The mismatch between urban women’s preferences for and experiences with primary care

Article The Mismatch Between Urban Women’s Preferences for and Experiences with Primary Care Ann S. O’Malley, MD, MPH Georgetown University Medical Center Division of Cancer Prevention Lombardi Cancer Center Washington, DC

Christopher B. Forrest, MD, PhD Department of Health Policy and Management Johns Hopkins Bloomberg School of Public Health Baltimore, Maryland

Abstract Socioeconomic disparities in women’s primary care experiences have been described previously. To better understand whether these disparities reflect personal preferences for primary care, rather than insurance or other access barriers, we conducted a telephone survey of a community-based sample of 1,205 women in Washington, DC. The study found that women of lower socioeconomic status had poorer primary care experiences compared with higher income counterparts, despite similarly high preferences for primary care. The poorer primary care experiences of lower socioeconomic status women were attenuated by better access to primary care. Differences in primary care attainment are not solely a matter of personal preferences; rather, they appear to be more strongly related to barriers to obtaining care.

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acial and socioeconomic disparities in the primary care experiences exist and are well documented among women.1,2 By “primary care experiences” we mean women’s reports of actual primary care received, including the accessibility of the practice, continuity with a specific practitioner, availability of a comprehensive range of services, and coordination of services in one medical home.3–5 These disparities threaten a national commitment, as articulated by the Public Health Service, to eliminate healthcare inequalities.6 Yet, we know little about women’s preferences for primary care, especially in lower socioeconomic groups. Patients in different sociodemographic groups attach different degrees of importance to components of health care. For example, lower-income respondents place more importance than counterparts on the doctor–patient relationship and continuity.7 There is a paucity of research on women’s preferences for primary care. We use the term “preferences” to indicate those aspects of primary care that women value. Prior research on preferences for the delivery of primary care has focused on patient expectations for specific tests and procedures8 or on their expectations for communication around specific medical problems within the clinic encounter.9 –11 One study of managed care

© 2002 by the Jacobs Institute of Women’s Health Published by Elsevier Science Inc. 1049-3867/02/$22.00 PII S1049-3867(02)00138-X

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enrollees in California found that patients place a high value on the firstcontact and coordinating roles of primary care physicians.12 Weisman and colleagues found that women’s satisfaction with primary care visits is more dependent on continuity of care and informational content than is men’s satisfaction.13 A qualitative study found that women valued easy access to the primary care site, and comprehensive and coordinated care.14 Less attention has been given to women’s preferences for specific attributes of the primary care practices where they receive care. We hypothesized that differences in lower income women’s primary care experiences would not be associated with their preferences for primary care. Otherwise stated, we hypothesized that the poorer primary care experiences of lower income women would not be a result of women simply feeling that primary care was less “important.” Examination of preferences would benefit from communitybased sampling, which includes women who may not find the concept of primary care appealing, nonusers, and those with barriers to accessing primary care. The purpose of this study was to contrast women’s preferences for primary care with their actual experiences receiving care among a communitybased, urban sample. Our specific aim was to understand whether differences in primary care experiences were a function of women’s preferences for primary care or whether they may be explained by other factors, such as more barriers to obtaining care.

METHODS Sampling and Survey This community-based telephone survey of 1,205 urban women is a follow-up study to a series of focus groups of women from the same areas in Washington, DC.15 In the focus groups, women identified their priorities for specific features of primary care. This follow-up study determines, via a population-based sampling methodology, whether women receive the types of primary care that they desire. To obtain an adequate number of low-income women for comparison to high-income groups, we identified a community-based sample of women residing in lower income Washington, DC census tracts where at least 30% of the households had an income ⬍ 200% of the 1999 poverty guideline.16 Because respondents were also asked about their use of cancer screening services within primary care, only women over age 40 were eligible for participation. A professional sampling system (Genesys Sampling Systems) generated a list of telephone numbers to obtain a sample of 25% random-digit-dial and 75% targeted listed households. A Random Digit Dialing sample was generated from the set of all telephone exchanges that service these low-income census tracts from throughout Washington, DC. A listed household sample was merged with sociodemographic information, from census and marketing data, which targeted inclusion criteria. The telephone survey was developed using focus groups15, prior research,17–20 and pilot testing. The survey contained numerous items on women’s primary care experiences, demographic and socioeconomic (SES) characteristics, insurance and health status, and respondents’ ratings of how important each feature of primary care was to her (i.e., her preferences). The computer-assisted telephone survey (CATI) was conducted by experienced, trained female interviewers. The study, including a verbal consent process, was approved by the Georgetown University Institutional Review Board. The survey response rate was 85%. The main dependent variables were women’s experiences with primary care and the importance (preferences) women placed on those features of care. 192

