Audit: definition, pitfalls and advantages ICPC as a tool for family medicine Practical applications of ICPC

Jean K Soler

The quality of health systems is defined as the level of attainment of health systems intrinsic goals for health improvement and responsiveness to legitimate expectations of the population. (WHO 2001) Clinical audit is a process that has been defined as "a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change. (NICE, 2002) NICE. Principles of Best Practice in Clinical Audit 2002 http://www.nice.org.uk/media/796/23/bestpracticeclinicalaudit.pdf WHO. A WHO Framework for Health System Performance Assessment. 2001 http://www.who.int/healthinfo/paper06.pdf

Highest standard Realistic and pragmatic

Standards often set against evidence base derived from other specialities Outcome measures??? Closing the loop implementing change

Quality of health care measured by diseasespecific evidence-based process-of-care guidelines shows primary care performs poorer than more specialised care Primary care achieves similar functional health status at lower cost for chronic disease Primary care achieves better quality, better health, greater equity and lower cost for people and populations Stange K, Ferrer RL. The Paradox of Primary Care. Annals of Family Medicine 2009; 7(4): 293-299

Potential to improve quality of care Provides evidence of quality of care Due diligence Advantages of empirical approach, when applicable

International Classification of Primary Care Its application as a tool for family medicine, for clinical care, practice manegement, audit, and research

A - General B - Blood, immune system D - Digestive F - Eye H - Ear (Hearing) K - Circulatory L Musculoskeletal (Locomotion) N - Neurological P - Psychological R - Respiratory S - Skin T - Metabolic, endocrine U - Urological W - Women s health, pregnancy, famil y planning X - Female genital Y - Male genital Z - Social problems

1. Complaints and symptoms Code: 01-29 2. Diagnostic, screening and preventive 30-49 3. Medication, treatment, procedures 50-59 4. Test results 60-61 5. Administrative 62 6. Referrals 63-69 7. Diagnostic / disease 70-99 infectious neoplastic injuries congenital anomalies other

1 2 3 4 5 6 7 A B D F H K L N P R S T U W X Y Z

Rubrics code mutually exclusive concepts Inclusion and exclusion criteria: definitions Covers the breadth of the domain Granularity appropriate for the domain Classification based on empirical data

Henk Lamberts

SYMPTOMS DIAGNOSES 200 400 ICPC: > 1 PER 1000 PPY 600 10.000 ICD: <1 PER 1000 PPY

Perceived health problem Perceived need for care RFE, demand for care Diagnosis Process RFE, demand for care Diagnosis Process RFE, demand for care Diagnosis Process

ICPC (WONCA) Conceptual construct Localisation About health problems and patient complaints Patient centred ICD (WHO) Historical construct Etiologic About diseases Provider centred Marc Jamoulle

ICPC and ICD relationships All included in UMLS ICD9 ICPC ICD10 All linked to Snomed-Ct

1 year dataframe databases Netherlands Malta Serbia Observation period 1995-2005 2001-2005 2003 Patients (cumulative over period) 168,497 49,479 72,673 Patient years denominator 158,370 43,577 72,673 Encounters 838,896 70,177 207,323 Sub-encounters/Diagnoses 1,178,178 93,606 405,150 Reasons for encounter (RfE) 1,326,920 131,537 363,520 RfE in New Episodes of care (EoC) 422,568 82,224 34,828 EoC 554,804 75,450 103,133 New EoC 337,348 55,821 41,172 Interventions 1,605,345 201,132 387,468 Prescriptions 810,894 54,352 Measurements and/or test results 252,812 Referrals primary care 28,822 859 Referrals specialist 38,250 3,928 Years of observation 11 5 1 Number of doctors 10 9 50 Practices 5 4 50

40 30 NETH POLAND SERBIA JAPAN MALTA 20 10 0 A B D F H K L N P R S T U W X Y Z

40 NETH JAPAN POLAND MALTA SERBIA 30 20 10 0 A B D F H K L N P R S T U W X Y Z

... because of the added accuracy of the Episode of Care data model; where more than one encounter for the same problem is only counted once (as appropriate)

