Les Toop and Education Dept Pegasus Health and Department of Public Health & General Practice
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Transcript of Les Toop and Education Dept Pegasus Health and Department of Public Health & General Practice
Optimising Patient Care by managing variation in clinical practice: (Do it yourself, or have it done to you).
Les Toop and Education Dept
Pegasus Health and Department of Public Health & General PracticeUniversity of Otago, Christchurch,
There is a foolish corner in the brain of the wisest man Aristiotle c 370BC
Why is clinical variation important?
• It provides the setting both for innovation and for patients and clinicians to make a variety of decisions
• However it appears to exists in most parts of the health system to a degree that defies rational explanation
• For interventions with potential benefit, the degree of variation probably reflects both under and over treatment / investigation
Variation in clinical practice
Under utilisation Healthy variation Over utilisation
Sometimes interpretation is difficult! Variation may be understandable
Or Variation may seem too extreme to be rational
Reducing variation in clinical practice
Unmet need addressed
Healthy variation Over treatment avoided
IF UU<OU, rational use is promoted whilst freeing up resources for other uses, win - win
Under utilisation
(UU)
Healthy variation Over utilisation
(OU)
UU OU
BMJ head to head on clinical variation
In the absence of compelling evidence, different prior beliefs are rational and differences in practice do not offer a disservice to patients. They are therefore not inequitable RJ Lilford BMJ 2009; 339:b4809
Stephen Richards reply
“A large amount of current variation remains unwarranted. Only by explaining the variation can we expect to improve quality and cost effectiveness. Yet knowing the cause of variation is only the first battle; the second is to convert that knowledge into action”
BMJ 2009; 339
“The need is not so much for payers and regulators to force the medical system into uniformity . . . but rather for the profession and its leaders to recognize that there is embedded in this cacophony of practice so much waste and hazard that physicians simply owe it to themselves to reduce the variation wherever they can
Berwick. DM Med Care 1991;29:1212-25
Pegasus edn the beginnings
• A Perceived need • Enthusiasm (optimism of youth?)• Opportunity (policy vacuum)• A willing funder• A belief in a model (post PreMeC)• An incentive • Organised General Practice
The likely lads 19 years ago
Martin Seers, Les Toop, Graham McGeoch, Chris Leathart, c 1992 all in their 30’s
Pegasus Mission Statement 1992
“The promotion of best clinical practice with optimal and ethical use of finite resources”
Finite resources Best practice
Our patients deserve well educated, up to date, reflective and critically thinking clinicians who have the time and ability to discuss currently understood evidence, including its inherent uncertainties, and assist in informed decision making…..
Our Hypotheses in 1992
• Doctors will practice rationally if given independent evidence, feedback , the opportunity to discuss with peers and appropriate incentives( a la PreMeC)
• Rational practice will result in efficiencies• Current methods were insufficient to counter
effective and sophisticated marketing from industry which was driving expenditure growth
• National safety alerts and information on new technologies were and remain inadequate
Essential ingredients (1992)
• Multi faceted approach, must feel safe• Feedback essential • Ownership of education methods and content
by learners crucial • Guidance rather than guidelines reinforces
professional educational approach• Develop in house evidence review and
analytical capacity (team of 10 in 2011)
Peg Health Core Education Team Facilitators 2010
The Growth of Interdisciplinary Education
• 1993 (5) to present, 90 % engagement of General Practitioners in Greater Christchurch engaged in peer led small group education - currently 20 groups of approx 15 – 20
• In 2000, joined by practice nurses, currently > 90% engagement - now 18 small groups
• In 2010, joined by pharmacists now 13 groups -more than 200 from around Canterbury
• 2011 Physiotherapy joins in with falls education
The Process
• Monitor utilisation for changes• Monitor changes in evidence / availability• Clinical reference group needed to interpret
and seek further data, iterative process• Decide if situation suitable for intervention• Choose most appropriate learning
environment• Monitor effect of intervention
A recent example of best vs actual practice dissonance
Might this be a problem?
• Smaller tablet size - likely off label use• Metabolic side effects worrisome • Becoming recreational drug of abuse overseas• Who is using it and for what?• Why is the rate of growth so steep?
Growth in Quetiapine Dispensingsby tablet strength
1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 32005 2006 2007 2008 2009
-
50,000
100,000
150,000
200,000
250,000
300,000
350,000
400,000 Units Dispensed
25mg
100mg
150mg
200mg
300mg
Partnership Health GP data
Pattern of Quetiapine Prescribing
Under 18 18 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75+ -
20,000
40,000
60,000
80,000
100,000
120,000
140,000
Quetiapine units dispensed (all strengths) for each age band q4 2007 vs q3 2009
20072009
Age bands
Unitsdispensed
Elderly are the group dispensed the most quetiapine by unit volume overall (this is mostly made up of 25mg tabs), followed by 35-44y olds
Highest growth in prescribing (by units dispensed) is seen in the 45-54y age band who are also 3rd highest total users
Data for Partnership Health GPs
Unique patients on Quetiapine per Partnership Health GP (1/7/09-31/12/09)
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
Patie
nt C
ount
380 GPs represented (includes locums and registrars), 3638 total patients dispensed quetiapine for this time period
Leaders Briefing Group
Provider Name Patient Count on Quetiapine EnrolledUnder 75y Over 75y Total Popn
0 0 0 N/A0 0 0 3321 0 1 N/A2 0 2 4992 0 2 5253 0 3 14 0 4 19944 1 5 17264 1 5 7205 0 5 855 1 6 12265 3 8 5348 0 8 10098 0 8 N/A4 6 10 16685 5 10 1415
10 0 10 N/A11 1 12 112317 1 18 91718 3 21 24295 16 21 1180
49 1 50 034 18 52 1367
Median GP = 6 patients
Individual Partnership Health affiliated GPs (each diamond represents a single GP)
25th Centile GP = 3 patients
75th Centile GP = 12 patients
The plan
• Pre reading• Case based interactive small group ed session• Focus on licensed and unlicensed use• Feedback on quetiapine prescribing• Group discussion of appropriate use and
reasons for growth• Post reading• Monitor usage
Step 1 Identification of Topic
Step 2 Identification of Specific Areas within Topic
Step 3 Selection of Topic Preparation Team
Step 4 Preparation of Resources and Presentation
Step 5 Rehearsal / Equipping the Presenters
Step 6 Review of Feedback and Making Changes
Step 7 Small Group Meetings
Step 8 Review of Feedback
Step 9Post-topic Communication
Steps t
o an e
ffecti
ve sm
all gr
oup
educ
ation
mee
ting
Pegasus HealthGP Small Group Education
May 2010
Atypical Antipsychotics
Often other issues are uncovered
Quetiapine + Antidepressant Use
1 2 3 4 1 2 3 42008 2008 2008 2008 2009 2009 2009 2009
0%
2%
4%
6%
8%
10%
12%
14%
16%
% Patients on both Quetiapine and SSRI / SNRI
%Venla_Quetiapine%Cita_Quetiapine%Parox_Quetiapine%Fluox_Quetiapine
CDHB-wide Primary Care data
Early evaluation showed effectiveness
• First four groups, first four topics, acted as own controls, seasonally adjusted
• Richards,(now Mangin) Toop et al Family Practice. 2003;20(2):199-206
Doubt is not a pleasant condition but certainty is absurd Voltaire