# paper.pdf ## Metadata - PDFFormatVersion=1.6 - Language=en - IsLinearized=false - IsAcroFormPresent=false - IsXFAPresent=false - IsCollectionPresent=false - IsSignaturesPresent=false - Author=Øyvind Bjertnæs; Mieke Rijken; Ian Porter; Rebecka M. Norman; Ingeborg S. Sjetne; Hilde H. Iversen; Guri Rørtveit; Jose M. Valderas - CreationDate=D:20260409065740+05'30' - Creator=Servigistics Arbortext Advanced Print Publisher 11.1.4546/W-x64 - Custom.EPSprocessor=PStill version 1.84.42 - Keywords=general practice; general practitioner; health care surveys; patient-centered outcomes research; continuity of care; patient satisfaction; physician-patient relations; quality improvement - ModDate=D:20260409094005+05'30' - Producer=PDFlib+PDI 9.0.7p3 (C++/Win64) - Subject=DOI: 10.1093/fampra/cmag017; Family Practice, 43, 3, 2026-04-09.; Abstract: Background: We aimed to: (i) examine to what extent care experiences and perceived outcomes among persons with chronic conditions depend on the GPs they are registered with and (ii) map the associations between patient and GP-level determinants of patient-reported experience and outcome measures. Methods: Cross-sectional general practice nested survey of patients (n = 6691). We estimated the amount of variation at the GP level and conducted multilevel regression analyses to test hypothesized associations between potential predictors (mostly registry-based) and the six Patient-Reported Experience Measures and five Patient-Reported Outcome Measures as dependent variables. Results: The ICC for four of six PREMs varied from 0.035 to 0.091, while the ICCs for the PROMs varied from 0.014 to 0.022. The main predictors of patients’ care experiences were health literacy (P < 0.001 for all measures) and the number of years on the GP list (P < 0.001 for five of six measures). The main predictors for patient-reported outcomes were the number of chronic conditions (P < 0.001 for all), income (P < 0.001 for all indicators for low income compared to high), health literacy (P < 0.001 for all) and the number of consultations in the last 24 months (P < 0.001 for all), and the number of years on the GP list was also significantly associated with all PROMs. Conclusions: Most PREMs demonstrated substantial variation between GPs, warranting GP-level initiatives to improve care experiences for persons with chronic conditions. Health literacy and continuity of care were important determinants of patient-reported experiences and outcomes, demonstrating the importance of these factors for health system performance. - Title=Identifying patient and provider determinants of primary care experiences and outcomes for persons with chronic conditions: a multilevel analysis of a nation-wide survey in Norway - dc:format=application/pdf - dc:identifier=10.1093/fampra/cmag017 - dc:lang=en - dc:publisher=Oxford University Press - dc:title=Identifying patient and provider determinants of primary care experiences and outcomes for persons with chronic conditions: a multilevel analysis of a nation-wide survey in Norway - dc:creator=Øyvind Bjertnæs; Mieke Rijken; Ian Porter; Rebecka M. Norman; Ingeborg S. Sjetne; Hilde H. Iversen; Guri Rørtveit; Jose M. Valderas,Mieke Rijken,Ian Porter,Rebecka M. Norman,Ingeborg S. Sjetne,Hilde H. Iversen,Guri Rørtveit,Jose M. Valderas - dc:description=DOI: 10.1093/fampra/cmag017; Family Practice, 43, 3, 2026-04-09.; Abstract: Background: We aimed to: (i) examine to what extent care experiences and perceived outcomes among persons with chronic conditions depend on the GPs they are registered with and (ii) map the associations between patient and GP-level determinants of patient-reported experience and outcome measures. Methods: Cross-sectional general practice nested survey of patients (n = 6691). We estimated the amount of variation at the GP level and conducted multilevel regression analyses to test hypothesized associations between potential predictors (mostly registry-based) and the six Patient-Reported Experience Measures and five Patient-Reported Outcome Measures as dependent variables. Results: The ICC for four of six PREMs varied from 0.035 to 0.091, while the ICCs for the PROMs varied from 0.014 to 0.022. The main predictors of patients’ care experiences were health literacy (P < 0.001 for all measures) and the number of years on the GP list (P < 0.001 for five of six measures). The main predictors for patient-reported outcomes were the number of chronic conditions (P < 0.001 for all), income (P < 0.001 for all indicators for low income compared to high), health literacy (P < 0.001 for all) and the number of consultations in the last 24 months (P < 0.001 for all), and the number of years on the GP list was also significantly associated with all PROMs. Conclusions: Most PREMs demonstrated substantial variation between GPs, warranting GP-level initiatives to improve care experiences for persons with chronic conditions. Health