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We employed the Institute of Medicine’s definition of primary care as “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.”3 Primary care’s core attributes thus include: continuity with a single provider; the patient–physician relationship; organizational, financial, and geographic accessibility of the primary care practice; comprehensive service delivery; and coordination of specialty care.3–5

Primary Care Experiences Based on pilot testing, we adapted the Primary Care Assessment Survey20 to assess primary care experiences and the patient–physician relationship. Because our survey was administered by telephone to a lower literacy sample, it was necessary to limit the number of response options to four (rather than the usual six). Each item was assessed as a separate variable. Item responses were categorized into two groups: the “highest” response level of that primary care characteristic versus all the other categories. Women’s perceptions of their primary care experiences were determined as follows: 1) Comprehensive service delivery—The first aspect, “comprehensiveness of medical services” was assessed by asking, “Thinking about how well your doctor knows you, how would you rate your regular doctor’s ability to take care of all of your health care needs? Would you say it is poor, fair, good or excellent?” A second aspect of comprehensiveness assessed whether mental health assessment/treatment were part of one’s primary care; this was an important priority for focus group participants in the first phase of this study.15 As depression/anxiety cause the most mental health morbidity and have a high prevalence in the population of focus for this study,21–23 this was the main focus of the mental health comprehensiveness variable. This was assessed by asking whether the primary care provider had ever: a) Asked if the woman “was feeling down, depressed or nervous,” b) Treated her with medication for being depressed or for mood, or, c) Suggested that she talk with a counselor to help with her mood. If the respondent said “yes” to any one of these three items, she was assigned to the group experiencing “higher” (vs. lower) comprehensiveness of mental health care by the primary care provider. 2) Coordination of specialty care was assessed by women’s ratings of their regular clinician’s help getting the patient an appointment with the specialist, involvement in the patient’s care when hospitalized or under the specialist’s care, and help to understand what the specialist said about her. These three variables were only assessed for the 748 women who had been referred to a specialist or hospitalized by their regular clinician. 3) Continuity of care included the degree to which office visits were with the same clinician (Clinician Continuity). Clinician Continuity was assessed by determining whether the woman had a usual site of primary care, whether she had a regular clinician at that site, and whether she saw that regular clinician for most (versus some) of her sick and well visits. Women whose ratings of continuity with a clinician fell into the highest response category were considered to have the “highest” continuity. 4) Patient–physician relationship—Using recognized conceptualizations of the patient– physician relationship24 –26 we included five items that assessed three of its aspects: trust, compassion and communication. Patient–physician communication was assessed by asking the respondent how she would rate her regular doctor’s explanations of her health problems or treatment that she needed. Responses were on a four-point scale ranging from “poor” to “excellent.” Physician compassion was assessed by asking the women to rate her regular physician’s: 1) patience with her questions or worries, 2) caring and concern for her, and 3) respect for her. Each item had the same four-point response options ranging from poor to excellent. Trust was assessed with a single item asking, “All things considered, how much do you trust your doctor? On a scale from 0 to 10 where 0 is “Not at all” and 10

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is “Completely.” All concepts were measured in the context of the global patient–physician relationship; items were not visit-specific. An overall dichotomous variable representing the strength of patient–physician relationship was created from these above five items. Women who gave the highest rating to each of the five items were considered to have “stronger” patient–physician relationships. 5) Accessibility—A structural feature of primary care, accessibility, was operationalized according to prior studies.19 Geographic access was assessed with a single item, the women’s rating of the convenience of her regular doctor’s office location. Organizational access involves factors involved in arranging and promoting encounters between patients and physicians.19 It was assessed with four separate items: hours open for appointments, wait for appointments, ability to get through by phone, and amount of time the doctor spent with the patient.

