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Patient enablement after a consultation with a general practitioner: explaining variation between countries, practices and patients.

Tolvanen, E., Groenewegen, P.P., Koskela, T.H., Bjerve Eide, T., Cohidon, C., Kosunen, E. Patient enablement after a consultation with a general practitioner: explaining variation between countries, practices and patients. Health Expectations: 2020, 23(5), 1129–1143
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Background
Patient enablement is a concept developed to measure quality in primary health care. The comparative analysis of patient enablement in an international context is lacking.

Objective
To explain variation in patient enablement between patients, general practitioners (GPs) and countries. To find independent variables associated with enablement.

Design
We constructed multi-level logistic regression models encompassing variables from patient, GP and country levels. The proportions of explained variances at each level and odds ratios for independent variables were calculated.

Setting and participants
A total of 7210 GPs and 58 930 patients in 31 countries were recruited through the Quality and Costs of Primary Care in Europe (QUALICOPC) study framework. In addition, data from the Primary Health Care Activity Monitor for Europe (PHAMEU) study and Hofstede's national cultural dimensions were combined with QUALICOPC data.

Results
In the final model, 50.6% of the country variance and 18.4% of the practice variance could be explained. Cultural dimensions explained a major part of the variation between countries. Several patient-level and only a few practice-level variables showed statistically significant associations with patient enablement. Structural elements of the relevant health-care system showed no associations. From the 20 study hypotheses, eight were supported and four were partly supported.

Discussion and conclusions
There are large differences in patient enablement between GPs and countries. Patient characteristics and patients' perceptions of consultation seem to have the strongest associations with patient enablement. When comparing patient-reported measures as an indicator of health-care system performance, researchers should be aware of the influence of cultural elements.