Primary care quality indicators for children: measuring quality in UK general practice

Primary care of mothers and infants by the same or different physicians: a population-based cohort study

BACKGROUND

Different primary care delivery models exist for mothers and their infants. We examined whether primary care system performance measures differed when mother-infant dyads received primary care from the same or different providers.

METHODS

We conducted a population-based cohort study using Ontario health administrative data from 2004 to 2016. We included primiparous women and their singleton term infants and classified the primary care practitioners who provided the majority of care to the infant and the mother as concordant (same family physician for both; reference group), discordant (a different family physician for each) or pediatrician (pediatrician for the child, family physician for the mother). The primary outcome was nonobstetric maternal hospital admissions between 42 days and 2 years after delivery.

RESULTS

Among 481 721 mother-child pairs, 239 033 (49.6%) received concordant care, 114 006 (23.7%) received discordant care, and 128 682 (26.7%) received pediatrician care. Mothers in the pediatrician group were older and had greater comorbidity. Relative to concordant care, maternal nonobstetric hospital admissions occurred similarly under discordant care (adjusted odds ratio [OR] 1.00, 95% confidence interval [CI] 0.96-1.04) and in the pediatrician group (adjusted OR 0.99, 95% CI 0.95-1.02). Maternal deaths were similar under discordant care (adjusted OR 1.00, 95% CI 0.62-1.63) but lower in the pediatrician group (adjusted OR 0.55, 95% CI 0.34-0.89). Maternal primary care visits were lower in both the discordant group (adjusted relative risk [RR] 0.68, 95% CI 0.68-0.69) and the pediatrician group (adjusted RR 0.75, 95% CI 0.75-0.76). Healthy children were more likely to miss the enhanced 18-month well-baby visit under discordant care (adjusted OR 1.06, 95% CI 1.03-1.09) but less likely to miss this visit under pediatrician care (adjusted OR 0.47, 95% CI 0.46-0.49).

INTERPRETATION

Concordant care provided to a new mother and her infant by the same family physician was not associated with better primary care health system performance. The reason that pediatric primary care is associated with better maternal and child outcomes remains to be determined.

Guideline-based quality indicators-a systematic comparison of German and international clinical practice guidelines

Background

Evidence-based clinical practice guidelines (CPGs) are relevant sources for generating quality indicators (QIs). The objective of this study was to compare guideline-based QIs of German and international CPGs and their underlying methodological approaches.

Methods

We conducted systematic searches in the guideline databases of G-I-N (Guidelines International Network) and NGC (National Guideline Clearinghouse) between February and June 2017 to identify international CPGs matching the topics of German evidence-based CPGs (n = 35) that report QIs, which were identified in a preceding study. Additionally, we searched the websites of the particular CPG providers for separate documents with regard to QIs. We included evidence-based CPGs which report QIs. Reported QIs, the underlying guideline recommendations, and information on methods of development were extracted. The selection and extraction of CPGs were conducted by one reviewer and checked by another. For each matched pair of CPGs, we assessed whether the suggested QIs matched or were not directly comparable.

Results

Twenty-five international CPGs, originating from seven CPG providers in total, met the criteria for inclusion. They matched the topics of 18 German CPGs. This resulted in 30 CPG pairs for the comparison of QIs (some of the international CPGs matched the topic of more than one German CPG). We found 27 QI pairs with QIs “not different or slightly different”, corresponding to 13% (27 of 212) of the QIs in German CPGs and 16% (27 of 166) in international CPGs. Only two QI pairs were judged to be “different/inconsistent”. For 183 of 212 (86%) QIs from German CPGs and 137 of 166 (83%) QIs from international CPGs, no direct comparison could be made. An explicit link to one or more guideline recommendations was found for 136 of 152 (89%) QIs from German CPGs and 82 of 166 (49%) QIs from international CPGs. Some information on methods for the development of QIs existed for 12 of 18 (67%) German CPGs and 8 of 25 (32%) international CPGs.

Conclusions

The majority of QIs in German and international CPGs were not comparable. Various reasons for this are conceivable. More transparent reporting of the underlying methods for generating guideline-based QIs is needed.

Electronic supplementary material

The online version of this article (10.1186/s13012-019-0918-y) contains supplementary material, which is available to authorized users.

