Improving the quality of care for patients with chronic diseases: What research and education in family medicine can contribute

Abstract

Background: The theme of the EGPRN conference in Ljubljana 2012 was ‘Quality improvement in the care of chronic disease in family practice: the contribution of education and research.’

Objective: In this contribution, we summarize our key note lectures and provide reflections on the theme.

Results: Many countries have established programmes for training of primary care professionals and quality improvement in family medicine. Research and development has focused on new educational methods, practice accreditation, patient safety in primary care, models of structured chronic care, and tailored improvement.

Conclusion: An international academic network of physicians, teachers and researchers in primary care should be nurtured to address the challenges of chronic illness care.

Key words::

• Primary care
• continuing education
• quality improvement

KEY MESSAGE:

• Well trained family physicians participating in quality improvement projects are crucial for primary care.

• Recent research focused on educational methods, practice accreditation, patient safety, models of chronic care, and tailored improvement.

• Addressing the challenges of chronic illness care implies nurturing an international academic network of physicians, teachers and researchers in primary care.

Introduction

Ageing, lifestyle changes, and medical advances have made chronic non-communicable diseases leading causes of morbidity and mortality all over the globe. Many patients with these diseases are treated in primary care (1). This poses a range of challenges for family physicians and other primary care professionals. They are expected to use the best available knowledge in their decisions, to possess a wide range of clinical skills, and to be effective co-ordinators of care for their patients. They have to respect their patients’ preferences at all times and involve them actively in the care received. In many countries, family physicians are also responsible for a reliable and efficient organization of their practice organization, including the supervision of other healthcare workers, such as nurses and assistants. Family physicians have to meet challenges in a context of rapid spread of modern information technology and access to the World Wide Web, societal worries about rising costs of healthcare, and concerns about the shortage of the work force in healthcare. How can research and teaching in family medicine help to address these challenges?

The theme of the EGPRN conference in Ljubljana 2012 was ‘Quality improvement in the care of chronic disease in family practice: the contribution of education and research.’ While this is a bit of an 'evergreen’—the topic has attracted interest for several decades—the organizers were interested to discuss recent developments in research and education in family medicine. In this contribution, we will summarize our key note lectures and give some further reflections on the theme.

Developments in education

It is widely understood that a strong primary care is an essential constituent of each health care system, which has a positive impact on health outcomes, equity, and healthcare costs (2). Well trained primary care physicians are crucial for strong primary care. Here, we focus mainly on family medicine as the discipline that is responsible for primary medical care in many countries. Family medicine provides key information on the epidemiology of diseases, and is an important place of training of health professionals because most patients contact primary care before, during, and after specialized treatments (3). Family practice has, therefore, a unique task profile, which is not an addition of the task profiles and expertise of other disciplines taught in medical schools (4).

Guidelines for training family physicians have become available. A European Union Directive asks from member states at least three years of specialist training in family practice, half of which should take place in a primary care setting (5). The European academy of teachers (EURACT) has played an important role in exchanging expertise and guiding educational activities in family practice in Europe (6–8). It has defined an educational agenda, which includes principles for teaching the discipline. Comprehensive care is one of the core principles and continuity of care is a prerequisite of high quality family practice. Integrated, comprehensive patient management should encompass health promotion, disease prevention, early detection and treatment as well continuous management and palliation. Principles of comprehensive management are: knowing your patients (lists), active seeking of patients at risk for disease development or ill, developing disease registers, teamwork, community orientation, patient groups education and targeted activities in accordance with local and societal needs. One of the key points of our future endeavours in the training of family physicians is the translation of biomedical science into meaningful practice recommendations, such as adaptation of advanced diagnostic tests and treatments for use in primary care.

Many countries introduced programmes of care for long-term conditions to improve patient care and to control healthcare costs. Various chronic care models have emerged and passed, but continuity of care of chronic patients remains a key target of family medicine. We should avoid feeding computers with data if this is only useful for the management of a programme for structured chronic care (9). Patient records should serve patient care, respect patients’ preferences and ideally also enhance their self-management. Therefore, medical students and vocational trainees in family medicine should also be taught in communication skills, team work, practice organization, and knowledge management. In addition, they should develop specific attitudes regarding excellence, humanism, accountability and altruism (10). Innovations, such as the use of art in teaching professional attitudes, for example movies are consistent with these principles (11). Instruct teachers to role model and teach future doctors in the art of family medicine as core primary health care discipline is of utmost importance to maintain professionalism in spite of politic drifts (4).

Developments in research

Many organizations of family physicians and health authorities across the world invested in educational programmes to improve primary care. Examples are clinical audit, quality circles, computerized decision support, and web-based learning. Programmes for accreditation of family physicians and primary care practice organizations build on these educational approaches (12). Accreditation programs have a range of purposes, including but not limited to quality improvement. The assessment for accreditation may focus on a variety of domains. For instance, the programme for accreditation of general practices in the Netherlands is strongly focused on organization and delivery of care for patients with chronic diseases. Ongoing research aims to assess whether accreditation effectively improves healthcare. A study in German family medicine found that a particular practice accreditation programme, which used the internationally validated EPA instrument (European Practice Assessment), led to improvements in a range of organizational domains (13). A study on the effectiveness of practice accreditation in the Netherlands (a cluster randomized trial focused on patients with chronic cardiovascular conditions) will report results in the coming years.

