Measuring chronic obstructive pulmonary disease (COPD) quality indicators using primary care electronic medical records (EMRs) in Ontario, Canada

Abstract

RATIONALE: Quality management standards are available for chronic obstructive pulmonary disease (COPD), but how often they are followed in community settings is uncertain.

OBJECTIVES: We sought to measure the adherence to standard quality of care criteria for COPD management in primary care using primary care electronic medical records as an indicator for quality of COPD management.

METHODS: We conducted a cross-sectional study using EMR data from Ontario and previously validated set of COPD quality indicators previously developed by the Ontario COPD Population Health Network. We analyzed how often the COPD quality indicators were met for patients with COPD at the population-level and at the family physician-level.

MEASUREMENTS AND MAIN RESULTS: Five quality indicators were assessed at population- and family physician (FP)-levels. We included 6995 patients with COPD under care of 247 FPs. The highest performing quality indicator was the recording of patients’ smoking history in the EMR. FPs varied in their rates of provision of smoking cessation support to current smokers, recording of spirometry, administration of pneumococcal and seasonal influenza vaccines. Five additional health care or medication utilization rates were assessed for all patients with COPD regardless of disease severity, including prescriptions for short-acting and long-acting bronchodilators, combined inhaled corticosteroids and long-acting bronchodilators, evidence of pulmonary rehabilitation and oxygen therapy use.

CONCLUSION: EMR data can be a useful data source to study COPD care, and there are opportunities for improvement in several areas of COPD management in primary care as well as standardization of EMR use for COPD care.

RÉSUMÉ

JUSTIFICATION: Des normes de gestion de la qualité sont disponibles pour la maladie pulmonaire obstructive chronique (MPOC), mais la fréquence à laquelle elles sont suivies en milieu communautaire est incertaine.

OBJECTIFS: Nous avons cherché à mesurer le respect des critères de qualité des soins pour la prise en charge de la MPOC dans les soins primaires en utilisant les dossiers médicaux électroniques des soins primaires comme indicateur de la qualité de la prise en charge de la MPOC.

MÉTHODES: Nous avons mené une étude transversale en utilisant les données des DME de l’Ontario et un ensemble déjà validé d’indicateurs de qualité pour la MPOC précédemment élaborés par le Réseau de la santé de la population MPOC de l’Ontario. Nous avons analysé la fréquence à laquelle les indicateurs de qualité de la MPOC étaient atteints pour les patients atteints de MPOC au niveau de la population et au niveau des médecins de famille.

MESURES ET PRINCIPAUX RÉSULTATS: Cinq indicateurs de qualité ont été évalués au niveau de la population et des médecins de famille (MF). Nous avons inclus 6 995 patients atteints de MPOC pris en charge par 247 médecins de famille. L’indicateur de qualité le plus performant était l’inscription des antécédents de tabagisme des patients dans le DME. Des variations ont été observées chez les médecins de famille en ce qui concerne leurs taux de soutien des médecins de famille au sevrage tabagique des fumeurs actuels, d’inscription de la spirométrie et d’administration de vaccins contre le pneumocoque et la grippe saisonnière. Cinq taux d’utilisation de soins de santé ou de médicaments supplémentaires ont été évalués pour tous les patients atteints de MPOC, quelle que soit la gravité de la maladie, y compris les prescriptions de bronchodilatateurs à courte et longue durée d’action, les combinaisons de corticostéroïdes inhalés et de bronchodilatateurs à action prolongée, les preuves de réadaptation pulmonaire et le recours à l’oxygénothérapie.

CONCLUSION: Les données provenant des DME peuvent être une source de données utile pour étudier les soins pour la MPOC. Il serait possible d’améliorer plusieurs aspects de la prise en charge de la MPOC dans les soins primaires et d’uniformiser l’utilisation des DME dans les soins pour la MPOC.

Keywords:

• COPD; electronic record; primary care

Acknowledgments

This study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health (MOH) and the Ministry of Long-Term Care (MLTC). This study also received funding from the Province of Ontario through a MOH and MLTC Health Systems Research Fund Capacity Grant. The analyses, conclusions, opinions and statements expressed herein are solely those of the authors and do not reflect those of the funding or data sources; no endorsement is intended or should be inferred.

Funding for this research was provided by the Province of Ontario through a Ministry of Health and Long-Term Care (MOHLTC) Health Systems Research Fund Capacity Grant. KT is supported by a University of Toronto Department of Family and Community Medicine Research Scholar Award. NI is supported by a Canada Research Chair in Implementation of Evidence-Based Practice and by a clinician scholar award from the Department of Family and Community Medicine, University of Toronto. AG is supported by a New Investigator Award from the Canadian Institutes of Health Research.

We would like to thank the physicians that contribute their EMR charts to EMRALD^® for their contribution to this study.

Disclosure statement

The authors declare that there are no competing interests.

Author contribution

The study was conceptualized by K.T. and A.G. The study was designed by K.T., A.G. and T.L. with feedback from N.M.I. and J.B. The data were analyzed by T.L. and interpreted by T.L., K.T., A.G., N.M.I. All authors reviewed the manuscript for intellectual content and approved the final version. A.G. obtained the funding for this study.

Terminology

COPD – chronic obstructive pulmonary disease

EMR – electronic medical record

EMRALD^® – Electronic Medical Record Administrative data Linked Database

FP – family physician

ICES – In 2018, the institute formerly known as the Institute for Clinical Evaluative Sciences formally adopted the initialism ICES as its official name. This change acknowledges the growth and evolution of the organization’s research since its inception in 1992, while retaining the familiarity of the former acronym within the scientific community and beyond.

IQR – inter-quartile range

Roster – in Ontario, insured individuals can belong to a family physician’s roster. Being rostered to the family physician means that the patient regularly sees the same family physician and the family physician is the most responsible primary care physician for the individual (as opposed to a physician in the emergency room or from a walk-in clinic).

SD – standard deviation

Data availability

The individual-level data underlying this study are based on records generated from the administration of Ontario’s publicly funded health system. ICES has a special designation under Ontario’s Personal Health Information Protection Act to use this data in studies that evaluate healthcare delivery and outcomes. This designation is granted by the Information and Privacy Commissioner of Ontario, and is contingent on a triennial review and ongoing oversight of the privacy practices at ICES. A variety of measures are deployed to protect the personal health information entrusted to ICES and, under the Personal Health Information Protection Act (Ontario Regulation 329/04), the underlying data are legally not allowed for public repository.

The dataset from this study is held securely in coded form at ICES. While legal data sharing agreements between ICES and data providers (e.g., healthcare organizations and government) prohibit ICES from making the dataset publicly available, access may be granted to those who meet pre-specified criteria for confidential access, available at www.ices.on.ca/DAS (email: [email protected]). The full dataset creation plan and underlying analytic code are available from the authors upon request, understanding that the computer programs may rely upon coding templates or macros that are unique to ICES and are therefore either inaccessible or may require modification.

Additional information

Funding

This study was also supported by the Canadian Respiratory Research Network (CRRN), which is supported by grants from the Canadian Institutes of Health Research (CIHR) - Institute of Circulatory and Respiratory Health; Canadian Lung Association (CLA)/Canadian Thoracic Society (CTS); British Columbia Lung Association; and Industry Partners Boehringer-Ingelheim Canada Ltd, AstraZeneca Canada Inc., and Novartis Canada Ltd. Funding for training of graduate students and new investigators within the network was supported by the above funding Sponsors and as well by GlaxoSmithKline Inc. The funders had no role in the study design, data collection and analysis, or preparation of the manuscript.