Priority measures for publicly reporting primary care performance: Results of public engagement through deliberative dialogues in 3 Canadian provinces

Abstract Objective While public reporting of hospital‐based performance measurement is commonplace, it has lagged in the primary care sector, especially in Canada. Despite the increasing recognition of patients as active partners in the health‐care system, little is known about what information about primary care performance is relevant to the Canadian public. We explored patient perspectives and priorities for the public reporting of primary care performance measures. Methods We conducted six deliberative dialogue sessions across three Canadian provinces (British Columbia, Ontario, Nova Scotia). Participants were asked to rank and discuss the importance of collecting and reporting on specific dimensions and indicators of primary care performance. We conducted a thematic analysis of the data. Results Fifty‐six patients participated in the dialogue sessions. Measures of access to primary care providers, communication with providers and continuity of information across all providers involved in a patient's care were identified as the highest priority indicators of primary care performance from a patient perspective. Several common measures of quality of care, such as rates of cancer screening, were viewed as too patient dependent to be used to evaluate the health system or primary care provider's performance. Conclusions Our findings suggest that public reporting aimed at patient audiences should focus on a nuanced measure of access, incorporation of context reported alongside measurement that is for public audiences, clear reporting on provider communication and a measure of information continuity. Participants highlighted the importance the public places on their providers staying up to date with advances in care.


| INTRODUC TI ON
Performance measurement is commonplace in health-care systems worldwide, used for quality improvement efforts, 1,2 public accountability, 3-7 patient engagement, [8][9][10] research and informed decision making. 11 Public reporting of performance measures is fundamental to achieving several of these goals. While public reporting on hospital-based procedures and care has been growing over the past two decades, public reporting of primary care performance measures has lagged behind; however, countries such as the United Kingdom, United States and Australia have led efforts in public reporting of primary care performance. [12][13][14] Canada, like many countries, has experienced two decades of primary care reforms in health service delivery. [15][16][17][18] While the majority of Canadians receive most of their health care from primary care providers, there is a paucity of publicly reported information to engage members of the public, 19 and no federal organizations are mandated to publicly report on primary care performance. While the Canadian Institute for Health Information has an active health system performance public reporting site, 20 it includes very few measures of primary care performance. Provinces, who are responsible for the delivery of primary care services, also do not consistently publicly report performance in primary care. 19 Patient engagement at the level of care decision making has been shown to improve both patient-and health system-level outcomes. 21,22 Canada's Strategy for Patient-Oriented Research (SPOR) highlights the importance of incorporating patients as active partners across the continuum of research to health system transformation 23 and primary care has embraced patient engagement in the realm of quality improvement. [24][25][26] While public perception of how the health system is performing is influenced by context and culture, 27,28 patients and citizens have reported that public reporting of primary care performance in Canada could support community advocacy and health system decision making and increase the public's trust in the care they receive. 29 While easily accessible data that engage the public in performance reporting is deemed important, 12,13,30 however, little is known about the Canadian public's perspective on which specific information related to primary care should be shared with them. [31][32][33] The objective of this manuscript is to examine patient perspectives and priorities for the public reporting of primary care performance measures in the Canadian context. This project is part of a larger programme of research to improve the science and reporting of primary care performance in Canada 29,34 and builds on our previous analysis that described how the public might use reports on primary care performance. 29

| MATERIAL S AND ME THODS
We conducted deliberative dialogues, a well-established approach for engaging the public in complex issues, [35][36][37] in three provinces that were selected for their varied approaches to primary care reform: British Columbia (BC), Ontario (ON) and Nova Scotia (NS). The methods for these dialogues have been previously reported. 29  Scotia. The regions were selected for their similarities in sociodemographics (eg, ethnicity, age and socioeconomic status) 38 and their differences in health reform, the availability of primary care physicians and proportion of the population with a primary care provider. One session in each region was conducted with patients with complex needs (multiple comorbid conditions) while the second event was for those with two or fewer medical conditions. The study was approved by the research ethics boards of the University of British Columbia, Nova Scotia Health Authority, Ottawa Hospital and Bruyère Continuing Care (Ottawa).

| Participants
We recruited patients 18 years of age or older, most of whom participated in a waiting room survey of patient experience 39 at their primary care practice and consented to being contacted for research opportunities. We used the patient experience survey to obtain information on respondents' age and medical conditions, and from this convenience sample, we purposefully recruited participants who spoke English with diverse ages, gender, types of chronic conditions and the practice where the individual received care. We used the number of chronic conditions as a proxy measure of medical complexity to recruit participants with diversity in experience with the health system. Participants received a $75 honorarium for their time, received meals during the event and reimbursement for transportation. The focus of this analysis is the discussion surrounding the prioritization of primary care performance dimensions and indicators for public reporting. Participants were provided with worksheets listing and defining key performance dimensions for primary care (access, patient-centred care, continuity, comprehensiveness, technical quality of care, safety, service integration and health equity, Table 2), based on an existing framework for comprehensive performance management in primary care. 40 This first discussion introduced participants to this broad and comprehensive view of primary care performance, with examples of indicators for each of these dimensions to help make the concepts more concrete. Participants were then asked to rank the importance of collecting and reporting on these primary care performance dimensions (ranging from not at all important to very important) followed by a group discussion of their ratings and corresponding rationales.

