**4. Discussion**

The quality of care in primary healthcare is a very important element of QOL and represents a combination of many dimensions, including access to healthcare and treatment effectiveness. Papers examining the full spectrum of dimensions of the quality of primary healthcare constitute important diagnostic tools in a health policy. As already mentioned, a well-organised and effective primary healthcare is able to respond to 80% of health needs, that is why it is so significant to medical care.

The first aim of the study was to identify variables for measuring access to primary healthcare and treatment effectiveness in primary healthcare units. The conducted literature analysis was aimed at suggesting appropriate initial sets of indicators for the assessment of access to primary healthcare and treatment effectiveness in remote conditions. The conducted statistical analyses were aimed at reducing and improving the critical empirical indicators used to measure the analysed constructs. Using various data reduction methodologies, the paper's objective was to identify a basic set of variables that could effectively measure the dimensions of remote primary healthcare accessibility and treatment effectiveness. The objective was achieved in the study. Referring to previous studies, seven variables were originally selected to measure the access do teleconsultations [34,41,58,59] and four variables to measure the treatment effectiveness [35,52,74–77]. As a result of a factor analysis, the number of variables to measure the access was reduced to four. The Exploratory Factor Analysis showed that the final model adopted for further research was correct.

The second aim was to study patients' satisfaction with these two dimensions of quality of primary healthcare and to analyse the impact of access to primary healthcare on the treatment effectiveness during the COVID-19 pandemic in Poland.

Most of the patients in this study positively assessed the access to primary healthcare and treatment effectiveness in the conditions of teleconsultation in primary healthcare facilities during the COVID-19 pandemic in Poland. This was the case even though telemedicine was never used in the Polish primary healthcare institutions before. 55.5% of the respondents believe that the medical care they received during teleconsultation was as good as meeting their GP face to face [82] The previous studies confirmed that, for some patients, telehealth can be as good as or even better than personal care, especially for those faced with problems concerning physical appointments, e.g., people living in rural areas [83].

According to the results, patients are rather satisfied with the access to remote primary healthcare. The vast majority of patients agree or strongly agree with all positive aspects of the care accessibility dimension. They are the least satisfied with the possibility of contacting the clinic via telephone/Internet (D6: x = 3.12) and the possibility of making an appointment with the GP of their choice (D2: x = 3.57). On the other hand, the clinic's working hours are rated the highest (D4: x = 4.68). Majority of respondents stated that they could obtain medical help whenever needed, even in an emergency (D1: x = 3.86). Quick access to GP appointments was assessed more positively in previous studies in which quick emergency care accessibility was rated the highest [84,85].

Systematic studies have shown that telemedicine has already been successfully used in other countries to provide routine and specialist medical services and has led to greater access to medical care. Moreover, telemedicine has shown similar, and in selected circumstances better, health effects compared to the conventional models of care [83,86], while demonstrating the ability to reduce unnecessary hospitalisations and costs [87].

In general, an analysis of other studies shows that telemedicine is actually pursuing its primary goal of improving access to care and it does so through innovative and constantly evolving tools. For instance, in Great Britain and Denmark, in order to ensure access to primary healthcare, teleconsultations take place in most primary care facilities as a standard procedure [88–90]. It is treated as "a strategic alternative to decentralisation and improving access to medical care, allowing to reduce costs and travel time for patients" [88].

Looking at the benefits, teleconsultations can reduce the patients' indirect costs in terms of time and money, and increase access to primary healthcare, especially if telehealth can be used to support routine or stable patient health problems [91]. The other benefits include less need for face-to-face consultations, the ability to manage physician workloads and allowing systems to be reorganised [88]. In addition, teleconsultation enable overcoming the distance barriers in a flexible and convenient way for patients, with the ability to contribute to the continuity of care, patient autonomy and resource savings. Other qualitative studies examining satisfaction with teleconsultation show that the main benefits commonly reported by patients are convenience, reduced travel time and precisely greater access to specialist care, as well as better appointment flexibility, enabling minimal disruption of everyday life [92,93].

Teleconsultations cannot replace personal medical care in all cases. Several studies have shown that patients were satisfied with the remote consultations, but would also like to be able to have face-to-face appointments [83]. The teleconsultations should not be used in rare or unstable conditions, or when a physical examination is needed. Some patients are more appreciative of direct contact with a physician (with direct examination if necessary) compared to the convenience of telehealth, which was also confirmed by previous studies [94–96]. Such direct contact is also necessary in the case of seriously ill patients. Unfortunately, this pilot study did not allow for the assessment of the quality of teleconsultation from the point of view of chronically ill people. Most of the respondents (40.4%) contacted a doctor for non-urgent reasons (administrative matters: prescription, referral to a specialist, sick leave) or for control reasons (30.3%). Only 12.1% of the respondents held a teleconsultation due to chronic treatment. The other studies show that it is important for the patients to have the choice and flexibility to use health services in the most appropriate way [97]. However, it should be remembered to enable personal appointments for people with more complex health needs [98].

The overall positive assessment of the quality of remote primary healthcare was also due to its high treatment effectiveness. Most patients participating in this study rated the treatment effectiveness quite high. The treatment applied helped or definitely helped most patients, as most of them have had their health problems solved (E1: x = 4.15). The patients' expectations were taken into account by the GPs in the majority of cases (E3: x = 4.44). Therefore, teleconsultations seem to be a safe and effective way of assessing and dealing with various clinical situations.

Also, other studies confirm that telemedicine maximises primary healthcare and offers the possibility of improving the treatment effectiveness [99]. The support for new communication technologies in the healthcare service provision is an important determinant of quality sought by all participants. Technological advances that are transforming traditional treatments and modern methods of care and diagnostics lead to positive changes in the form of better treatment outcomes for patients living in developing, rural areas or areas with limited healthcare options [100,101].

The correlation analysis and ANNOVA analysis conducted in this study pointed to a relationship between access to healthcare and treatment effectiveness in the primary healthcare. The regression model indicated that 14.3% of the variance is explained. The literature also consistently indicates that in the case of some diseases, telemedicine leads to the improvement of health outcomes. In areas such as type 2 diabetes, research shows that telemedicine intervention is comparable to the standards of traditional medical care and does not cause unnecessary risk or harm to patients [102]. Also, neurological and cardiological signs and simple ophthalmic symptoms such as strabismus can be safely diagnosed and treated through teleconsultation [83,88]. However, this study is the first one to show the impact of medical care accessibility on treatment effectiveness in primary healthcare in a crisis situation, such as the COVID pandemic.

There are some limitations to this study that need considering. Firstly, the indicators for measuring medical care accessibility and treatment effectiveness, despite their validation, have not been used in other populations, and therefore their external validity has not

yet been confirmed. The same limitation can be attributed to the study population, which despite a large size is derived solely from four entities located in one region and therefore must be generalised conservatively. Although the sample size of the patients studied was varied, the extent to which they are representative of patients in other clinics is unknown. It would be interesting to repeat the study in other healthcare entities or organisations to see if these variables do indeed still determine the ultimate quality of care based on access to healthcare and treatment effectiveness. Otherwise, the studies conducted among primary care patients in Europe suggest that interpersonal aspects (e.g., communication with a physician, trust and respect [34] are more important dimensions of healthcare quality than accessibility and effectiveness, thereby making it necessary to include them in future studies. It is fair to say that research into these relationships requires further attention. However, the deliberations are limited solely to primary healthcare. Patients with severe diagnoses, e.g., cancer or unstable chronic diseases, would probably assess healthcare services differently than patients requiring stable follow-up appointments, thereby requiring more attention to be paid to groups of patients with unstable health conditions.
