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Primary care patient experience and cancer screening uptake among women: an exploratory cross-sectional study in a Japanese population

Primary care patient experience and cancer screening uptake among women: an exploratory... Background: Patient experience and clinical quality, which are represented by preventive care measures such as cancer screening, are both widely used for the evaluation of primary care quality. The aim of this study was to examine the association between patient experience and cancer screening uptake among women in a Japanese population. Methods: We conducted a cross-sectional mail survey. The questionnaire was sent to 1000 adult female residents randomly selected from a basic resident register in Yugawara town, Kanagawa, Japan. We assessed patient experience of primary care using a Japanese version of Primary Care Assessment Tool (JPCAT ) and uptake of breast and cervical cancer screening. Results: The overall response rate was 46.5%. Data were analyzed for 190 female participants aged 21–74 years who had a usual source of primary care. Multivariate logistic regression analyses revealed that the JPCAT total score was significantly associated with uptake of breast cancer screening [odds ratio (OR) per 1 standard deviation increase = 1.63; 95% CI 1.11–2.41], but not with uptake of cervical cancer screening (OR per 1 standard deviation increase = 1.47; 95% CI 0.97–2.24). Conclusions: Patient experience of primary care was associated with uptake of breast cancer screening among Japanese women. The results of our study might support the argument that patient experience of primary care and the clinical process of preventive care, such as breast cancer screening, are linked. Keywords: Early detection of cancer, Patient experience, Primary health care, Process assessment (health care), Women’s health services assessment of quality of care by inquiring of patients Background about perceptions and events in the process of care, In recent years, patient experience has attracted a lot and has been increasingly used to assess the quality of of attention as one of the three pillars of quality health primary care and hospital care in many countries [2]. care, alongside clinical quality and patient safety [1]. According to previous studies, patient experience affects Patient experience is the most effective measure of health outcomes through patient behavior such as adher- patient-centeredness, which is defined as providing care ence to treatment and healthcare resource use [3, 4]. that is respectful of and responsive to patient prefer- It is no wonder that clinical quality is also a crucial ences, needs, and values. This method enables objective aspect of healthcare quality. One of the important clinical processes in primary care is preventive care, such as can- *Correspondence: taku5924@gmail.com cer screening. However, in Japan, low cancer screening Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Yoshida-Konoe-cho, uptake rates have been recognized as a big issue, particu- Sakyo-ku, Kyoto, Kyoto Prefecture 606-8501, Japan larly in women. The breast and cervical cancer screening Full list of author information is available at the end of the article © The Author(s) 2017. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/ publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Aoki and Inoue Asia Pac Fam Med (2017) 16:3 Page 2 of 7 rates are still 43.4 and 42.1%, respectively, which are structure, employment was provided by primary indus- lower than the rates in other OECD countries [5–7], try for 3.4%, secondary industry for 17.4%, and tertiary although incidences of the breast and cervical cancer industry for 79.1%. have progressively increased. In Japan, the 2012 age- Of the potential participants, eligible participants were standardized incidence rates for the breast and cervical women aged 21–74  years who had at least one usual cancer were 64.3 and 24.0 per 100,000 women, respec- source of care (USC). We defined the eligible age range to tively [8]. cover the recommended age groups for both breast and The Japanese unique primary care delivery system is cervical cancer screening (breast cancer screening: aged one of the possible causes of the low cancer screening 50–74 years; cervical cancer screening: aged 21–65 years) uptake among women. In Japan, primary care is typically by Japanese guidelines for breast and cervical can- delivered by specialists, who switch from hospital-based cer screening [13, 14], and recommendations from the specialty practice to mixed primary/specialty care outpa- United States Preventive Services Task Force (USPSTF) tient practice without emphasis on training for preven- [15]. For this study, we used the same three questions and tive care. Thus, generally, primary care providers, except the algorithm in the JPCAT [16] as an original Primary for gynecologists, do not directly participate in breast Care Assessment Tool adult expanded version (PCAT- and cervical cancer screening tests. However, there is no AE) [17] to identify an individual’s USC and the strength doubt that all primary care physicians should have a role of that affiliation: (1) Is there a doctor that you usually go in promoting cancer prevention activities for women in if you are sick or need advice about your health? (usual Japan as women have greater access to their primary care source); (2) Is there a doctor that knows you best as a per- physician than any other physicians, and primary care son? (knows best); and (3) Is there a doctor that is most physicians usually have a trusted and valued relationship responsible for your health care? (most responsible). A with patients [9]. participant was considered to have a USC if she answered Previous findings from other countries revealed that positively to any one of the three questions. patient experience correlates with the clinical process of We sent a self-administered questionnaire to total care for prevention and disease management in primary 1000 randomly selected adult women from the registers care settings [10, 11]. Therefore, it is increasingly impor - of sampling site. The data were collected between July tant to recognize the association between patient experi- and August 