Domains of Primary Care.The PCAT-AE was modeled on the previously validated PCAT-CE and is consistent with the 1978 Institute of Medicine (IOM) definition of primary care as accessibility, comprehensiveness, coordination, continuity, and accountability33 and with the 1996 IOM report 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 the community.34 When combined into scales, the PCATsurvey items dealing with primary care quality were designed to measure each of the core domains of primary care; that is, first contact, longitudinality, comprehensiveness, and coordination (definitions of the primary care domains are provided in the Appendix).
Nine experts were asked to rate the appropriateness and representativeness of the primary care domain items. These experts consisted of 3 policymakers in federal agencies, 2 directors of community pediatrics at major medical centers, a health research director at a major HMO, 2 family medicine professors, and a general internal medicine physician. Acard sorting technique was used to determine the degree of congruence between each item and the domain it was designed to measure. Each survey question with its response categories and descriptions of each of the primary care domains was printed on separate index cards and mailed to the experts who assigned each question to one of the defined domains and suggested revisions and/or addition of other items. The percent agreement among the experts was used to determine the degree of congruence on the placement of each item in a particular domain. In addition, students in a graduate course on primary care independently assigned each item to a domain as well as to its appropriate subdomain.
In addition to the 4 core primary care domains, 3 other related domains (family centeredness, community orientation, and cultural competence) were included; these domains were considered derivative in that their achievement would be related to the achievement of the major domains.1 However, they were separately specified as ancillary domains because of widespread appreciation of their likely importance.
Thus, the PCAT-AE consists of 7 domains represented by 9 scales. Each of the 4 core domains of primary care is represented by 2 components, 1 representing a characteristic of the facility of providers service organization and 1 representing a behavior of the provider or consumer.1 One of these 8 potential components (longitudinality strength of affiliation) is represented by an index rather than a scale and is scored from the responses to the 3 questions noted under the heading Identification of the Primary Care Source. One subdomain, the facility characteristics related to the achievement of coordination, is obtainable only from the facility or provider, since consumers would not be expected to know the nature of information systems that facilitate coordination of care. Thus, the PCATinstrument has 6 scales representing the 4 primary care domains: first contactaccessibility, first contactutilization (first contact domain), longitudinalityinterpersonal relationships or ongoing care (longitudinality domain), coordination of services (coordination domain), comprehensiveness services available, comprehensivenessservices received (comprehensiveness domain) and the 3 ancillary domains of family centeredness, community orientation, and cultural competence.
For first contactaccessibility 12 questions were developed to measure access to the source of care. For first contactutilization 3 questions addressed the extent to which the source of care is first used for various types of problems. Twenty questions addressed the nature and strength of the person-focused relationship with the source of care over time (longitudinality). Eight questions were used to address the coordination of services between a primary care provider and specialty care. The comprehensivenessservices available domain included 24 items of important primary care services. An additional 13 questions were used to measure comprehensivenessservices received. Two items were used to measure family-centeredness, 5 community orientation, and 3 cultural competence. Copies of both the original questionnaire and the revised condensed version are available on request.
For consistency in response and scoring, all items representing the primary care domains were represented by a 4-point Likert-type scale (1=definitely not; 2=probably not; 3=probably; and 4=definitely). The sum score for each domain was derived by adding (after reverse-coding where appropriate) the values for all the items under each domain. An additional Dont Know/Cannot Remember option was also provided for each item. At least 3 methods could be used to code this category. The missing value method treats this item as missing for those who answer Dont Know/Cant Remember. The median value method assigns a value of 2.5 for those who answer Dont Know/Cant Remember. The imputation method imputes the response based on the mean of the results from other items within the domain when at least 50% of the items have been answered. Since the internal consistency reliability (a) is the highest based on the imputation method, this method is adopted in coding the Dont Know/Cant Remember category. However, the other 2 methods also produced high internal consistency reliability (results available on request).