| Structure of session
Next, participants further explored three dimensions of primary care performance and related indicators purposefully selected in advance of the meeting: access, to capture an area perceived as highest priority for public reporting and a focus of reform efforts over the previous decade across the country 15 ; patient-centred care, selected as a key pillar of the next wave of primary care reforms towards medical homes that is not routinely public reported and an important component of patient experience in primary care 41,42 ; and technical quality of care, a dimension TA B L E 1 Examples of the most commonly used performance domains and indicators provided to participants as background information Access: The ease with which clients or patients can initiate contact with their primary health-care provider for a new or existing health problem How it is measured Percentage of respondents who report having a family physician or nurse practitioner that they see for their regular care, or when they are sick Percentage of patients who report that they were able to see their family physician or nurse practitioner on the same or next day Percentage of patients who report that getting medical care in the evening, on a weekend or on a public holiday was difficult Percentage of patients who report that, when they call their regular family physician's office with a medical question or concern during regular office hours, they get an answer on the same day Patient-Centred Care: Providing care that is respectful of and responsive to individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions How it is measured Percentage of adults with a regular family physician or nurse practitioner who said their regular health-care provider always explains things in a way that is easy to understand Percentage of patients who report that their family physician, nurse practitioner or someone else in their medical office spends enough time with them Percentage of patients who report their family physician, nurse practitioner or someone else in the medical office involves them as much as they want in decisions about their care or treatment Continuity: The delivery of services by different providers in a timely and complementary manner such that care is connected and coherent within an acknowledged care plan How it is measured Percentage of total primary care visits that are made to the patient's primary family physician or nurse practitioner Percentage of patients who report that there were often times when the health-care provider they were seeing did not have access to their recent tests or examination results Effectiveness: Providing care that works and is based on the best available scientific information How it is measured Percentage of eligible patients aged 50 to 74 who had a faecal occult blood test (FOBT) within the past two years, sigmoidoscopy or barium enema within five years or a colonoscopy within the past 10 years Percentage of people with diabetes who had a serious complication from it in last year Percentage of people with high blood pressure who had a BP check recorded in the last year aimed to show prevention and treatment activities. Participants were asked to rank on a worksheet the importance of each dimension's specific indicators for public reporting ( Table 2) followed by a group discussion of the shared rankings.

| Analysis
Each deliberation session was recorded and transcribed. The transcripts were read using immersion crystallization by two team members experienced in qualitative analysis (MH, SJ), one who was present for all sessions and was responsible for data cleaning. 43 A coding template, informed by the study objectives, our project framework for comprehensive performance measurement for primary care, 40

| RE SULTS
Fifty-six participants were involved across six deliberative dialogue sessions. Participants were mainly Caucasian, between 20 and 81 years old, with a range of medical conditions, from none to 10 different conditions (Table 3). 29 Gender was balanced across participants in the dialogues except for those in Nova Scotia where the participants were predominantly female. No recurring themes were limited to or significantly more prominent within the patient groups with more or less complex conditions. Participants provided their perspectives about both the importance of specific dimensions of performance and indicators as well as the value of reporting various measures to the public.

| Key dimensions of primary care performance
We present themes arising for each primary care performance dimension and specific indicator in the order in which the dimensions were presented to dialogue participants. There was little discussion among participants surrounding the dimensions of comprehensiveness, safety, service integration, or health equity and as such are not discussed.

| Patient-centred care
Across all groups, patient-centred care was also viewed as an important dimension to publicly report:  Age, years, mean, (SD) n/a a n/a a n/a a 64. Overall, these quotes suggest that communication and interaction between patients and their providers is important for patients to understand and have confidence beyond the primary care visit.

| Continuity
A recurrent theme across groups was that continuity of information is an important system-level measure that significantly impacts pri-  [NS_1] This topic was unprompted by facilitators and came up in three separate dialogues.

