Titre provisoire : La qualité des soins et les inégalités sociales de santé au prisme de la satisfaction de la patientèle à Genève

Quality of care in Switzerland: a multi-level study of secondary access to care and social inequalities in health in three Swiss hospital regions.

Introduction and issues

Switzerland is often regarded as an example of excellence in healthcare, thanks to its "world-leading research institutes and innovative pharmaceutical, biotechnology and medical technology companies" (FOPH 2023). However, Switzerland is not free of health inequalities, and many studies have investigated the links between socioeconomic inequalities and health conditions in the Swiss population (e.g.: Cullati 2018; Weber 2020; ...).

Since the early 2000s, the World Health Organization (WHO) has incorporated issues of equity and access to care into its values and principles. These aspects are considered essential for a country to be able to claim high-quality care (WHO 2019). The WHO defines quality of care through seven dimensions (2019): effectiveness, safety, person-centeredness, equity, timeliness, efficiency and integration of care.

Since the concept of quality of care became a priority in debates on healthcare systems, a great deal of progress has been made, particularly in terms of life expectancy and the geographical accessibility of healthcare infrastructures. Beyond these improvements in access to care and healthcare systems, there are still few studies on how this care is delivered, and whether it is delivered equitably; i.e., independently of the characteristics of the person receiving care (Cognet 2009).

Lombrail (2007) distinguishes between primary and secondary access to care. Primary access refers to proximity between home and hospital, or entry into the care process. These issues have been studied extensively. Secondary access refers to "the structurally determined way in which care proceeds after an initial contact (Lurie 1997 cited by Lombrail 2007), from the identification of the need for care, to the delivery of the necessary care(s)" (Lombrail 2007: 23-24). Lombrail and other researchers have demonstrated that secondary access to quality care is a key factor in reducing health disparities and promoting health equity (e.g.: Lombrail 2007; Priester, Browne, and Iachini et al. 2016; Kim, Maulsby, Kinsky et al. 2014; Staines and Vincent 2019). Secondary access to care is therefore considered a major determinant of health inequalities.

The terms (in)equalities and (in)iquities are an integral part of the discourse surrounding quality of care. Nevertheless, these concepts are often poorly defined in these works? and used indiscriminately. The term "social inequalities in health" refers to health inequalities that are "the fruit of social inequalities that exist within a society and expose certain groups to greater vulnerability when it comes to health" (Weber 2020). Compared to health inequalities, inequities are considered avoidable and reflect individual life situations and environmental aspects. Health inequalities are exempt from moral judgment as to the unfairness of these inequalities and represent biologically based aspects of health that vary between individuals (Arcaya M.C., Arcaya A.L., Subramanian 2015). An equitable quality of care, as described by the WHO, must ensure that all people, regardless of their socio-economic characteristics, have access to the same quality of care.

But how can we guarantee equitable quality of care without taking an interest in discrimination and how it is perceived by patients? This is the criticism levelled by Marguerite Cognet at the majority of research in this field. According to her, "in the field of healthcare, studies of discrimination on the grounds of origin focus mainly on access to healthcare rights, and on actual practical access (...). When it comes to the quality of care, studies rarely include a component on the perception of discrimination" (Cognet 2017: 26). This researcher is therefore interested in discrimination in care, which she defines as illegitimate and arbitrary differential treatment, based on her research in France and the work of Carde (2006, 2007) and Lochak (1987) (Cognet 2017:29). Thus, lack of treatment, or conversely, over-treatment, can stem from subjective criteria, without being justified by medical investigations and biological data (ibid.: 30). These discriminations take place in the course of care, and are therefore part of inequalities in secondary access to care, as Cognet and Lombrail postulate (Cognet 2007).

Thus, care recipients would be more or less likely to experience discrimination in their care episodes depending on their socio-economic characteristics. In Switzerland, this is also the case, despite the limited amount of research into health inequalities in the Swiss healthcare system (Merçay, Fasel and Taczanowski 2023: 5). A recent WHO report shows that 39.8% of people with three types of socio-economic disadvantage and a chronic illness expressed a lack of support from healthcare professionals. In addition to socio-economic level, migratory status is one of the factors of vulnerability: "it is possible to envisage here that migrants or people with socio-economic difficulties encounter specific difficulties, for example in relation to language comprehension or financial access, and that the care system is not always adapted to the needs of these patients." (ibid.). These different factors of vulnerability tend to accumulate and widen the gaps in the quality of care received between different populations.