literacy and continuity of care were important determinants of patient-reported experiences and outcomes, demonstrating the importance of these factors for health system performance. - dc:subject=general practice,general practitioner,health care surveys,patient-centered outcomes research,continuity of care,patient satisfaction,physician-patient relations,quality improvement - dc:rights=© The Author(s) 2026. Published by Oxford University Press. - pdf:keywords=general practice; general practitioner; health care surveys; patient-centered outcomes research; continuity of care; patient satisfaction; physician-patient relations; quality improvement - pdf:producer=PDFlib+PDI 9.0.7p3 (C++/Win64) - pdfuaid:part=1 - pdfx:epsprocessor=PStill version 1.84.42 - prism:aggregationtype=Journal - prism:copyright=© The Author(s) 2026. Published by Oxford University Press. - prism:doi=10.1093/fampra/cmag017 - prism:elssn=1460-2229 - prism:endingpage=10 - prism:issn=0263-2136 - prism:number=3 - prism:publicationname=Family Practice - prism:startingpage=1 - prism:url=https://doi.org/10.1093/fampra/cmag017 - prism:volume=43 - xmp:createdate=2026-04-09T06:57:40+05:30 - xmp:creatortool=Servigistics Arbortext Advanced Print Publisher 11.1.4546/W-x64 - xmp:metadatadate=2026-04-09T09:40:05+05:30 - xmp:modifydate=2026-04-09T09:40:05+05:30 - xmpmm:documentid=uuid:F52766CA-99CF-B88C-EC15-63D108D8ACDC - xmpmm:instanceid=uuid:461703a2-de70-4684-956d-426861af1ec5 - xmprights:marked=True - pdfaextension:schemas=http://www.aiim.org/pdfua/ns/id/pdfuaidPDF/UA Universal Accessibility SchemainternalIndicates, which part of ISO 14289 standard is followedpartInteger ## Contents ### Page 1 Family Practice, 2026, 43, 1–10Published: 9 April 2026Health service research # Identifying patient and provider determinants of primary care experiences and outcomes for persons with chronic conditions: a multilevel analysis of a nation-wide survey in Norway Øyvind Bjertnæs, Mieke Rijken,, Ian Porter, Rebecka M. Norman, Ingeborg S. Sjetne, Hilde H. Iversen, Guri Rørtveit, Jose M. Valderas,, Department of Health Services Research, Division for Health Services, Norwegian Institute of Public Health, Oslo 0473, Norway Primary Care Research Program at NIVEL, Netherlands Institute for Health Services Research (NIVEL), Utrecht, Netherlands Department of Health and Social Management, University of Eastern Finland, Kuopio, Finland Department of Health & Community Sciences, Exeter Collaboration for Academic Primary Care (APEx), University of Exeter, Exeter, United Kingdom Norwegian Institute of Public Health, Oslo 0473, Norway Department of Family Medicine, National University Health System, Level 9, Singapore, Singapore Centre for Research in Health Systems Performance, National University of Singapore, Singapore Corresponding author. Department of Health Services Research, Division for Health Services, Norwegian Institute of Public Health, Sandakerveien 24c Bygg D, Oslo 0473, Norway. E-mail: Abstract Background We aimed to: (i) examine to what extent care experiences and perceived outcomes among persons with chronic conditions depend on the GPs they are registered with and (ii) map the associations between patient and GP-level determinants of patient-reported experience and outcome measures. Methods Cross-sectional general practice nested survey of patients (n = 6691). We estimated the amount of variation at the GP level and conducted multilevel regression analyses to test hypothesized associations between potential predictors (mostly registry-based) and the six Patient-Reported Experience Measures and five Patient-Reported Outcome Measures as dependent variables. Results The ICC for four of six PREMs varied from 0.035 to 0.091, while the ICCs for the PROMs varied from 0.014 to 0.022. The main predictors of patients’ care experiences were health literacy (P < 0.001 for all measures) and the number of years on the GP list (P < 0.001 for five of six measures). The main predictors for patient-reported outcomes were the number of chronic conditions (P < 0.001 for all), income (P < 0.001 for all indicators for low income compared to high), health literacy (P < 0.001 for all) and the number of consultations in the last 24 months (P < 0.001 for all), and the number of years on the GP list was also significantly associated with all PROMs. Conclusions Most PREMs demonstrated substantial variation between GPs, warranting GP-level initiatives to improve care experiences for persons with chronic conditions. Health literacy and continuity of care were important determinants of patient-reported experiences and outcomes, demonstrating the importance of these factors for health system performance. Keywords general practice, general practitioner, health care surveys, patient-centered outcomes research, continuity of care, patient satisfaction, physician-patient relations, quality improvement Key messages - • Care experiences and outcomes from the perspective of primary care service users with chronic conditions are not well understood. - • Patient-reported experiences among persons with chronic conditions varied substantially between general practitioners. - • Higher health literacy and better continuity (number of years with the same GP) were systematically and positively associated with patient-reported experiences and outcomes. - • Poorer care experiences or reported outcomes were found for persons with low education or low income; women; and persons born in Eastern Europe, Asia, Africa, and South America. © The Author(s) 2026. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, dis- tribution, and reproduction in any medium, provided the original work is properly cited. ### Page 2 ## Introduction Chronic conditions and multimorbidity present significant and growing challenges for health systems worldwide, with negative consequences for mortality, quality of life, the ability to work, and healthcare costs [,]. In many countries, a considerable proportion of primary care consultations involve individuals with chronic con-ditions. However, little information is available about how health-care systems and services perform from the perspective of people living with chronic conditions []. In addition, information is lacking on how patient and care provider characteristics are associated with patient-reported care experiences and outcomes. Previous re-search has assessed patient and organizational factors associated with patient experiences with general practice, but without a specif-ic focus on care for patients with chronic conditions [] and without assessing patient-reported outcomes like self-reported health and quality of life []. The International Survey of People Living with Chronic Conditions (PaRIS) is an ambitious and innovative OECD initiative that integrates a provider survey with a large-scale patient survey across 19 countries []. The PaRIS conceptual framework views patient-reported experiences and outcomes as interconnected, multidimensional dependent outcomes, potentially influenced by a range of factors at the patient, provider, and system levels []. However, OECDs flagship report from the first PaRIS survey cycle showed that nine out of ten key patient-reported indicators only had 1–3% variation at the practice level [], thus explaining only a small proportion of the variation on these indicators. As the size of the variation across providers is often interpreted as a signal for improvement potential [], this could indicate less relevance of practice-level initiatives to improve results. Norway is one of the participating countries in PaRIS. Norway has a regular general practitioner scheme covering almost the whole popu-lation. Most GPs are self-employed and have responsibility for their own patient list. Thus, patients were sampled from individual GPs in Norway, not from group practices with shared patient lists as was the case in many other countries in PaRIS. For countries with an individual-level organization model, such as the Norwegian regu-lar GP scheme, the practice-level approach is less relevant. We expect that a GP-level approach will yield more provider-level variation than at practice level, at least for patient experiences, as previous research has shown substantial variation between individual physicians within practices [,]. Furthermore, access to a national registry gave ac-curate and complete data for additional registered patient character-istics as well as GP/practice characteristics that were not available in the international PaRIS dataset, and could serve as predictors of PREMs and PROMs at the patient and provider level. The objectives of our study were to (i) examine to what extent care experiences and perceived outcomes among persons with chronic conditions depend on the GPs they are registered with and (ii) map the associations between a range of potential patient and GP-level determinants of PREMs and PROMs, using both survey data and registry data. ## Methods ### Setting All residents in Norway are entitled to a regular GP, and around 99% of the population is part of the regular GP scheme []. The GPs have a list of patients for whom they have medical responsi-bility. GPs are gatekeepers for the national insurance scheme, and patients are referred by a GP to specialized medical care when needed. The GP practices are, in general, small units most often with four or more GPs, of which around 80% of GPs being self-employed []. ### Population and sampling Norway participated in the international PaRIS survey []. The eligible patient population was community-dwelling patients aged 45 years or older with at least one consultation with a pri-mary care provider in the 6 months prior to the survey []. In Norway, we used the national GP register as the sampling frame and randomly selected 250 individual GPs from all GPs in Norway (approximately 5200 at the