2015. Four weeks after the initial mailing, ence and other aspects of healthcare quality represented a reminder was sent out to increase the response rate. by clinical quality in order to improve our understand- Regardless of whether the participants responded to the ing of the quality of healthcare. However, it is unclear survey, they were given small gifts worth 200 JPY. whether there is a similar association between patient experience and clinical quality in the Japanese setting. In this study, we specifically aimed to investigate the asso - Measures ciation between patient experience of primary care and Patient experience of primary care uptake of breast and cervical cancer screening among We used the JPCAT [16] for data collection (Additional Japanese women. file  1). The JPCAT was based on the PCAT-AE [17], which was developed by Johns Hopkins Primary Care Policy Center, to measure the quality of primary care Methods using patient experience in Japan. This 29-item tool com - We conducted a cross-sectional study to examine the prises six multi-item subscales representing five primary association between patient experience of primary care care principles: first contact, longitudinally, coordination, and cancer screening uptake among women. Ethical comprehensiveness, and community orientation [18]. approval was obtained from Hamamatsu University of The JPCAT scoring system is structured as follows: each author’s former affiliation (approval number E15-089). response on a five-point Likert scale is reduced by a fac - tor of 1 and multiplied by 25. The score for each of the Subjects domains is computed as the mean value for all converted Potential study participants were randomly selected from scale scores in that domain. Thus the domain scores adult female residents in Yugawara Town in Kanagawa range from 0 to 100 points, with higher scores indicat- Prefecture, Japan, by using systematic random sampling ing better performance. The total score is the mean of from a basic resident register. Yugawara Town is located six domain scores and reflects an overall measure of the in the southern part of the Kanto area of eastern Japan. quality of core primary care principles. Previous work The total population of Yugawara Town was 26,442 has shown that the JPCAT has good reliability and valid- according to the 2015 population census [12], with 35.8% ity [16]. of residents ≧65  years old. In terms of occupational Aoki and Inoue Asia Pac Fam Med (2017) 16:3 Page 3 of 7 Uptake of cancer screening regression model (0–5.1% missing data); therefore, we The primary outcome measures in this study were performed complete case analyses. uptake of breast and cervical cancer screening. Female According to the sample size formula shown in a pre- participants answered questions about their breast and vious study, events per variable values of  ≥10 were nec- cervical cancer screening histories. According to Japa- essary for logistic regression analysis [19]. We estimated nese guidelines for breast and cervical cancer screening a minimum sample size of 125 because the maximum [13, 14], and recommendations from the USPSTF [15], number of variables was five in this study, and the pro - uptake of cancer screening was defined as completion portion of cancer screening uptake within the last 2 years of screening test within the last 2 years of the study in our target population was assessed to be 0.40 accord- period. Uptake of breast cancer screening was derived ing to the 2013 Japanese comprehensive survey of living from the question “Have you completed breast cancer conditions [7]. We used SPSS version 23 for statistical screening test within the last 2 years?” Similarly, uptake analyses. of cervical cancer screening was derived from the question “Have you completed cervical cancer screen- Results ing test within the last 2 years?” Female participants A total of 465 (46.5%) individuals responded to the answered the questions on binary scale (“yes” or “no”). mail survey. In the responses, we excluded participants aged <21 or >74 years, and participants who did not have a USC. We performed analyses of the 190 participants with complete data for the variables (Fig. 1). Covariates Table  1 shows the individual characteristics of the 190 Covariates were selected on the basis of a literature eligible participants surveyed. Among the participants, review to identify factors that may confound the asso- 47.9% were found to be aged  ≥65, and 55.8% of partici- ciation between patient experience and cancer screen- pants had no college education. The proportion of par - ing uptake. We included covariates for age, years of ticipants who underwent breast and cervical cancer education, household income, and self-rated health. All screening within 2 years were both 43.2%. covariates, except for age, were evaluated as categorical Table  2 shows the mean and standard deviation of the variables by a self-administered questionnaire. JPCAT scores. The average JPCAT total score was 52.3 out of 100 points; the most highly scored domain was longitudinally (65.7), and the most poorly scored domain Analyses was comprehensiveness (services provided) (37.2). The Descriptive statistics were obtained for the character- univariate associations between patient experience of istics of the female respondents and the JPCAT scores. primary care and outcomes are also shown in Table  2. According to Japanese guidelines [13, 14] and recom- The JPCAT total score was significantly associated with mendations from the USPSTF [15], responses from women aged 50–74 years were analyzed for breast can- cer screening uptake, and responses from women aged 21–65  years were analyzed for cervical cancer screen- ing uptake. We defined the eligible age ranges, which Randomly selected women aged 20 to 80 years in the sampling site are the recommended age groups for screening by (N = 1,000) both Japanese and the USPSTF guidelines. Unadjusted association between the JPCAT total score and cancer Did not respond (N = 535) screening uptake was analyzed by the Student’s t test. To determine whether the JPCAT total score was asso- Respondents (N = 465) ciated with cancer screening uptake, we used multivari- Excluded for age < 21 or > 74 years ate logistic regression analysis. The