**1. Introduction**

Quality of life (QOL) can be defined as an individual's perception of his or her life status in terms of the cultural systems and values of life, and concerning personal goals, expectations, standards, and concerns [1]. Quality of life became established as a significant concept and target for research and practice in the fields of health and medicine. Understanding QOL is important for improving symptom relief, care and rehabilitation of patients. QOL is also used for identifying the range of problems that can affect patients. This kind of information can be communicated to future patients to help them anticipate and understand the consequences of their illness and its treatment. QOL is also important for medical decision-making because it is a predictor of treatment success and is therefore useful in diagnostics [2]. The studies carried out so far show that medical care significantly contributes to the improvement of patients' QOL [3,4].

QOL indicators, aimed at measuring progress in a society, should reflect its multidimensionality and cover aspects contributing to life satisfaction. One of the indicated aspects is health. Health has already been defined by the World Health Organization (WHO) as "a state of complete physical, mental and social well-being, and not merely the absence of

**Citation:** Kludacz-Alessandri, M.; Walczak, R.; Hawrysz, L.; Korneta, P. The Quality of Medical Care in the Conditions of the COVID-19 Pandemic, with Particular Emphasis on the Access to Primary Healthcare and the Effectiveness of Treatment in Poland. *J. Clin. Med.* **2021**, *10*, 3502. https://doi.org/10.3390/jcm10163502

Academic Editor: Michele Roccella

Received: 2 July 2021 Accepted: 4 August 2021 Published: 9 August 2021

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**Copyright:** © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

disease or infirmity" [5,6]. Poor health not only has the potential to shorten people's life expectancy, but it can also worsen their quality of life. At the collective level, it hampers economic and social development, reducing the so-called "human capital" available to a society and generating additional costs. Thus, long and healthy life is an indicator of social prosperity and success and a QOL factor. This means that the improvement of the quality of life is very often seen as a desirable result of the provision of primary healthcare (PHC) [7].

Traditionally, the quality of life in the field of health sciences is also used as an outcome variable to evaluate treatment effectiveness [8]. Health-related indicators are also used in various studies to measure the quality of life, e.g., health and access to healthcare [9], deaths from cardiovascular diseases and government spending on healthcare [7]. On the other hand, some have suggested that the impact of health and medical care on the overall quality of life is rather small [10].

Health and well-being often depend on the quality of healthcare, which is defined as the degree to which health services for individuals and the population increase the likelihood of achieving desired health outcomes and are consistent with current professional knowledge [1]. The quality of healthcare is also defined as "the degree to which health services meet the needs, expectations and standards of medical care for patients, their families and other care recipients" [11]. These aspects are very often examined in patient satisfaction surveys [12–14]. Several terms are functioning interchangeably in the literature regarding healthcare quality, including health status, quality of life, quality of care and health-related quality of life (HRQoL) [5,15]. Most of the QOL research in medicine and healthcare is related to health, and HRQOL is becoming increasingly important in healthcare and clinical research [16].

The WHO suggests that quality of life covers several key areas known as "domains". In the domain defined as "environment", there is an area related to Health and social care, including the accessibility and quality dimension related to, inter alia, with effectiveness [17]. Overall, the goal of quality in healthcare is the continual improvement of the patient's condition. To decipher whether best practice on healthcare quality has been achieved, the concepts of access and effectiveness are systematically discussed in every healthcare environment [18,19]. For instance the studies that analyzed the impact of quality of care on patients' QoL have measured health and well-being in terms of access to health care, effective treatment and social care [20].

Health-related quality of life maximisation and to the pursuit to provide high-quality medical services are among the most important goals in the work of a family doctor and challenges for primary care organisations, especially in the context of limited treatment options during the COVID pandemic, where telemedicine is often the only possible form of patient care. The need to improve the quality of medical services also results from the legal and ethical obligations of the GP [1].

The scope of this study was deliberately narrowed to the primary healthcare. This was done due to the primary healthcare's fundamental role in many healthcare systems around the world [21] and in the Polish healthcare system [22]. It was already postulated that countries with developed primary healthcare enjoy fewer hospital admissions, better outcomes of patient treatments and, consequently, lower overall healthcare expenditure [23]. As a result, many scholars claim that the main objective of any governmental health policy should be the improvement of the primary healthcare quality [24]. The role of the primary healthcare is especially critical for the Polish healthcare system, mainly because of the following: ageing Polish society, substantial shortages in medical personnel (doctors and nurses) and lower expenditure compared to other EU countries on average.

Studies on the quality of primary healthcare during the COVID-19 pandemic in Poland are limited. On the other hand, researchers were dealing with this issue in the field of selected specialist services. This particularly included studies on access to medical care during pregnancy [25], bariatric care [26], cancer patients care [27], medical and nonmedical services for the elderly [28]. Researchers agree that the COVID-19 pandemic

situation leads to a growing problem of limited or complete lack of access to treatment for specific groups of patients who are in need of special care [29–31]. The perception of medical services during the COVID-19 pandemic was also studied in the context of cancer care [27]. However, no studies on patient satisfaction on the access to primary healthcare and treatment effectiveness in Poland could be found.