In order to integrate discrimination analysis into care quality improvement, many researchers, political players and international organizations agree on the need to consider patients' perceptions, satisfaction and experiences of the care they receive. According to the authors of the national report on quality of care in Switzerland, "patients and their caregivers can play an important role in guaranteeing and improving the quality and safety of care. For example, patients can accurately report errors and harm, and are often aware of problems that healthcare professionals do not perceive. They are directly confronted with certain crucial aspects on which professionals have little visibility, such as the coordination of care between different providers (...)" (Staines and Vincent 2019: 35).

Measures of patient perception of quality of care? are gaining in popularity and tend to be used more and more. Whether through the use of patient-reported outcome measures (PROMS), patient-reported experience measures (PREMS) or satisfaction, the patient voice is recognized as an important indicator in improving the quality of care (HAS 2021: 14-27). While the concepts of PROMS and PREMS are relatively clearly defined in the literature, that of patient satisfaction seems to be less so: "patient satisfaction is a multidimensional concept, rather poorly defined and on which there is no scientific consensus as to its definition, the dimensions to be included or considered important. (...) Interpretation of satisfaction levels is difficult because they depend on individual preferences, health status, characteristics and culture, in addition to the quality and outcome of care." (ibid.: 24). Because of this malleability, some scientists refuse to use satisfaction measures. Nevertheless, many instruments have been developed to measure patient satisfaction, among other objectives. Such is the case with the Picker questionnaire, which includes both satisfaction and care experience questions. It is considered that "(...) measuring the patient's perceived experience [is] a more discriminating and relatively more objective measure of the quality of care. Satisfaction and experience are different concepts; their measures each have advantages and limitations, making them potentially complementary measures" (ibid.: 25).

The various concepts presented - quality of care, equity/inequity, secondary access to care, patient satisfaction/experience, discrimination - are interconnected and operate at different levels of the healthcare system. Quality of care, as defined by the WHO, encourages healthcare systems to value a plurality of aspects in their governance and policies, ranging from the financial angle to the notion of equity. To better grasp the complexity of these interactions, it is therefore pertinent to adopt a multi-level approach that examines dynamics on several scales: micro, meso and macro.

At the micro level, direct interaction between medical staff and patients plays a crucial role. It is at this level that patients' individual perceptions of quality of care, experiences of satisfaction or dissatisfaction, and perceived discrimination take shape. Caregivers' attitudes, communication and behavior can have a significant impact on perceived quality of care and feelings of discrimination. Research shows that micro-level interactions are often the primary sources of perceived differentiation in patient treatment, directly influencing patient experience and satisfaction (HAS 2021).

In particular, this level highlights how healthcare professionals' personal biases or the way they interpret patients' needs can lead to discrimination, even when caregivers do not intend to discriminate (e.g.: Cognet 2017, Cooper et al. 2012; ...).

At the meso level, internal hospital dynamics, such as institutional policies and organizational practices, act as facilitators and barriers to secondary access to care, and influence the quality of care and the different concepts presented. Organizational practices such as access to translators, the presence of information boards in several languages, and staff training in non-discrimination and inclusion, play a crucial role in patients' perception of the quality of care. These measures can mitigate linguistic and cultural barriers, reducing perceptions of discrimination and increasing patient satisfaction and quality of care (e.g.: Al Shamsi et al. 2020 ; Diamonds and Jacob 2010 ; ...).

Finally, at the macro level, public health policies and healthcare system regulations influence institutional frameworks and practices at all levels. Differences between hospitals, particularly in terms of institutional policies, financing and strategic objectives, can lead to significant variations in patients' perceptions of quality of care. Comparisons between hospitals, with distinct institutional policies, therefore appear essential in order to observe, for example, whether those adopting more inclusive approaches and aiming to reduce social inequalities in health and experiences of discrimination, tend to achieve higher levels of satisfaction with the quality of care among their patients (e.g.: Williams and Cooper 2019; ...).

In order to deepen our understanding of the mechanisms underlying these dynamics and to fill existing gaps in the literature, we raise the following research questions:

- At the micro level: What mechanisms at the level of interactions between patients and caregivers explain variations in the quality of care perceived by individuals, depending on their socio-economic characteristics?

- Meso level: How do hospital organizational policies and practices influence social inequalities in health and perceptions of quality of care, particularly in terms of secondary access to care?

- Macro level: How are differences in perceptions of quality of care and experiences of patient discrimination in Switzerland influenced by public health policies and national regulations, particularly in terms of inclusion and health equity?