following possible (N = 61) confounders were included in the analysis: age, years Eligible participants (N = 404) of education, household income, and self-rated health. Excluded for not having USC We had two primary outcomes; therefore, we used a (N = 197) Bonferroni correction to control type I error, and only Participants having USC (N = 207) those associations with P  <  0.025 were considered to be significant. In addition, we performed exploratory Excluded for missing data (N = 17) analyses of the cancer screening uptake in relation to Participants in analyses (N = 190) each domain score of the JPCAT. Missing data were Fig. 1 Participant flow chart. USC usual source of care uncommon for independent variables included in the Aoki and Inoue Asia Pac Fam Med (2017) 16:3 Page 4 of 7 Table 1 Participants’ characteristics (N = 190) Table  3 shows the results of the multivariate logistic regression analyses modeling the association between Characteristic Number (%) patient experience of primary care and uptake of breast Age (years) cancer screening. We used responses from women aged 21–49 35 (18.4) 50–74  years for the analyses. After adjustment for pos- 50–64 64 (33.7) sible confounders, the JPCAT total score was positively 65–74 91 (47.9) associated with uptake of breast cancer screening [odds Education ratio (OR) per 1 standard deviation increase = 1.63; 95% Less than high school 25 (13.2) CI 1.11–2.41]. Community orientation had the strongest High school 81 (42.6) association with uptake of breast cancer screening (OR Junior college 63 (33.2) per 1 standard deviation increase  =  1.80; 95% CI 1.18– More than or equal to college 21 (11.1) 2.70), followed by coordination (OR per 1 standard devia- Annual household income (million JPY ) tion increase = 1.57; 95% CI 1.08–2.27). <2.00 (≒18,000 US dollar) 49 (25.8) Table  4 shows the results of the multivariate logistic 2.00–4.99 100 (52.6) regression analyses modeling the association between ≧5.00 41 (21.6) patient experience of primary care and uptake of cervical Self-rated health cancer screening. We used responses from women aged Very good 25 (13.2) 21–65 years for the analyses. In contrast with the results Good 45 (23.7) of breast cancer screening, the JPCAT total score was not Neutral 66 (34.7) significantly associated with uptake of cervical cancer Poor 44 (23.2) screening (OR per 1 standard deviation increase =  1.47; Very poor 10 (5.3) 95% CI 0.97–2.24). None of the domains of the JPCAT Breast cancer screening except for coordination were significantly associated with Uptake within 2 years 82 (43.2) uptake of cervical cancer screening. Cervical cancer screening Uptake within 2 years 82 (43.2) Discussion Our results revealed that patient experience of primary uptake of breast cancer screening (P = 0.008), and com- care was associated with uptake of breast cancer screen- munity orientation domain score was associated with ing among Japanese women. This association persisted uptake of breast cancer screening. However, the associa- after adjustment for possible confounders. In addition, tion between the JPCAT total score and uptake of cervi- associations with breast cancer screening uptake were cal cancer screening was not statistically significant. statistically significant for the coordination domain Table 2 Distribution of JPCAT, and unadjusted correlation with breast and cervical cancer screening uptake b d c d Scale Total (N = 190) Breast cancer screening (N = 155) P value Cervical cancer screening (N = 111) P value Uptake (N = 64) Non-uptake (N = 91) Uptake (N = 61) Non-uptake (N = 50) JPCAT Total score 52.3 (15.6) 58.4 (15.7) 51.9 (14.1) 0.008 53.7 (16.8) 49.9 (14.6) 0.238 First contact 46.3 (25.5) 52.9 (22.9) 50.4 (24.0) 0.514 43.9 (26.8) 43.3 (25.1) 0.912 Longitudinality 65.7 (18.4) 70.0 (17.1) 65.0 (19.1) 0.096 65.6 (18.2) 64.6 (20.0) 0.782 Coordination 57.7 (25.3) 64.8 (24.3) 58.1 (24.2) 0.096 58.2 (29.7) 51.7 (21.2) 0.196 Comprehensiveness 56.9 (23.7) 60.2 (22.4) 54.5 (23.6) 0.132 59.9 (25.0) 55.4 (25.3) 0.349 (services available) Comprehensiveness 37.2 (26.7) 43.3 (28.4) 35.0 (24.3) 0.055 44.1 (29.2) 36.6 (26.3) 0.167 (services provided) Community 49.6 (21.2) 58.3 (21.1) 48.4 (19.1) 0.003 49.2 (22.5) 46.9 (21.8) 0.586 orientation JPCAT Japanese version of Primary Care Assessment Tool Mean (SD) Used responses from women aged 50–74 years Used responses from women aged 21–65 years P value by t test Aoki and Inoue Asia Pac Fam Med (2017) 16:3 Page 5 of 7 Table 3 Factors associated with  breast cancer screening providers and specialists including gynecologists may be uptake (N = 155) effective in encouraging breast cancer screening in Japan, b reflecting a unique primary care delivery system. Scale aOR (95% CI) P value Community-oriented primary care (COPC) is a con- JPCAT tinuous process by which primary care is provided to a Total score 1.63 (1.11–2.41) 0.013 defined community on the basis of its assessed health First contact 1.14 (0.77–1.67) 0.486 needs through the planned integration of public health Longitudinality 1.29 (0.90–1.85) 0.173 practice with the delivery of primary care services. This Coordination 1.57 (1.08–2.27) 0.020 link with public health places health promotion and dis- Comprehensiveness (services available) 1.33 (0.91–1.88) 0.141 ease prevention at the forefront of the COPC concept Comprehensiveness (services provided) 1.24 (0.87–1.79) 0.232 [22]. In concordance with this concept of COPC, we Community orientation 1.80 (1.18–2.70) 0.006 found that the community orientation domain of the JPCAT Japanese version of Primary Care Assessment Tool, aOR adjusted odds JPCAT was significantly associated with uptake of breast ratio cancer screening. Used responses from women aged 50–74 years. Adjusted for age, years of In contrast to the results of breast cancer screening, education, annual household income, and self-rated health the association between patient experience and cervical Per 1 standard deviation increase cancer screening was not statistically significant. These results might be caused by the difference in sample size, and also indicate the possibility that primary care pro- Table 4 Factors associated with  cervical cancer screening viders in Japan have not been able to sufficiently dem - uptake (N = 111) onstrate