status quo of quo vadis? - KCE
status quo of quo vadis? - KCE
status quo of quo vadis? - KCE
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<strong>KCE</strong> Reports 76 Quality development in general practice in Belgium: <strong>status</strong> <strong>quo</strong> or <strong>quo</strong> <strong>vadis</strong> ? 15<br />
Most <strong>of</strong> the studies reported chronic conditions. Gaps were identified for quality<br />
initiatives in relation with acute care, preventive care and non-technical aspects <strong>of</strong> care.<br />
Grimshaw et al 45 undertook a systematic review to study the effectiveness and costs <strong>of</strong><br />
different guideline development, dissemination and implementation strategies.<br />
Studies on cost-effectiveness <strong>of</strong> dissemination and implementation strategies are scarce.<br />
Multifaceted interventions (encompassing practice visits or written materials) do not<br />
seem to be more effective than simple interventions. From a cost-effectiveness<br />
standpoint, the simple dissemination <strong>of</strong> guidelines may be therefore more cost-effective<br />
than interventions with multiple components.<br />
The review <strong>of</strong> Holden studied the effectiveness <strong>of</strong> audits in the UK. Substantial<br />
resources are needed to design and to implement audits. It is hard to study their<br />
isolated effects because audit is <strong>of</strong>ten a part <strong>of</strong> a multi targeted strategy, including for<br />
instance peer review. 46<br />
2.3.3 Effectiveness <strong>of</strong> peer reviews, practice visits and audits<br />
2.3.3.1 Audit<br />
2.3.3.2 Peer review<br />
Most audits use a few indicators only, <strong>of</strong>ten derived from guidelines. The agreement on<br />
the validity <strong>of</strong> the indicators used is <strong>of</strong>ten low, with a risk that audit would not measure<br />
what is intended to. 47 Many GPs do not seem able to apply audit techniques. 48 There is<br />
little evidence that audit procedures improve quality <strong>of</strong> care in the practice and Holden<br />
concludes that audits seem to be moderately effective. 46<br />
The effectiveness <strong>of</strong> peer review is questionable but there is some evidence that this<br />
may lead to improved test ordering in the Netherlands. 49 There is a lack <strong>of</strong> evidence on<br />
39, 38<br />
the effectiveness in Belgium, as detailed in chapters 1 and 4.<br />
2.3.3.3 Practice visit<br />
A practice is visited by a peer or, as in the Netherlands, by a specialised practice<br />
assistant or practice manager. Van den Hombergh et al. published a comparison<br />
between the scores <strong>of</strong> practice visits in single-handed and group practices. 50 Two<br />
preliminary projects in Australia and in the UK only showed the satisfaction <strong>of</strong> the<br />
51, 52<br />
participants.<br />
2.3.4 Quality indicators<br />
The former <strong>KCE</strong> study reviewed the definitions <strong>of</strong> quality indicators and clinical quality<br />
indicators. 3 One conclusion is the absence <strong>of</strong> clear-cut difference between the<br />
definitions <strong>of</strong> quality indicators and clinical quality indicators. All definitions agree on the<br />
fact that quality indicators measure a specific aspect <strong>of</strong> care.<br />
In general practice, the most frequently used definition <strong>of</strong> quality indicators also refers<br />
to ‘a measurable element <strong>of</strong> practice that can be used to assess the quality <strong>of</strong> care. 53<br />
The main domains <strong>of</strong> indicators are the following ones:<br />
• Organisational and management indicators. This field is emerging: the<br />
Nijmegen Group had some publications whilst those indicators also play now<br />
54, 43, 55<br />
an important role in the UK.<br />
• Patients´ experiences deal with how patients perceive the structure and<br />
process <strong>of</strong> care. Van den Hombergh describes the use <strong>of</strong> the EUROPEP<br />
patient questionnaire that was validated in Europe 50 It is currently also part <strong>of</strong><br />
the European Practice Assessment tool.<br />
• Clinical indicators. They relate to the clinical work in GP. They mostly relate<br />
54, 56<br />
to chronic conditions or prevention.<br />
An indicator is a measurement <strong>of</strong> a small part <strong>of</strong> the structure, process or outcome.<br />
The paper from Campbell et al. and the <strong>KCE</strong> report on clinical quality indicators listed<br />
the following attributes <strong>of</strong> a good indicator 57, 58, 3 . The measurement-related technical