Primary Care Preferences Women were asked about the extent to which they valued specific aspects of primary care (see Table 1). Nine items were developed to reflect each of the elements of primary care, including concepts that arose from focus groups of women in Washington, DC in the earlier qualitative phase of this study.15 Wording of items had been refined based on pilot testing. Each patient preference item followed the relevant primary care experience item in the interview. This ensured that the patient had first heard an explanation of what was being referred to in each question on importance. For example, after the five patient–provider relationship experience items on trust, compassion, and communication, the respondent was asked, “How important are these personal aspects to you? By personal aspects I mean the caring, respect, and patience of your physician?” Responses to each of the preference items (listed in Table 1) ranged from 1 (not at all important) to 5 (very important). Items on demographic and socioeconomic characteristics such as age,27 household income, race/ethnicity, education, health status, work status, and insurance status came from validated surveys.17,18 The insurance categories were: uninsured, public insurance only, and private. To be considered “uninsured” a woman had to lack coverage for the entire previous 12 months. Four hundred fifty-five women in the sample (37.8%) had Medicare. Of these 455 women, if they had no additional Medi-Gap policy, they were categorized as “Public Only” (includes those with Part B). If women had Medicaid and no additional private insurance, they were classified as “Public.” If they had a Medi-Gap policy in addition to Medicare, they were categorized as “Private, May Also have Public.” This was done to distinguish between women with and without additional private insurance coverage above and beyond what Medicaid or Medicare provides.

Analysis To assess the relationship between women’s sociodemographics and their preferences for and experiences with primary care, bivariate analyses were done using the chi-square statistic. We did logistic regression analyses to determine whether the poorer primary care experiences of lower SES women were a result of lack of insurance. Dependent variables in these regression analyses were the dichotomous primary care features (e.g. high versus low clinician continuity, more versus less comprehensiveness of services, more versus less coordination of specialty care, etc.). Independent variables were age, race/ethnicity, socioeconomic status (education, income, home ownership), health status, and insurance status (uninsured, public only, private). Analyses were performed in SAS 8.01.28 Other logistic regression models were 194

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Table 1. WOMEN’S PREFERENCES FOR SPECIFIC FEATURES OF PRIMARY CARE, WASHINGTON, DC, 2000, N ⫽ 1205 Survey Item

% Rating the feature “Very Important”*

PATIENT–PHYSICIAN RELATIONSHIP How important are the personal aspects (trust, caring, respect, patience) of your physician?

84.9

CLINICIAN CONTINUITY How important is it to you to see same doctor or nurse for all of your health care visits?

83.6

COMPREHENSIVENESS (OF MEDICAL SERVICES) How important is it to you to be able to go to the same provider for all of your health care needs? GEOGRAPHIC AND ORGANIZATIONAL ACCESSIBILITY How important are location of the office and waiting times? COORDINATION OF SPECIALTY CARE†: How important is your regular doctor’s involvement in your care when you were being treated by a specialist or were hospitalized? FINANCIAL ACCESSIBILITY How important is amount of money you pay for visits and treatments? COMPREHENSIVENESS (MENTAL HEALTH) How important is it that there is someone available at your health care site to help you with emotional concerns like when you feel down or depressed? COORDINATION OF SOCIAL SERVICES How important is it to you that your doc/nurse/place helps to arrange for social services that you might need, like medical assistance, housing assistance, disability, social services or legal services? CULTURAL SIMILARITY (An aspect of cultural competence): How important is it that doctor/nurse comes from same culture as you?

81.7

76.9 72.5

71.5 60.7

58.0

23.6

*Responses to each item were on a scale from 1 to 5, where 1 is “Not at All Important” and 5 is “Very Important”. †N ⫽ 748 women who had been referred to a specialist, or hospitalized, while under the care of their current primary care provider.

developed to assess whether primary care accessibility was associated with primary care experiences, despite lower socioeconomic status, adjusting for women’s preferences for primary care.