their role in younger residents’ preventive Scale aOR (95% CI) P value care activities, in contrast to the case with older resi- JPCAT dents. In concordance with this finding, previous study Total score 1.47 (0.97–2.24) 0.068 showed that many Japan’s primary care physicians have First contact 1.19 (0.75–1.88) 0.435 limited training in preventive care for young women Longitudinality 1.12 (0.76–1.63) 0.587 and few provide it [23]. However, the potential associa- Coordination 1.53 (1.00–2.33) 0.048 tion between contribution of primary care to residents’ Comprehensiveness (services available) 1.13 (0.77–1.64) 0.533 preventive care activities and age group requires fur- Comprehensiveness (services provided) 1.41 (0.95–2.09) 0.090 ther study. This is the first study revealing the association Community orientation 1.31 (0.86–1.99) 0.218 between patient experience and clinical quality repre- JPCAT Japanese version of Primary Care Assessment Tool, aOR adjusted odds ratio sented by the process of preventive care in Japan. Char- Used responses from women aged 21–65 years. Adjusted for age, years of acteristics of the Japanese primary care delivery system education, annual household income, and self-rated health are helpful to reinforce the findings of previous studies Per 1 standard deviation increase about the association between these two domains. The PCAT is an established measure for the evaluation of score and community orientation domain score. By patient experience of primary care internationally, and contrast, patient experience of primary care was not represents the core principles of primary care. significantly associated with uptake of cervical cancer Our study had several potential limitations. First, there screening, although there was a trend for positive asso- was a concern about the low response rate. However, in ciation between them. the case of patient experience surveys, there is little evi- Previous studies from other countries showed that dence that a low response rate introduces selective non- patient experience was associated with clinical quality response bias [24]. Second, although self-reported survey including cancer screening in primary care [10, 20, 21]. is a useful method for evaluating uptake of cancer screen- However, these findings were from settings in which pri - ing in population-based studies [25], recall bias may be mary care providers directly participate in breast and a factor in this type of survey. For example, participants cervical cancer screening tests, unlike Japan. The results who have good patient experience possibly over-report of our study could act as an extension of the research preventive care activities. Social desirability bias might findings on the association between patient experience also limit the study if such participants responded more and clinical process of preventive care. In addition, the favorably than others and overreported uptake of cancer coordination domain of the JPCAT was associated with screening. Third, we could not assess unnecessary can - breast cancer screening uptake in this study. This finding cer screening according to the guidelines as a marker of suggests that better coordination between primary care lower clinical quality in this study. Fourth, the data were Aoki and Inoue Asia Pac Fam Med (2017) 16:3 Page 6 of 7 Funding cross-sectional and a causal relationship between patient This work was supported by the Japan Science and Technology Agency, experience of primary care and uptake of cancer screen- Research Institute of Science and Technology for Society, Designing a Sustain- ing cannot be definitely established. Fifth, this study pop - able Society through Intergenerational Co-creation, Evaluation of Eec ff tive - ness of Intergenerational Co-creative Community on ME-BYO (Project Director: ulation covered only restricted rural area in Japan, thus Kenji Watanabe). our study may have limited external validity. Received: 13 September 2016 Accepted: 2 February 2017 Conclusions We found that patient experience of primary care was associated with uptake of breast cancer screening among women in the Japanese setting. The results of our study might support the argument that patient experience of References primary care and the clinical process of preventive care, 1. Institute of Medicine. Committee on quality of health care in America. Crossing the quality chasm: a new health system for the 21st century. such as breast cancer screening, are linked. Washington DC: National Academies Press; 2001. 2. Browne K, Roseman D, Shaller D, Edgman-Levitan S. Analysis & commen- Additional file tary measuring patient experience as a strategy for improving primary care. Health A. 2010;29:921–5. ff 3. Lee Y-Y, Lin JL. The effects of trust in physician on self-efficacy, adherence Additional file 1. Item contents of the Japanese version of Primary Care and diabetes outcomes. Soc Sci Med. 2009;68:1060–8. Assessment Tool. 4. Little P, Everitt H, Williamson I, Warner G, Moore M, Gould C, et al. Obser- vational study of effect of patient centredness and positive approach on outcomes of general practice consultations. BMJ. 2001;323:908–11. Abbreviations 5. Saika K, Sobue T. Time trends in breast cancer screening rates in the JPCAT: Japanese version of Primary Care Assessment Tool; USC: usual source of OECD countries. Jpn J Clin Oncol. 2011;41:591–2. care; PCAT-AE: Primary Care Assessment Tool adult expanded version; USPSTF: 6. Machii R, Saito H. Time trends in cervical cancer screening rates in the United States Preventive Services Task Force; OR: odds ratio; COPC: commu- OECD countries. Jpn J Clin Oncol. 2011;41:731–2. nity-oriented primary care. 7. Ministry of Health, Labor and welfare of Japan. 2013 Japanese compre- hensive survey of living conditions. 2013. http://www.mhlw.go.jp/toukei/ Authors’ contributions saikin/hw/k-tyosa/k-tyosa13/dl/04.pdf. Accessed 3 Aug 2016. TA participated in the proposal’s design, conducted the analyses, and drafted 8. Center for Cancer Control and Information Services, National Cancer and completed the manuscript. MI participated in the proposal’s design and Center, Japan. statistics. 2015. http://ganjoho.jp/reg_stat/statistics/index. data collection, and drafted and reviewed the manuscript. Both authors read html. Accessed 3 Aug 2016. and approved the final manuscript. 