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Seeking better quality science; Seeking better quality science; knowing what we measure matters knowing what we measure matters EQuIP EQuIP Annual Meeting Annual Meeting 9 April 2011 9 April 2011 Copenhagen, Denmark Copenhagen, Denmark Richard G. Roberts, MD, JD, FAAFP, FCLM Richard G. Roberts, MD, JD, FAAFP, FCLM Wonca Wonca President 2010 President 2010-2013 2013 Professor of Family Medicine Professor of Family Medicine University of Wisconsin University of Wisconsin School of Medicine & Public Health School of Medicine & Public Health 1100 1100 Delaplaine Delaplaine Court, Madison, WI 53715 USA Court, Madison, WI 53715 USA TEL: +1 608 263 3598; FAX: +1 608 263 5813 TEL: +1 608 263 3598; FAX: +1 608 263 5813 Email: richard.roberts@fammed.wisc.edu Email: richard.roberts@fammed.wisc.edu

History of Healthcare Quality History of Healthcare Quality • Florence Nightingale Florence Nightingale • Deming: measurable improvement Deming: measurable improvement • Donabedian • Donabedian Donabedian: structure Donabedian: structure : structure-process : structure-process process- outcome process- outcome outcome outcome • Berwick Berwick-IHI: continuous improvement IHI: continuous improvement • Institute of Medicine Institute of Medicine 2000: 2000: To Err is Human To Err is Human 2001: 2001: Crossing the Quality Chasm Crossing the Quality Chasm

History of Wonca Activities History of Wonca Activities 1989 1989 – – Working Party on Quality Working Party on Quality 2001 2001 – Family Doctors’ Journal to Quality Family Doctors’ Journal to Quality http://finohta.stakes.fi/NR/rdonlyres/72248539 http://finohta.stakes.fi/NR/rdonlyres/72248539-12A1 12A1-49C3 49C3-A3A5 A3A5- 403BEE934736/0/Kirja_Family.pdf 403BEE934736/0/Kirja_Family.pdf 1990 1990 – –EQuIP EQuIP 1995 1995 - QuIAP QuIAP

Science of Primary Care Quality Science of Primary Care Quality • 1993 1993 – – NHS: Audit to QOF NHS: Audit to QOF • 1998 1998 – – Europep Europep Grol Grol. Br J Gen . Br J Gen Pract Pract 2000;50(460):882 2000;50(460):882-7. 7. • 2002 2002 – – Review Review Elder. J Elder. J Fam Fam Pract Pract 2002;51(11):927 2002;51(11):927-32. 32.

Quality defined Quality defined • IOM IOM • WONCA WP on QIFM WONCA WP on QIFM • Reduction in variation • Reduction in variation Reduction in variation Reduction in variation • Value Value • Five A’s of quality Five A’s of quality • Patient Patient – – experience, outcomes experience, outcomes

IOM IOM Degree health services increase Degree health services increase likelihood desired health outcomes likelihood desired health outcomes c/w current professional knowledge c/w current professional knowledge

WONCA QIFM WONCA QIFM Best outcomes possible given Best outcomes possible given resources available and patient resources available and patient values and preferences values and preferences values and preferences values and preferences

Variation in Outcomes Variation in Outcomes • Morbidity and mortality Morbidity and mortality • Interventions/Hospitalization • Interventions/Hospitalization Interventions/Hospitalization Interventions/Hospitalization • Patient satisfaction Patient satisfaction

Family Medicine Family Medicine and and “A” Quality “A” Quality First Contact First Contact Access Access Continuity Continuity A relationship A relationship Competence Competence Ability Ability Comprehensive Comprehensive All All-in in-one one Context Context Appropriate Appropriate

Patient Experience: Get it Right Patient Experience: Get it Right • Right service Right service • Right time • Right time Right time Right time • Right person Right person • Right price Right price

Quality = doing right things right Quality = doing right things right Quality = doing right things right Quality = doing right things right

Barriers to QI Barriers to QI • Knowledge Gap Knowledge Gap • QA vs. QI QA vs. QI • Resource Intensive • Resource Intensive Resource Intensive - TIME Resource Intensive - TIME TIME TIME • Change is Threatening Change is Threatening • Financial Resources Financial Resources • Initial Productivity Declines Initial Productivity Declines

Creating Science, Using Best Practice Creating Science, Using Best Practice Clinical Evidence Performance Practice Measures Guidelines Treatment Screening Diagnostic Guidelines Guidelines Guidelines

