EFFICIENCY IN FAMILY MEDICINE Prevention and screening WHAT FAMILY PHYSICIANS DO?

Transcription

1 EFFICIENCY IN FAMILY MEDICINE Prevention and screening WHAT FAMILY PHYSICIANS DO? Dr. Renáta Papp PhD PTE - AOK - Institute of Primary Health Care Pécs, 6 th February 2018

2 General practice is the easiest job in the world to do badly, but the most difficult to do well. Prof. Sir Denis Pereira Gray

3 Complexity in Family Practice Average : problems / visit Diagnosis: Hospital specialists: the most frequent 5 = 90% of all admissions to outpatient clinic of specialty Family Physicians: the most frequent 25 = 60% of all admissions to the family practice Stange KC, et al. J Fam Pract 1998;46(5):363-8.

4 Patients are becoming more complex 4

5 Patients in PHC 40 % - Admissions which can not be diagnosed by any known criteria 40 % -Multimorbidity or comorbidity 50 % - ½ of those older than 65 having 3 or more disease

6 DIAGNOSTICS Rare symptoms of rare diseases Rare diseases frequent symptoms Frequent diseases rare symptoms Frequent diseases frequent symptoms

7 Cardiovascular and oncological mortality Y in the ratio of data from Y2016 % daganatok Oncological diseases Cardiovascular diseases keringési rendszer betegségei Between 2007 and 2013 stroke and AMI mortality/1000 capita decreased significantly, being associated with the increase of antihypertensive, antidiabetic and antilipemmic drug therapy.

8 PREVENTIVE STRATEGIES Primary channel Universal prevention the preventive program is targeting the entire population independent of the individual risk status. It is starting from childhood, encouraging the development of a healthy lifestyle and giving up unhealthy behavior. Selective prevention the preventive activities means the identification of groups at risk and the intervention is aimed at these risk groups. Media Education system Mass feeding Sanitation Taxes on products Health care system Targeted prevention is aimed at individuals showing early signs of disease as part of the health care activities. Health care system

9 exposition biological onset detectable with screening symptoms organ damage death not detectable detectable clinical phase Development of non-communicable chronic disease Engelgau et. al. 2000

10 PRIMARY PREVENTION Primary prevention is described as the collection of measures to prevent or eliminate the potential factors leading to health problems in the individual or the community (healthy lifestyle, antenatal care, vaccination). SECONDARY PREVENTION Secondary prevention aims at identifying the health problems of the individual or the community in an early stage, thus providing a higher chance of healing, halting or slowing the progression of the disease or its complications (screening). TERTIARY PREVENTION Tertiary prevention decreases the effects of chronic health conditions on the individual or the community. It aims at preventing damages resulting from diseases and conditions causing permanent health deficits (deteriorating quality of health, resulting in functional disorders, permanent pain or need for permanent care). Tertiary prevention comprises continuing care and rehabilitation.

11 QUATERNARY PREVENTION This category has appeared only recently and has not unequivocally been introduced and used even in public health and epidemiology. It focuses on the relation between the everyday reality of escalating and sometimes negative consequences of healthcare services, which is a more and more significant social factor Disease mongering is a term for the practice of widening the diagnostic boundaries of illnesses and aggressively promoting their public awareness in order to expand the markets for treatment.

12 Integrated preventive health care (WHO) - Change of paradigm - Support preventive activities - Ensure patient motivation, participation and skill - Prevention to be part of each doctor-patient encounter

13 Most prevalent cause of death Common risk factors Cardiovascular disease Oncolocical disease Diabetes mellitus COPD Smoking Unhealthy eating habits Physical inactivity Alcohol abuse

14 State of the Union 2017 Letter of intent to president Antonio Tajani and to prime minister Jüri Ratas Priority 4: A deeper and fairer Internal Market with a strengthened industrial base Initiatives to be launched and/or completed by end 2018: - Joint Action Plan on national vaccination policies.

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16 THE LIST OF (BASIC) CORE COMPETENCIES OF FAMILY PHYSICIANS CATEGORIES OF CORE COMPETENCIES: Emergency care Diagnostic tests and procedures Independent patient care tasks Specialist-guided patient care Knowledge

17 SPECIALTIES: 1. Prevention in primary care 2. Cardiology, angiology 3. Pulmonology 4. Gastroenterology 5. Endocrinology and metabolic diseases 6. Immunology, allergology 7. Haematology 8. Neurology 9. Psychiatry, addictology 10. Geriatrics 11. Surgery, traumatology 12. Otorhinolaryngology and Head and Neck Surery 13. Nephrology 14. Urology 15. Diseases of the musculoskeletal system 16. Ophthalmology 17. Stomatology 18. Oncology 19. Gynaecology, Obstetrics 20. Infectology 21. Dermatology 22. Emergency care 23. The List of Core Competencies of primary care paediatricians 24. The legal background of the activities of the general practitioner. The activities of the general practitioner as an expert 25. Medical registration file

