Danish Quality Unit of General Practice 41 th EQuiP assembly meeting Use of national or regional aggregated data in the local improvement processes of the practices Can structured data about own quality improve the quality in General Practice? Henrik Schroll Janus Laust Thomsen Danish Quality Unit of General Practice
General Practice in Denmark Status • There are 5.5 mill inhabitants in Denmark • • We are 3600 GPs in Denmark We are 3600 GPs in Denmark • Each doctor has about 1600 patients • GPs in Denmark are independent Henrik Schroll, GP, Senior researcher, PhD Director of the National Danish Quality Unit of General Practice
General Practice in Denmark Basic conditions • We have a patient list system • We are gate keepers • Patients do not pay for visiting their GP • Most patients with chronic disease(s) are controlled in General Practice • GPs have a national contract with renewal every third year
Sentinel / Data Capture The Challenge: How can data for quality development and research be and research be retrieved from 12 different electronic medical record systems in Denmark? Henrik Schroll www.dak-e.dk
Data Capture in general practice DAMD – Danish General Practice Database Health Data Clinic Network, SDN PC Data from DAMD is sent to NIP DAMD Clinic NIP Server Server Clinic New reports are generated to the doctor every weekend PC DAMD Report Server The doctor has access to his own quality reports by using internet and his digital signature The program Sentinel Data Capture collects key data as they enter into the GP’s EMR. The collected data are prescribed drugs , National Health Service disbursement codes , laboratory analysis results and ICPC diagnoses . In addition it is possible via pop-up screens to collect data for specific ”projects” including chronic diseases and special designed research projects. Every two hours data are sent to DAMD where updated quality reports are generated every weekend.
Quality development and quality control of diabetes • The family doctor usually has to register only the diagnosis in his patient’s file. • During the diabetes consultation a pop-up screen automatically appears once a year and the family automatically appears once a year and the family doctor has to answer the questions in the pop-up screen (less than two minutes/patient). • All other data are automatically transferred from the electronic medical record system to the central DAMD database. Henrik Schroll www.dak-e.dk
The pop-up screen Henrik Schroll www.dak-e.dk
Feedback to the family doctor • The family doctor has access to his own data by using his professional digital signature. • The following Diabetes report is shown from a doctor’s view. • 38 different quality reports about different • 38 different quality reports about different diseases are available for the doctor. • The overview – and the Diabetes report as example: Henrik Schroll www.dak-e.dk
Datafangst
Datafangst
• Patients’ access to their own diabetes data • Acess to demo: • http://www.dak-e.dk/flx/english/dak_e_it/demos_of_data_capture/
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The diabetes quality project Which advantages do the family doctors obtain from participating in the diabetes quality project? – Overview of his/her population of diabetes patients, especially patients with suboptimal treatment of their diabetes. – Benchmarking his/her performance with that of his/her colleagues. – Graphs of results for discussion with the patient. – Reports are updated every day. Henrik Schroll www.dak-e.dk
Status april 2012 • 53 % of all Doctors in Denmark er now using the system • 2.9 million patient er incluted • More than 100.000 diabetes patients are • More than 100.000 diabetes patients are incluted • April 2013 – All GP’ in Denmark must use the system
Danish Quality Unit of General Practice Does feedback improve diabetes care? • DAMD – Danish General Practice Database ~ 550.000 patients ~ 18.500 patients with type 2 diabetes We included patients with type 2 diabetes with at least two diabetes recordings (yearly controls) from Oct. 2009 to Oct. 2010 • The number of included patients was 7988; 5805 with recorded blood-pressure 7122 with recorded cholesterol levels
Danish Quality Unit of General Practice Proportion patients with values above recommendations among the 7988 included type 2 diabetes patients: Oct. 2009, Oct. 2010, Absolute risk N(%) N(%) reduction (95% CI) Diabetes control (HbA1c>7% and no 1.35%(0.89-1.81), 235 (2.94) 235 (2.94) 127 (1.59) 127 (1.59) antidiabetic medication) antidiabetic medication) p<0.001 p<0.001 Blood-pressure (Systolic>130 and no 4.51%(3.42-5.61), 722 (12.44) 460 (7.92) antihypertensive medication) p<0.001 Cholesterol (>4.5 mmol/l and no 1226 4.73% (3.56-5.90), 889 (12.48) cholesterol lowering medication) (17.21) p<0.001 (5805 with recorded blood-pressure, 7123 with recorded cholesterol levels)
Danish Quality Unit of General Practice Discussion: There is a general growing awareness of importance of better management for chronic diseases… With a lack of a control group, we might be looking at a general ongoing quality improvement Pay for performance was introduced in 2004 Effects of pay for performance on the quality of primary care in England. Campbell SM, Reeves D, Kontopantelis E, Sibbald B, Roland M. N Engl J Med. 2009;361:368-78.
