Improving the quality of preventive cardiovascular care provided by primary care physicians: insights from a US Quality Improvement Organization.

BACKGROUND: During 2000-03, Qualidigm, a US Quality Improvement Organization, conducted a project to improve the care received by elderly Medicare patients with coronary artery disease or cardiovascular risk factors. METHODS: We recruited primary care physicians in private practice in the state of Connecticut. Then, we identified approximately 30-50 patients per physician from the periods 1 January 2000 to 31 December 2000 and 1 November 2001 to 31 October 2002. We abstracted medical records to assess processes and outcomes of care, and we provided the physicians with performance data and a variety of practice-enhancing materials. The physicians utilized those materials that they perceived to be most helpful. RESULTS: We identified and recruited 974 primary care physicians to participate. Of these, 103 (10.6%) committed to participate, and 85 of the 103 completed the project. Among the intervention tools, physicians and their office personnel utilized personal digital assistants (PDAs) (36.5%) and patient education materials (34.1%) most commonly. Overall, quality of care improved for most physicians (mean quality score 62.0 to 67.8%, P < 0.001). However, not all improved, and most improvements were modest [mean absolute improvement in quality score 5.8%, standard deviation (SD) 6.8%]. CONCLUSIONS: Quality Improvement Organizations and others interested in improving outpatient quality of care face significant challenges in recruiting self-employed primary care physicians to quality improvement projects and in bringing about transformational change. Future primary care quality improvement projects should include careful assessments of practice-specific barriers, interventions that are linked to these barriers, and support of the practices on implementation.     

Quality of primary health care in Saudi Arabia: a comprehensive review.

OBJECTIVES: Little is known about the quality of primary care in Saudi Arabia, despite the central role of primary care centers in Saudi health strategy. This study presents an overview of quality of primary care in Saudi Arabia, and identifies factors impeding the achievement of quality, with the aim of determining how the quality of Saudi primary care could be improved. METHOD: Using a systematic search strategy, data were extracted from the published literature on quality of care in Saudi primary care services, and on barriers to achieving high-quality care. RESULTS: Of the 128 studies initially identified, 31 met the inclusion criteria for the review. Studies identified were diverse in methodology and focus. Components of quality were reviewed in terms of access and effectiveness of both clinical and interpersonal care. Good access and effective care were reported for certain services including: immunization, maternal health care, and control of epidemic diseases. Poor access and effectiveness were reported for chronic disease management programs, prescribing patterns, health education, referral patterns, and some aspects of interpersonal care including those caused by language barriers. Several factors were identified as determining whether high-quality care was delivered. These included management and organizational factors, implementation of evidence-based practice, professional development, use of referrals to secondary care, and organizational culture. CONCLUSION: There is substantial variation in the quality of Saudi primary care services. In order to improve quality, there is a need to improve the management and organization of primary care services. Professional development strategies are also needed to improve the knowledge and skills of staff.     

A Quality of Care Framework for Home-Based Medical Care

More than 6 million adults in the United States are homebound or semi-homebound and would benefit from home-based medical care (HBMC). There is currently no nationally recognized quality of care framework for home-based medical care. We sought to capture diverse stakeholder perspectives on the essential aspects of quality HBMC and create a quality of care framework for homebound adults. A qualitative analysis of semistructured interviews from purposive sampling of key HBMC stakeholders was performed. Leaders from 12 exemplar HBMC practices (clinicians and administrators), advocacy groups (American Association of Retired Persons, National Partnership for Women and Families, Kaiser Family Foundation), and representatives from 3 key professional medical societies associated with HBMC participated in phone interviews. Semistructured interviews were based on domains of quality developed by the National Quality Forum (NQF) for individuals with multiple chronic conditions. We identified 3 categories of quality HBMC: provider and practice activities; provider characteristics; and outcomes for patients, caregivers, and providers. Within these 3 categories, we identified 10 domains and 49 standards for quality HBMC. These included 3 new domains (comprehensive assessment, patient/caregiver education, and provider competency) as well as specification and adaptation of the NQF Framework for Multiple Chronic Conditions domains for HBMC. Notably, several quality domains emanating from the NQF Framework for Multiple Chronic Conditions (transitions, access, and patient/caregiver engagement) were applicable to HBMC. This quality of care framework serves as a guide for HBMC practices seeking to improve their care quality and as a starting point for health systems and payers to ensure value from HBMC practices with whom they work.     