9. Jr Avery Daniel MA. Family physician’s role in the prevention, diagnosis, and management of breast cancer. Am J Clin Med. 2010;7:76–9. Author details 10. Sequist TD, Schneider EC, Anastario M, Odigie EG, Marshall R, Rogers WH, Department of Healthcare Epidemiology, School of Public Health in the et al. Quality monitoring of physicians: linking patients’ experiences of Graduate School of Medicine, Kyoto University, Yoshida-Konoe-cho, Sakyo-ku, care to clinical quality and outcomes. J Gen Intern Med. 2008;23:1784–90. Kyoto, Kyoto Prefecture 606-8501, Japan. Division of General Medicine 11. Llanwarne NR, Abel GA, Elliott MN, Paddison CA, Lyratzopoulos G, Camp- and Primary Care, Beth Israel Deaconess Medical Center, Harvard Medical bell JL, et al. Relationship between clinical quality and patient experience: School, 330 Brookline Avenue, Boston, MA 02215, USA. Department of Fam- analysis of data from the english quality and outcomes framework and ily and Community Medicine, Hamamatsu University School of Medicine, the National GP Patient Survey. Ann Fam Med. 2013;11:467–72. 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Primary care patient experience and cancer screening uptake among women: an exploratory cross-sectional study in a Japanese population

Asia Pacific Family Medicine , Volume 16 (1) – Feb 7, 2017

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Springer Journals
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Copyright © 2017 by The Author(s)
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Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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10.1186/s12930-017-0033-7
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Abstract

Background: Patient experience and clinical quality, which are represented by preventive care measures such as cancer screening, are both widely used for the evaluation of primary care quality. The aim of this study was to examine the association between patient experience and cancer screening uptake among women in a Japanese population. Methods: We conducted a cross-sectional mail survey. The questionnaire was sent to 1000 adult female residents randomly selected from a basic resident register in Yugawara town, Kanagawa, Japan. We assessed patient experience of primary care using a Japanese version of Primary Care Assessment Tool (JPCAT ) and uptake of breast and cervical cancer screening. Results: The overall response rate was 46.5%. Data were analyzed for 190 female participants aged 21–74 years who had a usual source of primary care. Multivariate logistic regression analyses revealed that the JPCAT total score was significantly associated with uptake of breast cancer screening [odds ratio (OR) per 1 standard deviation increase = 1.63; 95% CI 1.11–2.41], but not with uptake of cervical cancer screening (OR per 1 standard deviation increase = 1.47; 95% CI 0.97–2.24). Conclusions: Patient experience of primary care was associated with uptake of breast cancer screening among Japanese women. The results of our study might support the argument that patient experience of primary care and the clinical process of preventive care, such as breast cancer screening, are linked. Keywords: Early detection of cancer, Patient experience, Primary health care, Process assessment (health care), Women’s health services assessment of quality of care by inquiring of patients Background about perceptions and events in the process of care, In recent years, patient experience has attracted a lot and has been increasingly used to assess the quality of of attention as one of the three pillars of quality health primary care and hospital care in many countries [2]. care, alongside clinical quality and patient safety [1]. According to previous studies, patient experience affects Patient experience is the most effective measure of health outcomes through patient behavior such as adher- patient-centeredness, which is defined as providing care ence to treatment and healthcare resource use [3, 4]. that is respectful of and responsive to patient prefer- It is no wonder that clinical quality is also a crucial ences, needs, and values. This method enables objective aspect of healthcare quality. One of the important clinical processes in primary care is preventive care, such as can- *Correspondence: taku5924@gmail.com cer screening. However, in Japan, low cancer screening Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Yoshida-Konoe-cho, uptake rates have been recognized as a big issue, particu- Sakyo-ku, Kyoto, Kyoto Prefecture 606-8501, Japan larly in women. The breast and cervical cancer screening Full list of author information is available at the end of the article © The Author(s) 2017. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/ publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Aoki and Inoue Asia Pac Fam Med (2017) 16:3 Page 2 of 7 rates are still 43.4 and 42.1%, respectively, which are structure, employment was provided by primary indus- lower than the rates in other OECD countries [5–7], try for 3.4%, secondary industry for 17.4%, and tertiary although incidences of the breast and cervical cancer industry for 79.1%. have progressively increased. In Japan, the 2012 age- Of the potential participants, eligible participants were standardized incidence rates for the breast and cervical women aged 21–74  years who had at least one usual cancer were 64.3 and 24.0 per 100,000 women, respec- source of care (USC). We defined the eligible age range to tively [8]. cover the recommended age groups for both breast and The Japanese unique primary care delivery system is cervical cancer screening (breast cancer screening: aged one of the possible causes of the low cancer screening 50–74 years; cervical cancer screening: aged 21–65 years) uptake among women. In Japan, primary care is typically by Japanese guidelines for breast and cervical can- delivered by specialists, who switch from hospital-based cer screening [13, 14], and recommendations from the specialty practice to mixed primary/specialty care outpa- United States Preventive Services Task Force (USPSTF) tient practice without emphasis on training for preven- [15]. For this study, we