National Register for Quality Improvement in Primary Care

Andy MaunUniversity of Gothenburg, Sweden

Declaration of conflicts of interest or relationship

• Speaker Name: Andy Maun• GP Trainee, PhD student• Member of the Swedish Quality Council• Member of the Development Team of a National

Register for Quality Improvement in Primary Care

• I have no conflicts of interest to disclose with regard to the subject matter of this presentation

Healthcare systems in Sweden

In health care and certainly primary healthcare:21 counties and regions

differing in: payment systems IT – systemsfollow–up of quality

Reform on Choice of Care 2008

Aim: Increase the number of healthcare centres• Patients can choose a centre but not personal GP -

centres compete!

• Resulted in a lot of new centres mostly run by great companies owned by risk capitalists.

Trends in most Counties

• Payment by individual capitation based on– age – socio-economy – morbidity burden (ACG - adjusted clinical groups)

• The centre pays all costs for laboratory services, x-ray and drugs

Quality surveillance

Existing quality registers• mandatory to report to the National Diabetes

Register• often also mandatory to report to other

registers (heart failure, asthma, COPD, etc.)• Problem: most existing registers are

constructed by and for hospital clinicians

Public debate

National Register for Quality Improvement in Primary Care?

• The Swedish Association of Local Authorities and Regions (SALAR) stimulates the development of a national register (550.000 Euro 2012)

• 3 initiatives merged to 1 national group:– SFAM – Swedish Association of General Practice (Vision of a

database for research) – Quality Consil / pvkvalitet.se feedback and benchmarking– Register for Quality Improvement of the Western Region VGR

National development team for the register

National database• Malin André (chairperson), GP, docent, chairperson SFAM research council• Jörgen Månsson, GP, docent, CMO Carema

Register of the Western Region VGR• Claes Hegen GP, chairperson of the VGR register• Fredrik Bååthe, senior projectleader RC VGR

pvkvalitet.se• Sven Engström, GP, PhD, chairperson SFAM quality council• Andy Maun, GP-Trainee, PhD student

• Define relevant variables from daily practice that can be collected automated from regional databases

• in a legally applicable system• Target groups:

– Healthcare centres - internal improvements– Academy - scientific research– Other Registers - delivery and sharing of data– Political management - results, follow-up– Patient – empowerment

Assignment

National coordination!

Relevant variables from daily practice?

• Ryggvärk M54*• Myalgier M790, M791 M797• Arthros M16, M17• Ledvärk M254, M255, M256 M250• Tendinit/bur. M70*, M75*, M766, M771 M770• Osteoporos M80*-M828• Diabetes E10* - E14*• AngP/Isch/AF I20*-I25*• Astma/KOL J45*, J44* J46*• Stroke I64*, I67P*. I69* I65-68*• Luftvägsinf. B27, B34*, J01*-J06*, J18*, J22, R05* J00*, J12*-18*, J20*-21* (finns gen. viros)• UVI N30* N39.0• Hudinf. L01*, L02*, L03*, L08*, A46, A692• Depression F32*, F33*, F39* F34*, F38*• Ångest F410, F41*• Sömnstörn. F51* • Demens G30*, F01*, F03 F00*, F02*• Stressreaktion F43* -F43.2

Experiences from other countries

Experiences from earlier projects

medical outcomes, structural / process measures?

How to avoid silos?

Feasibility? Legally applicable?

IT?

Pvkvalitet.se - Philosophy• Quality indicators developed by clinical active

GPs

• We GPs think that we follow guideline to much greater extent than we actually do!

• We have to study how we do in practice to understand that we need to work differently!

Health centre PeriodGP

Emergency/unplanned visits last

yearYes Yes Yes YesNo No No No

Smoking registred

Have inhaled cortico-steroids

Spirometry last 2 years

Sum

Notes

Asthma

• Note indicators in the form for each sample patient

• Summarize the results

Registration form

Proportion who had emergency/ unplanned visit for asthma last year

Proportion who had a check up including spirometry last 2 years

common conditions and chronic diseases• Tonsillitis• Cystitis in women• Asthma• COPD• Heart failure• Leg ulcer• Pneumonia• Atrial fibrillation• Urinary incontinence• Otitis media

Quality improvement• Review ones own work, my own “exceptions” • Discuss together: What could we do better?• Read patients records

– Sample small but enough to see trends– Possible to find things like unplanned/emergency

visits for asthma– quality of patient records, diagnosis

Pvkvalitet.se

• 261 Health Centres participating• 37 000 patients reviewed

= 950 local improvement projects supported!