Feasibility testing of the Core set of quality Indicators for Paediatric Primary Care in Europe, COSI-PPC-EU

There is a need to measure and improve the quality of paediatric primary care in Europe where major differences in the delivery and outcomes of child health care exist. A collaborative panel of paediatric senior experts developed a Core Set of Indicators for Paediatric Primary Care in Europe by compiling 42 quality indicators in a modified consensus process following the RAND/UCLA appropriateness method. The aim of this study was to explore the feasibility of the quality indicator set in European paediatric primary care practices. Seventy-nine practices from eight countries participated in a detailed online interview. The practices rated the applicability, relevance, reliability and acceptance of the 42 quality indicator as well as the availability, technical feasibility and effort to retrieve the needed data from their medical records. Most quality indicators were considered applicable, available, reliable, acceptable and relevant for monitoring quality of care in paediatric primary care. Respondents rated feasibility and effort to retrieve the data lowest because of difficulties collecting the data from the medical records.Conclusion: European paediatric primary care practices generally agree with the proposed quality indicator set. They document most of the parameters. However, the collection of specific needed values from available routine patient-data is considered technically difficult and time-consuming. What is Known? • Paediatric primary care systems in Europe show striking differences in their performance. Pre-existing sets of quality indicators are predominantly limited to national populations, specific diseases and hospital care. • A Core Set of 42 quality indicators for paediatric primary care in Europe was developed by European paediatricians using a systematic literature review and a consensus process following a modified RAND/UCLA appropriateness method. What is New? • Paediatric primary care providers in Europe agree with the idea to use COSI-PPC-EU to monitor and improve the quality of care. The set was considered applicable, available, reliable, acceptable, and relevant for quality improvement. • The score for feasibility and effort to retrieve the data was low, because of technical reasons; the electronical or paper-based medical documentation in most cases does not allow convenient access to all necessary data.

Developing and evaluating a tool to measure general practice productivity: a multimethod study

Background

Systems for measuring the performance of general practices are extremely limited.

Objectives

The aim was to develop, pilot test and evaluate a measure of productivity that can be applied across all typical general practices in England, and that may result in improvements in practice, thereby leading to better patient outcomes.

Methods

Stage 1 – the approach used was based on the Productivity Measurement and Enhancement System (ProMES). Through 16 workshops with 80 general practice staff and 72 patient representatives, the objectives of general practices were identified, as were indicators that could measure these objectives and systems to convert the indicators into an effectiveness score and a productivity index. This was followed by a consensus exercise involving a face-to-face meeting with 16 stakeholders and an online survey with 27 respondents. An online version of the tool [termed the General Practice Effectiveness Tool (GPET)] and detailed guidance were created. Stage 2 – 51 practices were trained to use the GPET for up to 6 months, entering data on each indicator monthly and getting automated feedback on changes in effectiveness over time. The feasibility and acceptability of the GPET were examined via 38 telephone interviews with practice representatives, an online survey of practice managers and two focus groups with patient representatives.

Results

The workshops resulted in 11 objectives across four performance areas: (1) clinical care, (2) practice management, (3) patient focus and (4) external focus. These were measured by 52 indicators, gathered from clinical information systems, practice records, checklists, a short patient questionnaire and a short staff questionnaire. The consensus exercise suggested that this model was appropriate, but that the tool would be of more benefit in tracking productivity within practices than in performance management. Thirty-eight out of 51 practices provided monthly data, but only 28 practices did so for the full period. Limited time and personnel changes made participation difficult for some. Over the pilot period, practice effectiveness increased significantly. Perceptions of the GPET were varied. Usefulness was given an average rating of 4.5 out of 10.0. Ease of use was more positive, scoring 5.6 out of 10.0. Five indicators were highlighted as problematic to gather, and 27% of practices had difficulties entering data. Feedback from interviews suggested difficulties using the online system and finding time to make use of feedback. Most practices could not provide sufficient monthly financial data to calculate a conventional productivity index.

Limitations

It was not possible to create a measure that provides comparability between all practices, and most practices could not provide sufficient financial data to create a productivity index, leaving an effectiveness measure instead. Having a relatively small number of practices, with no control group, limited this study, and there was a limited timescale for the testing and evaluation.

Implications

The GPET has demonstrated some viability as a tool to aid practice improvement. The model devised could serve as a basis for measuring effectiveness in general practice more widely.