used the same three questions and tive care. Thus, generally, primary care providers, except the algorithm in the JPCAT [16] as an original Primary for gynecologists, do not directly participate in breast Care Assessment Tool adult expanded version (PCAT- and cervical cancer screening tests. However, there is no AE) [17] to identify an individual’s USC and the strength doubt that all primary care physicians should have a role of that affiliation: (1) Is there a doctor that you usually go in promoting cancer prevention activities for women in if you are sick or need advice about your health? (usual Japan as women have greater access to their primary care source); (2) Is there a doctor that knows you best as a per- physician than any other physicians, and primary care son? (knows best); and (3) Is there a doctor that is most physicians usually have a trusted and valued relationship responsible for your health care? (most responsible). A with patients [9]. participant was considered to have a USC if she answered Previous findings from other countries revealed that positively to any one of the three questions. patient experience correlates with the clinical process of We sent a self-administered questionnaire to total care for prevention and disease management in primary 1000 randomly selected adult women from the registers care settings [10, 11]. Therefore, it is increasingly impor - of sampling site. The data were collected between July tant to recognize the association between patient experi- and August 2015. Four weeks after the initial mailing, ence and other aspects of healthcare quality represented a reminder was sent out to increase the response rate. by clinical quality in order to improve our understand- Regardless of whether the participants responded to the ing of the quality of healthcare. However, it is unclear survey, they were given small gifts worth 200 JPY. whether there is a similar association between patient experience and clinical quality in the Japanese setting. In this study, we specifically aimed to investigate the asso - Measures ciation between patient experience of primary care and Patient experience of primary care uptake of breast and cervical cancer screening among We used the JPCAT [16] for data collection (Additional Japanese women. file  1). The JPCAT was based on the PCAT-AE [17], which was developed by Johns Hopkins Primary Care Policy Center, to measure the quality of primary care Methods using patient experience in Japan. This 29-item tool com - We conducted a cross-sectional study to examine the prises six multi-item subscales representing five primary association between patient experience of primary care care principles: first contact, longitudinally, coordination, and cancer screening uptake among women. Ethical comprehensiveness, and community orientation [18]. approval was obtained from Hamamatsu University of The JPCAT scoring system is structured as follows: each author’s former affiliation (approval number E15-089). response on a five-point Likert scale is reduced by a fac - tor of 1 and multiplied by 25. The score for each of the Subjects domains is computed as the mean value for all converted Potential study participants were randomly selected from scale scores in that domain. Thus the domain scores adult female residents in Yugawara Town in Kanagawa range from 0 to 100 points, with higher scores indicat- Prefecture, Japan, by using systematic random sampling ing better performance. The total score is the mean of from a basic resident register. Yugawara Town is located six domain scores and reflects an overall measure of the in the southern part of the Kanto area of eastern Japan. quality of core primary care principles. Previous work The total population of Yugawara Town was 26,442 has shown that the JPCAT has good reliability and valid- according to the 2015 population census [12], with 35.8% ity [16]. of residents ≧65  years old. In terms of occupational Aoki and Inoue Asia Pac Fam Med (2017) 16:3 Page 3 of 7 Uptake of cancer screening regression model (0–5.1% missing data); therefore, we The primary outcome measures in this study were performed complete case analyses. uptake of breast and cervical cancer screening. Female According to the sample size formula shown in a pre- participants answered questions about their breast and vious study, events per variable values of  ≥10 were nec- cervical cancer screening histories. According to Japa- essary for logistic regression analysis [19]. We estimated nese guidelines for breast and cervical cancer screening a minimum sample size of 125 because the maximum [13, 14], and recommendations from the USPSTF [15], number of variables was five in this study, and the pro - uptake of cancer screening was defined as completion portion of cancer screening uptake within the last 2 years of screening test within the last 2 years of the study in our target population was assessed to be 0.40 accord- period. Uptake of breast cancer screening was derived ing to the 2013 Japanese comprehensive survey of living from the question “Have you completed breast cancer conditions [7]. We used SPSS version 23 for statistical screening test within the last 2 years?” Similarly, uptake analyses. of cervical cancer screening was derived from the question “Have you completed cervical cancer screen- Results ing test within the last 2 years?” Female participants A total of 465 (46.5%) individuals responded to the answered the questions on binary scale (“yes” or “no”). mail survey. In the responses, we excluded participants aged <21 or >74 years, and participants who did not have a USC. We performed analyses of the 190 participants with complete data for the variables (Fig. 1). Covariates Table  1 shows the individual characteristics of the 190 Covariates were selected on the basis of a literature eligible participants surveyed. Among the participants, review to identify factors that may confound the asso- 47.9% were found to be aged  ≥65, and 55.8% of partici- ciation between patient experience and cancer screen- pants had no college education. The proportion of par - ing uptake. We included covariates for age, years of ticipants who underwent breast and cervical cancer education, household income, and self-rated health. All