Patient safety obviously has always been an important component of quality of care, but in recent years it has gained extensive interest. In essence, patient safety means absence of preventable harm to patients. Initially, the emphasis was strongly on patient safety in hospitals, but more recently safety of primary care has also received attention. Patient safety incidents in family practice do occur, but their incidence is much lower than in hospital settings (14). While patient safety is potentially very broad, incidents with a high risk of harm tend to relate to the diagnosis and treatment of major chronic diseases. The challenge in primary care is to enhance patient safety, but avoid defensive medicine and heavy administrative programmes. When asked, family physicians prioritized educational tools related to patient safety and initiatives to improve patient safety culture (15). In some countries, major investments were made in research and development to improve patient safety in family medicine. In other countries such investments have not yet been made, or have stopped because of change of political priorities.

A perhaps simple, but hardly implemented, insight from implementation science is that interventions to improve healthcare should be tailored to relevant barriers and enablers for change (16). This is the same as in patient care, where patients receive treatments that are tailored to diagnosis or working definitions of their health problems. Likewise, to improve performance, not every family physician needs the same type of intervention—whether educational, organizational, financial, or otherwise. More research is needed on methods for tailoring, because little is known about the values and limitations of various methods. For instance, tailoring varies from a two-hour brainstorm in a group of clinicians to a nine-month structured intervention mapping process. In an ongoing European study, we explore different methods for tailoring implementation interventions, focusing on improving chronic illness care (17).

In addition to educational activities to support family physicians, it is crucial to optimize the organization of primary care to meet the challenges of caring for patients with chronic diseases. The Chronic Care Model (CCM), which is supported by the American College of Family Physicians, is a concept suggesting how such optimally organized healthcare looks like. It proposes several quality improvement interventions (including organizational structures) related to the design of the clinical process, information technology, decision support, and self-management support. The model is popular among policy makers in many countries, but its relevance to European primary care is not well studied. The evidence on cost-effectiveness of chronic care models is still limited as yet (18). Interestingly, a study of an approach that resembled elements of the Chronic Care Model found that only diabetes patients with co-morbidities showed better quality of life compared to usual care (19).

Discussion

In this paper, we summarized our presentations at the EGPRN conference in Ljubljana, which focused on developments in education and research in family medicine related to the care for patients with chronic diseases. In this final section, we will provide some further reflections on this theme.

The assessment of clinical and organizational processes and outcomes remains a key component in both training of health professionals and quality improvement. The introduction of evidence based medicine should not be interpreted as a requirement to follow practice guidelines blindly in all situations. Teaching complexity, communication skills, patient involvement and adherence, medical professionalism and humanism should be at the core of family practice teaching (20). A related misconception is that computerized medical records and decision support systems will automatically improve healthcare. In fact, their impact is moderate (21). We believe that the best available knowledge should always play a role in clinical decision making, but that few (if any) recommendations for clinical practice should be followed at all times. An important area of future research is, therefore, the development of measures that better capture the use of knowledge by health professionals and patients in daily practice.

Family medicine was among the first medical professions to develop and evaluate programmes for quality improvement. Notably, performance measures now often have a broad set of purposes. Besides quality improvement, these include quality control, accountability in relation to contracts, pay for performance, public reporting, and marketing. There are risks associated with these new purposes. For instance, patient privacy and autonomy may be threatened by widespread use of and access to computerized data. Methods that focus heavily on measuring and streamlining performance may reduce patients to organs, diseases and target values. Paying for performance may be beneficial for improvement in target areas, but may be causing inequalities in the disease or other characteristics not included in the payment package. We believe that quality improvement should remain the core of performance measurement and that active involvement of healthcare professionals is required actually to improve organization and delivery of health services. Both, professional training and research should prioritize the broad implementation of effective quality improvement programmes, and future studies should help to optimize such programmes by providing insight into determinants of their effectiveness.

We cannot ignore the realities of a continuously growing body of knowledge, rising costs of healthcare, and disappointingly poor quality in some area of healthcare. Policy makers, funders of healthcare, and managers of healthcare have only limited means to address these challenges. Well-developed, complementary and collaborating international academic networks of physicians, teachers and researchers in primary care are needed to address these challenges. No profession can survive (as a profession) without such knowledge infrastructure. Concepts like the ‘chronic care model’ or ‘pay for performance’ have been coined, perhaps with good intentions, but they imply an ideology focused on introducing management and economic concepts in healthcare (22). It is crucial to keep the interests of patients and populations at the centre of our work.

Funding

Research reported in this contribution is funded by several research funders, including the European Commission and the Netherlands Organization for Health Research (ZonMW).

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.