The core value of primary healthcare is that a well-organised and effective system of PHC is able to respond to the vast majority (even as much as 80%) of health needs with relatively small funds. Appreciation of the role of primary healthcare was the aftermath of analyses determining the impact of individual factors on healthy societies [32]. Barbara Starfield [33] has proven beyond any doubt that the quality of the entire healthcare system depends much more on the level of primary healthcare development than on the overall expenditure for the healthcare system.

Quality in primary healthcare is defined as the combination of access to healthcare, treatment effectiveness, while the improvement of the population's health and the access to medical care are considered as two important objectives related to the core activities of health systems [34,35]. QOL assessments related to primary healthcare access and effectiveness can benefit patients, clinicians, researchers, administrators, health organizations, and policymakers. As the effects of the COVID-19 pandemic are likely to persist, research into the accessibility and effectiveness of primary healthcare is becoming extremely important, particularly in the context of telemedicine and QOL [36]. To check if best practice on primary healthcare quality has been achieved, the concepts of access and effectiveness should be systematically discussed in every primary healthcare entity [18,19].

Access is critical to the functioning of primary healthcare systems around the world. However, access to primary healthcare remains a complex concept as exemplified by the concept's interpretations diversity by authors. In primary healthcare, access is often defined as access of a service, provider or institution, and is thus defined as the possibility or ease with which patients can use adequate medical services relative to their needs [37]. Some researchers tend to equate access to a delivery system (for example, distribution and volume regarding the medical workforce and medical facilities, availability of providers and health facilities). Others argue that access can best be assessed using performance indicators for a patient's passage through the system, such as utilisation rates or satisfaction scores [24,38,39].

In terms of remote medical appointments, access (accessibility) is considered as the patient's ability to receive primary healthcare [40]. Accessibility is also defined as a way of organising primary care resources to accommodate a wide range of patient opportunities to contact physicians and access to primary healthcare services. This includes the doctors' working hours, consultation times, telephone services and a flexible system enabling having an appointment for medical consultation [41].

Effectiveness was recognised as an important dimension of primary healthcare quality, but the literature emphasises the difficulty of characterising the definition of effectiveness for the primary healthcare sector. For example, in a 2004 study using the Delphi method to establish operational definitions for different dimensions of primary healthcare quality, despite repeated efforts, it was impossible to find a concise operational definition of effectiveness to which all experts could agree [41].

In real life, the concept of effectiveness is used interchangeably with the terms efficacy and efficiency, which is not correct from a scientific point of view. These three concepts have been originally distinguished by Drucker in management sciences [42] in which they bear the following meanings:


• efficiency—doing things in the most economical way. It is the ratio of performance to the inputs of any system [43].

In the healthcare sector, efficacy is defined as the possibility of a beneficial change (or the therapeutic effect) as result of an intervention (e.g., drug, medical treatment, surgery, or public health intervention) under ideal or controlled conditions. Effectiveness is the ability of a [44] medical intervention (e.g., teleconsultation) to have a significant effect on patients under normal clinical conditions. In turn, efficiency must also clearly identify the inputs that are used to obtain the effect of interest (for example, hours of medical care, days when drugs are supplied or medical expenses) [45] Some authors define efficiency as achieving the desired results with the most profitable use of resources [41]. According to Głodzi ´nski, efficiency is the achievement of the highest level of satisfaction possible with the given inputs and technologies [46].

The dimensions of medical service effectiveness and efficacy were announced as quality dimensions in the PHC by the WHO Eastern Mediterranean Regional Office (EMRO) [47]. In turn, the efficiency and effectiveness dimensions were proposed by the US Agency for Healthcare Research and Quality (AHRQ) [48]. Effectiveness and efficiency were also used in the tools for quality assessment in Iran's PHC systems [44].

However, effectiveness is the most popular dimension among the tools for assessing the quality of primary healthcare. For instance, in the Iranian primary healthcare quality assessment framework, (QAF) out of 40 Quality Indicators (QIs), 33.5% were related to the effectiveness dimension. This dimension had the highest share among the quality dimensions [44]. The effectiveness dimension was also in common with the QAF of such countries as Australia, Canada and the United States in terms of the classification of dimensions and QIs [49,50].

Effectiveness plays an essential role in the tools for quality assessments designed for patient opinion surveys. The effectiveness of primary healthcare in regards to obtaining achievable health benefits based on an objective or subjective assessment stating that primary healthcare helped to improve the patient's health or well-being [51]. Effectiveness in primary healthcare facilities is a set of coordinated actions taken at various levels of reference, improving the patients' health through prevention and the provision of primary healthcare [52].