Future work

Some additional research is needed to refine the GPET. Enhanced testing with a control sample would evaluate whether or not it is the use of the GPET that leads to improved performance.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Clinical indicators for common paediatric conditions: Processes, provenance and products of the CareTrack Kids study

BACKGROUND

In order to determine the extent to which care delivered to children is appropriate (in line with evidence-based care and/or clinical practice guidelines (CPGs)) in Australia, we developed a set of clinical indicators for 21 common paediatric medical conditions for use across a range of primary, secondary and tertiary healthcare practice facilities.

METHODS

Clinical indicators were extracted from recommendations found through systematic searches of national and international guidelines, and formatted with explicit criteria for inclusion, exclusion, time frame and setting. Experts reviewed the indicators using a multi-round modified Delphi process and collaborative online wiki to develop consensus on what constituted appropriate care.

RESULTS

From 121 clinical practice guidelines, 1098 recommendations were used to draft 451 proposed appropriateness indicators. In total, 61 experts (n = 24 internal reviewers, n = 37 external reviewers) reviewed these indicators over 40 weeks. A final set of 234 indicators resulted, from which 597 indicator items were derived suitable for medical record audit. Most indicator items were geared towards capturing information about under-use in healthcare (n = 551, 92%) across emergency department (n = 457, 77%), hospital (n = 450, 75%) and general practice (n = 434, 73%) healthcare facilities, and based on consensus level recommendations (n = 451, 76%). The main reason for rejecting indicators was 'feasibility' (likely to be able to be used for determining compliance with 'appropriate care' from medical record audit).

CONCLUSION

A set of indicators was developed for the appropriateness of care for 21 paediatric conditions. We describe the processes (methods), provenance (origins and evolution of indicators) and products (indicator characteristics) of creating clinical indicators within the context of Australian healthcare settings. Developing consensus on clinical appropriateness indicators using a Delphi approach and collaborative online wiki has methodological utility. The final indicator set can be used by clinicians and organisations to measure and reflect on their own practice.

The PIPc Study-application of indicators of potentially inappropriate prescribing in children (PIPc) to a national prescribing database in Ireland: a cross-sectional prevalence study

OBJECTIVES

Evidence is limited regarding the quality of prescribing to children. The objective of this study was to apply a set of explicit prescribing indicators to a national pharmacy claims database (Primary Care Reimbursement Service) to determine the prevalence of potentially inappropriate prescribing in children (PIPc) in primary care.

PRIMARY AND SECONDARY OUTCOMES MEASURES

To determine the overall prevalence of potentially inappropriate prescribing (PIP) in children in primary care. To examine the prevalence of PIPc by gender.

DESIGN AND SETTING

Cross-sectional study. Application of indicators of commission of PIP and omission of appropriate prescribing to a national prescribing database in Ireland.

PARTICIPANTS

Eligible children <16 years of age who were prescribed medication in 2014.

RESULTS

Overall prevalence of PIPc by commission was 3.5% (95% CI 3.5% to 3.6%) of eligible children <16 years of age who were prescribed medication in 2014. Overall prevalence of PIPc by omission was 2.5% (95% CI 2.5% to 2.6%) which rose to 11.5% (95% CI 11.4% to 11.7%) when prescribing of spacer devices for children with asthma was included. The most common individual PIPc by commission was the prescribing of carbocisteine to children (3.3% of eligible children). The most common PIPc by omission (after excluding spacer devices) was failure to prescribe an emollient to children prescribed greater than one topical corticosteroid (54% of eligible children). PIPc by omission was significantly higher in males compared with females (relative risk (RR) 1.3; 95% CI 1.0 to 1.7) but no different for PIPc by commission (RR 1.0; 95% CI 0.7 to 1.6).

CONCLUSION

This study shows that the overall prevalence of PIP in children is low, although results suggest room for improved adherence to asthma guidelines.

Quality indicators for responsible use of medicines: a systematic review

OBJECTIVE

All healthcare systems require valid ways to evaluate service delivery. The objective of this study was to identify existing content validated quality indicators (QIs) for responsible use of medicines (RUM) and classify them using multiple frameworks to identify gaps in current quality measurements.

DESIGN

Systematic review without meta-analysis.