The main objective of this research is to explore how perceptions of quality of care vary according to patients' socio-economic characteristics, focusing specifically on secondary access to care in the Swiss context. The study aims to understand the mechanisms operating at different levels (micro, meso, macro) that influence satisfaction with the quality of care received, experiences of discrimination, and social inequalities in health. By examining these dynamics, the research aims to identify factors facilitating or hindering equitable and inclusive quality of care within the Swiss healthcare system.

We make the following assumptions:

1. Interactions between patients and caregivers are influenced by implicit biases and attitudes differentiated according to patients' socio-economic characteristics, leading to experiences of discrimination and variations in perception and satisfaction with quality of care.

2. Hospital organizational policies and practices are linked to the perception of quality of care by patients of different socio-economic levels, thus reducing or increasing social inequalities in health, particularly in terms of secondary access to care.

3. Variations in public health policies and national regulations between Swiss hospitals significantly influence perceptions of quality of care and experiences of secondary access to care according to patients' socio-economic characteristics.

Methods

This study uses a mixed-methods approach, combining secondary data analysis with primary data collection and analysis. This approach is broken down into three complementary phases, each providing a distinct but interconnected perspective that enables the different levels involved in meeting the research objectives to be taken into account.

Phase 1: scoping review on social inequalities in health, access to care and quality of care

The aim of this review is to provide an overview of current knowledge on the links between social inequalities in health, access to care and quality of care.

The three concepts will be searched, in the form of Boolean equations, in the following datasets: Embase, PubMed, Web Of Science (WOS), Worldwide Political Science Abstracts (WPSA), International Bibliography of the Social Sciences (IBSS). As the subject concerned the fields of medicine and the social sciences, it was decided to select databases in these two areas. Inclusion and exclusion criteria will include publication type, study design, population, comparator and outcome. Data will be collected using Rayyan software, and each article will be selected on the basis of a reading of the title and abstract by two independent readers.

Phase 2: Association between quality of care, socio-economic characteristics, and satisfaction with care

This second stage will look at the association between socio-economic and socio-demographic factors and the level of satisfaction with the care received, using :

1. The HUG patient satisfaction survey (approx. 30,000 patients) for the last five years (2019-2024). In addition to 20 closed questions, the form includes a space for patients to leave a free comment. Geneva's Health Care Quality Department uses these patient satisfaction surveys, in several languages, to assess patient satisfaction in various HUG departments. This method, which combines closed-ended questionnaires with free-form comments, enables us to take into account patients' views on their experience of care, and to pass on these assessments to the relevant departments. It is possible to combine these data with several items of information from the patient file, providing an approximation of the patient's socio-economic level, such as income, type of health insurance, nationality and language spoken.

2. The PRIORITY study of equity indicators in three Swiss hospitals (see Courvoisier et al. 2023). This national research project, carried out in the hospitals of Geneva, Mendrisio and Zurich, aimed to test the availability of 11 equity indicators on over 700,000 patients. These indicators are set against 5 vulnerability criteria, namely the gender with which patients are identified, allophone status, age, migratory status and "homeless" status. Possession of one of these vulnerability criteria (e.g. allophone status) would increase the risk of experiencing a lower quality of care, without any medical basis. In this project, we will compare individuals possessing at least one of the 5 vulnerability criteria with those possessing none. In addition, a comparison between the three hospitals of how patients are treated according to their vulnerability criteria will enable us to assess the role of hospital organizational policies in supporting more or less equitable treatment.

Part 3: Qualitative study in three hospitals on the mechanisms underlying the perception of quality of care in secondary access to care according to observed social inequalities in health.

The main aim of this qualitative section is to gain a better understanding of the mechanisms underlying social inequalities in secondary access to care, by investigating patients' experiences of discrimination in three Swiss hospitals. The aim will be to document how patients with certain socio-economic characteristics (associated with a vulnerability criterion) evaluate the quality of care received and their satisfaction with that care. The study will be carried out at hospitals in Geneva, Mendrisio and Zurich, and will be based on semi-structured interviews. The design of this qualitative study will be refined on the basis of the findings of the scoping review and the quantitative component (satisfaction surveys and equity indicators). In particular, a purposive sample will be selected using equity indicators, targeting patient types with characteristics associated with a large difference in equity indicators in a given hospital. For example, migrants will be more widely selected if they are particularly less satisfied with care at the HUG. Based on a sample size calculation for qualitative studies, we anticipate 10 interviews per hospital (80% power to detect at least once a perception felt by 15% of patients).

