Quality Assessment for Primary Health Care in Practice: A Descriptive Systematic Review_Chinese Journal of Evidence-Based Medicine

Authors：

 YUANSha-sha ¹ , WANGFang ¹ , HENGChi ² , YANGTing ² , LIChen-chen ²

1. Center for Health Policy and Management, Institute of Medical Information, Chinese Academy of Medical Sciences, Beijing 100020, China;
2. Institute of Medical Information, Peking Union Medical College/Chinese Academy of Medical Sciences, Beijing 100730, China;

Corresponding author：

Keywords：

Primary health care; Quality assessment; Systematic review

DOI：

10.7507/1672-2531.20160111

Video：

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Objective To systematically review indicators and methods of quality assessment for primary health care, to provide empirical evidence for quality improvement in this area. Methods We electronically searched databases including Proquest Dissertations and Theses, ISI Web of Knowledge, PubMed, EMbase, IDEAS, Jstor, SSRN, Popline and The Cochrane Library (Issue 4, 2014) and network resources on World Bank, World Health Organization and Google from inception to April 2014. Empirical studies about quality assessment of primary care system, organization and personnel were collected. Data was extracted using pre-designed form for qualitative analysis and description. Results A total of 59 studies were included. The quality assessment for primary health care in practice was mainly from four dimensions: (1) emphasize on the implementation of such basic characteristics of primary health care as first contact, coordination, comprehensiveness and continuous; (2) focus on the evaluation of primary care contents, such as basic medical care, preventive care, chronic diseases, etc.; (3) based on the structure, process and outcome quality proposed by Donabedian; (4) emphasize on patients’ perceived quality. Seven relevant tools were widely used in the process of quality assessment in practice. Conclusion The majority of included studies were from developed countries while such empirical studies lacked in developing countries. Included studies varied in the connotation and angel of the primary health care quality, among which, the GPAS (General Practice Assessment Survey) used for evaluating pati ent perceived quality and PCAT (Primary Care Assessment Tools) used for evaluating the basic characteristics of primary care were widely used.

Citation： YUANSha-sha, WANGFang, HENGChi, YANGTing, LIChen-chen. Quality Assessment for Primary Health Care in Practice: A Descriptive Systematic Review. Chinese Journal of Evidence-Based Medicine, 2016, 16(6): 719-729. doi: 10.7507/1672-2531.20160111 Copy