time of measurement). We did not stratify GPs but selected a random sample of GPs from the na-tional sampling frame. The goal was to obtain responses from 100 GPs and 75 patients for each responding GP, which was OECD’s sample size targets for Norway []. The patient sample was recruited from GPs who responded to the primary care prac-tice questionnaire, the PaRIS-PCPQ []. We received valid re-sponses from 118 GPs in Norway and randomly selected 175 patients from each of these using the eligibility criteria described above. To secure the target of 75 patient responses for each GP, 175 patients were randomly selected for each GP given an esti-mated patient response rate around 45% (estimate based on a pilot survey in Norway). ### Data collection The survey invitation was sent to the included patients in May 2023 (n = 19 637), using the national digital portal Helsenorge.no. The invitation included a link and a unique ID val-idation code to the digital questionnaire. We sent up to three SMS reminders to non-respondents in the digital group. Patients not registered for communication through the national portal (12.3%) were sent a postal invitation letter and up to one postal reminder, both including a pen-and-paper questionnaire in Norwegian. ### Registry data We obtained background data about GPs from the national GP register, while background patient data was collected from the GP register, The Norwegian Control and Payment of Health Reimbursements Database and Statistics Norway (variable lists in). ## Questionnaire The conceptual model for the PaRIS survey has been described elsewhere []. The PaRIS patient questionnaire (PARIS-PQ) consisted of 118 items, mainly based on existing validated Patient-Reported Experience Measures (PREMs), Patient-Reported Outcome Measures (PROMs) and potential predictors like health and health care capabilities, health behaviors, and individual and ### Page 3 sociodemographic factors. In Norway, we also included a five-item short version of the GP scale of the Patient Experiences with GP Questionnaire, the PEQ-GP []. The source patient questionnaire in English is provided as. ### Outcome measures We selected the ten key PaRIS outcome measures []. PREMs: (i) confidence in self-management (adapted from the Person- Centered Coordinated Care Experiences Questionnaire—P3CEQ; []); (ii) experienced care coordination (adapted five-item sub-scale of the P3CEQ; []); (iii) experienced person-centered care (adapted eight-item subscale of the P3CEQ; []); (iv) experienced quality (single item, adapted for PaRIS from the Commonwealth Fund International Health Policy Survey; []); (v) trust in the healthcare system (single item, based on OECD Guidelines on measuring trust and similar to questions in selected national surveys). PROMs: (i) physical health (four-item scale of PROMIS Global scale; []); (ii) mental health (four-item scale of PROMIS Global scale; []); (iii) social functioning (single item from PROMIS Global scale; []); (iv) well-being—(WHO five-item Wellbeing Index; []); (v) general health (single item from PROMIS Global scale, []). Finally, we included the five-item GP scale from the generic PEQ-GP instrument []. ### Predictors We selected predictors based on previous research [,,] and available data, using survey data and registry data about pa-tients and GPs as potential predictors (see). Considering the study objectives and the broad-ness of outcomes, we were inclusive in the selection process to avoid excluding potentially important predictors in multilevel analysis. Chronic condition(s) and health literacy were based on self-report (), the latter repre-sented by a scale with two items from the PaRIS survey, which had been constructed from the Porter-Novelli scale []. ### Statistical analysis Descriptive statistics were generated for patient and provider background characteristics and the 11 outcome measures. We ran empty multilevel models (patient and GP levels) to estimate the intraclass correlation coefficient (ICC), i.e. the provider-level variation divided by the total variation. Thresholds for defining low variability are uncommon (Fung et al. []), but based on the ICC and the number of valid responses we calculated the provider-level reliability for each outcome. Provider-level reli-ability is the proportion of the variance of GP-level mean scores that is due to actual differences between GPs, with reliability greater than 0.70 indicating acceptable reliability [,]. We hy-pothesized that the clustering effect would be largest for GP ex-periences which are GP specific, followed by experienced quality/ coordination/person centeredness which are somewhat less spe-cific. Confidence in self-management is a capability [], while trust in the health system is much broader than the GP, hence we expected both to have small cluster effects. For PROMs, the level of clustering was expected to be more homogenous as the constructs are a