status quo of quo vadis? - KCE

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12 Quality development in general practice in Belgium: status quo or quo vadis ? KCE Reports 76 2 QUALITY SYSTEM IN GENERAL PRACTICE: ANALYSIS OF FIVE SELECTED COUNTRIES 2.1 INTRODUCTION This chapter reviews the quality systems in five selected countries i.e., the national quality initiatives, the indicators used and the evidence that a specific quality system improves process and outcome measures in general practice. The final objective is to derive suggestions for a quality development framework in Belgium. 2.2 METHODOLOGY A first literature search in electronic databases (i.e., Medline, Embase and DARE) was followed by a more in-depth analysis of the five country systems using grey literature and native experts´ opinions. 2.2.1 Selection of the countries Some countries were pioneering quality initiatives in the 70’s and 80’s i.e., the United Kingdom, the Netherlands and Scandinavian countries. The other states followed them to some extent. 2 Nowadays, most Western European countries have national and local policies on quality development in general practice. The selection of countries focused on Western European countries, in order to get results applicable to the Belgian health care system: • France has a health care system similar to Belgium; • Germany has a national policy for quality in family practice, obligatory for all GPs; • The UK pioneered quality initiatives in GP and developed great innovations in that area; • The Netherlands also have a long history of research and quality development in general practice. Moreover, collaborations exist with Belgium like for instance in the field of guidelines development. The addition of Australia answered to the need for analysing an outstanding example of recent development of a quality system based on a preliminary conceptual framework. The US was not included in the review because the health care system and the working conditions of general practitioners are far different from the Belgian ones. The Scandinavian countries were also excluded because they mostly publish grey literature in their native language, making it very hard to analyse comprehensively the available literature and websites from professional bodies. 2.2.2 Search strategy in electronic databases The literature search relied on a ‘waterfall’ methodology, beginning with good quality reviews further completed by more recent papers. The first search strategy outlined in appendix 1 applied the following limitations: • Publication date since 1996: quality systems have been set up from 1990 onwards. A few of them only were operational in the 90’s. • Publications on the selected European countries and Australia. The last and most relevant review ended its literature search in 2003. A first complementary search analysed all types of papers since 2003 until May 2007. A second search focused more specifically on peer review, audit and practice visits as these are the major methods described in the literature about GP quality development. 40 Moreover, possible decisions about the implementation of EPA in Belgium after this field study (chapter 3) must rely on the evidence about the effectiveness of practice visits.
KCE Reports 76 Quality development in general practice in Belgium: status quo or quo vadis ? 13 2.2.3 Grey literature: electronic sources and additional information on the selected countries The main sources of information were the websites of the National Health Authorities, professional bodies and colleges and third parties engaged with quality development (see appendix 2). The results were summarized in a narrative text using the following headings: • Organization of the health care system, with focus on family medicine/general practice; • Quality development in action: legislation, financing, organisation and implementation; • Evidence for the effectiveness of the system; • Future developments. Two national experts in the field of GP quality reviewed the description of their country. They were selected through the EQuiP working party (European Association for Quality in General Practice/Family Medicine) or by personal contacts for Australia. The natives checked the first description of their national quality system and provided further internet sources and documents. The researchers added their amendments in the text and if necessary held a telephone interview. The appendix 3 details the national representatives for each country. 2.3 RESULTS OF THE LITERATURE STUDY 2.3.1 Selected reviews and papers The initial search of reviews yielded 937 papers. During the selection process, LS and RR independently applied the following exclusion criteria i.e., major topic not related to family medicine/general practice, focus on specific pathologies (i.e. diabetes mellitus), focus on a non-Western European country (i.e. US, Canada). The papers included concerned • either family practice/general practice AND quality of care AND practice based evaluation systems, • or family practice/general practice AND quality of care but not specifically about practice evaluation systems. RR, LS and PL reached agreement on papers that were disputable for entry and selected fifty-seven papers for the reading of full texts. A second selection was based on the following exclusion criteria i.e., other country than the five countries of interest, descriptive study of a local project, methodology for the development of clinical quality indicators (described in the former KCE report 3 ). After full text reading by two independent readers (RR and HP) and check by LS, the researchers selected six reviews for final analysis. The selection of other interesting papers aimed at providing food for thoughts in the discussion or at completing the descriptions of the countries. A first complementary search in Medline and Embase used an identical methodology from 2003 onwards without any limitation on the type of article. This strategy yielded 301 papers. After reading the abstracts and joint appreciation of HP, RR and LS, using the same inclusion criteria as above (but excluding the limit ´review´), 30 papers were included for the analysis. A second complementary search in Medline looked for papers on quality circles, peerreview and audit. This search yielded 132 papers. After discarding double references, seven papers were selected. Four papers were duplicates, one paper was a letter and one paper 41 was already in the selection of the reviews. Hence 31 additional papers were added to the selection.
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