RESULTS The sample was predominantly African American (82%), and had a wide range of incomes with over half at or below 200% of the federal poverty guidelines.16 Detailed descriptions of the sample and its comparison to Current Population Survey estimates for the same census tracts have been published elsewhere.29 Distribution of the sample by age, education, income, ethnicity/race, home ownership, health status, and health insurance status are presented as frequencies in the first column of Table 2. Eighty-four percent of respondents said that they had a usual health care provider; of these, the majority (62%) used private doctors’ offices or a health maintenance organization (HMO). Twenty-seven percent attended Community Health Centers or other nonprofit community health clinics.

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Table 2. WOMEN’S PREFERENCES* FOR SPECIFIC FEATURES OF THE PROCESS OF PRIMARY CARE, ACCORDING TO DEMOGRAPHIC AND SOCIOECONOMIC CHARACTERISTICS Percentage of Women Rating Each Feature of Primary Care as “Very Important” Personal Characteristic

(Freq.)

Patient–Physician Relationship

Clinician Continuity

Comprehensiveness of Medical Services

Age 41–65 ⱖ65

(539) (666)

85.5 84.4

82.6 84.5

79.4‡ 83.6

60.1 61.1

70.9 73.9

(996)

85.0

84.3

82.8‡

62.3¶

74.5§

(80) (129)

81.0 87.0

77.2 82.5

70.9 80.0

43.0 57.0

50.9 70.2

(317) (404) (482)

85.5 84.2 85.1

81.7 84.6 81.6

87.1§ 85.9 74.5

68.1§ 66.6 50.8

78.0‡ 75.5 67.9

(324)

87.6

84.9

84.6§

63.9§

73.7§

(512) (369)

84.1 83.5

84.3 81.6

85.5 74.1

66.1 50.3

77.0 66.9

(410) (795)

84.3 85.2

83.3 83.8

83.6 80.7

65.7§ 57.9

75.6 71.1

(316) (439) (450)

84.8‡ 81.9 87.8

86.7 81.7 83.3

83.2 82.9 79.8

67.6§ 59.8 56.7

74.1 74.5 69.2

(112) (275) (818)

77.5 85.3 85.8

72.1§ 85.7 84.6

80.2 83.1 81.7

61.3 64.3 59.5

69.2 74.7 72.1

Ethnicity/Race African American Caucasian Hispanic/Other Education ⬍12 years HS grad/GED ⱖSome college Household Income Don’t Know/ Ref㛳 ⱕ$30,000 ⬎$30,000 Home Ownership Rents Owns Health Status Poor–Fair Good Very Good–Excel Health Insurance Uninsured Public Only Private¶

Comprehensiveness of Mental Health

Coordination of Specialty Care†

*The patient–physician relationship and continuity of care were universally highly valued, regardless of differences in respondents’ personal characteristics. †N ⫽ 748 women who had been referred to a specialist, or hospitalized, while under the care of their current primary care provider. ‡p ⱕ .05. §p ⱕ .01. 㛳Most similar to the ⬍$10K group in terms of other socioeconomic variables, demographics, and use of health services. ¶May also have had Medicare/Medicaid.

Table 1 presents women’s preference rankings of specific components of primary care. The patient–physician relationship was the primary care feature that the highest percentage of women ranked as “Very Important.” Clinician continuity and comprehensiveness of medical services at one place were also highly ranked. Table 2 presents the top five preference ratings stratified by women’s personal and socioeconomic characteristics. The patient–physician relationship and clinician continuity were highly valued by all women, 196

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Women ranked the patient-physician relationship as “Very Important”

regardless of their socioeconomic, demographic, or health status/insurance characteristics. Lower income and less educated women placed an even higher value on specific aspects of primary care such as comprehensiveness of services, coordination of specialty care, and cultural similarity of provider, than did higher income and more educated women (p ⫽ .001 for each comparison). Among women with household incomes under $10,000, 82% rated geographic and organizational access as “very important,” whereas 74% of women with higher incomes rated this as “very important” (p ⬍ .01). In terms of financial access (i.e., out-of-pocket costs for the primary care office visit), 76% of younger women rated this as “very important” versus 68% of older women (p ⬍ .01). In terms of cultural similarity of the provider, women who were older, less educated, in poorer health, in low-income groups, and uninsured were more likely to rate as “very important” having a provider who comes from the same culture than were their counterparts (p ⬍ .01 for each comparison). The top five primary care features from Table 1 were examined with respect to the actual experiences of the respondents (Table 3). Women consistently rated their actual primary care experiences (Table 3) lower than their preferences (Table 2). For example, whereas 85% of women expressed that the patient–physician relationship was “very important” to them (the highest level of the four level response), about half that percentage actually felt that they experienced a patient–physician relationship of the highest level. These differences between preferences and experiences were especially pronounced among women of lower socioeconomic status. Less educated women and those of lower socioeconomic status (home ownership as proxy for SES) were significantly less likely to have had primary care experiences that were consistent with their preferences. Analyses for Table 3 were rerun for just the subset of women who rated their preference for primary care most highly; the significant differences in primary care attainment by socioeconomic status did not change.