SETTING

All care settings.

SEARCH STRATEGY

CINAHL, Embase, Global Health, International Pharmaceutical Abstract, MEDLINE, PubMed and Web of Science databases were searched up to April 2018. An internet search was also conducted. Articles were included if they described medication-related QIs developed using consensus methods. Government agency websites listing QIs for RUM were also included.

ANALYSIS

Several multidimensional frameworks were selected to assess the scope of QI coverage. These included Donabedian's framework (structure, process and outcome), the Anatomical Therapeutic Chemical (ATC) classification system and a validated classification for causes of drug-related problems (c-DRPs; drug selection, drug form, dose selection, treatment duration, drug use process, logistics, monitoring, adverse drug reactions and others).

RESULTS

2431 content validated QIs were identified from 131 articles and 5 websites. Using Donabedian's framework, the majority of QIs were process indicators. Based on the ATC code, the largest number of QIs pertained to medicines for nervous system (ATC code: N), followed by anti-infectives for systemic use (J) and cardiovascular system (C). The most common c-DRPs pertained to 'drug selection', followed by 'monitoring' and 'drug use process'.

CONCLUSIONS

This study was the first systematic review classifying QIs for RUM using multiple frameworks. The list of the identified QIs can be used as a database for evaluating the achievement of RUM. Although many QIs were identified, this approach allowed for the identification of gaps in quality measurement of RUM. In order to more effectively evaluate the extent to which RUM has been achieved, further development of QIs may be required.

Development of a core set of quality indicators for paediatric primary care practices in Europe, COSI-PPC-EU

Paediatric ambulatory healthcare systems in Europe are, because of historical reasons, diverse and show strikingly different outcomes. All across Europe, the benchmarking of structures, processes and outcomes could reveal opportunities for improving Paediatric Primary Care (PPC). The aim of this study was to develop a set of Quality Indicators (QIs) to assess and monitor PPC in Europe. In a three-step process, we used the available external evidence and European expert consensus in a modified RAND/UCLA Appropriateness Method (RAM) to develop an indicator set. (1) A broad literature and online research of published QI and guidelines yielded an inventory of 1516 QI. (2) A collaborative panel of paediatric senior experts from the European Academy of Paediatrics (EAP) and the European Confederation of Primary Care Paediatricians (ECPCP) from 15 European countries participated in a first consensus process to reduce the initial indicator inventory by eliminating not PPC-focused indicators and duplicates. (3) In a second consensus process, the panel rated the QI regarding validity and feasibility. The final QI set "COSI-PPC-EU" consists of 42 indicators in five categories of PPC: (A) health promotion/prevention/screening (13 QI), (B) acute care (9 QI), (C) chronic care (8 QI), (D) practice management (3 QI) and (E) patient safety (9 QI).

CONCLUSION

COSI-PPC-EU represents a consented set of a limited number of valid quality indicators for the application in paediatric primary care in different healthcare systems throughout Europe. What is Known: • Paediatric ambulatory healthcare systems in Europe are diverse and show strikingly different outcomes. • There are known gaps in quality performance measures of paediatric primary care in Europe. Pre-existing sets of quality indicators are predominantly limited to national populations, specific diseases and hospital care. What is New: • A set of 42 quality indicators for primary paediatric care in Europe was developed in a multi-country collaborative effort. The method combined a systematic literature review and a consensus process among European paediatric experts. • The quality indicator set can facilitate quality improvement of PPC. After studying the feasibility, providers can use COSI-PPC-EU to monitor, compare and improve performance of practices, regions and countries.

Quality indicators for the acute and long-term management of anaphylaxis: a systematic review

Background

The quality of acute and long-term anaphylaxis management is variable and this contributes to the poor outcomes experienced by many patients. Clinical practice guidelines have the potential to improve outcomes, but implementing guideline recommendations in routine practice is challenging. Quality indicators have the potential to support guideline implementation efforts.

Objective

To identify quality indicators to support the acute and long-term management of anaphylaxis.

Methods

We conducted a systematic review of the literature that involved searching Medline, EMBASE and CINAHL databases for peer-reviewed published literature for the period 1 January 2005–31 December 2015. Additionally we searched Google for grey and unpublished literature. The identified indicators were descriptively summarized against the most recent international anaphylaxis guidelines (i.e. those produced by the European Academy of Allergy and Clinical Immunology) and critically evaluated using the Agency for Healthcare Research and Quality’s criteria for indicator development.