The three phases of this research are designed to be complementary, each providing a unique but interconnected perspective. Phase 1 provides a theoretical framework by exploring existing knowledge and identifying potential gaps in the literature on social inequalities in health, quality of care and secondary access to care. Phase 2 uses local and national quantitative data to examine the association between patients' socio-economic status, their satisfaction with care and their perception of their care experience, enabling different patterns to be identified in Switzerland. Phase 3 complements these perspectives with a qualitative analysis of patients' experiences, exploring in depth the mechanisms underlying inequalities and perceptions of care received.

By integrating the results of these three phases, the study will provide practical tools and recommendations for improving the quality and equity of care at hospital and national policy levels.

5-year timetable

Year 1 (March 2023 - March 2024)

• March 2023 - May 2023 :

o Deepening knowledge of thesis topics

• June 2023 - September 2023 :

o Scoping review: Work on databases and Boolean equations with a librarian. Export of articles from databases.

• October 2023 - March 2024:

o Review of article abstracts, then texts, through a double adjudication process

o Drafting of an initial interview guide for the qualitative phase. 2 half-days of observation and testing of the guide at CAMSCO.

o Drafting of research project for ethics commission (CCER)

• October 2023 - February 2024: Design of phase 2, including the collection of HUG patient satisfaction data and the PRIORITY study, and development of analysis tools.

Year 2 (April 2024 - January 2025) is not a year

• April 2024 - October 2024:

o Full extraction of selected articles on RedCap

• November 2024 - January 2025: Analysis and synthesis of scoping review results, drafting of article and submission.

Year 3 (February 2025 - February 2026)

• February 2025 - April 2025: Quantitative analysis of patient satisfaction data (HUG) to assess the association between patient socio-economic characteristics and satisfaction with care received.

• May 2025 - July 2025:

o Writing up the results and submitting the article

o Submission of qualitative project to ethics commission

• August 2025 - October 2025: Analysis of equity indicators (PRIORITY study) to assess the association between vulnerability criteria and perceived quality of care.

• November 2025 - January 2026: Writing of results and submission of article on equity indicators

• February 2026:

o Integration of quantitative results

o Preparing hypotheses for the qualitative study

Year 4 (March 2026 - March 2027)

• March 2026 - April 2026: Finalization of qualitative interview guides, training of interviewers

• May 2026 - July 2026: Conduct of semi-structured interviews with patients at hospitals in Geneva, Mendrisio and Zurich

• August 2026 - November 2026: Analysis of qualitative data to identify, among other things, mechanisms influencing perceptions of quality of care and disparities in secondary access to care.

• December 2026 - January 2027: Comparison of results between hospitals

• February 2027 - May 2027: Writing of results and submission of qualitative article

Year 5 (February 2027 - February 2028)

• June 2027 - July 2027: Integration of qualitative and quantitative data, development of recommendations for hospital practices and healthcare policies.

• August 2027 - October 2027: Complete revision of the thesis, validation with the thesis committee, and preparation for the defense.

• November 2027 - February 2028: Thesis conference with jury, public defense, dissemination of results and presentation at international conferences.

References

Al Shamsi, Hilal, Abdullah G. Almutairi, Sulaiman Al Mashrafi, and Talib Al Kalbani. 2020. "Implications of Language Barriers for Healthcare: A Systematic Review." Oman Medical Journal 35(2):e122e122 . doi: 10.5001/omj.2020.40.

Arcaya, Mariana C., Alyssa L. Arcaya, and S. V. Subramanian. 2015. "Inequalities in Health: Definitions, Concepts, and Theories". Global Health Action 8(1):27106. doi: 10.3402/gha.v8.27106.

Carde, Estelle. 2006. "Les discriminations selon l'origine dans l'accès aux soins. Étude en France métropolitaine et en Guyane française". Doctoral thesis. Université Paris XI.

Carde, Estelle. 2007. " Les discriminations selon l'origine dans l'accès aux soins: " Santé Publique Vol. 19(2):99109 . doi: 10.3917/spub.072.0099.

Carde, Estelle. 2021. "De quoi les inégalités sociales de santé sont-elles le nom?": Revue française des affaires sociales (3):10715 . doi: 10.3917/rfas.213.0107.

Cognet, Marguerite, Céline Gabarro, and Emilie Adam-Vezina. 2009. "Between right to care and quality of care". Hommes & migrations (1282):5465 . doi: 10.4000/hommesmigrations.443.