Useful to report what we do Less useful to individual patients in our practice

The Netherlands Malta Serbia Incidence Prevalence Incidence Prevalence Incidence Prevalence Diagnosis Rate Standardised Rate Standardised Rate Standardised Rate Standardised Rate Standardised Rate Standardised T90 - diabetes type II 4.1 4.3 31.9 33.3 3.1 4.5 17.8 28.8 4.6 3.3 28.4 19.9 K86 - hypertension 5.3 5.5 75.7 79.2 4.6 6.2 41.1 59.9 19.3 14.4 114.1 79.8 U95 - renal stone 2.0 2.1 4.5 4.7 3.4 3.5 5.4 5.9 3.7 3.0 6.7 5.3 D98 - cholecystits/lithiasis 2.1 2.1 4.8 5.0 2.0 2.3 3.6 4.5 3.2 2.3 5.3 3.7 S70 - herpes zoster 3.9 4.0 5.1 5.2 1.5 1.9 1.7 2.2 1.1 0.8 1.4 1.1 A72 - chicken pox 2.4 2.2 2.5 2.3 4.9 3.7 5.4 4.1 0.7 1.3 0.8 1.6 P70 - dementia 0.7 0.8 2.8 2.8 0.1 0.2 0.5 1.1 0.2 0.3 0.7 0.6 P72 - schizophrenia 0.1 0.1 1.4 1.4 0.0-0.5 0.7 0.3 0.3 2.6 2.8 All chapter P component 7 21.0 21.3 69.6 70.7 12.2 13.5 42.5 51.5 23.3 18.3 81.0 61.5 All chapter P 80.5 81.4 206.4 210.5 31.0 34.0 95.6 110.6 38.7 32.2 113.3 88.0 All chapter S 320.1 319.8 457.4 459.3 110.2 109.6 132.4 132.5 45.3 40.4 72.1 61.3 All chapter K 76.7 79.1 275.2 286.2 35.9 48.5 104.4 153.5 66.4 49.4 294.4 208.1

Diabetes Prevalence All non standardised data 250 Rates per 1000 200 150 100 50 Belgium UK Bham UK Nottm Netherlands France Spain Italy Denmark Malta 0 0-4 5-14 15-24 25-44 45-64 65-74 75+ Age Bands

All Dr Assessed Mental Illness Prevalence non standardised data 350 300 Rate per 1000 250 200 150 100 Belgium UK Bham Netherlands France Spain Denmark 50 0 0-4 5-14 15-24 25-44 45-64 65-74 75+ Age Bands

The Netherlands Malta Serbia Incidence Prevalence Incidence Prevalence Incidence Prevalence Diagnosis Rate Standardised Rate Standardised Rate Standardised Rate Standardised Rate Standardised Rate Standardised All chapter P component 7 21.0 21.3 69.6 70.7 12.2 13.5 42.5 51.5 23.3 18.3 81.0 61.5 All chapter P 80.5 81.4 206.4 210.5 31.0 34.0 95.6 110.6 38.7 32.2 113.3 88.0

The Netherlands Malta Serbia Incidence Prevalence Incidence Prevalence Incidence Prevalence Diagnosis Rate Standardised Rate Standardised Rate Standardised Rate Standardised Rate Standardised Rate Standardised All chapter P component 7 21.0 21.3 69.6 70.7 12.2 13.5 42.5 51.5 23.3 18.3 81.0 61.5 All chapter P 80.5 81.4 206.4 210.5 31.0 34.0 95.6 110.6 38.7 32.2 113.3 88.0 70.7 p 1000 py (Nl) 51.5 p 1000 py (Mt) 61.5 p 1000 py (Sb)

More direct impact on patient care than epidemiology of disease Information on how I am doing Possibility to close the audit cycle and implement change in my practice

Follow up of asthma patients in my practice

Audit of referrals in my practice

Note: component 1 refers to symptom diagnoses (e.g. Back pain ), component 7 refers to disease labels (e.g. Sciatica ) ICPC Chapters: A general; B - blood, immune system; D digestive; F eye; H - ear (hearing); K circulatory; L musculoskeletal; N neurological; P psychological; R respiratory; S skin; T - metabolic, endocrine; U urological; W - women s health, pregnancy, family planning; X - female genital; Y - male genital; Z - social problems.

Audit of prescribing for diabetes in family medicine in Malta

Label Total 0-4 5-1415-2425-44 45-64 65-74 75+ 1 Glibenclamide 5mg tablet 5250 0 0 0 150 2708 1185 1208 2 Metformine 500mg tablet 4506 0 0 4 322 2265 1406 509 3 Gliclazide 80mg tablet mga 2784 0 0 0 30 915 706 1132 4 Zinkinsuline krist 100ie/ml 2625 0 0 0 375 1625 375 250 5 Glibenclamide 2,5mg tablet 848 0 0 0 19 169 585 75 6 Metformine 850mg tablet 382 0 0 0 76 38 230 38 7 Insuline gew 100ie/ml injvl 356 0 0 19 112 112 112 0 8 Insuline isofaan 100ie/ml 344 0 0 19 0 0 325 0 9 Insuline gew+iso 30/70ie/ml 206 0 0 0 19 131 38 19 10 Insuline gew+iso 10/90ie/ml 206 0 0 0 19 112 56 19 11 Zinkinsuline comb 30/70 inj 200 0 0 0 0 0 0 200 12 Glimepiride 2mg tablet 180 0 0 0 0 0 0 180 13 Acetylsalicylzuur 100mg tab 120 0 0 0 0 60 30 30 14 Fluvastatine 20mg capsule 105 0 0 0 0 105 0 0 15 Glimepiride 1mg tablet 105 0 0 0 0 90 0 15 16 Insuline gew 100ie/ml injvl 100 0 0 0 0 0 0 100 17 Glimepiride 4mg tablet 60 0 0 0 0 0 0 60 18 Glipizide 5mg tablet 45 0 0 0 0 45 0 0 19 Isosorbidedinitr 5mg tablet 45 0 0 0 0 45 0 0 20 Perindopril 4mg tablet 30 0 0 0 0 30 0 0 Total 18587 0 0 42 1122 8488 5054 3881