screening within 2 years were both 43.2%. covariates, except for age, were evaluated as categorical Table  2 shows the mean and standard deviation of the variables by a self-administered questionnaire. JPCAT scores. The average JPCAT total score was 52.3 out of 100 points; the most highly scored domain was longitudinally (65.7), and the most poorly scored domain Analyses was comprehensiveness (services provided) (37.2). The Descriptive statistics were obtained for the character- univariate associations between patient experience of istics of the female respondents and the JPCAT scores. primary care and outcomes are also shown in Table  2. According to Japanese guidelines [13, 14] and recom- The JPCAT total score was significantly associated with mendations from the USPSTF [15], responses from women aged 50–74 years were analyzed for breast can- cer screening uptake, and responses from women aged 21–65  years were analyzed for cervical cancer screen- ing uptake. We defined the eligible age ranges, which Randomly selected women aged 20 to 80 years in the sampling site are the recommended age groups for screening by (N = 1,000) both Japanese and the USPSTF guidelines. Unadjusted association between the JPCAT total score and cancer Did not respond (N = 535) screening uptake was analyzed by the Student’s t test. To determine whether the JPCAT total score was asso- Respondents (N = 465) ciated with cancer screening uptake, we used multivari- Excluded for age < 21 or > 74 years ate logistic regression analysis. The following possible (N = 61) confounders were included in the analysis: age, years Eligible participants (N = 404) of education, household income, and self-rated health. Excluded for not having USC We had two primary outcomes; therefore, we used a (N = 197) Bonferroni correction to control type I error, and only Participants having USC (N = 207) those associations with P  <  0.025 were considered to be significant. In addition, we performed exploratory Excluded for missing data (N = 17) analyses of the cancer screening uptake in relation to Participants in analyses (N = 190) each domain score of the JPCAT. Missing data were Fig. 1 Participant flow chart. USC usual source of care uncommon for independent variables included in the Aoki and Inoue Asia Pac Fam Med (2017) 16:3 Page 4 of 7 Table 1 Participants’ characteristics (N = 190) Table  3 shows the results of the multivariate logistic regression analyses modeling the association between Characteristic Number (%) patient experience of primary care and uptake of breast Age (years) cancer screening. We used responses from women aged 21–49 35 (18.4) 50–74  years for the analyses. After adjustment for pos- 50–64 64 (33.7) sible confounders, the JPCAT total score was positively 65–74 91 (47.9) associated with uptake of breast cancer screening [odds Education ratio (OR) per 1 standard deviation increase = 1.63; 95% Less than high school 25 (13.2) CI 1.11–2.41]. Community orientation had the strongest High school 81 (42.6) association with uptake of breast cancer screening (OR Junior college 63 (33.2) per 1 standard deviation increase  =  1.80; 95% CI 1.18– More than or equal to college 21 (11.1) 2.70), followed by coordination (OR per 1 standard devia- Annual household income (million JPY ) tion increase = 1.57; 95% CI 1.08–2.27). <2.00 (≒18,000 US dollar) 49 (25.8) Table  4 shows the results of the multivariate logistic 2.00–4.99 100 (52.6) regression analyses modeling the association between ≧5.00 41 (21.6) patient experience of primary care and uptake of cervical Self-rated health cancer screening. We used responses from women aged Very good 25 (13.2) 21–65 years for the analyses. In contrast with the results Good 45 (23.7) of breast cancer screening, the JPCAT total score was not Neutral 66 (34.7) significantly associated with uptake of cervical cancer Poor 44 (23.2) screening (OR per 1 standard deviation increase =  1.47; Very poor 10 (5.3) 95% CI 0.97–2.24). None of the domains of the JPCAT Breast cancer screening except for coordination were significantly associated with Uptake within 2 years 82 (43.2) uptake of cervical cancer screening. Cervical cancer screening Uptake within 2 years 82 (43.2) Discussion Our results revealed that patient experience of primary uptake of breast cancer screening (P = 0.008), and com- care was associated with uptake of breast cancer screen- munity orientation domain score was associated with ing among Japanese women. This association persisted uptake of breast cancer screening. However, the associa- after adjustment for possible confounders. In addition, tion between the JPCAT total score and uptake of cervi- associations with breast cancer screening uptake were cal cancer screening was not statistically significant. statistically significant for the coordination domain Table 2 Distribution of JPCAT, and unadjusted correlation with breast and cervical cancer screening uptake b d c d Scale Total (N = 190) Breast cancer screening (N = 155) P value Cervical cancer screening (N = 111) P value Uptake (N = 64) Non-uptake (N = 91) Uptake (N = 61) Non-uptake (N = 50) JPCAT Total score 52.3 (15.6) 58.4 (15.7) 51.9 (14.1) 0.008 53.7 (16.8) 49.9 (14.6) 0.238 First contact 46.3 (25.5) 52.9 (22.9) 50.4 (24.0) 0.514 43.9 (26.8) 43.3 (25.1) 0.912 Longitudinality 65.7 (18.4) 70.0 (17.1) 65.0 (19.1) 0.096 65.6 (18.2) 64.6 (20.0) 0.782 Coordination 57.7 (25.3) 64.8 (24.3) 58.1 (24.2) 0.096 58.2 (29.7) 51.7 (21.2) 0.196 Comprehensiveness 56.9 (23.7) 60.2 (22.4) 54.5 (23.6) 0.132 59.9 (25.0) 55.4 (25.3) 0.349 (services available) Comprehensiveness 37.2 (26.7) 43.3 (28.4) 35.0 (24.3) 0.055 44.1 (29.2) 36.6 (26.3) 0.167 (services provided) Community 49.6 (21.2) 58.3 (21.1) 48.4 (19.1) 0.003 49.2 (22.5) 46.9 (21.8) 0.586 orientation JPCAT Japanese version of Primary Care Assessment Tool Mean (SD) Used responses from women aged 50–74 years Used responses from women aged 21–65 years P value by t test Aoki and Inoue Asia Pac Fam Med (2017) 16:3 Page 5 of 7 Table 3 Factors associated with  breast cancer screening providers and specialists including gynecologists may be uptake (N = 155) effective in encouraging breast cancer screening in Japan, b reflecting a unique primary care delivery system. Scale aOR (95% CI) P value Community-oriented