Cognet, Marguerite. 2017. "From differential treatment to racist discrimination in clinical practices": Les cahiers de la LCD N° 5(3):2542 . doi: 10.3917/clcd.005.0025.

Cognet, Marguerite. 2020. "Racismes de France. P. 7486 in Cahiers libres. La Découverte.

Cooper, Lisa A., Debra L. Roter, Kathryn A. Carson, Mary Catherine Beach, Janice A. Sabin, Anthony G. Greenwald, and Thomas S. Inui. 2012. "The Associations of Clinicians' Implicit Attitudes About Race With Medical Visit Communication and Patient Ratings of Interpersonal Care." American Journal of Public Health 102(5):97987 . doi: 10.2105/AJPH.2011.300558.

Courvoisier, Delphine S., Patrick Bodenmann, Yves Jackson, Joachim Marti, Clément P. Buclin, Kevin Morisod, Stéphane Cullati, and Laura Bertini. 2023. Measuring equity of care in Swiss hospitals: feasibility and case study. PRIORITY study - Panorama of Indicators on Equity in Healthcare. Study commissioned by the Swiss Federal Office of Public Health. Bern: FOPH. See complete list of authors above.

Cullati, Stéphane, Claudine Burton-Jeangros, and Thomas Abel. 2018. "Vulnerability in Health Trajectories: Life Course Perspectives." Swiss Journal of Sociology 44(2):20316 . doi: 10.1515/sjs-2018-0009.

Diamond, Lisa C., and Elizabeth A. Jacobs. 2010. "Let's Not Contribute to Disparities: The Best Methods for Teaching Clinicians How to Overcome Language Barriers to Health Care." Journal of General Internal Medicine 25(S2):18993 . doi: 10.1007/s11606-009-1201-8.

HAS, Haute Autorité de santé. 2021. Quality of care as perceived by the patient - PROMs and PREMs indicators: Overview of foreign experiences and main lessons learned.

Kim, Jeeyon Janet, Cathy Maulsby, Suzanne Kinsky, Maura Riordan, Vignetta Charles, Positive Charge Intervention Team, Kriti Jain, and David R. Holtgrave. 2014. "The Development and Implementation of the National Evaluation Strategy of Access to Care, a Multi-Site Linkage to Care Initiative in the United States." AIDS Education and Prevention: Official Publication of the International Society for AIDS Education 26(5):42944 . doi: 10.1521/aeap.2014.26.5.429.

Lochak D. 1987. "Réflexions sur la notion de discrimination. Droit social (11): 778-790.

Lombrail, Pierre. 2007. "Inequalities in health and secondary access to care". Revue d'Épidémiologie et de Santé Publique 55(1):2330 . doi: 10.1016/j.respe.2006.12.002.

Lurie N. Studying access to care in managed care environments. Health Serv Res 1997;32:691-701.Weber, Dominik. 2020. Report Equal opportunities in health promotion. Definitions, theoretical introduction, practical recommendations. Basic report. Bern: PSCH, OFSP, CDS.

Merçay, Clémence, Nicole Fasel, and Marie Taczanowski. 2023. Iniquities in experiences of care in Switzerland. Insights from the International Health Policy Survey 2020. Obsan Report 08/2023. Neuchâtel: Swiss Health Observatory.

FOPH, Federal Office of Public Health. n. d. "World Health Organization (WHO). Accessed September 5, 2024 (https://www.bag.admin.ch/bag/fr/home/strategie-und-politik/internationale-beziehungen/multilaterale-zusammenarbeit/organisation-mondiale-sante.html).

WHO, World Health Organization. n. d. "Quality of care. Accessed September 5, 2024 (https://www.who.int/fr/health-topics/quality-of-care).

Priester, Mary Ann, Teri Browne, Aidyn Iachini, Stephanie Clone, Dana DeHart, and Kristen D. Seay. 2016. "Treatment Access Barriers and Disparities Among Individuals with Co-Occurring Mental Health and Substance Use Disorders: An Integrative Literature Review." Journal of Substance Abuse Treatment 61:4759 . doi: 10.1016/j.jsat.2015.09.006.

Staines, Anthony, and Charles Vincent. 2019. IMPROVING THE QUALITY AND SAFETY OF CARE IN SWITZERLAND: National report on the quality and safety of care in Switzerland, commissioned by the Federal Office of Public Health.

Williams, David R., and Lisa A. Cooper. 2019. "Reducing Racial Inequities in Health: Using What We Already Know to Take Action." International Journal of Environmental Research and Public Health 16(4):606. doi: 10.3390/ijerph16040606.