Issue 28 / 23 July 2012

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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6 thoughts on “Aniello Iannuzzi: Indicator overload

  1. Sue Ieraci says:

    Brett – one of the points that is being made here is that super-specialists look at practice within their own area of specialty, while generalists (especially GPs) have to manage the health of the whole person. Perhaps look there for the reasons that each individual guideline may not be applied in every patient – another guideline may be taking precedence!

  2. Brett Montgomery says:

    Dr Ianuzzi says: “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.”

    I don’t perceive a lot of controversy over statins for people with established coronary heart disease. With the possible exception of very old patients (who have been neglected by trialists) I think the evidence for statins in secondary prevention is robust.

    I perceive much more controversy regarding statins in primary prevention, and some controversy internationally regarding whether we should pursue particular cholesterol targets when using statins.

    I therefore think it is wise that the RACGP statin clinical indicator merely looks at whether a statin is prescribed (not whether the lipids are to target) and is confined to patients with coronary heart disease.

    There have been some Australian observational studies recently which suggest 30-40% of patients with coronary heart disease are not being prescribed statins. This seems to be potentially a concern, suggesting that a clinical indicator on this topic is reasonable.

    On the other hand, I don’t think we know enough about why these apparent evidence-practice gaps exist, and to what extent they are reasonable decisions as opposed to missed opportunities. I look forward to more research on this topic.

  3. Experienced GP says:

    The basic difficulty for most GPs is that they can’t spend enough time with patients to get the drift of what the actual problem is. Suggesting more relevant or irrelevant tasks makes this difficulty even worse. Many (?most) patients are unclear, even in their own minds, what ails them and their own perceptions are no substitute for a professional assessment.
    Time spent getting a full history (like past history, social, work, marital problems etc) is the most rewarding thing in getting in touch with important ill-health factors. This time is not “wasted”. On the contrary it will avoid useless, expensive “wild goose chases”.
    If health authorities were aware of this, they would ensure that longer consultations were economically possible in primary care. Ultimately, this would certainly benefit patients and
    make General Practice more professionally and personally rewarding.

  4. Sue Ieraci says:

    In an idealised world, where all the products we produce are the same, standardisation makes sense. Where there are harms from variable practise – it also makes sense to standardise. However, these guidelines should be used as audit filters, not KPIs. If one’s practice is found to be outside the norm, an audit might show that the variability is both safe and appropriate for that particular practice or for a particular group of patients. For example, if a GP has a large group of very old patients (in their nineties and beyond) – should they all stay on anticoagulants and statins? It seems that the practice of clinical governance has a long way to develop before it becomes as sophisticated and nuanced as clinical practice itself.

  5. Christopher says:

    Just a note – Appropriate triaging of patients calling or attending with urgent or life-threatening symptoms is already a requirement under the accreditation standards (criterion 1.1.1, 1.1.2, 3.2.3), and furthermore, has previously been challenged in a court of law.

  6. Peter B says:

    Looking with interest at the vote spread to the poll, (to which I admit I selected the 3rd option), as I totally agree with the thrust of the article, it appears not only the RACGP, but most GPs seem determined to assist those who would make our life and work harder and harder. Once again…because it seems like a good idea at the time….and we still tend to look at things through our altruistically tinted lenses, without thinking through fully as to just where this might all lead. Politicians know this trait we have, and work it to the max. They just love the way we make it easy for them to enslave us for paltry pickings…wake up people…before it is too late…the water is already simmering…

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