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“TICK BOX” medicine cannot be mandated until a range of doctors has developed the clinical standards behind the boxes, according to AMA president Dr Steve Hambleton.
He was commenting on a study and linked Perspective article published in this week’s issue of the MJA, whose authors called for urgent national standards, indicators and tools to bridge the “large gaps in the provision of appropriate care” identified by their research.
The $2 million NHMRC-funded CareTrack study found only 57% of adult Australians in a sample of 1154 received appropriate care (in line with evidence-based or consensus-based guidelines) for 22 common conditions, including coronary artery disease, hypertension, low back pain, diabetes, depression, asthma and obesity. (1)
The health care was provided in practices and hospitals with GPs, specialists, physiotherapists, chiropractors, psychologists and counsellors.
Compliance with indicators of appropriate care ranged from 1% for use of four risk assessment tools to 13% for alcohol dependence and 90% for coronary artery disease.
“There is an urgent need to agree at a national level what constitutes basic care for important conditions, to embed this information in clinical standards, and for groups of experts to ensure that these standards are kept up to date”, the authors said. “Redundant guidelines must be retired.”
In the linked Perspective article, the authors called for the measurement of appropriateness of care to be routine and prospective. “This would allow the community, health professions and payers such as government to better calibrate their approaches to health services improvement”, they said. (2)
An editorial warned that the authors’ suggestion of validating and updating quality indicators — using a web-based “wiki” tool — could run into a major bottleneck. (3)
“Trying to achieve consensus among almost every auditable clinician, plus interested members of the lay public, for indicators that are evidence-poor sounds virtually impossible”, the editorial said.
Dr Hambleton said the goal was to “close the gap between what we know and what we do”.
“We do have guidelines and there are occasions when we comprehensively ignore the guidelines because they just aren’t practical. But there are clearly things we can do better and if you don’t measure it, you can’t change it.”
The authors said their suggestions would necessitate changing some work practices, which would require negotiation and inevitably be inconvenient for busy clinicians, but the looming alternative to self-regulation — heavy-handed external regulation — should provide an incentive.
Lead author Professor Bill Runciman told MJA InSight any external regulation would most likely be via accreditation of practices or services, or credentialling of individuals.
Dr Hambleton agreed that external regulation would be solving the problem in the wrong way. “It is far better to engage the profession”, he said. “We don’t want to increase red tape, we want to decrease it. We want to facilitate good care, not force good care.”
Leadership was needed from the medical and surgical colleges but they needed to confer with doctors at the front line. “If you want to develop a tool for GPs, it has got to fit into the GP workflow”, he said.
Dr Hambleton said the best driver of behaviour change was clinicians looking at their own performance data and comparing it with their peers, as was done with prescribing patterns.
Professor Debora Picone, chief executive officer of the Australian Commission on Safety and Quality in Health Care, said the commission was about to start developing clinical care standards and associated indicators for three areas: antimicrobial stewardship, transient ischaemic attack and stroke, and acute coronary syndromes.
“They will focus on the clinical care a person should receive.”.
The commission had adopted a bottom-up collaborative approach and legislation required it to consult clinicians, jurisdictions, consumers, carers and the public, she said.
When there was the system capacity to routinely gather information about performance against indicators, the commission would publish aggregated data on extent of adherence to the standards, but not doctor-specific information, Professor Picone said.
– Cathy Saunders
Professor Picone and the commission’s director of implementation support, Dr Heather Buchan, outline commision plans to develop standards aimed at achieving consistent delivery of appropriate care in a Comment article in this week’s MJA InSight. Please click here to read.
1. MJA 2012; 197: 100-105
2. MJA 2012; 197: 78-81
3. MJA 2012; 197: 67-68
Posted 16 July 2012
Every simple audit system will miss, and discourage, complexity. In the rush to be seen to be standardising, we need to avoid a few key errors: Firstly, we must avoid forcing care into separately auditable components, neglecting overall patient care. Secondly, we need to resist the allure of process over outcome – things are only worth doing if they lead to a tangible benefit. And thirdly, we need to be really cautious about guidelines in one specific area creating greater harm in another area. Medicine is highly complex and sophisticated. The system that audits practice should be at least as sophisticated.
Between ‘system improvement’ and ‘patient outcomes’ are two sets of relationships. Those between the doctors who deliver care (most frequently a GP and a specialist), and those between each front-line doctor and their patient. These human relationships are the foundation of the ‘system’. The doctors are not box-tickers any more than the patients are series of boxes to be ticked. So while addressing quality of clinical information is essential, it is only half the picture. To develop and disseminate consistent, up to date, evidence-based information (no matter how high-quality the data) without supporting application via the clinical autonomy of every local GP and specialists will not result in meaningful change. This doesn’t mean we need guideline consensus between every ‘auditable clinician’ in Australia, but we do need processes that support local networks of doctors to pragmatically determine what works best for them. We should be celebrating and reward their experience and local knowledge and supporting them to integrate it with overarching guidelines. This will strengthen the effectiveness of their professional relationships with each other and support their individual commitment to quality of care for their patients.
Please wake me up when they come up with *OUTCOME* based criteria, instead of demanding “compliance with process”.
What armchair clinicians of academic persuasion typically fail to understand is that while available evidence (gained from a certain studied population subgroup) is often but not always transferable to the individual.
Will lipid profile testing in a 104 yo bed ridden nursing home patient be “required for best care” if I just diagnosed ischaemic heart disease in him? Extreme example perhaps, but otherwise too many might not understand where coalface clinicians are coming from.
It is nice to have evidence based guiding protocols, and we should be obliged to justify when we deviate from them – but in the hands of bureaucrats with their usual borderline personality traits such guidelines turn into weapons against individualized care – the type of care most likely to deliver the best outcome at the lowest cost
There are problems with determining, or dictating, defined standards due to conflict of interest. Patients and the profession need to ensure that the minimum quality of care is sufficient, and I think there have been deficiencies in GP services offered to me, and to my wife prior to her death, over the years. However, the government and the bureaucracy have another agenda – cost control – and we may finish up with that determining the “standards” if we let them define them. Also, there needs to be room for divergence and challenging official positions as that is where real progress comes from. Strict conformity to “approved practice” would have us still bleeding people for most diseases…
The age of robotic professions is here – the university industry is now merely an industry that is reliant on turnover – just like Coles & Woolworths turnstiles. The abbreviated courses increase turnover and allow increased charges – no person could afford the cost of a full course to become a competent professional – eventually there will be unemployment in all the professions.. There is no time to absorb professional ethos and history – the concept of ethics is history – what is not regulated is acceptable behaviour.
So appoint university professors – who have plenty of time on their hands as they can perform multiple jobs [busy professionals are too occupied ] to overseer publicly funded efforts to repair the defects caused by the university industry.
Educate don’t mandate