The National Home-Based Primary Care Learning Network: A Practice-Based Quality Improvement and Research Network

Home-based primary care (HBPC) provides interdisciplinary, comprehensive care at home for homebound older adults and has been largely excluded from the national conversation on care quality and quality improvement. In this Pragmatic Innovations article, we describe the work of the National HBPC Learning Network (LN), which focuses on fostering a continuous learning culture among HBPC practices to improve practice quality, elevate the field of HBPC, and create a community of continuous growth and quality of care accountability. The LN recruits HBPC practices in waves of 9 to 10 practices. It currently comprises 38 HBPC practices that care for 58,000 patients across 25 states (approximately 26% of all patients receiving HBPC in the United States). In a Kickoff meeting, the HBPC practices in each wave are instructed in the basics of quality improvement, develop project aim statements and their first plan-do-study-act cycle, receive an introduction to the LN quality improvement software platform, and review plans for LN engagement. Each month, practices submit updates and receive real-time feedback on their quality improvement work. Monthly virtual workshops are held with all practices that include sharing results of a “1-minute survey” (a monthly 1-to 3-question survey sent to all LN participants on a topic relevant to HBPC practices), a didactic and discussion related to the 1-minute survey topic, and interactive progress updates from LN participants regarding their quality improvement work. Each wave ends with “Moving-up Day,” where practices report on their overall project and reflect on how their practice has changed as a result of the LN. LN practices have addressed and improved performance in multiple HBPC-related quality areas including assessment of functional status and cognitive impairment, falls prevention, advanced care planning, COVID-19 vaccination, and others. We present case studies of 3 LN practices and how LN participation strengthened their practices.     

Care management for depression in primary care practice: findings from the RESPECT-Depression trial

PURPOSE This qualitative study examined the barriers to adopting depression care management among 42 primary care clinicians in 30 practices.METHODS The RESPECT-Depression trial worked collaboratively with 5 large health care organizations (and 60 primary care practices) to implement and disseminate an evidence-based intervention. This study used semistructured interviews with 42 primary care clinicians from 30 practice sites, 18 care managers, and 7 mental health professionals to explore experience and perceptions with depression care management for patients. Subject selection in 4 waves of interviews was driven by themes emerging from ongoing data analysis.RESULTS Primary care clinicians reported broad appreciation of the benefits of depression care management for their patients. Lack of reimbursement and the competing demands of primary care were often cited as barriers. These clinicians at many levels of initial enthusiasm for care management increased their enthusiasm after experiencing care management through the project. Psychiatric oversight of the care manager with suggestions for the clinicians was widely seen as important and appropriate by clinicians, care managers, and psychiatrists. Clinicians and care managers emphasized the importance of establishing effective communication among themselves, as well as maintaining a consistent and continuous relationship with the patients. The clinicians were selective in which patients they referred for care management, and there was wide variation in opinion about which patients were optimal candidates. Care managers were able to operate both from within a practice and more centrally when specific attention was given to negotiating communication strategies with a clinician.CONCLUSIONS Care management for depression is an attractive option for most primary care clinicians. Lack of reimbursement remains the single greatest obstacle to more widespread adoption.     

Quality assessment program in primary care clinics: a tool for quality improvement.

BACKGROUND: Assessment of quality of health care is a major ongoing project of the Israeli Defense Forces (IDF) medical corps. OBJECTIVE: (i) To describe mechanisms of quality assessment (QA) in IDF primary care clinics; (ii) to compare quality of care in different types of primary care clinics; and (iii) to test the hypothesis that implementation of the QA program results in improved quality of care. RESEARCH DESIGN: A prospective, single-blinded, uncontrolled, non-randomized study. MEASURES: Teams of two physicians carry out the QA process once or twice a year according to clinic size. Five areas were evaluated: (i) physician-patient interaction; (ii) medical chart evaluation; (iii) high-risk patients management; (iv) medical care provided by specialists; and (v) medical staff guidance. Clinics were classified in two groups: single-physician clinics (battalion troop clinics) and multi-physician clinics (home-front base clinics). General Linear Models were used for analysis. A P-value <0.05 was considered significant. RESULTS: In 2000 and 2001, 99 primary clinics and 162 primary care physicians were assessed. Seventy-four (45%) physicians were evaluated twice. Single-physician clinics scored higher than multi-physician clinics on most QA parameters. Physicians had significantly better QA results at the second encounter, regardless of the type of clinic. CONCLUSIONS: A primary care medicine QA system is feasible in the IDF. It allows for standardized, reliable, and comprehensive assessment of primary care across the military clinics. We postulate that the increase in QA assessment scores from one examination to the next one indicates an improvement in quality due to the QA program.     