ResultsAreas with systematic use

• Antibiotics – Quinolones for cystitis in women 6% 1% (2006 - 2007)

• Asthma– Patients with spirometry last 2 years 38% 62% (2006 - 09)

• Heart failure– Proportion investigated with UCG 65% 81% (2006-2009) (p < 0.05)

– Patients treated with ACE / AII 71% 83% (2006 - 2007)(p = 0.002)

Development of a register for Quality Improvement of the Western Region

• Aim: regional primary healthcare register with the potential for a national register

• Target group:– Healthcare centres - internal improvements– Academy - scientific research– Political management - results, payment– Patient – choice of healthcare centre

Get a new…

…perspective

Indicators

• Five chronic diseases: (< age 75)– Diabetes (National Diabetes Register)– Ischemic heart disease– Hypertension– Asthma – COPD

Medical variabels• Diagnosis• Smoking• Weight• Length• Waistlines

• Age / Gender

• Spirometry• HbA1c• Blood lipids• Blood pressure

Results can be linked to - other registers e.g. stroke register- prescription register- socioeconomic data

Effects?

Diabetes diagnosis

Primary Healthcare, Western Region

Before/after ACG

(Payment for morbidity burden)

0

10 000

20 000

30 000

40 000

50 000

60 000

70 000

20052006

20072008

20092010

Num

ber o

f ind

ivid

uals

Staffan Björck, Analysis Unit Western Region

Hypertoni 198 238

Diabetes 65 730

Ischemiska. hjärtsjukdomar

44 317

58 %

9 %

14 %

6 %

1 % 3 %

8 %

Totalt 239 349

individer med en

Co-morbidity

8 35

62

34

1

TRYCK>140/90

RÖKNING

LDL>2,57

Percentage of individuals with high blod pressure, high LDL cholesterol and smoking.

Identifying high-risk groups

0

1

2

3

4

5

6

0 10 20 30 40 50 60 70 80 90

HbA1c<52

CN

I

Effects?

Relation between socioeconomic index and

percentage of patients with HbA1c < 52

Difficulities for centres in poor districts?

Preliminary data Staffan Björck, Analysis Unit Western Region

Preliminary data Staffan Björck, Analysis Unit Western Region

Percentage of patients with atrial fibrillation that receive Warfarin in different healthcare centres

1 2 3 4 5 6 7 8 9 10 11 12 VGR0%

10%

20%

30%

40%

50%

60%

Percentage of patients atrial fibrillation and Warfarin Different parts of the Western Region

Preliminary data Staffan Björck, Analysis Unit Western Region

Män Kvinnor0%

10%

20%

30%

40%

50%

60%

Percentage of patients atrial fibrillation and Warfarin by Sex

Male Female

Preliminary data Staffan Björck, Analysis Unit Western Region

15-29 30-44 45-59 60-74 75-89 90-0%

10%

20%

30%

40%

50%

60%

Preliminary data Staffan Björck, Analysis Unit Western Region

Percentage of patients atrial fibrillation and Warfarinby Age

15-29 30-44 45-59 60-74 75-89 90-0%

10%

20%

30%

40%

50%

60%

70%

Percentage of patients atrial fibrillation and Warfarinby Age and Sex

Preliminary data Staffan Björck, Analysis Unit Western Region

Pilot study - continuity

• Aim: to examine the feasibility of a larger study, where the correlation between provider continuity and health outcomes is to be explored

• Method: – retrospective study (Oct 2009-Febr 2012) – four primary care centres (33485 individuals)– health outcomes (blood pressure, HbA1c) – usual provider continuity (UPC) and continuity of care

index (COC) for physician/nurse

Results – No distinct correlations

• No distinct correlations could be found between interpersonal continuity with physician/nurse and blood pressure and HbA1c values

• A timeline-study on the whole population of the region (1,5 million inhabitants) is feasible and necessary to gain more knowledge

Benefit?

• See the whole population / ”your own” population

– new thoughts and discussions • Knowledge on effects of treatments in “real populations” vs study populations• Primary Care influence strengthened

– on guidelines – on development of healthcare system

The challenge remains

• systems that measure quality and stimulate improvement

• validity / complexity / interpretation of data• no evidence of benefit of P4P but some

evidence of harm• the hard part is to ensure the change and

stimulate improvement

Thank you for your attention!