1.	陈育德, 郭岩, 王志峰, 等. 中国农村初级卫生保健发展的回顾与思考. 中国社会医学杂志, 2008, 25(1): 1-3.
2.	Schoen C, Osborn R, Huynh PT, et al. Primary Care and Health System Performance: Adults' Experiences in Five Countries. Health Affairs, 2004, W4: 487-503.
3.	Hsiao CJ, Boult C. Effects of quality on outcomes in primary care: a review of the literature. Am J Med Qual, 2008, 23(4): 302-310.
4.	Bentler SE, Morgan RO, Virnig BA, et al. Do claims-based continuity of care measures reflect the patient perspective? Med Care Res Rev, 2014, 71(2): 156-173.
5.	Hetlevik ø, Gjesdal S. Personal continuity of care in Norwegian general practice: A national cross-sectional study. Scand J Prim Health Care, 2012, 30(4): 214-221.
6.	Grumbach K, Selby JV, Schmittdiel JA, et al. Quality of primary care practice in a large HMO according to physician specialty. Health Serv Res, 1999, 34(2): 485-502.
7.	Green ME, Hogg W, Savage C, et al. Assessing methods for measurement of clinical outcomes and quality of care in primary care practices. BMC Health Serv Res, 2012, 12(1): 214.
8.	Given CW, Branson M, Zemach R. Evaluation and application of continuity measures in primary care settings. J Community Health, 1985, 10(1): 22-41.
9.	Lee JH, Choi YJ, Lee SH, et al. Association of the length of doctor-patient relationship with primary care quality in seven family practices in Korea. J Korean Med Sci, 2013, 28(4): 508-515.
10.	Lee JH, Choi YJ, Sung NJ, et al. Development of the Korean primary care assessment tool - Measuring user experience: Tests of data quality and measurement performance. Int J Qual Health Care, 2009, 21(2): 103-111.
11.	Jung JW, Sung NJ, Park KH, et al. Patients' Assessment of Community Primary and Non-primary Care Physicians in Seoul City of South Korea. Korean J Fam Med, 2011, 32(4): 226-233.
12.	Pasarin MI, Berra S, González A, et al. Evaluation of primary care: The "Primary Care Assessment Tools - Facility version" for the Spanish health system. Gac Sanit, 2013, 27(1): 12-18.
13.	Macinko J, Almeida C, de Sá PK. A rapid assessment methodology for the evaluation of primary care organization and performance in Brazil. Health Policy Plan, 2007, 22(3): 167-177.
14.	Mohr DC , Young GJ. Slack resources and quality of primary care. Med Care, 2012, 50(3): 203-209.
15.	Shi L, Starfield B, Xu J, et al. Primary care quality: community health center and health maintenance organization. South Med J, 2003, 96(8): 787-795.
16.	Yang H, Shi L, Lebrun LA, et al. Development of the Chinese primary care assessment tool: data quality and measurement properties. Int J Qual Health Care, 2013, 25(1): 92-105.
17.	Campbell SM, Hann M, Hacker J, et al. Identifying predictors of high quality care in English general practice: observational study. BMJ, 2001, 323(7316): 784-787.
18.	Hedeen AN, Heagerty PJ, Fortney JC, et al. VA community-based outpatient clinics: quality of care performance measures. Med Care, 2002, 40(7): 570-577.
19.	Ballard DJ. Indicators to improve clinical quality across an integrated health care system. Int J Qual Health Care, 2003, 15 Suppl 1(6): i13-i23.
20.	Hasna F, Hundt GL, Al-Smairan M, et al. Quality of primary nursing care for Bedouin in Jordan. Int J Nurs Pract, 2010, 16(6): 564-572.
21.	Marshall M, Klazinga N, Leatherman S, et al. OECD Health Care Quality Indicator Project. The expert panel on primary care prevention and health promotion. Int J Qual Health Care, 2006, 18 Suppl 1: 21-25.
22.	Downing A, Rudge G, Cheng Y, et al. Do the UK government's new Quality and Outcomes Framework (QOF) scores adequately measure primary care performance? A cross-sectional survey of routine healthcare data. BMC Health Serv Res, 2007, 7: 166.
23.	Sahota N, Hood A, Shankar A, et al. Developing performance indicators for primary care: Walsall's experience. Br J Gen Pract, 2008, 58(557): 856-861.
24.	Ashworth M, Schofield P, Doran T, et al. The Public Health Impact score: a new measure of public health effectiveness for general practices in England. Br J Gen Pract, 2013, 63(609): e291-299.
