PowerPointpresentatie

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Michel Wensing, PhD Radboud University Nijmegen
Medical Centre(Netherlands) for Topas Europe
Association (www.topaseurope.eu)
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Outline

• What are quality indicators and why do we need
  them ?
• Introduction to EPA instrument
• Topas Europe Assocation

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Practice management/quality management

• QM systems developed for industry or service
  organisations (i.e. ISO, EFQM etc.) are also
  promoted for primary or ambulatory health care
  settings
• National or statutory accreditation bodies in
  some countries also require measurement of
  quality
• Extra workload, additional costs, but not much
  evidence about impact on processes and outcomes
  (Wensing 2006)

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Some are very proud of their quality certificate
Foto J. Szecsenyi, 2005
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But does it really reflect reality?
Foto J. Szecsenyi, 2005
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Measurement and management

• If you cant measure it, you cant change
  it(D. Berwick)
• If you dont want to change it, dont measure
  it

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What is an indicator?

• A measurable element of practice performance for
  which there is evidence or consensus and that can
  be used to assess the quality, and hence change
  the quality of care provider
• (Lawrence, 1997)

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Indicators

• Quality indicators show (indicate) measurable
  aspects of quality,
• they do not judge
• about quality

Index
Less complexity
Indicator
Evaluative studies
Data
Reality (quality of care)
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Criteria for good quality indicators

• Valid Relevant aspects covered
• Communicable Relevance easily explained
• Objective Independent of subjective
  interpretation
• Discriminate Detect differences among practices
• Responsive Can detect change in performance
• Influenceable Possible to change if required
• Practical Feasible to measure and collect data
  on

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How are indicators used?

• For education and improvement
• For accountability (inspectorate etc.)
• For contracts and pay for performance
• For public reporting

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What are useful indicatorsfor good practice
management?
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EPA developers

• NL, UK , F, B, CH, D
• Later A, SLO, IS
• Initiative and coordination Centre for Quality
  of Care Research Nijmegen Bertelsmann
  Foundation, Gütersloh

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Objectives

• To develop indicators and tools for assessment of
  practice management enabling primary care
  practices to assess and improve their practice
  organisation
• Secondary
• Contribute to external objectives, eg.
  accreditation and certification, reimbursement
  standards, public reporting
• International ly comparative data allow
  comparisons between countries

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Why international?

• To get input from international experts
• To increase the robustness of the method
• To enhance the comparability of data across
  practices and systems
• But adaptation to national situations is possible

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Implementation in different countries (Jan 2008)

• Germany
• gt 1.000 practices (1.400 doctors, gt 4.000
  practice assitants and nurses)
• Switzerland EPA in GP practices and in managed
  care organisations
• 150 practices (360 GPs, gt500 nurses)
• Netherlands
• EPA indicators part of national accreditation
  programme for GPs
• Slovenia, Romania, Belgium, Denmark
• EPA implementation projects planned in 2007
• Saudi-Arabia, Emirate of Quartar, Denmark Pilot
  tests planned
• More countries outside Europe? ? International
  Practice Assessment (IPA)??

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EPA indicators, training materials and the
Visotool instrument in different languages

• English (source version)
• Dutch
• French
• German
• Hebrew (indicators only)
• Romanian
• Slowenian
• Arab

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EPA domains
Quality
Safety
Finances
Information
People / Staff
Infrastructure
Actual version 220 indicators, core
international set 105 indicators national
adaptations or extensions possibble
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Elements and processes of EPA-GermanyMultiperspec
tive, multifaceted intervention

• 1. Self assessment
• 2. Patient survey (EUROPEP)
• 3. Team questionnaire (work satisfaction scale)
• - A preparatory team meeting in the practice
  (self organized)
• 4. Practice visit by a trained visitor
• Check of premises and equipment
• Interview with main GP
• Team session with feedback (online), duration 1
  ½ - 2 ½ hrs
• 5. Written feedback, further online feedback
  (benchmarking)
• 6. To-do-lists, plan for improvement
• 7. Continuous improvement activities

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Results of the international pilot study
(Examples)

• Core and international set of indicators
  (acceptable, feasible, valid, sensitive)
• 9 countries, 30 practices each (convenience
  sample, stratified for practice size and
  location)
• Structured feedback to these practices

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Accessibility / Availability
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Emergency drugs / doctors bag
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Storage of sensible and controlled material
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Critical incidents / errors
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Hygiene/ Infection control
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Critical incident register ()

• Mean (all countries) 32
• Belgium 26
• France 3
• Germany 19
• Netherlands 28
• Switzerland 25
• UK 89
• Slovenia 36
• Austria 18
• Israel 53
• Grol et al. (eds) Quality Management in Primary
  Care 2005

