“Tick box” medicine concerns

“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

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