Aniello Iannuzzi: Indicator overload

THE Royal Australian College of General Practitioners has released a dashboard (sic) of clinical indicators for GPs. GP practices and external stakeholders are invited to comment on the proposed indicators by 30 July.

On its website the RACGP says: “The proposed indicators deal exclusively with the safety and quality of clinical care provided by Australian general practices and are intended for voluntary use”.

My initial reaction to this was “NOT MORE!” as not a week seems to go by without an email, fax or some other document landing on my desk with some sort of guidelines or “suggestions” on how to do things.

Just last week, the MJA published the CareTrack study, with the authors calling for agreement at a national level on 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 RACGP site alone carries no fewer than 35 guideline documents for GPs.

Those of us who do hospital work also have to adhere to other numerous policies and protocols, and practice accreditation imposes further guidelines and indicators.

A financial imperative is added through the Practice Incentives Program, which pays practices that meet outcomes the government deems desirable.

To help with its proposed indicators, the RACGP has released a Q&A document — sadly, it is not in a live interactive format like the ABC’s TV program Q&A, as I think the committee responsible would be well and truly peppered by its GP members.

To my mind, the Q&A reads more like an apologia than an explanation. The college has gone to great pains to trumpet its role in leading the way in clinical indicators, stating it prefers to be doing the job rather than having a top-down situation imposed on GPs.

The RACGP states that this is a voluntary system and is not intended to be linked to payment for performance or practice accreditation, and that the indicators are not meant to be used for information gathering for government.

It then distances itself from the UK’s National Health Service (NHS) Quality and Outcomes Framework, which has not been well received. Disturbingly, the first sentence on the NHS site is that the system is also “voluntary” but it links pay to performance.

It is impossible to make an overall comment on whether the RACGP’s clinical indicators are good or bad. The 22 items are so diverse that they need to be assessed individually.

Each indicator features an explanation of the rationale, gives levels of evidence and references from medical literature, and a template that practices can use to assist them in implementing the measures.

A number of the indicators are quite benign. For instance, the need to take a history of cigarette smoking and alcohol use, which no one would dispute.

On a clinical level, some are worth debating. The use of statins is becoming increasingly controversial, yet the clinical indicators would suggest we should have as many people as possible on statins for heart disease.

Indicators with respect to benzodiazepine use and radiology in low back pain are all very nice but do not adequately take into account the many non-GP-related influences on these figures.

For example, imaging for back pain is often done in hospitals or demanded by insurance companies and lawyers, not to mention allied health “members of the team”, so the GP generally has to comply to keep the peace.

After a good look at all this, I fancy that I side with the sceptics. The temptation for government agencies, accreditation bodies and other fund holders is too great, and the UK experience proves this. The concern is that they will take these indicators and force them upon us with a one-size-fits-all approach.

An even greater threat is the legal profession. The best example of this is the indicator of a “practice system for triaging patients with acute illness”.

Say patients come to grief and decide to sue because they could not see the GP in a timely fashion. It is not unreasonable to envisage a barrister hurling the indicators at the receptionists and practice managers to build a case against the GP.

Rather than being presented to government and lawyers on a plate, indicators are best left buried in the depths of medical journals, where they can be accessed by the disciples of protocol medicine.

Dr Aniello Iannuzzi is a GP practising in Coonabarabran, NSW.

Posted 23 July 2012

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