status quo of quo vadis? - KCE

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14 Quality development in general practice in Belgium: status quo or quo vadis ? KCE Reports 76 Table 2 summarizes the origin and the number of selected papers. The appendix 4 describes briefly the selected reviews. The appendix 5 lists the papers selected from both complementary literature searches. Table 2. Number of selected papers First search Selection after review process Selected reviews First Complementary search Selected papers Second Complementary search MEDLINE 727 43 5 250 26 132 EMBASE 87 10 (2 duplicates) 1 51 4 CRD 103 2 Not performed Not performed Not performed COCHRANE 20 2 Not applicable Not applicable Not applicable 937 57 301 30 1 Final selection 2.3.2 Description of the selected reviews 6 31 The most recent and relevant review was the paper from Contencin et al. 40 This paper describes an overview of the current quality systems. Moreover, it addresses the strengths and weaknesses of different approaches in relation to the culture of the countries and to the health care systems. All studies included in the review addressed the doctors’ behaviour but data on effectiveness on patient outcomes were not available. The authors argue that the most powerful and common instruments within quality systems in general practice are the following ones: • Practice audits. This term has been defined above as a detailed review and evaluation of selected clinical records by qualified professionals for evaluating the quality of medical care. The analysis is often conducted by a third party. Audit implies nowadays the use of computer infrastructure. • Peer-review. A group of GPs review and discuss about their patients or practice records. Peer reviews exist in the Netherlands and in Germany. Recent studies focused on pilots of this method in the UK. • Practice visits. This is the most advanced and individualised peer review technique. Feedback and willingness to change are key aspects. Colleagues or peers visit the practice, offering the possibility to observe the structure and process of the practice. The literature review of King and Wilson was the theoretical basis for launching a large scale program on quality development in Australia. 42 The bulk of information came from the UK and Australia. These authors concluded that evidence about the effectiveness of quality development is very scarce given and because of the early stage of quality development in general practice. They listed a number of components for quality development and identified a set of precursors and enablers. For instance, a shared culture, strong leadership, effective organisation of general practitioners, professional and financial incentives are important in the Australian context. The authors see the development of primary care trusts as an important precursor to develop a comprehensive approach. Rhydderch´s paper analysed the peer reviewed literature on organizational assessments. 43 From the available studies, the authors discuss about an incremental scale ranging from applying minimal standards in one practice towards the emergence of an organisational culture in primary care. Narrowing the scope to clinical care, Seddon et al. reviewed the available evidence in the UK, Australia and New Zealand. 44
KCE Reports 76 Quality development in general practice in Belgium: status quo or quo vadis ? 15 Most of the studies reported chronic conditions. Gaps were identified for quality initiatives in relation with acute care, preventive care and non-technical aspects of care. Grimshaw et al 45 undertook a systematic review to study the effectiveness and costs of different guideline development, dissemination and implementation strategies. Studies on cost-effectiveness of dissemination and implementation strategies are scarce. Multifaceted interventions (encompassing practice visits or written materials) do not seem to be more effective than simple interventions. From a cost-effectiveness standpoint, the simple dissemination of guidelines may be therefore more cost-effective than interventions with multiple components. The review of Holden studied the effectiveness of audits in the UK. Substantial resources are needed to design and to implement audits. It is hard to study their isolated effects because audit is often a part of a multi targeted strategy, including for instance peer review. 46 2.3.3 Effectiveness of peer reviews, practice visits and audits 2.3.3.1 Audit 2.3.3.2 Peer review Most audits use a few indicators only, often derived from guidelines. The agreement on the validity of the indicators used is often low, with a risk that audit would not measure what is intended to. 47 Many GPs do not seem able to apply audit techniques. 48 There is little evidence that audit procedures improve quality of care in the practice and Holden concludes that audits seem to be moderately effective. 46 The effectiveness of peer review is questionable but there is some evidence that this may lead to improved test ordering in the Netherlands. 49 There is a lack of evidence on 39, 38 the effectiveness in Belgium, as detailed in chapters 1 and 4. 2.3.3.3 Practice visit A practice is visited by a peer or, as in the Netherlands, by a specialised practice assistant or practice manager. Van den Hombergh et al. published a comparison between the scores of practice visits in single-handed and group practices. 50 Two preliminary projects in Australia and in the UK only showed the satisfaction of the 51, 52 participants. 2.3.4 Quality indicators The former KCE study reviewed the definitions of quality indicators and clinical quality indicators. 3 One conclusion is the absence of clear-cut difference between the definitions of quality indicators and clinical quality indicators. All definitions agree on the fact that quality indicators measure a specific aspect of care. In general practice, the most frequently used definition of quality indicators also refers to ‘a measurable element of practice that can be used to assess the quality of care. 53 The main domains of indicators are the following ones: • Organisational and management indicators. This field is emerging: the Nijmegen Group had some publications whilst those indicators also play now 54, 43, 55 an important role in the UK. • Patients´ experiences deal with how patients perceive the structure and process of care. Van den Hombergh describes the use of the EUROPEP patient questionnaire that was validated in Europe 50 It is currently also part of the European Practice Assessment tool. • Clinical indicators. They relate to the clinical work in GP. They mostly relate 54, 56 to chronic conditions or prevention. An indicator is a measurement of a small part of the structure, process or outcome. The paper from Campbell et al. and the KCE report on clinical quality indicators listed the following attributes of a good indicator 57, 58, 3 . The measurement-related technical
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