Testa and Simonson argue that any area of health can be measured objectively and subjectively [53]. There are therefore two main trends in the literature regarding the measurement of HRQoL. The first one concerns the measurement based on objective indicators, and the second one is based on subjective indicators. While the objective dimension is used to determine the patient's health status, the patient's subjective assessment is used to translate this condition into the patient's actual HRQoL. Hence, two patients with identical health status may have very different HRQoL depending on their subjective experiences, expectations and perceptions of health [5].

Today, most HRQoL tools are based on patient assessments and have a wide range of applications. A key distinguishing feature of HRQoL is the consideration of the patient's values, judgments and preferences [15,54]. Therefore, literature suggests the construction of social indicators to assess the quality of primary healthcare in a subjective manner [55].

A literature review clearly demonstrated that primary healthcare accessibility and treatment effectiveness are multidimensional constructs. They were taken into consideration in terms of many variables and indicators used to measure them.

In many studies, accessibility has been measured using quantitative indicators that can be objective measures of the availability of primary healthcare. Such objective indicators selected to measure the availability of primary healthcare concern, for instance, the waiting time for an appointment with a specific family doctor, with any family doctor, and for the initiation of consultations [34], the share of people who had or didn't have contact with the provider at a certain time, or the total number of services provided after contact. Such objective indicators also include the travel time, waiting time in the waiting room, the actual patient consultation time at the medical facility and the weighted sum of the

difference between the ideal and the actual number of services, personnel and equipment in the community. In the scale of the entire primary healthcare system, patients' access to the system can also be measured by the number and availability of primary care physicians (the number of medical personnel, medical facilities per unit of population and per unit of geographic area) [56,57].

As already mentioned, literature suggests the construction of social indicators to assess the quality of medical care in a subjective manner [55]. Subjective accessibility indicators concern the patients' assessments of various aspects of their experience of being provided with care. Due to the fact that patients play a unique and important role as evaluators of quality of care, it can be concluded that the patients' opinions should also be taken into account by primary healthcare managers.

Therefore, our tested model provides an accessibility measurement that covers only more subjective indicators related to patients' opinions regarding access to a primary teleconsultation with a General Practitioner (GP), possibility of contacting a primary healthcare facility via telephone/Internet, possibility of obtaining help in emergency situations, convenient opening hours, punctuality of consultations. Such variable were also used in other studies [34,58,59]. This study did not take into account the accessibility dimensions adapted in terms of residential care, such as the location of the healthcare facility and the person's ability to access the facility [60], the ease and convenience of reaching a doctor, the availability of services at the place needed [56]. This study also ignores the more detailed accessibility dimensions adopted by Levesque et al. [61], which do not apply to the Polish conditions and the accessibility definition adopted for the purpose of the study. According to these authors, access to healthcare is affected by individual and environmental factors of the healthcare supply-side factors (e.g., approachability; accommodation; affordability) as well as demand-side factors (ability to perceive; ability to seek; ability to reach; ability to pay ability to engage).

The effectiveness is measured most often with indicators based on an objective or subjective assessment of whether primary healthcare has helped to improve the patient's health or well-being [51]. The most common measures of effectiveness are related to the quality of life, changes in health status, measures of health or well-being, the results reported by the patient, and the patient's knowledge [51]. Some authors recommend measuring effectiveness based on the skills and competencies of the medical personnel (physician's ability to make a proper diagnosis and treatment) [62].

The assessment of the treatment effectiveness of can be considered in three dimensions: (1) the health dimension assessed by the mortality and morbidity rates, (2) the satisfaction dimension, defined as the level of meeting the patient's expectations regarding primary healthcare, (3) the economic dimension regarding the cost of the services provided [63].

The paper is focused on the satisfaction dimension and examines the effectiveness of treatment as measured by patient satisfaction with improving health, solving a health problem and met expectations towards the treatment plan applied. It was assumed in the study that an effective GP helps to solve a health problem and improves the patient's health condition, and the treatment plan proposed by him or her meets the patient's expectations and does not require additional appointments with other specialists [62,64].

The study aims to describe patient satisfaction with the access to primary healthcare and treatment effectiveness in the conditions of remote medical care caused by the COVID-19 pandemic. The study is dealing with the subjective assessment of patient satisfaction in two dimensions: access to primary healthcare and treatment effectiveness. 98 patients of primary healthcare facilities participated in the survey. The other part of this paper is structured as follows. Section 2 includes the specification of the applied research methods. The Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA) are used to define the remote healthcare quality factors. Section 3 provides the results obtained in the study on patient satisfaction from access to primary healthcare and treatment effectiveness during the COVID-19 pandemic in Poland. It also includes comments on the impact of access to teleconsultations on the treatment effectiveness. Section 4 includes a discussion

about the limitations of this study. Finally, the paper also provides conclusions and practical implications.