A collaborative approach to embedding graduate primary care mental health workers in the UK National Health Service

The UK National Health Service (NHS) workforce has recently seen the arrival of the Graduate Mental Health Worker (GMHW) in primary care. We established a Quality Improvement Collaborative to assist in embedding this new workforce in one Strategic Health Authority Area of England. The intervention utilised 'collaborative' technology which involves bringing together groups of practitioners from different organizations to work in a structured way to improve the quality of their service. The process was evaluated by an action research project in which all stakeholders participated. Data collection was primarily qualitative. During the project, there was an increase in throughput of new patients seen by the GMHWs and increased workforce satisfaction with a sense that the collaborative aided the change process within the organizations. Involvement of managers and commissioners from the Primary Care Trusts where the GMHWs were employed appeared to be important in achieving change. This was not, however, sufficient to combat significant attrition of the first cohort of workers. The project identified several barriers to the successful implementation of a new workforce for mental health problems in primary care, including widespread variation in the level and quality of supervision and in payment and terms of service of workers. A collaborative approach can be used to support the development of new roles in health care; however, full engagement from management is particularly necessary for success in implementation. The problems faced by GMHWs reflect those faced by other new workers in healthcare settings, yet in some ways are even more disturbing given the lack of governance arrangements put in place to oversee these developments and the apparent use of relatively unsupported and inexperienced novices as agents of change in the NHS.     

Effects of a monetary incentive on primary care prescribing in Ireland: Attitudes and perceptions of healthcare professionals and patients

Objective: In 1993, a scheme to provide incentives to general practitioners to contain the costs of their prescribing to publicly funded patients was introduced in Ireland. We set out to describe the attitudes to this scheme of each of the major stakeholder groups: patients, general practitioners and community pharmacists.

Methods: Questionnaire survey of each stakeholder group: 200 general practitioners (by telephone), five patients from each general practitioner (total 1000), and also 250 community pharmacists: these last two groups were surveyed by post.

Results: Response rates for GPs were 79%, pharmacists 52%, and patients 29%. General practitioners were broadly supportive of the scheme, with those GPs achieving savings being most supportive. Their patients were generally unaware of the scheme, but many seemed to have experienced the effects of the scheme, with 38% reporting having had less expensive brands of medication substituted for more expensive. No patients reported suffering any harm as a result. Patients were keen to know more about the scheme. Pharmacists were generally opposed to the scheme, and their level of opposition was related to the financial losses that they had suffered as a result of it.

Conclusions: Doctors generally supported the scheme and pharmacists opposed it. Their support for the scheme was dependent on the benefits that it brought to them individually. Patients were unaware of the scheme but seemed to have suffered no harm as a result. Such incentive schemes need to include careful evaluation of their effects on each of the stakeholders.     

Digital technologies in primary care: Implications for patient care and future research

Digital health is the convergence of digital technologies with health, healthcare, living, and society. Contrasting with the slow trend during the last decades, in the last few years, we have observed an expansion and widespread adoption and implementation. In this paper, we revisit the potential that digital health presents for the delivery of higher quality, safer and more equitable care. Focussing on three examples – patient access to health records, big data analytics, and virtual care – we discuss the emerging opportunities and challenges of digital health, and how they can change primary care. We also reflect on the implications for research to evaluate digital interventions: the need to evaluate clear outcomes in light of the six dimensions of quality of care (patient-centredness, efficiency, effectiveness, safety, timeliness, and equity); to define clear populations to understand what works and for which patients; and to involve different stakeholders in the formulation and evaluation of the research questions. Finally, we share five wishes for the future of digital care in General Practice: the involvement of primary healthcare professionals and patients in the design and maintenance of digital solutions; improving infrastructure, support, and training; development of clear regulations and best practice standards; ensuring patient safety and privacy; and working towards more equitable digital solutions, that leave no one behind.     