Women rated primary care experiences lower than their preferences

Multivariable Models Logistic regression models were done to assess whether the poorer primary care experiences of women with lower SES were a result of more uninsured women in these groups. (Data presented in text only). Dependent variables were the dichotomous primary care features (e.g., high versus low visit continuity, more versus less organizational access of the primary care site, etc.). Adjusting for insurance status, socioeconomic disparities in primary care experiences were attenuated for visit continuity and coordination of specialty care. For example, women with either public or private insurance had 1.94 and 2.14 the adjusted odds, respectively, of having better coordination of care compared with uninsured women (p ⫽ .01 and p ⫽ .002 respectively). For all other features of primary care (organizational and geographic access, financial access, comprehensiveness of services, patient–physician communication, compassion, caring, patience, and respect), adding insurance status to the regression did not alter the significant socioeconomic disparities in primary care experiences. To examine whether the mismatch in women’s primary care preferences and experiences was a result of access barriers, logistic regression models were constructed to determine the added effect of the access variables. By including women’s individual preference for specific features of the primary care process, these models can identify the extent to which differences in primary care experiences are associated with personal preferences versus access barriers to obtaining primary care (see Table 4). When we controlled for a woman’s organizational access, the socioeconomic covariates (education, income, home ownership) were no longer significantly associated with better primary care

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Table 3. WOMEN’S EXPERIENCES WITH SPECIFIC FEATURES OF THE PROCESS OF PRIMARY CARE, ACCORDING TO DEMOGRAPHIC AND SOCIOECONOMIC CHARACTERISTICS Percentage of Women Rating Their Primary Care Experiences Highest in terms of . . . . Personal Characteristic

Patient–Physician Relationship

Clinician Continuity

Comprehensiveness of Medical Services

Comprehensiveness of Mental Health Services

Coordination of Specialty Care*

Age 41–65 ⱖ65

40.8 34.8†

49.7 54.5

46.0 49.1

50.3 39.7‡

35.6 35.8

Ethnicity/Race African-American Caucasian Hispanic/Other

36.6 41.7 45.5†

52.6 51.9 50.1

47.8 50.7 44.3

44.8 33.3 47.7

35.5 39.2 34.0

Education ⬍12 years HS grad/GED ⱖSome college

25.5 36.6 46.1‡

48.3 51.2 56.0

43.2 46.3 51.9†

44.8 42.8 45.6

33.9 31.3 39.3†

Income of Household Don’t Know/Ref§ ⱕ$30,000 ⬎$30,000

31.2 35.0 46.5‡

49.0 51.3 56.7

43.8 46.9 52.2

39.2 47.9 44.2§

34.4 34.2 38.2

Home Ownership Rents Owns

31.7 40.7‡

47.6 54.9†

42.7 50.4‡

45.9 43.6

33.2 36.8

31.4 33.6 45.3‡

47.3 52.5 55.8

46.0 43.8 52.7†

54.1 40.4 41.5‡

33.9 30.2 43.1‡

32.4 32.0 40.2†

31.5 50.7 55.7‡

40.5 45.2 49.8

43.8 54.2 41.5‡

33.3 31.5 37.3

Health Status Poor–Fair Good Very Good–Excellent Health Insurance Uninsured entire yr. Public Only Private㛳

*N ⫽ 748 women who had been referred to a specialist, or hospitalized, while under the care of their current primary care provider. †p ⱕ .05. ‡p ⱕ .01. §Most similar to the ⬍$10K group in terms of other socioeconomic variables, demographics, and use of health services. 㛳May also have had Medicare/Medicaid.

experiences of comprehensiveness, coordination, continuity or patient–physician relationship. When the covariates measuring organizational access were included in the models, the model fit was excellent (c statistics for each model ranged from .822 to .894).

