SLIDE 1 EQuIP EQuIP Annual Meeting Annual Meeting 9 April 2011 9 April 2011 Copenhagen, Denmark Copenhagen, Denmark Seeking better quality science; Seeking better quality science; knowing what we measure matters knowing what we measure matters
Richard G. Roberts, MD, JD, FAAFP, FCLM Richard G. Roberts, MD, JD, FAAFP, FCLM Wonca Wonca President 2010 President 2010-2013 2013 Professor of Family Medicine Professor of Family Medicine University of Wisconsin University of Wisconsin School of Medicine & Public Health School of Medicine & Public Health 1100 1100 Delaplaine Delaplaine Court, Madison, WI 53715 USA Court, Madison, WI 53715 USA TEL: +1 608 263 3598; FAX: +1 608 263 5813 TEL: +1 608 263 3598; FAX: +1 608 263 5813 Email: richard.roberts@fammed.wisc.edu Email: richard.roberts@fammed.wisc.edu
SLIDE 2 History of Healthcare Quality History of Healthcare Quality
Florence Nightingale
- Deming: measurable improvement
Deming: measurable improvement
Donabedian: structure : structure-process process- outcome
Donabedian: structure : structure-process process- outcome
Berwick-IHI: continuous improvement IHI: continuous improvement
Institute of Medicine 2000: 2000: To Err is Human To Err is Human 2001: 2001: Crossing the Quality Chasm Crossing the Quality Chasm
SLIDE 3 History of Wonca Activities History of Wonca Activities
1989 1989 – – Working Party on Quality Working Party on Quality
2001 2001 – Family Doctors’ Journal to Quality Family Doctors’ Journal to Quality http://finohta.stakes.fi/NR/rdonlyres/72248539 http://finohta.stakes.fi/NR/rdonlyres/72248539-12A1 12A1-49C3 49C3-A3A5 A3A5- 403BEE934736/0/Kirja_Family.pdf 403BEE934736/0/Kirja_Family.pdf
1990 1990 – –EQuIP EQuIP 1995 1995 - QuIAP QuIAP
SLIDE 4 Science of Primary Care Quality Science of Primary Care Quality
1993 – – NHS: Audit to QOF NHS: Audit to QOF
1998 – – Europep Europep Grol
. Br J Gen Pract Pract 2000;50(460):882 2000;50(460):882-7. 7.
2002 – – Review Review Elder. J
Fam Pract Pract 2002;51(11):927 2002;51(11):927-32. 32.
SLIDE 5 Quality defined Quality defined
IOM
WONCA WP on QIFM
Reduction in variation
Reduction in variation
Value
Five A’s of quality
Patient – – experience, outcomes experience, outcomes
SLIDE 6
IOM IOM
Degree health services increase Degree health services increase likelihood desired health outcomes likelihood desired health outcomes c/w current professional knowledge c/w current professional knowledge
SLIDE 7
WONCA QIFM WONCA QIFM
Best outcomes possible given Best outcomes possible given resources available and patient resources available and patient values and preferences values and preferences values and preferences values and preferences
SLIDE 8 Variation in Outcomes Variation in Outcomes
Morbidity and mortality
- Interventions/Hospitalization
Interventions/Hospitalization
- Interventions/Hospitalization
Interventions/Hospitalization
Patient satisfaction
SLIDE 9 Family Medicine Family Medicine and and “A” Quality “A” Quality
First Contact First Contact Continuity Continuity Access Access A relationship A relationship Competence Competence Comprehensive Comprehensive Context Context Ability Ability All All-in in-one
Appropriate Appropriate
SLIDE 10 Patient Experience: Get it Right Patient Experience: Get it Right
Right service
Right time
Right time
Right person
Right price
SLIDE 11
Quality = doing right things right Quality = doing right things right Quality = doing right things right Quality = doing right things right
SLIDE 12 Barriers to QI Barriers to QI
Knowledge Gap
QA vs. QI
Resource Intensive - TIME TIME
Resource Intensive - TIME TIME
Change is Threatening
Financial Resources
- Initial Productivity Declines
Initial Productivity Declines
SLIDE 13 Evidence Clinical Practice Guidelines Performance Measures
Creating Science, Using Best Practice Creating Science, Using Best Practice
Screening Guidelines Diagnostic Guidelines Treatment Guidelines
SLIDE 14 How good is the evidence? How good is the evidence?
Design Design: Review of all original clinical research in 3 major : Review of all original clinical research in 3 major general clinical journal or high general clinical journal or high-impact specialty journals impact specialty journals from 1990 from 1990-2003 that were cited more than 1000 times. 2003 that were cited more than 1000 times. Results Results: Of 49 highly cited studies, 45 claimed that the : Of 49 highly cited studies, 45 claimed that the intervention was effective. intervention was effective. intervention was effective. intervention was effective.
- 7 (16%) contradicted by subsequent studies
7 (16%) contradicted by subsequent studies
- 7 (16%) found effects stronger than those of subsequent
7 (16%) found effects stronger than those of subsequent studies studies
20 (44%) were replicated
- 11 (24%) remained largely unchallenged
11 (24%) remained largely unchallenged
Source: Ioannidis JPA. JAMA 2005;294:218 Source: Ioannidis JPA. JAMA 2005;294:218-228. 228.
