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