CONCLUSIONS This study examined the preferences for and experiences with primary care among a community-based sample of urban, predominantly African American 198

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Table 4. ADJUSTED ODDS OF EXPERIENCING A “HIGH” LEVEL OF PARTICULAR FEATURES OF THE PRIMARY CARE PROCESS, ACCORDING TO ONE’S ORGANIZATIONAL ACCESS Comprehensiveness Comprehensiveness of Mental Health of Medical Services Services OR (95% CL) OR (95% CL) N ⫽ 1205 N ⫽ 1205

Coordination of Specialty Care OR (95% CL) N ⫽ 748

Patient–Physician Relationship OR (95% CL) N ⫽ 1205

Clinician Continuity OR (95% CL) N ⫽ 1205

Access Ratings Convenience of the Office/Clinic Location Better Worse

1.59 (1.12, 2.27) Ref

1.28 (0.96, 1.69) Ref

1.40 (1.03, 1.92) Ref

0.97 (1.07, 1.28) Ref

1.32 (0.88, 1.99) Ref

Hours that Office/Clinic is Open for Appointments Better Worse

1.75 (1.21, 2.52) Ref

0.79 (0.58, 1.08) Ref

1.43 (1.03, 1.99) Ref

0.87 (0.64, 1.18) Ref

1.95 (1.27, 2.98) Ref

Usual Wait for appointment if sick and call office Better Worse

2.47 (1.73, 3.53) Ref

1.25 (0.93, 1.67) Ref

1.89 (1.37, 2.62) Ref

1.34 (1.00, 1.79) Ref

2.02 (1.35, 3.02) Ref

Ability to get through to doctor’s office by Phone Better 2.18 (1.53, 3.11) Worse Ref

1.82 (1.34, 2.46) Ref

2.05 (1.47, 2.85) Ref

1.10 (0.81, 1.49) Ref

1.54 (1.03, 2.29) Ref

Amount of Time Doctor Spends with You Better Worse

9.50 (6.78, 13.3) Ref

1.48 (1.13, 1.93) Ref

5.93 (4.44, 7.91) Ref

1.43 (1.08, 1.87) Ref

2.54 (1.72, 3.75) Ref

Preference Rating Preference for the relevant primary care feature Higher Lower

3.19 (1.73, 5.89) Ref

2.00 (1.43, 2.81) Ref

1.46 (1.01, 2.13) Ref

1.49 (1.16, 1.92) Ref

6.08 (3.60, 10.26) Ref

1594 1456

1667 1606

1667 1626

1625 1560

974 862

957

1550

1231

1544

733

⫺2 Log Likelihood Intercept Only Base Model Without the above access ratings* Model With the above access ratings†

OR ⫽ odds ratio; CL ⫽ confidence limits. *Base Model (OR not shown for the base model) that contains: frequency of primary care visits in the past 12 months (a measure of realized access), age, ethnicity/race, education, income, home ownership status, health status, insurance status, and preference rating for the dependent variable (primary care variable top row) of interest (without the access covariates). †In addition to variables in the base model (age, ethnicity/race, education, income, home ownership status, health status, insurance status, and preference rating), the full model also includes the five access covariates listed in this table, first column.

