International Journal for Quality in Health Care 14:340-341 (2002)
© 2002 International Society for Quality in Health Care
Book Review |
Quality indicators for general practice: A practical guide for health professionals and managers. Edited by Martin Marshall, Stephen Campbell, Jenny Hacker and Martin Roland
Edited by Martin Marshall, Stephen Campbell, Jenny Hacker and Martin Roland
Published in 2002 by Royal Society of Medicine Press Ltd, London, UK. ISBN 1-85315-488-1; Price £19.50.
Quality indicators for general practice: A practical guide for health professionals and managers is a practical book. It briefly overviews a process for developing quality indicators relevant to British general practice, and then presents indicators for 19 common clinical conditions. A final chapter discusses the possible uses (and avoidance of misuses) of the indicators. This edited text will be of great use to clinicians working in British general practice, as well as managers, clinical governance leaders, and others working to improve the quality of primary care. Because it is the result of a binational collaboration, the process and results of the indicator development work will also be useful to those interested in improving the quality of generalist practice in other countries, including the US.
The book is part of a larger initiative on quality of care, and is one outcome of collaboration between the Nuffield Trust in the UK and the RAND Corporation in the US. This collaboration involved building on some of the methodological work already accomplished by RAND, but moving forward with a process that assured relevance to British general practice.
The opening chapter puts quality indicators into the context of a growing international focus on quality assessment and improvement. This chapter outlines the benefits and pitfalls of using quality indicators. The use of brief clinical examples and tables to encapsulate the main points is quite effective in concisely conveying the important points. An understanding of the limited but important role of quality indicators is particularly important to understanding what follows.
The next chapter overviews the process used to create the quality indicator sets that form the rest of the book. This approach began with the selection of 19 conditions that were found to be common in UK general practice based on the most recent National Morbidity Survey, and that had previously been reviewed as part of the RAND project. These conditions represent much of the bread and butter of general practice in the UK and elsewhere. Next, limited literature reviews were performed, with an emphasis on evidence felt to be directly relevant to general practice in the UK. Reviewers then developed a preliminary set of quality indicators for each condition, based on ’the evidence, national guidelines and professional statements’. Who these ’reviewers’ were is never specified.
A panel of experts was selected to rate the preliminary indicators. The selection of reviewers who were Fellows by Assessment of the Royal College of General Practitioners gives credibility to the process by assuring that the raters were both grounded in the realities of practice and likely to be highly knowledgeable about what constitutes quality in general practice. Two panels rated each preliminary indicator for the conditions assigned to their panel, indicating both the validity and degree to which each item was felt to be important to include in the medical record. The results of these ratings were fed back to the panelists in a face-to-face meeting, during which each panel member re-rated each indicator after participating in a discussion that particularly focused on indicators with wide variation in initial ratings. Indicators that survived this process with ratings of greater than seven (out of nine) for validity, and greater than six for necessity to record, were included in the final indicator set. Out of 435 indicators considered, 229 were rated as valid measures of quality. The percentage of indicators rated as valid varied widely, from 86% for asthma to 14% for acute low back pain.
Thus, the procedure used to develop the indicators was an expert consensus process. It began with the scientific literature and previous indicator development work by RAND, but relied on the judgment of local experts to identify indicators that were both valid and clinically necessary. The use of a panel of experts whose primary expertise is in general practice results in a different flavor for these indicator conditions, compared with similar processes that are typically conducted with experts in the specific disease. The resulting indicators, while limited by the available scientific evidence and measurement and service availability considerations, have a more pragmatic feel to them than indicators developed by similar processes using disease content experts rather than general practice experts.
The indicator conditions discussed in the next 19 chapters will thus feel a bit more practical to the general practitioner than indicators from other groups. Readers from other countries and disease-specialized fields may gain insights from reading the chapters on specific indicators as a window into general practice in the UK. As the authors and editors note, however, these indicators often represent areas for which good scientific evidence and practical measures are available. These are not necessarily the most important areas to consider in caring for patients with particular conditions. Thus, for a number of conditions, the indicators seem strangely irrelevant to where most of the effort goes in providing quality care. The indicators for acne, acute back pain and allergic rhinitis, for example, seem to be valid screens for care that is clearly bad, but do not reflect the most important aspects of good care. This is not a criticism of those who created these indicators, but of the availability of relevant markers and scientific evidence for these conditions.
The clinical indicators for these 19 common clinical conditions are presented by a distinguished group of academic generalists. The recommended indicators are clearly summarized in a table at the end of each chapter. Even more useful for the clinician reader is each chapter’s review of the evidence relating to the indicator set. The reference to data sources used in each review and the list of both published and online references will be helpful to those who wish to delve a bit more deeply into the topic.
One striking point for the US reader is the number of indicators that begin with the need for a practice registry of patients with the condition. Such a registry is more easily defined for British general practices than for US primary care practices, where the lack of a defined panel of patients for most clinicians shows a major shortcoming of the US health care ’system’ [1].
The final chapter by Martin Roland, on how to use the indicators, is important. The sections on using the indicators in individual practices and in primary care organizations both contain references to useful online resources. Moreover, this chapter, like the two introductory chapters by the other editors, contains useful caveats that will keep the overzealous reader from asking the indicators to be more than they are.
This pragmatic, succinct, and easy-to-read book will find wide use among British general practices, clinical governance leaders, and managers of primary care organizations working to measure and improve the quality of care. The process used by the editors, authors, and their colleagues is a model for a process of developing locally relevant clinical indicators. Finally, the actual indicators developed from this process can provide insights to those in other health care systems and settings, if they are understood as a reflection of the overlap between available scientific evidence, measurable components of care, and insights of general practitioners caring for patients with common conditions.
For a commentary on the relevance of disease-specific measures to primary care practice, see the Editorial in this issue of the Journal.
Kurt C. Stange
Case Western Reserve University
Cleveland, OH, USA
REFERENCES
- Stange KC. The best of times and worst of times. Br J Gen Pract 2001; 51: 963–966.[Medline]
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