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Unlabelled: Comprehensiveness relates both to scope of services offered and to a whole-person clinical approach. Comprehensive services are defined as "the provision, either directly or indirectly, of a full range of services to meet most patients' healthcare needs"; whole-person care is "the extent to which a provider elicits and considers the physical, emotional and social aspects of a patient's health and considers the community context in their care." Among instruments that evaluate primary healthcare, two had subscales that mapped to comprehensive services and to the community component of whole-person care: the Primary Care Assessment Tool - Short Form (PCAT-S) and the Components of Primary Care Index (CPCI, a limited measure of whole-person care)., Objective: To examine how well comprehensiveness is captured in validated instruments that evaluate primary healthcare from the patient's perspective., Method: 645 adults with at least one healthcare contact in the previous 12 months responded to six instruments that evaluate primary healthcare. Scores were normalized for descriptive comparison. Exploratory and confirmatory (structural equation modelling) factor analysis examined fit to operational definition, and item response theory analysis examined item performance on common constructs., Results: Over one-quarter of respondents had missing responses on services offered or doctor's knowledge of the community. The subscales did not load on a single factor; comprehensive services and community orientation were examined separately. The community orientation subscales did not perform satisfactorily. The three comprehensive services subscales fit very modestly onto two factors: (1) most healthcare needs (from one provider) (CPCI Comprehensive Care, PCAT-S First-Contact Utilization) and (2) range of services (PCAT-S Comprehensive Services Available). Individual item performance revealed several problems., Conclusion: Measurement of comprehensiveness is problematic, making this attribute a priority for measure development. Range of services offered is best obtained from providers. Whole-person care is not addressed as a separate construct, but some dimensions are covered by attributes such as interpersonal communication and relational continuity.

Unlabelled: The operational definition of first-contact accessibility is "the ease with which a person can obtain needed care (including advice and support) from the practitioner of choice within a time frame appropriate to the urgency of the problem"; accommodation is "the way healthcare resources are organized to accommodate a wide range of patients' abilities to contact healthcare providers and reach healthcare services, that is to say telephone services, flexible appointment systems, hours of operation, and walk-in periods.", Objective: To compare how well accessibility is measured in validated subscales that evaluate primary healthcare from the patient's perspective., Method: 645 adults with at least one healthcare contact in the previous 12 months responded to six instruments that evaluate primary healthcare with four subscales that measure accessibility: the Primary Care Assessment Survey (PCAS), the Primary Care Assessment Tool - Short Form (PCAT-S, two subscales) and the first version of the EUROPEP (EUROPEP-I). Scores were normalized to a 0-to-10 scale for descriptive comparison. Exploratory and confirmatory (structural equation modelling) factor analysis examined fit to operational definition, and item response theory analysis examined item performance on common constructs., Results: The subscales demonstrate similar psychometric measures to those reported by developers. The PCAT-S First-Contact Utilization subscale does not fit the accessibility construct. The remaining three subscales load reasonably onto a single factor, presumed to be accessibility, but the best-fitting model has two factors: "timeliness of obtaining needed care" (PCAT-S First-Contact Access, some EUROPEP-I items) and "how resources are organized to accommodate clients" (PCAS Organizational Access and most of EUROPEP-I organization of care). Items in the PCAS and PCAT-S subscales have good discriminability., Conclusion: Only three of the four subscales measure accessibility; all are appropriate for use in Canada. The PCAT-S First-Contact Access subscale is the best measure for first-contact accessibility, and PCAS Organizational Accessibility has good metric properties and measures for accommodation.

Unlabelled: Evaluating the extent to which groups or subgroups of individuals differ with respect to primary healthcare experience depends on first ruling out the possibility of bias., Objective: To determine whether item or subscale performance differs systematically between French/English, high/low education subgroups and urban/rural residency., Method: A sample of 645 adult users balanced by French/English language (in Quebec and Nova Scotia, respectively), high/low education and urban/rural residency responded to six validated instruments: the Primary Care Assessment Survey (PCAS); the Primary Care Assessment Tool - Short Form (PCAT-S); the Components of Primary Care Index (CPCI); the first version of the EUROPEP (EUROPEP-I); the Interpersonal Processes of Care Survey, version II (IPC-II); and part of the Veterans Affairs National Outpatient Customer Satisfaction Survey (VANOCSS). We normalized subscale scores to a 0-to-10 scale and tested for between-group differences using ANOVA tests. We used a parametric item response model to test for differences between subgroups in item discriminability and item difficulty. We re-examined group differences after removing items with differential item functioning., Results: Experience of care was assessed more positively in the English-speaking (Nova Scotia) than in the French-speaking (Quebec) respondents. We found differential English/French item functioning in 48% of the 153 items: discriminability in 20% and differential difficulty in 28%. English items were more discriminating generally than the French. Removing problematic items did not change the differences in French/English assessments. Differential item functioning by high/low education status affected 27% of items, with items being generally more discriminating in high-education groups. Between-group comparisons were unchanged. In contrast, only 9% of items showed differential item functioning by geography, affecting principally the accessibility attribute. Removing problematic items reversed a previously non-significant finding, revealing poorer first-contact access in rural than in urban areas., Conclusion: Differential item functioning does not bias or invalidate French/English comparisons on subscales, but additional development is required to make French and English items equivalent. These instruments are relatively robust by educational status and geography, but results suggest potential differences in the underlying construct in low-education and rural respondents.

