chronic morbidities or acute complaints (Sándor et al., 2016).
Population expectancy is influenced by national traditions and previous experiences (Janka, 2017). Hungarian GPs are managing many social issues, including administrative tasks and for the past 60 years (including decades of Communism) they were considered as the only stable points in the health care, mainly in the years when 'reforms' were initiated in the health care system. In the future, more focus needed to person-centred care, to better involvement of patient in decision-making and appropriate delivery of preventative services (Lionis et al., 2017). Patients require equity, accessibility and good quality of PC services (Oleszczyk et al., 2017).
Reasons for visits, medical problems to be solved and individual expectations were similar in the recent publications of other participating countries (Eide et al., 2016;2017;Miedema et al., 2016;Lionis et al., 2017;Oleszczyk et al., 2017;Tolvanen et al., 2017). In Hungary and in most of the participating countries, the QUALICOPC study proved a high population satisfaction with the primary health care system (Lionis et al., 2017;Oleszczyk et al., 2017;Sanchez-Piedra et al., 2017;Tolvanen et al., 2017). We are still waiting for the findings of other countries where the study run.