25.	Bos JT, Frijters DH, Wagner C, et al. Variations in quality of Home Care between sites across Europe, as measured by Home Care Quality Indicators. Aging Clin Exp Res, 2007, 19(4): 323-329.
26.	Kontopantelis E, Springate D, Reeves D, et al. Withdrawing performance indicators: retrospective analysis of general practice performance under UK Quality and Outcomes Framework. BMJ, 2014, 348: g330.
27.	Ai-Osimy MH. Evaluation of primary health care in riyadh, saudi arabia. J Family Community Med, 1994, 1(1): 45-54.
28.	Mandel D, Amital H, Zimlichman E, et al. Quality assessment program in primary care clinics: a tool for quality improvement. Int J Qual Health Care, 2004, 16(2): 175-180.
29.	Yeh SH, Lin LW, Lo SK. A longitudinal evaluation of nursing home care quality in Taiwan. J Nurs Care Qual, 2003, 18(3): 209-216.
30.	Varatharajan D, Thankappan R, Jayapalan S. Assessing the performance of primary health centres under decentralized government in Kerala, India. Health Policy Plan, 2004, 19(1): 41-51.
31.	Remmen R, Seuntjens L, Paulus D, et al. Can we import quality tools? a feasibility study of European practice assessment in a country with less organised general practice. BMC Health Serv Res, 2009, 9: 183.
32.	Howie JG, Heaney D, Maxwell M. Quality, core values and the general practice consultation: issues of definition, measurement and delivery. Fam Pract, 2004, 21(4): 458-468.
33.	Howie JG, Porter AM, Heaney DJ, et al. Long to short consultation ratio: a proxy measure of quality of care for general practice. Br J Gen Pract, 1991, 41(343): 48-54.
34.	Howie JG, Heaney DJ, Maxwell M, et al. Developing a 'consultation quality index' (CQI) for use in general practice. Fam Pract, 2000, 17(6): 455-461.
35.	Mohr DC, Benzer JK, Young GJ. Provider workload and quality of care in primary care settings: moderating role of relational climate. Med Care, 2013, 51(1): 108-114.
36.	Donabedian A. Explorations in quality assessment and monitoring. Vol. 2, The criteria and standards of quality. Michigan: Health Administration Press, 1982.
37.	Donabedian A. Explorations in quality assessment and monitoring. Vol. 3, The methods and findings of quality assessment and monitoring. The methods and findings of quality assessment and monitoring. Michigan: Health Administration Press, 1985.
38.	Donabedian A. The quality of care - how can it be assessed? JAMA, 1988, 260(12): 1743-1748.
39.	Bower P, Mead N, Roland M. What dimensions underlie patient responses to the General Practice Assessment Survey? A factor analytic study. Fam Pract, 2002, 19(5): 489-495.
40.	Mead N, Bower P, Roland M. The General Practice Assessment Questionnaire (GPAQ) - development and psychometric characteristics. BMC Fam Pract, 2008, 9: 13.
41.	Baltussen RM, Ye Y, Haddad S, et al. Perceived quality of care of primary health care services in Burkina Faso. Health Policy Plan, 2002, 17(1): 42-48.
42.	Beal A , Hernandez S. Patient reports of the quality of care in community health centers: the importance of having a regular provider. J Health Care Poor Underserved, 2010, 21(2): 591-605.
43.	Hasson H , Arnetz JE. Care recipientsa and family membersa perceptions of quality of older people care: a comparison of homeabased care and nursing homes. J Clin Nurs, 2011, 20(9): 1423-1435.
44.	Harmsen JA, Bernsen RM, Bruijnzeels MA, et al. Patients' evaluation of quality of care in general practice: what are the cultural and linguistic barriers? Patient Educ Couns, 2008, 72(1): 155-162.
45.	Hansen PM, Peters DH, Viswanathan K, et al. Client perceptions of the quality of primary care services in Afghanistan. Int J Qual Health Care, 2008, 20(6): 384-391.
46.	Campbell S, Steiner A, Robison J, et al. Is the quality of care in general medical practice improving? Results of a longitudinal observational study. Br J GenPract, 2003, 53(489): 298-304.
47.	Ramsay J, Campbell JL, Schroter S, et al. The General Practice Assessment Survey (GPAS): tests of data quality and measurement properties. Fam Pract, 2000, 17(5): 372-379.
48.	Krol MW, Boer D de, Rademakers J, et al. Overall scores as an alternative to global ratings in patient experience surveys; a comparison of four methods. BMC Health Serv Res, 2013, 13: 479.