SLIDE 15 How good is the evidence? How good is the evidence?
<1 <1 5 9 9 9 9 250 250 750 750 1000 1000
Information taken from Green et al. N Engl J Med 2001;344:2021 Information taken from Green et al. N Engl J Med 2001;344:2021-25, 25, and and White et al. N Engl J Med 1961;265:885 White et al. N Engl J Med 1961;265:885-92. 92.
SLIDE 16 Case of Hemoglobin A1c Case of Hemoglobin A1c
ACCORD (N=10,251) NEJM 2008;358:2545
NEJM 2008;358:2545-59. 59.
ADVANCE (N=11,140) NEJM 2008;358:2560
NEJM 2008;358:2560-72. 72.
VA Trial (N=1791) NEJM 2009;360:129
NEJM 2009;360:129-39. 39.
VA Trial (N=1791) NEJM 2009;360:129
NEJM 2009;360:129-39. 39.
SLIDE 17 Evidence & Guidelines Clinical Practice Performance Measures
Doing, and measuring, what matters Doing, and measuring, what matters
Outcomes that matter to patients
SLIDE 18 United Kingdom United Kingdom - QOF QOF
2004 – – 146 metrics 146 metrics
2006 – – 135 metrics 135 metrics
- 1 billion additional funds
1 billion additional funds
- 1 billion additional funds
1 billion additional funds
Campbell et al. Ann Fam Med 2008;6:228 Campbell et al. Ann Fam Med 2008;6:228-234 234
SLIDE 19 United Kingdom United Kingdom - QOF QOF
Improved disease-specific care specific care
Improved data capture
- Changed behavior regardless of values
Changed behavior regardless of values
- Changed behavior regardless of values
Changed behavior regardless of values
- Improved physician income
Improved physician income
Campbell et al. Ann Fam Med 2008;6:228 Campbell et al. Ann Fam Med 2008;6:228-
234
SLIDE 20 United Kingdom United Kingdom - QOF QOF
Dual QOF-patient agenda patient agenda
Deskill doctors
Decrease continuity
Decrease continuity
- Disgruntled staff if not rewarded
Disgruntled staff if not rewarded
- Impact of performance culture
Impact of performance culture
Campbell et al. Ann Fam Med 2008;6:228 Campbell et al. Ann Fam Med 2008;6:228-
234
SLIDE 21 Paradox of Primary Care Paradox of Primary Care
- Specialists do better on disease focused
Specialists do better on disease focused measures, but no difference in health measures, but no difference in health
- utcomes.
- utcomes. Universal Truths
Universal Truths
- Primary care clinicians achieve better health,
Primary care clinicians achieve better health,
- Primary care clinicians achieve better health,
Primary care clinicians achieve better health, more effective health care, & greater equity. more effective health care, & greater equity. Local/individual Truths Local/individual Truths
Stange Stange KC, KC, Ferrer Ferrer RL. The Paradox of Primary Care.
- RL. The Paradox of Primary Care. Ann
Ann Fam Fam Med Med 2009; 7: 293 2009; 7: 293-299. 299.
SLIDE 22
SLIDE 23
Learn the basic patterns Learn the basic patterns
SLIDE 24
Then can see them in new situations Then can see them in new situations
SLIDE 25
SLIDE 26 Old versus New Science Old versus New Science
OLD OLD
Academic health centers
RCTs
Reductive NEW NEW
Practice-based (PBRN) based (PBRN)
Quality Improvement
Integrative
Reductive
Univariate
Epidemiology
Short term (12 week)
Expert outcomes
Integrative
Multivariate
Complexity & Systems
Long term (years)
Patient outcomes
SLIDE 27
Importance of measurement Importance of measurement
You better value what you measure, You better value what you measure, because what you measure because what you measure because what you measure because what you measure will be valued. will be valued.
SLIDE 28 Outcomes that Matter Outcomes that Matter
Death
Disability
Discomfort
Distress
Dollars
SLIDE 29 Measuring Primary Health Care Measuring Primary Health Care
Continuity
Comprehensive
Comprehensive
SLIDE 30
Personal Personal Professional Professional
Primary Health Care Primary Health Care
Population Population Public Public
Primary Health Care Primary Health Care
SLIDE 31
Personal Personal Professional Professional
Primary Health Care Primary Health Care
Tar Wars Tar Wars Counseling, Counseling, medication medication Population Population Public Public Registry, Registry, immunization immunization Tobacco control Tobacco control Tobacco Tobacco-related disease related disease
SLIDE 32
More important More important than knowing the disease than knowing the disease is knowing the person is knowing the person with the with the dis dis-ease. ease. with the with the dis dis-ease. ease.
SLIDE 33
It’s the It’s the
RELATIONSHIP! RELATIONSHIP! RELATIONSHIP! RELATIONSHIP!
SLIDE 34
Clinical Clinical Decision Decision Decision Decision
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