A study of the diagnosis of diabetes in Malta

The likelihood ratio (LR) summarises the operating characteristics of a diagnostic test It is the amount by which the test updates the prior probability, and reflects the utility of a diagnostic test (Post Prob = Prior Prob X LR) A likelihood ratio of greater than 1 indicates that the test is associated with the presence of the disease, whilst a likelihood ratio of less than 1 indicates that the test result is associated with the absence of the disease Knottnerus JA, Buntinx F (Ed.). (2009). The evidence base of clinical diagnosis. Theory and methods of diagnostic research. 2 nd Edition. Oxford, UK: John Wiley & Sons Ltd. Guyatt and Rennie. (2002). Users' Guides to the Medical Literature: A Manual for Evidence-Based Clinical Practice. USA: American Medical Association

Reason for encounter (* significant) LR+ (95% CI) Malta LR- (95% CI) Malta LR+ (95% CI) Dutch LR- (95% CI) Dutch U02 (Urinary frequency) 6.55 0.95 2.99 0.98 (2.99-14.33)* (0.90-1.00) (1.96-4.57)* (0.97-0.99)* T90 (Diabetes type II) T01 (Excessive thirst) (156.56-4057.38)* 797 0.95 543.58 0.86 (0.90-0.99)* (392.09-753.61)* (0.83-0.88)* 136.63 0.97 107.26 0.85 (35.87-520.5)* (0.93-1.00) (86.37-133.19)* (0.83-0.88)* T08 (Weight loss) 19.62 0.96 11.00 0.97 (7.29-52.77)* (0.92-1.00) (7.43-16.28)* (0.95-0.98)* A91 (Abnormal result inv.) A04 (Weakness/ tiredness) 49.05 0.98 7.83 1.00 (11.22- (0.95-1.01) (2.49-24.57)* (0.99-1.00) 214.39)* 0.32 1.02 1.00 1.00 (0.04-2.22) (1.00-1.05) (0.74-1.37) (0.98-1.02)

Patient suspects he/she has diabetes Excessive thirst Abnormal results of investigations Weight loss Urinary frequency Not tiredness! Soler JK, Okkes IM. 2005. Diagnosis of diabetes mellitus in Malta. The contribution of patients reasons for encounter and doctors interventions to the final diagnosis of diabetes. Poster presentation. EGPRN meeting, Tartu, Estonia. www.egprn.org

The likelihood of a diagnosis in a new episode of care for cough

A strong, reliable predictor for the diagnoses: Cough, acute bronchitis, URTI, acute laryngitis/tracheitis Less strong, but reliable predictor of the diagnoses: Sinusitis, pneumonia, influenza, other viral diseases (NOS), whooping cough The absence of cough (as a symptom) is a moderately strong and reliable predictor to exclude the diagnoses: cough, acute bronchitis and tracheitis Its presence allows strong, reliable exclusion of the diagnoses: gastroenteritis, no disease and health promotion/prevention, and less strong exclusion of the diagnosis adverse effects of medication. There is less reliable evidence that cough supports making the diagnosis of COPD, and supports the exclusion of fever and muscle pain as a diagnosis

Organised information in record Decision support systems Practice management Easy audit

Image to come

This study would not have been possible without the participation of the Transition Project doctors. From the Netherlands: C. van Boven MD, PhD, Franeker; P.H. Dijksterhuis MD, PhD, Wirdum and Olst; A. Groen, MD, Amstelveen; J. de Haan, MD, Franeker; A.M.Honselaar- De Groot MD, Amstelveen; D. Janssen MD, Franeker; T.A.L. Polman MD, Franeker; G.O. Polderman MD, Amstelveen; K.E.I. Stolp MD, Amstelveen; N. Valken MD, Wirdum; M.T.M. Veltman MD, PhD (deceased), Amstelveen; M. Woerdeman MD, Amstelveen. From Malta: Francis Paul Calleja MD, Birkirkara; Carmen Sammut MD, Siggiewi; Mario R Sammut MD MSc, Siggiewi; Daniel Sammut MD, Zabbar; David Sammut MD, Zabbar; Jason Bonnici MD, Zabbar; John Buhagiar MD, Zabbar; Andrew Baldacchino MD, Zabbar. From Serbia: the FDs in the region of Kraljevo, part of the ICRC project.