Social Dimensions of Health Institute, Universities of Dundee & St Andrews Standards and individuals: GPs’ views of what matters for quality Vikki Entwistle.

Social Dimensions of Health Institute, Universities of Dundee & St Andrews

Standards and individuals: GPs’ views of what matters for quality

Vikki Entwistle

31 October 2007

Seminar for School of Public Health

University of Sydney


• University of Sydney International Visiting Fellowship Scheme

• Alex Barratt and Lyndal Trevena

• Many other members of School of Public Health who have helped with this study and/or otherwise helped to ensure my visit has been productive and enjoyable.

Thank you!


Help!

• Thoughts on this ‘work in progress’ will be welcome!


Background

• Understandings of what constitutes ‘good’ medical practice continue to evolve.

• Current notions emphasise evidence based medicine (EBM) and patient involvement (PI).

• Governments have invested in various strategies to improve (aspects of) health care quality.

• There have been few studies of GPs’ views of shifting agendas and improvement initiatives.


EBM: issues in 1990s

• First accounts downplayed clinical expertise

• Compatibility with patient-centred care disputed

• Applicability to general practice contested

• Studies of GPs’ attitudes found concerns about:– Lack of relevant evidence– Lack of resources for accessing evidence– Lack of skills for appraising evidence


EBM: more recently

Clinical state & circumstance

Research evidencePatient’s preferences and actions

Clinical expertise

Haynes et al, 2002

• More research conducted in general practice• Research findings more accessible • Clinical expertise now emphasised


Quality incentive payments

• Australia and UK both offer incentive payments for GP management of chronic conditions

• For, e.g. diabetes, they promote similar forms of care with similar goals…

• … but incentives were introduced into different ‘basic’ payment systems…

• … and the UK scheme rewards ‘outcomes’ as well as care processes


Key Medicare items of interest

• Service and Practice Incentive Payments (SIPs and PIPs), including for: – Having diabetes register / recall system– Completing annual ‘cycle of care’ for diabetes patients– Having completed cycle for 20% of diabetes patients

• Enhanced Primary Care items, including:– Care planning for people with chronic conditions– Care planning for people with mental health problems


Study aim

• Investigate GPs’ perspectives on what is required of good GP today, including:– Understandings of and attitudes towards:

Evidence based medicine

Patient involvement in decision making

– Experiences of financial incentive schemes and thoughts about their implications for quality


Target sample

• About 20 GPs from metropolitan NSW (pragmatic considerations)

• Reasonably diverse in terms of: – Gender– Length of time in practice– Practising in more/less affluent areas– [Interest in EBM / patient involvement]


Recruitment

• Invitations were: – posted to NSW GPs identified from Medical

Directory of Australia– e-mailed to USyd academic GP list– given/left at occasional GP meetings– passed on by participants and colleagues

• Invitations included: – Initial response form, pre-paid reply envelope– Offer of $150 honorarium


Data collection

• Face-to-face interviews

• ≥1 hour conversations

• Focusing on key topic areas, but not strictly structured

• Audio-recorded

• Transcribed


Data collection


Topic areas

• Key features of good quality GP care– Evidence based medicine (EBM)– Patient involvement (PI)

• Quality improvement initiatives – Influence in practice, implications for quality

• Current challenges and possible solutions in their efforts to deliver quality care


Analysis

• Initial familiarisation

→ Development of thematic framework

→ Systematic coding of data (N-vivo)

→ Charting to summarise and further analyse e.g. relationships between:– Understandings of EBM & views of its importance– Practice characteristics & implications of incentives– Views of incentives & aspects of quality emphasised

• NB general statements cf specific examples

•


Sample

• 18 GPs interviewed to date:– 9 male, 9 female– Graduated 12 - 46 years ago– Some diversity in ethnic background– 4 solo practitioners, 2 in two GP practices– Practicing in more and less affluent areas– 2 don’t bulk bill at all

• 4 more interviews scheduled


Health warning!

