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THE CareTrack study published in this week’s MJA highlights a significant issue for the medical profession.
Some aspects of the study, such as the evidence base for a number of the indicators used and the relatively small numbers of patients and encounters, can be criticised. However, the general message — that a substantial number of people do not receive the most appropriate care for their condition — has been previously reported for a number of specific conditions in Australia and elsewhere.
Five years ago, a paper in the MJA noted that in Australian general practice only about half of patients with chronic diseases such as asthma, type 2 diabetes and hypertension received recommended care. The CareTrack study suggests that the overall picture in Australia differs little from other countries where similar studies have been undertaken.
The findings support the outcome of recent consultations by the Australian Commission on Safety and Quality in Health Care on key safety and quality challenges. Improving appropriateness of care was identified as an area needing coordinated national action and is one of the draft National Safety and Quality Health Care Goals to be considered by health ministers later this year.
National Safety and Quality Health Service (NSQHS) Standards developed by the Commission identify the processes and systems that acute health care organisations should have in place. A national accreditation system for all acute health services and day care centres based on these NSQHS Standards will be introduced over the coming year.
The Commission has also started to develop clinical care standards, with accompanying indicators, for a range of conditions, which will differ from the NSQHS Standards.
The standards will describe measurable aspects of care that should be offered or performed routinely — the usual care that most of us would want to be offered if we had the condition.
This does not prevent care being appropriately tailored for individuals but it does create an expectation that departures from the standard are documented and justified.
The MJA study identifies some of the problems with current guidelines and the Commission’s standards will be developed taking account of existing knowledge about features that are likely to improve uptake of guideline recommendations such as use of behaviourally specific language. There will be extensive consultation and the clinical care standards will be developed collaboratively with clinical experts and consumers.
The CareTrack authors highlight the need for routine, ongoing systematic performance monitoring. The capacity to measure the care that is delivered and monitor change underlies all improvement efforts.
It is unlikely that we will ever have a system that captures hundreds of indicators about care processes and outcomes, but we will be identifying some key performance indicators that can be collated and aggregated for reporting nationally with more detailed audit tools that can be used for local collection, feedback and improvement initiatives.
The ultimate challenge, however, is not in the development of standards and indicators (although that is no easy task). It is in finding ways to ensure that care that is known to be effective and appropriate is consistently practised.
We only have to look at handwashing — a practice that was shown to be of importance in preventing the spread of infection 150 years ago — to see how difficult it is to ensure that even simple actions are consistently and appropriately practised.
We are still expending significant resources and effort in an attempt to reach the hand hygiene benchmark rates of 70% in Australian hospitals, with hand hygiene compliance by nurses at 74% and by doctors at 52% after 2 years of the National Hand Hygiene Initiative.
While clinical care standards can identify the care that people should expect to receive, regardless of where they are treated within Australia, changing practice to achieve consistent delivery of appropriate care will require clinical leadership and system-wide coordinated action.
Dr Heather Buchan is the director of implementation support at the Australian Commission on Safety and Quality in Health Care and Professor Debora Picone, AM is the Commission’s Chief Executive Officer.
Posted 16 July 2012
There are many problems with prescriptive guidelines about absolutely everything for example
1. They may represent only Level 4 evidence which is unreliable and open to internal politics among those coming to the concensus
2. They may go out of date quickly
3. They may not really represent international best practice
Etc etc
The project was overseen by administrators, not doctors, who will not understand the nuances of medical practice. This was not actually evident from the media coverage. Overprescriptive micromanaged KPIs may work well in banks (although even that would be arguable) but not always so well in a general practice setting.
That is not to say that some measurable standards are definitely required but hundreds of standards covering minor conditions is not reasonable or helpful to the general public.
Many real world patients have co-morbidity, multiple pathology, limited mobility,and other reasons why they do not want mindless unfeeling automatons, but GPs who can be flexible . Guidelines are just that- a guide- not a protocol.
Also, much over-investigation, and overtreatment, is concerned with medico-legal aspects.
Have the authors of this poorly deisgned study not been following the debate in the BMJ about “guideline fatigue”? see http://www.bmj.com/content/344/bmj.e2685 . Conflicting, out of date or impractical guidelines abound. Most studies these guidelines rely on exclude comorbidities, hence most guidelines do not account for the typical General Practice patient who has comorbidities, may well be over the age the trial applied to, may live in a rural area where there isn’t ready access to what’s recommended, or may have had the condition longer than the trial time! A “study” involving 1000 patients, presumably non randomly selected can be manipulated to get any answer the authors desire. “Guidelines” on, for example, cholesterol lowering below total cholesterol 6.5 only finally became accepted when the WOSCOPS study on 40,000 patients over 5 years produce unarguable results, irresepective of whether the sample was non random (by their very nature all trials are at least partly non random-selection bias towards those who agree (compliant patients), those available (non workers and city dwellers) are inherent in any trial. Before I will take any notice of a survey of 1000 patients opinions of their care I would like to see a lot more detail of exactly how this survey was done. Did they compare it to BEACH, which has the numbers? Did they check the prescibing data on use of the various categories of drugs thoughout Australia? I don’t think its fair to criticise all GPs in Australia on the basis of 1000 cases. Many of my patients are semi-literate, I often give them printed material, but they lose it. There are lots of reasons other than poor performance by the doctor as to why patients aren’t on “recommended” treatment.