Danish Quality Unit of General Practice Improved quality of Type 2 diabetes care following electronic feedback of treatment status to general practitioners • A Danish study using an earlier version of the rapport system • cluster randomized, controlled trial with 15 months follow-up. • 86 clinics with 158 GPs and 2458 people 40-70 years old with Type 2 diabetes • GPS randomized to receive or not to receive electronic feedback on quality of care. Guldberg et al. Diabet Med. 2011 Mar;28(3):325-32.
Danish Quality Unit of General Practice People with Type 2 diabetes in the intervention group more often redeemed recommended prescriptions than people in the control group: oral antidiabetic treatment (32.8 vs. 12.0%, P =0.002) insulin treatment (33.8 vs. 12.4%, P <0.001) lipid-lowering medication (38.3 vs. 18.6%, 0.004) lipid-lowering medication (38.3 vs. 18.6%, 0.004) blood pressure medication (27.6 vs. 16.3%, P = 0.026). There were no differences in mean glycated haemoglobin and serum cholesterol between the intervention and control group: HbA1c changes 0.07 vs. 0.12 (-0.05 (-4.2;14.2), P=0.065) Cholesterol change -0.08 vs. -0.08 (0.00 (-2.1;81), P=0.244) Guldberg et al. Diabet Med. 2011 Mar;28(3):325-32.
How to organize the work with quality development in the clinic From a clinic in Korsør, Denmark
Goals in 3 areas • Goals for the clinic • Goals for each doctor • Goals for each doctor • Goals for the patients
Model for quality development • Overview over own quality • All staff members in the clinic must be involved • Work with setting goals • Work with setting goals • Updating common knowledge • Introducing new routines in the organization • Monitoring the effort
Example of use of own quality reports • Analysis of own data: The diabetes report shows that only 55 % The diabetes report shows that only 55 % of the diabetic patients are measured with microalbuminuria at least once a year! www.dak-e.dk
Question to ask? • Can targeted action increase the number of patients who are examined for microalbuminuria to 70 % within a year? microalbuminuria to 70 % within a year? www.dak-e.dk
Process • Who is coordinator and facilitator? • Teaching in why the detection of microalbuminuria is important microalbuminuria is important • Guidelines for handling the test • Time to start – time to follow up • Deadline for reorganization of the task www.dak-e.dk
Organization • Microalbuminuria examination becomes part of all the standard tests at the annual control of diabetes • A nurce is responsible for studying the • A nurce is responsible for studying the quality report to find the patients who have not been tested – and for securing the follow up • Patient leaflet to inform the patient why it is important to test the urin for albumin www.dak-e.dk
Evaluation – new project • After six months the proportion of examined patients is 73 % • But the new analysis shows that we have not followed up on pathological values not followed up on pathological values • New project to ensure � that all pathological values are repeated 2 – 3 times � that relevant patients are given appropriate treatment with an ACE inhibitor www.dak-e.dk
Keep it simple! It takes time to build up a methodology and structure when working with quality development
Thank you for your attention!
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