18 Garner J et al. 1999

19 TEAM WORK IN FAMILY PRACTICE General agreement score 8.5/10 Nurse 8.9 District nurse 7.5 Pharmacist 6.6 Secretary 6.4 Receptionist 6.0 Health Care Assistant 5.9 Health Visitor 5.8

20 FAMILY PHYSICIAN: PREVENTION AND DISEASE MANAGEMENT FOR ALL AGES Registration to the practice list First check-up Health plan (screening scheme/repeat check-ups) Acute complain? Acute treatment/acute case management Chronic disease? Chronic disease management

21 Public health screening scheme 51/1997. NM decree *CV: cardiovascular risk based on family history, manifest cardiovascular disease, SCORE: gender, smoking, diabetes, RR, cholesterol **risk for renal diseases: family history, hipertension, diabetes mellitus (se-creatinin, creatinin clearance, proteinuria, hematuria) metabolic syndrome diagnosis (waist circumference >80 cm in women, >94cm in men and 2 other factors elevated blood pressure, fasting glucose, triglicerid, lower HDL-cholesterol) Age group Screening Frequency (year) 21low, medium, high CV risk* low CV risk 5 medium, high CV risk 2 renal disease risk** 2 stomato-oncological exam low CV risk 5 medium, high CV risk 2 renal disease risk** 2 stomato-oncological exam low CV risk 5 medium, high CV risk 2 Doppler 2 renal disease risk** 2 stomato-oncological exam 2 chest X-ray low CV risk 2 medium, high CV risk 2 Doppler 2 renal disease risk** 2 stomato-oncological exam 2 chest X-ray 1 sensory organ check cervical cancer screening (25-65 y) 3 mammography (45-65y) 2

22 Vizsgáltak aránya (%) Cardiovascular risk stratification 100% 80% 60% nincs nagy 40% közepes kis 20% 0 0% >80 kordecilis (év)

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24 DIMENSIONS OF CARE (I) The model is most often represented by a chain of three boxes containing structure, process, and outcome connected by unidirectional arrows in that order. These boxes represent three types of information that may be collected in order to draw inferences about quality of care in a given system. Structure includes all of the factors that affect the context in which care is delivered. This includes the physical facility, equipment, and human resources, as well as organizational characteristics such as staff training and payment methods. These factors control how providers and patients in a healthcare system act and are measures of the average quality of care within a facility or system. Structure is often easy to observe and measure and it may be the upstream cause of problems identified in process. Process is the sum of all actions that make up healthcare. These commonly include diagnosis, treatment, preventive care, and patient education but may be expanded to include actions taken by the patients or their families. Processes can be further classified as technical processes, how care is delivered, or interpersonal processes, which all encompass the manner in which care is delivered. According to Donabedian, the measurement of process is nearly equivalent to the measurement of quality of care because process contains all acts of healthcare delivery. Information about process can be obtained from medical records, interviews with patients and practitioners, or direct observations of healthcare visits. Outcome contains all the effects of healthcare on patients or populations, including changes to health status, behavior, or knowledge as well as patient satisfaction and health-related quality of life. Outcomes are sometimes seen as the most important indicators of quality because improving patient health status is the primary goal of healthcare. However, accurately measuring outcomes that can be attributed exclusively to healthcare is very difficult. Drawing connections between process and outcomes often requires large sample populations, adjustments by case mix, and long-term follow ups as outcomes may take considerable time to become observable.

25 DIMENSIONS OF CARE (II)

26 INDICATORS - PRICIPLES - Evidence based - Optimal number - No duplication in documentation - Data protection - Time serries - Mainly focusing on process, rather that outcomes

27 Example (NHS QOF): Clinical domain: management of hypertension Indicator Score Target Documentation HYP001 Theres is a register of patients diagnosed with hypertension 6 Management process HYP006 Ratio of patients with blood pressure lower than < 150/90 mmhg (based on last 12 month measurement) %

28 QUALITY INDICATORS IN ADULT/MIXED FAMILY PRACTICES Flu vaccination (>65y) Mammography Management of hypertension (40-54y; 55-69y) Se-creatinine measurement in hypertensive/diabetic patients Beta-blocker therapy after MI HbA1c/retina examination in diabetic patients Management of patients with COPD Referral to secondary care Prescription of antibiotics

29 QUALITY INDICATORS IN PEDIATRIC FAMILY PRACTICES Meningococcus vaccination (<2y) Colecalciferol preventive administration (<3y) Exclusive breast feeding (6 months) Iron supplementation (10-18y girls) Referral to secondary care Out-of-hours care Prescription of antibiotics

30 Patients generally report positive experience with family physicians 30

31 Career satisfaction varies by specialty Obs Specialty Frequency Mean satisfaction score 3Dermatology Pediatrics Cardiovascular diseases Ophthalmology Psychiatry Otolaryngology Family practice Emergency medicine Orthopedic surgery General surgery Internal medicine Neurology Obstetrics and gynecology J Paul Leigh, Daniel J Tancredi and Richard L Kravitz: Physician career satisfaction within specialties BMC Health Services Research2009 9:166

32 THANK YOU FOR YOUR ATTENTION!