| D ISCUSS I ON
Despite the proliferation of publicly reported information on health system performance, there are few studies that focus on understanding the patient point of view. [31][32][33] In this study, we found that patients identified clear priorities for primary care performance measurement and reporting that could be taken into account when deploying information on health-care performance. Specifically, measures of access to a family physician, patients perceiving that their primary care provider spent enough time with them, and continuity of information across all providers were identified as high priority indicators of the performance of the primary care system. Interestingly, several other commonly used performance measures, such as rates of cancer screening or regular blood pressure measurements, were viewed as being patient-dependent and as such were not felt to be an accurate measure to evaluate the health system or the primary care provider's performance. Participants were concerned that primary care physicians were up to date with current research evidence and highlighted the importance of continuing professional development. Our findings were relatively consistent across the three provinces included in our deliberative dialogues, despite the diversity in primary care policies and regional health concerns. 38 Access to primary care was found to be fundamental to understanding the performance of the health-care system from the patient's perspective. This is not surprising and may be a function of the common role of primary care as the entry point for most patients into the health-care system across the country. As such, this finding might not be replicated in health-care systems in which a primary care provider does not function as an access point and gatekeeper for the whole system. While all participants had a regular family physician and most were recruited during visits to their own primary care practice, this finding may also have been shaped by the commonly held perspective that it is difficult to get a family physician or nurse practitioner for some people or in some regions in Canada, 29 where 83%, 90% and 89% of the population in BC, ON and NS, respectively, report having a regular source for primary care. 45 Participants provided insight on the value of specific measures of access: optimal access might depend on the context of the health issue rather than a single measure of same-day access.
This may reflect people's experience in primary care involving care across a wide range of concerns or the longitudinal relationship-based nature of primary care in which patients typically are cared for by one person who they may come to see as having needs of their own. It might also reflect the view which emerged in multiple dialogues about primary care as a publicly funded scarce resource rather than a consumer-oriented service. While there was support for the importance of after-hours access to care, the debate about its value as a performance measure for primary care highlighted similar tensions recognising a need for some form of available primary care while balancing the view of it being a limited resource and respecting primary care providers as individuals with limits as well.
The emphasis on measuring and reporting on continuity of information rather than on continuity of care with a single provider was as measures of their self-care rather than an indicator of the system overall. If the goal of public reporting is to increase public engagement in improving the system, we will need to educate the public as to why these measures speak to the overall performance of the system and frame the use of these measures in the context of a learning health system 52 rather than as punitive, given the understanding of patient agency in many of these measures. However, it is not clear that such explanation or qualification of measures is required given that not all information will be accessed by the general public; rather, effective public reporting of performance measurement needs to be simple and layered with different information targeted to reach different audiences (eg patients, health-care providers, health system managers). 12,13,30 There are a variety of reasons to report primary care performance to the public, including accountability for public funds, and public engagement in shaping the system. [1][2][3][4][5][6][7][8][9][10][11]29 If notions about individual responsibility for health and experiences seeking and receiving care shape people's perception of the value of specific measures, the measures best suited for these purposes are influenced by the system and culture in which they are being deployed. 53,54 Without an accompanying understanding of the context in which the measures occur and the role of social determinants in a person's health-promoting behaviour, some measures seeming to reflect patients' 'choices' may exacerbate social misconceptions.
Patients recognize that they may not be the primary users of publicly reported performance data and see public reporting as a means to fuel accountability and drive improvement among providers. 29 Assessing relative performance by different patient groups will allow providers to determine what additional strategies are needed to support successful outcomes among these patients. This also speaks to the importance of including information about the context of primary care practices in a province or region, changing the focus from single providers to a wholistic view of the system. It is important to note limitations associated with this study. Each deliberative dialogue was held over one day and included time for both education and discussion of complex topics. As a result, the depth of insights and perspectives we were able to gather was limited. Given the significant time required for education about public reporting, we recommend that future studies in this area allow for more time for these discussions. In addition, while participants were asked to assign priorities to all dimensions of care, there was little discussion of some dimensions (ie comprehensiveness, safety, service integration or health equity). This lack of discussion should not be viewed as an indicator of their lack of importance. Further, participants did not have the same opportunities to discussion indicators for all dimensions as discussions were focused on three domains (access, patient-centred care and technical quality of care).
Participants were provided with specific indicators for certain dimensions that may have influenced the discussion. Additionally, the majority of participants in this study had a regular primary care provider and the views of patients who have more difficulty accessing primary care might be different. The participants in this study mainly discussed family physicians as primary care providers; while nurse practitioners (NPs) are playing an increasingly important role in primary care in Canada, 64 there are few NPs practicing in these regions (especially in NS and BC), 18 and thus, participants may not have had the opportunity to see an NP. Finally, it is important to note that the sample is not necessarily representative of the general public.

| CON CLUS ION
Several key measures of primary care performance emerged as priorities for public reporting across deliberative dialogues in three different regions across Canada. Performance reporting serves different functions for different audiences; to be relevant to the patient perspective, public reporting aimed at reaching patient populations could focus on access, with a more nuanced approach to timeliness, the presentation of context alongside measurement that is designed specifically for a public audience and clear reporting on communication with health-care providers. Interestingly, participants highlighted the importance of continuing professional development to ensure that primary care physicians were up to date with current evidence. Our finding that continuity of information is important to patients goes beyond simply developing measures for reporting and is a call to action to set up the infrastructure to support this need. Overall, the selection of optimal performance measures for primary care may be significantly influenced by culture and health policy context.

CO N FLI C T S O F I NTE R E S T
None declared.

AUTH O R S ' CO NTR I B UTI O N S
JA, SW, JL, FB, WH, RMM and SJ conceived and designed the study.
MS, MH and SJ completed the data analysis. All authors contributed to the interpretation of the data. MS drafted the manuscript. All authors critically revised the manuscript, gave final approval and agree to be accountable for the work.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request.