lot more distal than PREMs, hence less direct impact. We conducted multilevel analysis of the association between patient- and GP-level predictors and the PREMs and PROMs. To assess patient-level and GP-level predictors for the 11 measures, we ran multilevel linear regression models with patient variables as fixed predictors at level 1, providers as a random intercept and provider-level variables as fixed effects at level 2. We report standardized coefficients in the main tables and unstandardized coefficients in. All statistical analyses were conducted with R (version 4.3.0). ## Results ### Patient and GP characteristics Of the 19 637 approached patients, 8683 responded to the ques-tionnaire (44.2%), of which 6691 reported one or more chronic conditions (our study sample). The majority of persons with chronic conditions were women (54.8%), while 55–69-year-olds comprised the largest age group with 43.8% of respondents (). Of the 118 GPs, 54.2% were men, 66.1% were 50 years or younger, and 60.2% were a specialist in general practice (). ### Reliability and cluster effects The GP-level reliability was satisfactory for experienced care co-ordination (reliability: 0.67), person-centered care (reliability: 0.74), experienced quality (reliability: 0.83), and GP experience (reliability: 0.83) (). For the two PREMs with highest GP-level reliability (>0.80), the mean GP-level scores varied from 52.1 to 86.6 (SD: 6.3, GP experiences) and 40.0 to 86.4 (SD: 8.3, experienced quality). For PROMs the provider-level reli-ability varied from 0.44 on social functioning to 0.56 on well-being. Four of the PREMs had substantial variation at the GP level: ex-perienced care coordination (ICC: 0.035), experienced person- centered care (ICC: 0.061), experienced quality (ICC: 0.084), and GP experiences (ICC: 0.091). The ICCs for the PROMs were low (0.01–0.02). ### Determinants of PREMs Health literacy was positively associated with all PREMs, with beta values ranging from 0.159 for experienced coordination to 0.375 for confidence in self-management (P < 0.001 for all,). The number of years on the GP list and age were posi-tively associated with five of six PREMs (P < 0.001 for five of six measures), with higher beta values for years on the GP list than age on most measures. Sex and the number of chronic con-ditions were significantly associated with five PREMs, with four showing better care experiences of men and patients with fewer chronic conditions. The exceptions were that having more chron-ic conditions was associated with better experienced care coord-ination (P < 0.001), while women reported more confidence in ### Page 4 self-management than men (P < 0.001). High educated patients reported worse care experiences on four PREMs compared to low educated patients (P < 0.05) and on three PREMs compared to patients with a medium-level education (P < 0.05). Three variables at the GP level were negatively associated with patients’ care experiences: list length (P < 0.05 for three PREMs), practice size (P < 0.05 for three PREMs), and being employed by the municipality (P < 0.05 for two PREMs). ### Determinants of PROMs The most important predictors for PROMs () were income (P < 0.001 for all indicators for low income compared to high; ### Page 5 beta values ranging from −0.256 for physical health to −0.425 for mental health), the number of chronic conditions (P < 0.001 for all; beta values ranging from −0.143 for mental health to−0.266 for physical health), the number of consultations the last 24 months (P < 0.001 for all; beta values ranging from−0.205 for mental health to −0.249 for physical health), and health literacy (P < 0.001 for all; beta values ranging from 0.137 for general health to 0.203 for mental health) . Other socio- demographic variables associated with PROMs were age (better scores with higher age, P < 0.001 for all), sex (women had poorer scores on two measures, P < 0.001), education (poorer scores for low education than high education on three measures, P < 0.01), and birth country (Eastern Europe scored poorer than Norwegian-born on all measures, P < 0.05; Asia/Africa/South America scored poorer on three, P < 0.01). The number of years with the same GP was positively and significantly associated with all PROMs (P < 0.001), while two variables at the GP level were negatively associated with PROMs: the use of locum doctors the last 12 months (P < 0.05 for all indicators) and the number of years as GP (P < 0.05 for three indicators). ## Discussion A substantial part of the variation in primary care patients’ care experiences was related to the GP they receive care from. Health literacy, the number of chronic conditions, age, and the number of years on the GP list were consistent predictors for patients’ care experiences and self-reported outcomes. Several other socio-demographic factors (sex, education, birth country) were weakly or moderately related to patients’ care experiences and self-reported outcomes, while income was strongly related to all patient-reported outcomes and trust in the health system. OECDs PaRIS flagship report showed that most PREMs and PROMs had little variation at the provider level, with sampling on the practice level for most countries []. For countries with an individual-level organization model, such as the Norwegian regular GP scheme, the practice-level approach is less relevant. Our study, restricted to the target group of persons with chronic conditions, identified four PREMs with substantial variation be-tween GPs, all with satisfactory GP-level reliability. Previous re-search has shown substantial variation between physicians within a practice [,], meaning that a practice-level approach will average out differences in the experiences of patients with individual physicians within practices and consequently produce lower ICCs. Thus, our findings were as expected but show the im-portance of in-depth within-country data and analyses to supple-ment the international analyses. Our study underlines the relevance and importance of measuring and improving patient experiences at the GP level in Norway, and probably in other countries with an individual-level organization model. Health literacy was the single most important predictor of vari-ation in the key measures. Health literacy has been connected to health outcomes in previous systematic reviews [,], but the as-sociation with PREMs is more seldom assessed. We found that health literacy had an especially strong association with two PREMs, namely confidence in self-management and patient- centered care. Confidence in self-management was included as a PREM in the OECD flagship report [], but according to the concep-tual model this is not a PREM but a health and health care capabil-ity construct []. The data empirically supported the conceptual model by showing a pattern of association quite different from all other PREMs, including no association with any of the provider- level variables, while it showed the highest degree of association with the other capability measure, health literacy. Incidentally it is not surprising that person-centeredness also has also an associ-ation with literacy as all these capabilities measures (literacy, con-fidence, and activation) are a prerequisite to effectively implementing a person-centered approach. The most important risk factor for low health literacy is low education [], which ### Page 6 means that less educated persons with chronic conditions are an important target group for initiatives to strengthen health literacy, confidence in self-management and person-centered care. We also found poorer results for persons with low income, for women, younger persons and some birth country groups, which are add-itional target groups for interventions. Continuity of care was linked to patients experiencing better care and better outcomes, with the number of years on the GP list positively related to both, and less use of locum doctor positively related to patients’ reported outcomes. Previous re-search has identified a connection between continuity and a range of positive outcomes [], and GP continuity was ### Page 7 the key predictor for patient-perceived accessibility to general practice in a recent Norwegian study []. We are not aware of previous nationwide studies among patients in general prac-tice showing a consistent association between continuity of care and broad PROMs related to physical health, mental health, social functioning, well-being, and general health. Thus, our study adds value to the literature on the importance of continuity in primary care for persons with chronic conditions []. Several other GP-level variables were asso-ciated with two or more measures including the number of GPs in the practice, list length, employment type, and the number of years working as GP. These are potential GP and practice- level factors that could be leveraged in efforts to improve care experiences and outcomes for persons with chronic condi-tions, but we underline that these were less important than the most important patient-level predictors. ### Page 8 ### Limitations Less than half of the GPs participated and the response rate for patients was 44%. This opens the possibility for selection bias and non-response bias. Compared to the other 18 countries par-ticipating in the OECD PaRIS survey, Norway had a high response rate for both patients and providers []. E.g. the patient response rate varied from 6% in Romania to 47% in Spain, with Norway having the second highest response rate for patients (44%), only slightly below Spain []. We used two interconnected out-comes in our study (PREMs, PROMs), but without assessing how they are connected. The conceptual and empirical broad-ness of the PaRIS survey facilitates the assessment of the inter-connection between these constructs [], which should be an important