Sustainability for Planetary Health: A Seventh Domain of Quality in Primary Care

Climate change is one of the biggest threats to public health. Sustainability is characterized by using resources wisely in a way that protects finite resources and the environment, and takes into account the needs of our planets’ inhabitants in the future. Sustainability in health care should be considered as a seventh domain of quality, as it can lead to improvement of patient outcomes, and more capacity for health care workers to engage in quality improvement and thereby improve the quality of care.The carbon footprint of primary care is high, mainly due to prescribing medication, but also due to the transport of patients to hospitals and primary care services for interventions requested by family medicine. Other causes are the transport of staff and supplies, consumables and staff involved in laboratory analysis and radiation, medical and non-medical equipment, clinical and non-clinical waste, heating and cooling systems and other activities. Small adjustments in these areas could significantly decrease the carbon footprint of primary care practices. The suggested steps for primary care to achieve a more sustainable practice are fostering research, raising awareness, reducing the burden on primary care, engaging in quality improvement, and leadership and advocacy.Each individual primary care practice has the potential to be a leader and role model for sustainable health care. With the implementation of interventions to reduce carbon footprints, primary care could set an example within the health sector and for patients. This could significantly raise the awareness of the public about the need to take actions for a greener health system.     

Quality Improvement in Healthcare Delivery Utilizing the Patient-Centered Medical Home Model

Despite the fact that the United States dedicates so much of its resources to healthcare, the current healthcare delivery system still faces significant quality challenges. The lack of effective communication and coordination of care services across the continuum of care poses disadvantages for those requiring long-term management of their chronic conditions. This is why the new transformation in healthcare known as the patient-centered medical home (PCMH) can help restore confidence in our population that the healthcare services they receive is of the utmost quality and will effectively enhance their quality of life. Healthcare using the PCMH model is delivered with the patient at the center of the transformation and by reinvigorating primary care. The PCMH model strives to deliver effective quality care while attempting to reduce costs. In order to relieve some of our healthcare system distresses, organizations can modify their delivery of care to be patient centered. Enhanced coordination of services, better provider access, self-management, and a team-based approach to care represent some of the key principles of the PCMH model. Patients that can most benefit are those that require long-term management of their conditions such as chronic disease and behavioral health patient populations. The PCMH is a feasible option for delivery reform as pilot studies have documented successful outcomes. Controversy about the lack of a medical neighborhood has created concern about the overall sustainability of the medical home. The medical home can stand independently and continuously provide enhanced care services as a movement toward higher quality care while organizations and government policy assess what types of incentives to put into place for the full collaboration and coordination of care in the healthcare system.     

Out-of-hours primary care: development of indicators for prescribing and referring

Background. Dutch general practitioners have reorganized their out-of-hoursprimary health care to general practice cooperatives. Good insightinto the quality of delivered medical care is important to makethe accountability of health practitioners and managers transparentto society and to identify and minimize medical errors. Objective. Development of a set of quality indicators for internal qualityimprovement in out-of-hours primary clinical care. Method. A systematic approach combining the opinion of three differentgeneral practitioner expert panels, and an empirical test indaily practice. The indicators were based on clinical, evidence-based,national guidelines. We tested the validity, feasibility, reliabilityand opportunity for quality improvement. Results. Of the 80 available national clinical guidelines, 29 were approvedand selected by the first general practitioner expert panel.Out of these 29 guidelines, 73 indicators concerning prescribingand referring were selected by the second panel. In an empiricaltest on 36 254 patient contacts, 7344 patient contacts (22.7%)were relevant for the assessment of these 73 indicators. Sixindicators were excluded because they scored more than 15% missingvalues. In total, 38 indicators were excluded because the opportunityfor quality improvement was limited (performance score 90%).In the final meeting, the third general practitioner expertpanel excluded five indicators, leading to a final set of 24indicators. Conclusion. This study shows the importance of subjecting indicators toan empirical test in practice. The national clinical guidelinesare only partially applicable in the assessment of out-of-hoursprimary care. They need to be expanded with topics that arerelated to general practitioner care in an out-of-hours settingand acute medical problems.