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Medical record contains smoking status ()

• Mean (all countries) 76
• Belgium 77
• France 69
• Germany 56
• Netherlands 53
• Switzerland 79
• UK 100
• Slovenia 94
• Austria 67
• Israel 90
• Grol et al. (eds) Quality Management in Primary
  Care 2005

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Recall system for patients

• Asthma () Diabetes () CVD ()
• Belgium 65 42 32
• France 0 0 0
• Germany 22 47 28
• Netherlands 62 91 50
• Switzerland 14 32 21
• UK 96 100 96
• Slovenia 16 35 32
• Austria 12 24 12

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TOPAS Europe Association(www.topaseurope.eu)

• International collaboration of researchers and
  practitioners to enhance the development and
  implementation of quality instruments in Europe.
• Based on the EPA project, linked to EQuiP
• Established in 2005 as formal association under
  Dutch law
• Currently four instruments in Topas
• EPA -practice management (coordinator B.Broge)
• Europep R-patient experiences (coordinator
  M.Wensing)
• Maturity Matrix practice development
  (coordinator G.Elwyn)
• EPA Cardio (in development)

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Messages

• Improvement starts with measuring (indicators)
• EPA is a feasible validated and robust tool
• Assessment and practice visit motivates
  measurable change and improvement. GPs in the
  beginning are somewhat sceptical against practice
  visitations practice staff is less sceptical.
  Once they have done it, they like it

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• www.topaseurope.eu

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EPA data and policy-related research two examples

• EPA is primarily developed for assessing and
  improving the quality of practice management
• But the data can be used for international
  comparitive research in order to support health
  policy
• Advantage more detail (and validity?) than many
  other data sources for international studies

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Accessibility of primary care

• Secondary analysis of EPA data from 9248 patients
  in 284 practices from 10 countries
• Health Expectations 2008 (in press)

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Background

• Accessibility for all individuals with all types
  of health problems and coordination of care
  key features of primary care (Wonca 1991)
• Previous research showed that patients had more
  favourable views of accessibility in practices
  with fewer physicians (data from 1998)
• Practice size hascontinued to grow in a number
  of countries has this influenced patient
  expectations?

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Methods

• Convenience samples of practices and patients
  (data from 2004)
• Europep to measure patient evaluations of general
  practice, a previously validated and widely used
  questionnaire
• Six practice characteristics were selected from
  EPA
• Mixed linear regression models

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Some Practice characteristics (n284)
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Predictors of patient evaluations of
accessibility and co-ordination (n9248)
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Mesages

• Patients remain more positive about accessibility
  and coordination in small practices small few
  care providers (rather than physicians)
• Warning observational research

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Chronic care and physician workload

• Secondary analysis of EPA data from 140 practices
  in 10 countries
• Revised paper submitted

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Background

• Delivery of chronic care is an important task of
  primary care
• Primary care practices are relatively small
• A higher volume of chronic patients may be
  associated with better performance and higher
  efficiency
• Many factors could influence such associations
  international research needed

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Methods

• Data from 140 practices in 10 countries
  (convenience samples)
• Physician workload working hours per 1000
  yearly attending patients
• Post-hoc measures based on EPA to measure aspects
  of the chronic care model
• Practice size number of yearly attending
  patients
• Non-physician staff total units of full time
  equivalance staff in the practice
• Mixed linear regression analysis models

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Some descriptive figures (n140 practices)
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Structured chronic care (n140 practices)
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Main findings

• Practice size was the single most important
  predictor of physician workload per 1000
  patients each additional 1000 patients was
  associated with 1.29 fewer working hours per week
  per 1000 patients
• More non-physician staff was associated with
  higher physician workload each additional 0.1
  fte led to an additional 1.6 physician hours per
  week per 1000 patients

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Messages

• Practice size, not chronic care delivery, was the
  most important determinant of physician worklload
• Involving more nurses in primary does not imply
  reduced physician workload, and may in fact imply
  higher workload
• Warning observational research

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Some reflections

• Qualty assessment for education and improvement
  excellent opportunities for health policy studies
• Conditions advantage for particpating practices,
  guarantees for privacy, adequate sampling
  procedures,
• Simultanious collection of the same data, for
  different purposes, should be avoided

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Continued

• EPA provides a rich source of data, which is also
  relevant for health policy and research
• Structures are needed for the implementation of
  EPA in each country
• TOPAS brings together researchers
  internationally, who want to develop and
  implement measures of quality of care

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• www.topaseurope.eu