primary care (COPC) is a con- JPCAT tinuous process by which primary care is provided to a Total score 1.63 (1.11–2.41) 0.013 defined community on the basis of its assessed health First contact 1.14 (0.77–1.67) 0.486 needs through the planned integration of public health Longitudinality 1.29 (0.90–1.85) 0.173 practice with the delivery of primary care services. This Coordination 1.57 (1.08–2.27) 0.020 link with public health places health promotion and dis- Comprehensiveness (services available) 1.33 (0.91–1.88) 0.141 ease prevention at the forefront of the COPC concept Comprehensiveness (services provided) 1.24 (0.87–1.79) 0.232 [22]. In concordance with this concept of COPC, we Community orientation 1.80 (1.18–2.70) 0.006 found that the community orientation domain of the JPCAT Japanese version of Primary Care Assessment Tool, aOR adjusted odds JPCAT was significantly associated with uptake of breast ratio cancer screening. Used responses from women aged 50–74 years. Adjusted for age, years of In contrast to the results of breast cancer screening, education, annual household income, and self-rated health the association between patient experience and cervical Per 1 standard deviation increase cancer screening was not statistically significant. These results might be caused by the difference in sample size, and also indicate the possibility that primary care pro- Table 4 Factors associated with  cervical cancer screening viders in Japan have not been able to sufficiently dem - uptake (N = 111) onstrate their role in younger residents’ preventive Scale aOR (95% CI) P value care activities, in contrast to the case with older resi- JPCAT dents. In concordance with this finding, previous study Total score 1.47 (0.97–2.24) 0.068 showed that many Japan’s primary care physicians have First contact 1.19 (0.75–1.88) 0.435 limited training in preventive care for young women Longitudinality 1.12 (0.76–1.63) 0.587 and few provide it [23]. However, the potential associa- Coordination 1.53 (1.00–2.33) 0.048 tion between contribution of primary care to residents’ Comprehensiveness (services available) 1.13 (0.77–1.64) 0.533 preventive care activities and age group requires fur- Comprehensiveness (services provided) 1.41 (0.95–2.09) 0.090 ther study. This is the first study revealing the association Community orientation 1.31 (0.86–1.99) 0.218 between patient experience and clinical quality repre- JPCAT Japanese version of Primary Care Assessment Tool, aOR adjusted odds ratio sented by the process of preventive care in Japan. Char- Used responses from women aged 21–65 years. Adjusted for age, years of acteristics of the Japanese primary care delivery system education, annual household income, and self-rated health are helpful to reinforce the findings of previous studies Per 1 standard deviation increase about the association between these two domains. The PCAT is an established measure for the evaluation of score and community orientation domain score. By patient experience of primary care internationally, and contrast, patient experience of primary care was not represents the core principles of primary care. significantly associated with uptake of cervical cancer Our study had several potential limitations. First, there screening, although there was a trend for positive asso- was a concern about the low response rate. However, in ciation between them. the case of patient experience surveys, there is little evi- Previous studies from other countries showed that dence that a low response rate introduces selective non- patient experience was associated with clinical quality response bias [24]. Second, although self-reported survey including cancer screening in primary care [10, 20, 21]. is a useful method for evaluating uptake of cancer screen- However, these findings were from settings in which pri - ing in population-based studies [25], recall bias may be mary care providers directly participate in breast and a factor in this type of survey. For example, participants cervical cancer screening tests, unlike Japan. The results who have good patient experience possibly over-report of our study could act as an extension of the research preventive care activities. Social desirability bias might findings on the association between patient experience also limit the study if such participants responded more and clinical process of preventive care. In addition, the favorably than others and overreported uptake of cancer coordination domain of the JPCAT was associated with screening. Third, we could not assess unnecessary can - breast cancer screening uptake in this study. This finding cer screening according to the guidelines as a marker of suggests that better coordination between primary care lower clinical quality in this study. Fourth, the data were Aoki and Inoue Asia Pac Fam Med (2017) 16:3 Page 6 of 7 Funding cross-sectional and a causal relationship between patient This work was supported by the Japan Science and Technology Agency, experience of primary care and uptake of cancer screen- Research Institute of Science and Technology for Society, Designing a Sustain- ing cannot be definitely established. Fifth, this study pop - able Society through Intergenerational Co-creation, Evaluation of Eec ff tive - ness of Intergenerational Co-creative Community on ME-BYO (Project Director: ulation covered only restricted rural area in Japan, thus Kenji Watanabe). our study may have limited external validity. Received: 13 September 2016 Accepted: 2 February 2017 Conclusions We found that patient experience of primary care was associated with uptake of breast cancer screening among women in the Japanese setting. The results of our study might support the argument that patient experience of References primary care and the clinical process of preventive care, 1. Institute of Medicine. Committee on quality of health care in America. Crossing the quality chasm: a new health system for the 21st century. such as breast cancer screening, are linked. Washington DC: National Academies Press; 2001. 2. Browne K, Roseman D, Shaller D, Edgman-Levitan S. 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Asia Pacific Family MedicineSpringer Journals

Published: Feb 7, 2017

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