• Data collection is ongoing• Only 16 interviews have been transcribed• Only 12 transcriptions have been checked• I’m presenting impressions and preliminary

observations only

Your thoughts about issues we should be careful to look at further are welcome!


What has surprised me?• Features (and implications) of Australian system

I hadn’t appreciated:– Pervasiveness of financial considerations– Variety within general practice – Mobility of GPs– Ease/frequency of patient “doctor (s)hopping”

• Amount of concern expressed about other GPs’ clinical competence and ethics

• Disclosure of behaviours thought less than ideal


Evidence based medicine

• All have the gist…• Some have more sophisticated understandings• Descriptor ‘evidence based’ often attached to

particular clinical interventions or targets• All think EBM is somehow important for quality

– “Everything we do should be evidence based”

or– “It’s very important – just not the whole story”

(See what EBM requires as perhaps conflicting with what patient can/wants to do)


“Doing” evidence based medicine

• Updating by reading Australian Doctor etc., listening to specialists, being wary of drug reps, doing CME…

• Following guidelines• Getting on top of research relating to common

problem then just doing (not consciously EBM)• [Few, including academics] searching Medline or

Cochrane when uncertain– Patient brings alternative remedy / information in– Waiting to get patient into specialist


Challenges of doing EBM (1)

• Lack of accessible information resources• Lack of ability to interpret / appraise research• Volume of potentially relevant information• Lack of time for update reading• No time to look things up in consultations (and

no reimbursement)• Mishaps like Vioxx• Gaps or biases in research


Challenges of doing EBM (2)

• Not sure when research findings apply

• [GP’s preferences and experiences]

• Patient’s preferences and actions…

• … in a context in which a patient who doesn’t like what you offer/recommend might just take their business to another GP


GPs’ views of EBM model

• Mostly “yes!”• Goal is increased overlap• Some qualifiers:

– If ‘clinical expertise’ isn’t cold clinical

– Unless patient preferences are off the page

– The circles might not always be equalDoes this ring true?


Which forms of use of research evidence, which

ways of attending to patients’ preferences should

‘count’ as EBM?


Discussing evidence with patients (1)

When and why?• So patients know basis of recommendations• To show “it’s not just me saying this”• To support recommendations • To “sell” preventive interventions• To overcome patient concerns• To respond to “my friend…”, “my naturopath…”,

“this information… ” queries• Because (affluent, educated) patients expect it


Discussing evidence with patients (2)How?• Show guidelines• Talk through flowchart• Mention studies in conversation

– Variable presentation! • Patient might not need/want details• GP might not know/recall details

How does this relate to GP talk about how things work?


About SIPs and PIPs for diabetes

• Cycle of care items are important

• “We were doing them anyway”

• Reasons for not claiming:– Object to accreditation requirement– Practice not accredited (not worth effort)– Administrative burden (esp. small practices)– Salaried GP– Not ‘main’ GP for many people with diabetes– Mobile population, difficulties with follow up


About care plans• Can usefully encourage thorough review

– But formal structure may ↓ holism, rapport – Busy GPs don’t have time to complete

• Don’t necessarily improve care quality– ‘Cavalier’ completion, not evidence-based– May lead to some over-servicing

• Could be more effective with built-in templates

• Some inapp’te (AHP prompted) patient demand • Good income earner for GPs (often abused)• Waste of collective health care $?


Initial thoughts about possible Australia – UK differences

Patient mobility in Australia:• (Combined with financial considerations) may

incline GPs to accede to patients’ wishes• Lets GPs glean what their colleagues do • Raises issues of professional etiquette and who

claims incentive payments

Differences in broader payment arrangements:• Render individual GP circumstances more

important in Australia

Social Dimensions of Health Institute, Universities of Dundee & St Andrews Standards and individuals: GPs’ views of what matters for quality Vikki Entwistle.

Documents

quality slide

aspects of health care

emphasised slide

mental health problems

care planning

care processes

annual cycle of care

primary care items