Measuring patients' attitudes to care across the primary/secondary interface: the development of the patient career diary

Background-A growing number of new ways of organising services across the p rimary/secondary interface are being introduced and evaluated. The principa l motive for such reorganisation is to improve the efficiency of health car e. However, unless the impact of the new services on patients is investigat ed and taken into account, it is possible that patients' reactions could be negative, a factor that could lead to unexpected consequences in the use a nd costs of services. Objective-To develop a measure of patients' attitudes towards care across t he interface between primary and secondary care. Design-Generation of questions to be included in the measure from a qualita tive study of patients' experiences of care across the interface; administr ation of pilot versions of the measure to samples of patients referred to s econdary care; refinement of questions guided by analysis of response patte rns, principal components analysis and internal consistency; administration of the final version of the patient career diary in complete form retrospe ctively to patients referred to secondary we, and one section alone to pati ents attending outpatient departments for follow up appointments. Face vali dity was assessed by analysis of open comments in a sample of 50 diaries, a nd review of the diary by 34 health professionals. Construct validity was a ssessed by investigation of levels of correlation between components of eac h section of the diary and the components of the healthcare section overall . Setting-In the final field test, patients were attending various hospital services, including cardiology, dermatology, neurology, gynaecology, gener al surgery, general medicine, ophthalmology, trauma and orthopaedics, and g astroenterology. Setting-The final version of the diary included 109 questions in seven sect ions: general practitioner (GP) visits and referral, other GP visits, first outpatient visit, other outpatient visits, inpatient stay and discharge, c are after discharge, and care overall. Response rates were poor for retrosp ective completion of the entire diary, but excellent when a section was giv en separately. Principal components analysis confirmed that components rela ting to issues identified as important to patients in the qualitative study had been included in the diary. Levels of internal consistency were good, and comments of patients and health professionals supported validity. Conclusion-The patient career diary is a valid and reliable measure of pati ents' attitudes to care across the interface. It should be given in section s to ensure adequate response rates, and is suitable for use in the evaluat ion or quality of patterns of care across the interface. In future, the imp act on patients of new ways of organising services across the interface sho uld be investigated by use of measures such as the patient career diary.