49.	Lionis C, Tsiraki M, Bardis V, et al. Seeking quality improvement in primary care in Crete, Greece: the first actions. Croat Med J, 2004, 45(5): 599-603.
50.	Roland M, Roberts M, Rhenius V, et al. GPAQ-R: development and psychometric properties of a version of the General Practice Assessment Questionnaire for use for revalidation by general practitioners in the UK. BMC Fam Pract, 2013, 14: 160.
51.	Valius L, Rastenyte D, Malinauskiene V, et al. Evaluation of the quality of services in primary health care institutions. Medicina (Kaunas), 2011, 47(1): 57-62.
52.	Rao KD, Peters DH, Bandeen-Roche K. Towards patient-centered health services in India - a scale to measure patient perceptions of quality. Int J Qual Health Care, 2006, 18(6): 414-421.
53.	Gilson L, Kitange H, Teuscher T. Assessment of process quality in Tanzanian primary care. Health Policy, 1993, 26(2): 119-139.
54.	Wettermark B, Nyman K, Bergman U. Five years' experience of quality assurance and feedback with individual prescribing profiles at a primary healthcare centre in Stockholm, Sweden. Quality in Primary Care, 2004, 12(3): 225-234.
55.	Spiegel W, Mlczoch-Czerny MT, Jens R, et al. Quality circles for pharmacotherapy to modify general practitioners' prescribing behaviour for generic drugs. J Eval Clin Pract, 2012, 18(4): 828-834.
56.	Winters-Van Der Meer S, Kool RB, Klazinga NS, et al. Are the Dutch long-term care organizations getting better? A trend study of quality indicators between 2007 and 2009 and the patterns of regional influences on performance. Int J Qual Health Care, 2013, 25(5): 505-514.
57.	Klemenc-Ketiš Z, Kuhar P, Kersnik J, et al. Self-assessment questionnaire for family doctors’ assessment of quality improvement competencies: a cross-cultural adaptation in Slovenia. Slovenian J Pub Health, 2014, 53(1): 34-41.
58.	Brown C, Lilford R. Cross sectional study of performance indicators for English Primary Care Trusts: testing construct validity and identifying explanatory variables. BMC Health Serv Res, 2006, 6: 81.
59.	Hoodless M, Bourke L, Evans F. Quality of rural primary health care: Including the consumer. Aust J Prim Health, 2008, 14(2): 82-88.
60.	Gribben B, Coster G, Pringle M, et al. Quality of care indicators for population-based primary care in New Zealand. N Z Med J, 2002, 115(1151): 163-166.
61.	Jenni P, Timo S. Dimensions of health care system quality in Finland. Government Institute for Economic Research Finland (VATT), 2012.
62.	Houghton G, Rouse A. Are NHS primary care performance indicator scores acceptable as markers of general practitioner quality? Br J Gen Pract, 2004, 54(502): 341-344.
63.	Geboers H. Continuous Quality Improvement in Family Practice: Feasibility, Effectiveness and Assessment. 2002.
64.	Vingerhoets E, Wensing M, Grol R. Feedback of patients’ evaluations of general practice care: a randomised trial. Qual Health Care, 2001, 10(4): 224-228.
65.	Sanci LA, Coffey CM, Veit FC, et al. Effects of an educational intervention for general practitioners in adolescent health care principles: a randomized controlled study. West J Med, 2000, 172(3): 157-163.
66.	Gardner K, Mazza D. Quality in general practice - definitions and frameworks. Aust Fam Physician, 2012, 41(3): 151-154.
67.	Heath I, Hippisley-Cox J, Smeeth L. Measuring performance and missing the point? BMJ, 2007, 335(7629): 1075-1076.
68.	Nietert PJ, Wessell AM, Jenkins RG, et al. Using a summary measure for multiple quality indicators in primary care: the Summary QUality InDex (SQUID). Implement Sci, 2007, 2(1): 11.
69.	Coma E, Ferran M, Mendez L, et al. Creation of a synthetic indicator of quality of care as a clinical management standard in primary care. Springerplus, 2013, 2(1): 51.
70.	Renedo A, Marston C. Developing patient-centred care: an ethnographic study of patient perceptions and influence on quality improvement. BMC Health Serv Res, 2015, 15: 122.
71.	Geyndt WD. Managing the Quality of Health Care in Developing Countries. The International Bank for Reconstruction and Development/THE WORLD BANK: Washington, D.C. 1995.