Unlabelled: The operational definition of interpersonal communication is "the ability of the provider to elicit and understand patient concerns, to explain healthcare issues and to engage in shared decision-making if desired.", Objective: To examine how well interpersonal communication is captured in validated instruments that evaluate primary healthcare from the patient's perspective., Method: 645 adults with at least one healthcare contact in the previous 12 months responded to instruments that evaluate primary healthcare. Eight subscales measure interpersonal communication: the Primary Care Assessment Survey (PCAS, two subscales); the Components of Primary Care Index (CPCI, one subscale); the first version of the EUROPEP (EUROPEP-I); and the Interpersonal Processes of Care Survey, version II (IPC-II, four subscales). Scores were normalized for descriptive comparison. Exploratory and confirmatory (structural equation) factor analysis examined fit to operational definition, and item response theory analysis examined item performance., Results: Items not pertaining to interpersonal communication were removed from the EUROPEP-I. Most subscales are skewed positively. Normalized mean scores are similar across subscales except for IPC-II Patient-Centred Decision-Making and IPC-II Hurried Communication. All subscales load reasonably well on a single factor, presumed to be interpersonal communication. The best model has three underlying factors corresponding to eliciting (eigenvalue = 26.56), explaining (eigenvalue = 2.45) and decision-making (eigenvalue = 1.34). Both the PCAS Communication and the EUROPEP-I Clinical Behaviour subscales capture all three dimensions. Individual subscales within IPC-II measure each sub-dimension., Conclusion: The operational definition is well reflected in the available measures, although shared decision-making is poorly represented. These subscales can be used with confidence in the Canadian context to measure this crucial aspect of patient-centred care.

Unlabelled: Management continuity, operationally defined as "the extent to which services delivered by different providers are timely and complementary such that care is experienced as connected and coherent," is a core attribute of primary healthcare. Continuity, as experienced by the patient, is the result of good care coordination or integration., Objective: To provide insight into how well management continuity is measured in validated coordination or integration subscales of primary healthcare instruments., Method: Relevant subscales from the Primary Care Assessment Survey (PCAS), the Primary Care Assessment Tool - Short Form (PCAT-S), the Components of Primary Care Instrument (CPCI) and the Veterans Affairs National Outpatient Customer Satisfaction Survey (VANOCSS) were administered to 432 adult respondents who had at least one healthcare contact with a provider other than their family physician in the previous 12 months. Subscales were examined descriptively, by correlation and factor analysis and item response theory analysis. Because the VANOCSS elicits coordination problems and is scored dichotomously, we used logistic regression to examine how evaluative subscales relate to reported problems., Results: Most responses to the PCAS, PCAT-S and CPCI subscales were positive, yet 83% of respondents reported having one or more problems on the VANOCSS Overall Coordination subscale and 41% on the VANOCSS Specialist Access subscale. Exploratory factor analysis suggests two distinct factors. The first (eigenvalue=6.98) is coordination actions by the primary care physician in transitioning patient care to other providers (PCAS Integration subscale and most of the PCAT-S Coordination subscale). The second (eigenvalue=1.20) is efforts by the primary care physician to create coherence between different visits both within and outside the regular doctor's office (CPCI Coordination subscale). The PCAS Integration subscale was most strongly associated with lower likelihood of problems reported on the VANOCSS subscales., Conclusion: Ratings of management continuity correspond only modestly to reporting of coordination problems, possibly because they rate only the primary care physician, whereas patients experience problems across the entire system. The subscales were developed as measures of integration and provider coordination and do not capture the patient's experience of connectedness and coherence.