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women. Marked socioeconomic disparities in primary care experiences were found among these women, despite similarly high preferences for primary care. Socioeconomic disparities in women’s primary care experiences appeared to be mediated by their access to primary care. Thus, differences in primary care attainment are not a matter of personal preferences, but rather related to modifiable health care delivery factors. Differences in primary care experiences by SES were minimized for two primary care features, visit continuity and coordination of specialty care, by adjusting for insurance status. But, for all of the other features of primary care (comprehensiveness of services, patient–physician communication, compassion, caring, patience, and respect), having insurance did not compensate for the poorer primary care experiences of lower SES women in these domains. Issues such as poor financial access (i.e., out-of-pocket costs for the primary care office visit), availability of high-quality practitioners, or other unmeasured factors may contribute to the failure of some lower SES women to attain “quality” primary care. These are areas that have received a fair amount of attention in prior research. Consistent with the prior findings from clinic-based studies,14,30,31 women valued some aspects of primary care more than others. For example, continuity of care and the patient–physician relationship were rated as “very important” by higher proportions of women than all other features. Consistent with a prior study from Sweden, respondent age was associated with patient preferences for certain aspects of primary care, such as comprehensive service delivery and continuity.32 In our study, all respondents were older adults and all valued continuity highly. Only 24% of respondents gave the highest rating to having a provider who came from the same culture. This surprisingly low percentage was likely due to the low numbers of Latinas in our sample, with over 82% of respondents being African-Americans, predominantly U.S.-born. Respondents tended to focus on the interpersonal aspects of care delivered, rather than the race or ethnicity of the provider. Most prior studies on patient preferences in the United States assessed clinical samples of patients enrolled in primary care practices.8,12,13,31,33 By using a community-based (rather than clinic-based) sample, we avoid the selection bias toward patients with more favorable views of primary care or patients who prefer the primary care-oriented model of health care delivery. Our community-based sample has the advantage of including women who did not necessarily ascribe to the benefits of primary care or believe that primary care is important. It also increases the chances that the voices of women with less access to primary care are heard. A limitation of this study is that these data may not generalize to women under age 40 or to persons without telephones or in rural areas. It is estimated that 94% of African-American households in the District of Columbia have phones.34 In addition, we did not validate patients’ attainment of primary care via provider surveys. We were more interested in patients’ perceptions of and experiences with their primary care providers. Patients’ self-reports of their own perceived access to care are valid indicators of whether or not they actually receive optimal primary care.35 The data are cross-sectional; hence, we cannot ascertain temporal relationships between patient preferences, barriers to care, and experiences. We acknowledge that the potential for correlation of factors is a limitation. Primary care research has found low to moderate correlations between the domains we assess, but not complete overlap. Because primary care is considered to be a multidimensional construct,3 it is necessary to present domain measures that are separate, rather than grouped into a summary index. In addition, we did not measure the proportion of our sample receiving care from a primary care clinician and an ob-gyn, the so-called “dual 200

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primary care provider” arrangement. The majority of respondents (93%) identified their regular primary care provider as a traditional primary care provider (internist, family practitioner, general practitioner); 7% said that their regular provider was an ob-gyn. Finally, since we did not sample women under age 40, and since the average age of our sample was 64, we did not measure the extent to which women’s child care needs affected their preferences for or experiences with primary care. Consistent with the findings of others36 our study suggests that processbased performance measures on primary care should be stratified not just by race as others have suggested, but by socioeconomic status. In light of the mismatch between preferences and experiences demonstrated with these data, it appears that the system is not responding adequately to women’s preferences. Better identification of women’s preferences through performance measures stratified by SES might further identification of such subgroup preferences. Finally, patients are not passive consumers of health care; they act on their preferences.7,37 The Community Tracking Study38 found that two-fifths of those who changed their usual health care provider did so because of personal preferences, such as the desire to obtain better quality care. Disenrollment from health plans among Medicare beneficiaries was associated with the quality of patient–physician communication, trust, and coordination of specialty care.39 Quality improvement to meet this increasing consumerism requires adequate measurement of patients’ perceptions and experiences.40 To this end, understanding women’s preferences for primary care helps us to interpret their satisfaction ratings.41 Faced with limited resources and numerous demands from consumers and providers for health care, the design and selection of health services should incorporate patient preferences as one of the planning factors.31,42 Patient centeredness is one of the core structural elements of quality that will be evaluated in the forthcoming National Health Care Quality Report.43 This aspect of quality is realized when practitioners form partnerships with patients and explicitly account for preferences, wants, and needs. Our findings suggest that there is a large quality gap between women’s preferences for and their experiences with primary care. Addressing women’s preferences for primary care, and the poorer experiences of lower socioeconomic groups, should inform efforts to make the health care system more responsive to their needs.

Quality improvement requires measurement of patients’ perceptions and experiences

ACKNOWLEDGMENTS This work was funded in part by NCI CA83338-02 (ASO) and by 1 KO7 CA91848-01 (ASO).

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