1. 陈育德, 郭岩, 王志峰, 等. 中国农村初级卫生保健发展的回顾与思考. 中国社会医学杂志, 2008, 25(1): 1-3.
2. Schoen C, Osborn R, Huynh PT, et al. Primary Care and Health System Performance: Adults' Experiences in Five Countries. Health Affairs, 2004, W4: 487-503.
3. Hsiao CJ, Boult C. Effects of quality on outcomes in primary care: a review of the literature. Am J Med Qual, 2008, 23(4): 302-310.
4. Bentler SE, Morgan RO, Virnig BA, et al. Do claims-based continuity of care measures reflect the patient perspective? Med Care Res Rev, 2014, 71(2): 156-173.
5. Hetlevik ø, Gjesdal S. Personal continuity of care in Norwegian general practice: A national cross-sectional study. Scand J Prim Health Care, 2012, 30(4): 214-221.
6. Grumbach K, Selby JV, Schmittdiel JA, et al. Quality of primary care practice in a large HMO according to physician specialty. Health Serv Res, 1999, 34(2): 485-502.
7. Green ME, Hogg W, Savage C, et al. Assessing methods for measurement of clinical outcomes and quality of care in primary care practices. BMC Health Serv Res, 2012, 12(1): 214.
8. Given CW, Branson M, Zemach R. Evaluation and application of continuity measures in primary care settings. J Community Health, 1985, 10(1): 22-41.
9. Lee JH, Choi YJ, Lee SH, et al. Association of the length of doctor-patient relationship with primary care quality in seven family practices in Korea. J Korean Med Sci, 2013, 28(4): 508-515.
10. Lee JH, Choi YJ, Sung NJ, et al. Development of the Korean primary care assessment tool - Measuring user experience: Tests of data quality and measurement performance. Int J Qual Health Care, 2009, 21(2): 103-111.
11. Jung JW, Sung NJ, Park KH, et al. Patients' Assessment of Community Primary and Non-primary Care Physicians in Seoul City of South Korea. Korean J Fam Med, 2011, 32(4): 226-233.
12. Pasarin MI, Berra S, González A, et al. Evaluation of primary care: The "Primary Care Assessment Tools - Facility version" for the Spanish health system. Gac Sanit, 2013, 27(1): 12-18.
13. Macinko J, Almeida C, de Sá PK. A rapid assessment methodology for the evaluation of primary care organization and performance in Brazil. Health Policy Plan, 2007, 22(3): 167-177.
14. Mohr DC , Young GJ. Slack resources and quality of primary care. Med Care, 2012, 50(3): 203-209.
15. Shi L, Starfield B, Xu J, et al. Primary care quality: community health center and health maintenance organization. South Med J, 2003, 96(8): 787-795.
16. Yang H, Shi L, Lebrun LA, et al. Development of the Chinese primary care assessment tool: data quality and measurement properties. Int J Qual Health Care, 2013, 25(1): 92-105.
17. Campbell SM, Hann M, Hacker J, et al. Identifying predictors of high quality care in English general practice: observational study. BMJ, 2001, 323(7316): 784-787.
18. Hedeen AN, Heagerty PJ, Fortney JC, et al. VA community-based outpatient clinics: quality of care performance measures. Med Care, 2002, 40(7): 570-577.
19. Ballard DJ. Indicators to improve clinical quality across an integrated health care system. Int J Qual Health Care, 2003, 15 Suppl 1(6): i13-i23.
20. Hasna F, Hundt GL, Al-Smairan M, et al. Quality of primary nursing care for Bedouin in Jordan. Int J Nurs Pract, 2010, 16(6): 564-572.
21. Marshall M, Klazinga N, Leatherman S, et al. OECD Health Care Quality Indicator Project. The expert panel on primary care prevention and health promotion. Int J Qual Health Care, 2006, 18 Suppl 1: 21-25.
22. Downing A, Rudge G, Cheng Y, et al. Do the UK government's new Quality and Outcomes Framework (QOF) scores adequately measure primary care performance? A cross-sectional survey of routine healthcare data. BMC Health Serv Res, 2007, 7: 166.
23. Sahota N, Hood A, Shankar A, et al. Developing performance indicators for primary care: Walsall's experience. Br J Gen Pract, 2008, 58(557): 856-861.
24. Ashworth M, Schofield P, Doran T, et al. The Public Health Impact score: a new measure of public health effectiveness for general practices in England. Br J Gen Pract, 2013, 63(609): e291-299.
25. Bos JT, Frijters DH, Wagner C, et al. Variations in quality of Home Care between sites across Europe, as measured by Home Care Quality Indicators. Aging Clin Exp Res, 2007, 19(4): 323-329.
