Collaborating to bridge the research/practice gap

What percentage of your patients with coronary artery disease are on aspirin?
How many of your diabetic patients have had their lipids checked in the last 12 months?
Do other practices have systems in place that make them more efficient or more profitable than yours?
Do they manage their appointment scheduling more efficiently?

In this information age, GPs are expected to implement no end of ‘evidence based’ interventions and adhere to an expanding pool of ‘expert guidelines’.

Our traditional role has been to treat the symptoms with which our patients present. To identify asymptomatic patients with particular risk factors requires a different approach. There is an increasing gap between the ideals espoused by our colleagues in research and the actuality of what we can achieve. We will need to treat (and sometimes harm) many patients to benefit some. We will not be able to identify all the individuals within our patient pool that would benefit from evidence based guidelines. And even if we could, there are limits to the degree that real life people are willing to adopt measures that involve lifestyle change, cost or side effects. New strategies are required.

The ‘quality movement’ is a management concept used in industry that uses system change to improve outcomes.(1) Sir John Oldham, a British GP, applied the techniques to primary care and a National Primary Care Collaborative was established in the UK in 2000. It has now engaged almost 5000 practices covering more than 32 million patients, which makes it the largest health improvement program worldwide.(2)

A Collaborative is a means of spreading improvement quickly and effectively. The process used in the UK has involved gathering selected members of each participating practice (doctors and practice staff), in a series of workshops. Existing ‘best practice’ research is presented by an expert panel, and the participants are introduced to an improvement tool incorporating small, rapid cycles of change - PDSA cycles (Plan/Do/Act/Study). Practices develop their own strategies aimed at meeting a best practice standard, and implement them during three ‘action periods’. Local trained coordinators assist practices in implementing their changes and recording monthly measures of improvement. The results of each participating practice are shared at the next workshop. Successful ‘stories’ can therefore be spread across the whole collaborative. The approach means that participants not only become skilled in the topic areas, but also develop expertise in improvement itself, and can therefore apply their learning to other areas of patient care.(2)

The initial Collaborative wave in the UK project focused on secondary prevention of coronary heart disease and improvements in access to GP services. The results have been impressive.

Regions involved in the Collaborative have, on average, delivered a four-fold greater reduction in CHD mortality compared with the rest of England. Some areas, that have systematically monitored practice CHD mortality rates, can point to a reduction of 30% in CHD deaths in only one year.

The average waiting time to see a GP in participating practices has decreased by 60%.

The Federal Government, noting these results, and the well-described differences between UK and Australian primary care systems(4), has funded an Australian implementation of the Collaborative Project. This will be coordinated by Flinders University(3). In accordance with the model, a number of ‘early adopter’ practices will be recruited to collaborate on strategies aimed at improving outcomes in diabetes, heart failure or access to services, with the first wave of practices to be recruited later this year.

Twenty-five divisions of general practice will be invited to participate in the program. They will be funded to employ a local coordinator to assist participating practices, which will also receive supportive funding. All up, one GP and practice nurse (or other staff member) will participate in one introductory workshop and three learning workshops over the course of the collaborative. The practice will be reimbursed for its time away and for other expenses incurred in participating, and will have developed skills in implementing quality improvement techniques. Expressions of interest from divisions are required by the end of October 2004.

The UK experience of collaboratives indicates that they can achieve significant benefits for our patients. Our division will nominate if there is a sufficient number of interested practices in this area. The time-frame before implementation is very short, so please contact us if you would like to participate or would like further information.

What will the experience in a collaborative be like for participating practices? If we could postulate a hypothetical coronary heart disease collaborative, perhaps something like this:

You (a GP) and a practice nurse from your practice attend a workshop where an expert panel presents the best available evidence on the management of CHD. The group, as a whole, decides initially to focus on the role of antiplatelet agents.

You return to the practice and together with the local coordinator audit your charts, noting that only 60% of CHD patients are actually taking an antiplatelet agent. Possible strategies to improve this are discussed in a meeting of the entire practice team (doctors, nurses, reception staff). A process of flagging all patients with CHD is decided upon, so that their antiplatelet status can be checked at their next visit to your practice. At the end of the action period, with the assistance of the local coordinator, the percentage of patients with CHD on appropriate treatment is again measured.

The resulting improvement, if any, is reported to the combined collaborative group at the next workshop. Another practice may report that they decided to implement a general mailout of patient education material about CHD and antiplatelet therapy, with a better result.

In your practice, you decide to implement an ongoing program based on these shared stories, and measure how that fares. Meanwhile, you implement a new strategy aimed at ensuring all CHD patients are on appropriate statin therapy, the results of which you will share at the next workshop.

References and further information
(1) Institute for Healthcare Improvement: www.ihi.org/
(2) National Primary Care Development Team (UK)
www.npdt.org/scripts/default.asp?site_id=5
(3) National Primary Care Collaboratives (Aust) http://som.flinders.edu.au/FUSA/GP-Evidence/SARNet/npcc.htm
(4)The collaborative method. A strategy for improving Australian general practice Knight, A., 2004. Australian Family Physician http://som.flinders.edu.au/FUSA/GP-Evidence/SARNet/pdfs/
20040413knight.pdf

Tony Lembke attended the Collaboratives meeting at the National Divisions Forum held in September in Adelaide.