Results

Our searches revealed 830 publications, from which we identified five sources for 54 indicators addressing both acute (n = 27) and long-term (n = 27) management of anaphylaxis. The majority of indicators were developed through expert consensus with relatively few of these having been formally piloted or tested to demonstrate that they could discriminate between variations in practice and/or that they were sensitive to change.

Conclusions

There is a need for a comprehensive set of quality indicators for anaphylaxis management. We have however identified some indicators for the acute and long-term management of anaphylaxis that could with relatively little additional work support efforts to translate guideline recommendations into clinical care.

Electronic supplementary material

The online version of this article (doi:10.1186/s13601-017-0151-1) contains supplementary material, which is available to authorized users.

PIPc study: development of indicators of potentially inappropriate prescribing in children (PIPc) in primary care using a modified Delphi technique

OBJECTIVE

There is limited evidence regarding the quality of prescribing for children in primary care. Several prescribing criteria (indicators) have been developed to assess the appropriateness of prescribing in older and middle-aged adults but few are relevant to children. The objective of this study was to develop a set of prescribing indicators that can be applied to prescribing or dispensing data sets to determine the prevalence of potentially inappropriate prescribing in children (PIPc) in primary care settings.

DESIGN

Two-round modified Delphi consensus method.

SETTING

Irish and UK general practice.

PARTICIPANTS

A project steering group consisting of academic and clinical general practitioners (GPs) and pharmacists was formed to develop a list of indicators from literature review and clinical expertise. 15 experts consisting of GPs, pharmacists and paediatricians from the Republic of Ireland and the UK formed the Delphi panel.

RESULTS

47 indicators were reviewed by the project steering group and 16 were presented to the Delphi panel. In the first round of this exercise, consensus was achieved on nine of these indicators. Of the remaining seven indicators, two were removed following review of expert panel comments and discussion of the project steering group. The second round of the Delphi process focused on the remaining five indicators, which were amended based on first round feedback. Three indicators were accepted following the second round of the Delphi process and the remaining two indicators were removed. The final list consisted of 12 indicators categorised by respiratory system (n=6), gastrointestinal system (n=2), neurological system (n=2) and dermatological system (n=2).

CONCLUSIONS

The PIPc indicators are a set of prescribing criteria developed for use in children in primary care in the absence of clinical information. The utility of these criteria will be tested in further studies using prescribing databases.

UK quality statements on end of life care in dementia: a systematic review of research evidence

BACKGROUND

Globally, the number of people who die with dementia is increasing. The importance of a palliative approach in the care of people with dementia is recognised and there are national polices to enhance current care. In the UK implementation of these polices is promoted by the National Institute for Health and Care Excellence (NICE) Dementia Quality Standards (QS). Since publication of the QS new care interventions have been developed.

AIM

To explore critically the current international research evidence on effect available to inform NICE Dementia QS relevant to end of life (EOL) care.

DESIGN

We used systematic review methods to seek the research evidence for three statements within the Dementia QS. These are those that recommend: (1) a case management approach, (2) discussing and consideration of making a statement about future care (SFC) and (3) a palliative care assessment (PCA). We included evaluative studies of relevant interventions that used a comparative design, such as trials and cohort studies, and measured EOL care outcomes for persons dying with moderate to severe dementia. Our primary outcome of interest was whether the intervention led to a measurable impact on wellbeing for the person with dementia and their family. We assessed included studies for quality using a scale by Higginson and colleagues (2002) for assessment of quality of studies in palliative care, and two authors undertook key review processes. Data sources included Cinahl, Embase, and PsychINFO from 2001 to August 2014. Our search strategy included free text and medical subject headings relevant to population and recommended care.

RESULTS

We found seven studies evaluating a care intervention; four assessed SFC, three PCA. None assessed case management. Studies were of weak design; all used retrospective data and relied on others for precise record keeping and for accurate recall of events. There was limited overlap in outcome measurements. Overall reported benefits were mixed.

CONCLUSIONS

Quality statements relevant to EOL care are useful to advance practice however they have a limited evidence base. High quality empirical work is needed to establish that the recommendations in these statements are best practice.