26. Kontopantelis E, Springate D, Reeves D, et al. Withdrawing performance indicators: retrospective analysis of general practice performance under UK Quality and Outcomes Framework. BMJ, 2014, 348: g330.
27. Ai-Osimy MH. Evaluation of primary health care in riyadh, saudi arabia. J Family Community Med, 1994, 1(1): 45-54.
28. Mandel D, Amital H, Zimlichman E, et al. Quality assessment program in primary care clinics: a tool for quality improvement. Int J Qual Health Care, 2004, 16(2): 175-180.
29. Yeh SH, Lin LW, Lo SK. A longitudinal evaluation of nursing home care quality in Taiwan. J Nurs Care Qual, 2003, 18(3): 209-216.
30. Varatharajan D, Thankappan R, Jayapalan S. Assessing the performance of primary health centres under decentralized government in Kerala, India. Health Policy Plan, 2004, 19(1): 41-51.
31. Remmen R, Seuntjens L, Paulus D, et al. Can we import quality tools? a feasibility study of European practice assessment in a country with less organised general practice. BMC Health Serv Res, 2009, 9: 183.
32. Howie JG, Heaney D, Maxwell M. Quality, core values and the general practice consultation: issues of definition, measurement and delivery. Fam Pract, 2004, 21(4): 458-468.
33. Howie JG, Porter AM, Heaney DJ, et al. Long to short consultation ratio: a proxy measure of quality of care for general practice. Br J Gen Pract, 1991, 41(343): 48-54.
34. Howie JG, Heaney DJ, Maxwell M, et al. Developing a 'consultation quality index' (CQI) for use in general practice. Fam Pract, 2000, 17(6): 455-461.
35. Mohr DC, Benzer JK, Young GJ. Provider workload and quality of care in primary care settings: moderating role of relational climate. Med Care, 2013, 51(1): 108-114.
36. Donabedian A. Explorations in quality assessment and monitoring. Vol. 2, The criteria and standards of quality. Michigan: Health Administration Press, 1982.
37. Donabedian A. Explorations in quality assessment and monitoring. Vol. 3, The methods and findings of quality assessment and monitoring. The methods and findings of quality assessment and monitoring. Michigan: Health Administration Press, 1985.
38. Donabedian A. The quality of care - how can it be assessed? JAMA, 1988, 260(12): 1743-1748.
39. Bower P, Mead N, Roland M. What dimensions underlie patient responses to the General Practice Assessment Survey? A factor analytic study. Fam Pract, 2002, 19(5): 489-495.
40. Mead N, Bower P, Roland M. The General Practice Assessment Questionnaire (GPAQ) - development and psychometric characteristics. BMC Fam Pract, 2008, 9: 13.
41. Baltussen RM, Ye Y, Haddad S, et al. Perceived quality of care of primary health care services in Burkina Faso. Health Policy Plan, 2002, 17(1): 42-48.
42. Beal A , Hernandez S. Patient reports of the quality of care in community health centers: the importance of having a regular provider. J Health Care Poor Underserved, 2010, 21(2): 591-605.
43. Hasson H , Arnetz JE. Care recipientsa and family membersa perceptions of quality of older people care: a comparison of homeabased care and nursing homes. J Clin Nurs, 2011, 20(9): 1423-1435.
44. Harmsen JA, Bernsen RM, Bruijnzeels MA, et al. Patients' evaluation of quality of care in general practice: what are the cultural and linguistic barriers? Patient Educ Couns, 2008, 72(1): 155-162.
45. Hansen PM, Peters DH, Viswanathan K, et al. Client perceptions of the quality of primary care services in Afghanistan. Int J Qual Health Care, 2008, 20(6): 384-391.
46. Campbell S, Steiner A, Robison J, et al. Is the quality of care in general medical practice improving? Results of a longitudinal observational study. Br J GenPract, 2003, 53(489): 298-304.
47. Ramsay J, Campbell JL, Schroter S, et al. The General Practice Assessment Survey (GPAS): tests of data quality and measurement properties. Fam Pract, 2000, 17(5): 372-379.
48. Krol MW, Boer D de, Rademakers J, et al. Overall scores as an alternative to global ratings in patient experience surveys; a comparison of four methods. BMC Health Serv Res, 2013, 13: 479.