topic for further research. We aimed to map the asso-ciations between a range of potential patient and GP-level deter-minants of PREMs and PROMs, but associations do not imply causality. The complex interaction between predictors, PREMs, and PROMs should be assessed in future research. The generaliz-ability to countries with a different structure and organization of primary care is questionable, especially the cluster effects and provider-level predictors. We recommend further research in oth-er countries using physician-level sampling or other approaches to conduct disaggregated analyses. ### Implications Chronic conditions and multimorbidity have negative conse-quences for quality of life, the ability to work and healthcare costs [,,]. Our findings stress the necessity for novel pri-mary care models to empower and better support the growing number of persons living with chronic conditions [,], extend-ing beyond traditional healthcare’s single disease focus. There is a need for more person-centered primary care focusing on the needs and preferences of persons with chronic conditions, in-cluding health literacy, self-management support, continuity, and coordinated care. The large differences in care experiences and outcomes be-tween patients with high and limited health literacy, and the large differences in trust in the health system and self-reported outcomes between high- and low-income groups underline the importance of tailoring primary care services to disadvantaged groups. While health inequalities are well documented [], our study showed systematic inequality across a broad set of per-formance dimensions for primary care users. To ensure improve-ments for all it is essential that improvement efforts and research measure and monitor not only overall effects, but effects on in-equality as well [,]. ## Conclusions Patients’ care experiences depended for a substantial part on the GP they receive care from, while health literacy and relationship continuity were the most important predictors of patients’ care experiences and outcomes. A shortage of primary care physi-cians, together with aging populations and a growing number of people with chronic conditions among future users of primary care, makes it essential to develop and implement person- centered, effective, and innovative primary care models. These should promote health literacy and self-management capabil-ities among people with chronic conditions, while also being re-sponsive to possible inequalities across socio-demographic groups. ## Acknowledgements We thank Inger Opedal Paulsrud from the Norwegian Institute of Public Health for performing administrative and technical tasks during data collection. We thank the OECD PaRIS team and the PaRIS consortium for collaboration on the PaRIS surveys. ## Author contributions Øyvind Bjertnæs contributed to conception, design, analysis, in-terpretation of data, drafting, and approving the submitted ver-sion. Mieke Rijken, Ian Porter, Rebecka M. Norman, Ingeborg S. Sjetne, Hilde H. Iversen, Guri Rørtveit, and Jose M. Valderas contributed to the conception of the work, drafting, and revising of the article, gave final approval for the version to be published, and agree to be accountable for all aspects of the work. ## Supplementary material Supplementary material is available at online. ## Conflicts of interest The authors declare that they have no competing interests. ## Funding The authors did not receive any funding for this study. ## Data availability Anonymous data is available from the corresponding author on reasonable request. ## Ethical approval and consent to participate The study was part of a national quality assurance project (“OECDs Patient-reported Indicator survey in Norway 2021–25”, project number: 3103). Research Director Atle Fretheim of the NIPH healthcare services division approved the Data Protection Impact Assessment (DPIA) for the quality assurance project. According to the joint body of the Norwegian Regional Committees for Medical and Health Research Ethics, research ap-proval is not required for quality assurance projects. Informed consent was obtained for all participants. Returning the com-pleted questionnaire constituted patient consent, which is the standard procedure in all patient-experience surveys conducted by the Norwegian Institute of Public Health. Patients were in-formed that participation was voluntary. The study was ### Page 9 performed in accordance with relevant guidelines and regula-tions including the Declaration of Helsinki. ## Consent for publication Not applicable. ## References Hacker K. The burden of chronic disease. Mayo Clin Proc Innov Qual Outcomes 2024;8:112–9. Fouad AM, Waheed A, Gamal A et al. Effect of chronic dis-eases on work productivity: a propensity score analysis. J Occup Environ Med 2017;59:480–5. de Boer D, van den Berg M, Ballester M et al. 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