How good is the evidence? How good is the evidence? Design : Review of all original clinical research in 3 major : Review of all original clinical research in 3 major Design general clinical journal or high general clinical journal or high-impact specialty journals impact specialty journals from 1990 from 1990-2003 that were cited more than 1000 times. 2003 that were cited more than 1000 times. Results Results : Of 49 highly cited studies, 45 claimed that the : Of 49 highly cited studies, 45 claimed that the intervention was effective. intervention was effective. intervention was effective. intervention was effective. � � 7 (16%) contradicted by subsequent studies 7 (16%) contradicted by subsequent studies � � 7 (16%) found effects stronger than those of subsequent 7 (16%) found effects stronger than those of subsequent studies studies � � 20 (44%) were replicated 20 (44%) were replicated � � 11 (24%) remained largely unchallenged 11 (24%) remained largely unchallenged Source: Ioannidis JPA. JAMA 2005;294:218 Source: Ioannidis JPA. JAMA 2005;294:218-228. 228.

How good is the evidence? How good is the evidence? <1 <1 5 9 9 9 9 250 250 750 750 1000 1000 Information taken from Green et al. N Engl J Med 2001;344:2021 Information taken from Green et al. N Engl J Med 2001;344:2021-25, 25, and and White et al. N Engl J Med 1961;265:885 White et al. N Engl J Med 1961;265:885-92. 92.

Case of Hemoglobin A1c Case of Hemoglobin A1c • • ACCORD (N=10,251) ACCORD (N=10,251) NEJM 2008;358:2545 NEJM 2008;358:2545-59. 59. • • ADVANCE (N=11,140) ADVANCE (N=11,140) NEJM 2008;358:2560 NEJM 2008;358:2560-72. 72. • • VA Trial (N=1791) • • VA Trial (N=1791) VA Trial (N=1791) NEJM 2009;360:129 VA Trial (N=1791) NEJM 2009;360:129 NEJM 2009;360:129-39. NEJM 2009;360:129-39. 39. 39.

Doing, and measuring, what matters Doing, and measuring, what matters Evidence Performance Clinical & Measures Practice Guidelines Outcomes that matter to patients

United Kingdom United Kingdom - QOF QOF • • 2004 2004 – – 146 metrics 146 metrics • • 2006 2006 – – 135 metrics 135 metrics • � 1 billion additional funds • � 1 billion additional funds � 1 billion additional funds � 1 billion additional funds • • Campbell et al. Ann Fam Med 2008;6:228 Campbell et al. Ann Fam Med 2008;6:228-234 234

United Kingdom United Kingdom - QOF QOF • • Improved disease Improved disease-specific care specific care • • Improved data capture Improved data capture • • Changed behavior regardless of values • Changed behavior regardless of values • Changed behavior regardless of values Changed behavior regardless of values • • Improved physician income Improved physician income Campbell et al. Ann Fam Med 2008;6:228 Campbell et al. Ann Fam Med 2008;6:228- -234 234

United Kingdom United Kingdom - QOF QOF • • Dual QOF Dual QOF-patient agenda patient agenda • • Deskill doctors Deskill doctors • Decrease continuity • • Decrease continuity • Decrease continuity Decrease continuity • • Disgruntled staff if not rewarded Disgruntled staff if not rewarded • • Impact of performance culture Impact of performance culture Campbell et al. Ann Fam Med 2008;6:228 Campbell et al. Ann Fam Med 2008;6:228- -234 234

Paradox of Primary Care Paradox of Primary Care • Specialists do better on disease focused Specialists do better on disease focused measures, but no difference in health measures, but no difference in health outcomes. outcomes. Universal Truths Universal Truths • Primary care clinicians achieve better health, • Primary care clinicians achieve better health, Primary care clinicians achieve better health, Primary care clinicians achieve better health, more effective health care, & greater equity. more effective health care, & greater equity. Local/individual Truths Local/individual Truths Stange Stange KC, KC, Ferrer Ferrer RL. The Paradox of Primary Care. RL. The Paradox of Primary Care. Ann Ann Fam Fam Med Med 2009; 7: 293 2009; 7: 293-299. 299.

Learn the basic patterns Learn the basic patterns

Then can see them in new situations Then can see them in new situations

Old versus New Science Old versus New Science OLD OLD NEW NEW • Academic health centers Academic health centers • Practice Practice-based (PBRN) based (PBRN) • RCTs RCTs • Quality Improvement Quality Improvement • Reductive • Reductive Reductive Reductive • Integrative • Integrative Integrative Integrative • Univariate Univariate • Multivariate Multivariate • Epidemiology Epidemiology • Complexity & Systems Complexity & Systems • Short term (12 week) Short term (12 week) • Long term (years) Long term (years) • Expert outcomes Expert outcomes • Patient outcomes Patient outcomes