49. Lionis C, Tsiraki M, Bardis V, et al. Seeking quality improvement in primary care in Crete, Greece: the first actions. Croat Med J, 2004, 45(5): 599-603.
50. Roland M, Roberts M, Rhenius V, et al. GPAQ-R: development and psychometric properties of a version of the General Practice Assessment Questionnaire for use for revalidation by general practitioners in the UK. BMC Fam Pract, 2013, 14: 160.
51. Valius L, Rastenyte D, Malinauskiene V, et al. Evaluation of the quality of services in primary health care institutions. Medicina (Kaunas), 2011, 47(1): 57-62.
52. Rao KD, Peters DH, Bandeen-Roche K. Towards patient-centered health services in India - a scale to measure patient perceptions of quality. Int J Qual Health Care, 2006, 18(6): 414-421.
53. Gilson L, Kitange H, Teuscher T. Assessment of process quality in Tanzanian primary care. Health Policy, 1993, 26(2): 119-139.
54. Wettermark B, Nyman K, Bergman U. Five years' experience of quality assurance and feedback with individual prescribing profiles at a primary healthcare centre in Stockholm, Sweden. Quality in Primary Care, 2004, 12(3): 225-234.
55. Spiegel W, Mlczoch-Czerny MT, Jens R, et al. Quality circles for pharmacotherapy to modify general practitioners' prescribing behaviour for generic drugs. J Eval Clin Pract, 2012, 18(4): 828-834.
56. Winters-Van Der Meer S, Kool RB, Klazinga NS, et al. Are the Dutch long-term care organizations getting better? A trend study of quality indicators between 2007 and 2009 and the patterns of regional influences on performance. Int J Qual Health Care, 2013, 25(5): 505-514.
57. Klemenc-Ketiš Z, Kuhar P, Kersnik J, et al. Self-assessment questionnaire for family doctors’ assessment of quality improvement competencies: a cross-cultural adaptation in Slovenia. Slovenian J Pub Health, 2014, 53(1): 34-41.
58. Brown C, Lilford R. Cross sectional study of performance indicators for English Primary Care Trusts: testing construct validity and identifying explanatory variables. BMC Health Serv Res, 2006, 6: 81.
59. Hoodless M, Bourke L, Evans F. Quality of rural primary health care: Including the consumer. Aust J Prim Health, 2008, 14(2): 82-88.
60. Gribben B, Coster G, Pringle M, et al. Quality of care indicators for population-based primary care in New Zealand. N Z Med J, 2002, 115(1151): 163-166.
61. Jenni P, Timo S. Dimensions of health care system quality in Finland. Government Institute for Economic Research Finland (VATT), 2012.
62. Houghton G, Rouse A. Are NHS primary care performance indicator scores acceptable as markers of general practitioner quality? Br J Gen Pract, 2004, 54(502): 341-344.
63. Geboers H. Continuous Quality Improvement in Family Practice: Feasibility, Effectiveness and Assessment. 2002.
64. Vingerhoets E, Wensing M, Grol R. Feedback of patients’ evaluations of general practice care: a randomised trial. Qual Health Care, 2001, 10(4): 224-228.
65. Sanci LA, Coffey CM, Veit FC, et al. Effects of an educational intervention for general practitioners in adolescent health care principles: a randomized controlled study. West J Med, 2000, 172(3): 157-163.
66. Gardner K, Mazza D. Quality in general practice - definitions and frameworks. Aust Fam Physician, 2012, 41(3): 151-154.
67. Heath I, Hippisley-Cox J, Smeeth L. Measuring performance and missing the point? BMJ, 2007, 335(7629): 1075-1076.
68. Nietert PJ, Wessell AM, Jenkins RG, et al. Using a summary measure for multiple quality indicators in primary care: the Summary QUality InDex (SQUID). Implement Sci, 2007, 2(1): 11.
69. Coma E, Ferran M, Mendez L, et al. Creation of a synthetic indicator of quality of care as a clinical management standard in primary care. Springerplus, 2013, 2(1): 51.
70. Renedo A, Marston C. Developing patient-centred care: an ethnographic study of patient perceptions and influence on quality improvement. BMC Health Serv Res, 2015, 15: 122.
71. Geyndt WD. Managing the Quality of Health Care in Developing Countries. The International Bank for Reconstruction and Development/THE WORLD BANK: Washington, D.C. 1995.

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