Primary care quality improvement: Is data the future?

Family doctors are being offered personalized reports that identify gaps in the quality of care they provide, from cancer screening to diabetes management. But can data really drive better performance?

Alberta’s Chinook Primary Care Network serves more than 170,000 residents, bringing together health-care groups that include 140 physicians, as well as nurse practitioners and dietitians. But it also includes some more surprising positions: a director of evaluation, three senior quality analysts, and an information management lead. What kind of group needs five full-time data analysts? One that believes in the importance of regular feedback and metrics. The primary care network (PCN) has been measuring performance indicators for a decade, and it offers customized reports on demand to its physician leadership board as well as individual doctors. For example, knowing that diabetes increases the risk of cardiovascular disease, they often look at how many diabetes patients are on a statin. They further break that information down by age, sex, BMI and tobacco use. And they can track how often diabetes patients are seeing their care providers – including who hasn’t been seen within the past year, and might need to be called in for an appointment. (Click here to see a sample report.) “One doctor who had just taken over another doctor’s panel of patients asked me, ‘Proportionally, how many of my diabetic patients are on a statin?’ I said about 40%, and he was really alarmed,” says Charles Cook, director of evaluation at the PCN. “This allows us to provide that bird’s eye view.” This kind of data-driven analysis is now available to family doctors in both Ontario and Alberta province-wide. Known as audit and feedback, it offers doctors – and teams of doctors – the chance to have their information analyzed and submitted to them as a report. (Such reports have also been used in Canadian hospitals, but this article focuses on its use in primary care teams.) Audit and feedback compares their performance on key indicators, like the use of lab tests or of cancer screening against those of other practitioners in the region. For now, those reports are most often presented quarterly or once a year. But we’re moving towards faster feedback. Some health care workers in the Chinook network can access current reports on a private website, which will evolve into a continually updating hub – like a Google Analytics page for clinical care. “Our plan over the next couple years is to get it as close to real time as we can,” says Cook. The idea of audits doesn’t resonate with everyone, however. A 2011 mixed-methods study looked at how seven Ontario family health teams responded to having their performance measured. It found that, on the whole, physicians were supportive of the idea, but some also had concerns. “It can be threatening to someone who has done stuff the same way for 25 years, to be told that people can measure this now and they can tell you whether you are effective or not, and their records are completely accessible for analysis,” one physician told the researchers. “Some doctors who haven’t used this before are anxious about having people looking at their data – or are even anxious about looking at their own data,” echoes Lara Cooke, associate dean of Continuing Medical Education and Professional Development at the University of Calgary and co-leader of the Alberta Physician Learning Program. “It’s a culture shift.” The effectiveness of audits also varies greatly with the quality of implementation – with poorly executed audit and feedback having no impact at all on quality. And of course, it’s not possible to measure everything that’s important. “There are limitations,” says Noah Ivers, a family physician and scientist focusing on quality in primary care. “But there is also incredible potential.”

Alberta and Ontario’s data-driven primary care improvements

Audit and feedback systems are seen as a way to ensure more accountability and to shape continuing professional development. Worldwide, it has been tied to public accountability and physicians’ pay, but in Canada, many audit and feedback programs are framed as part of quality improvement and professional development, and therefore are voluntary and not publicly available. Alberta offers multiple audit and feedback programs, including the Physician Learning Program (PLP). The PLP is “basically thought of as a service to the members of the [Alberta Medical Association],” says Cooke. It offers tailored reports – a key component of successful audit and feedback, in addition to providing general reports. “Doctors or groups of doctors might come to us with questions about some specific clinical thing – how are we doing with management of condition X – and we sit down with them and figure out how to tailor the report to them,” she says.

“None of us is terribly good at knowing what our actual performance is…but the data tells the tale, and brings out the gaps.”

Last year, they created 300 reports across the province, which combine charts and data with structured feedback, including looking at evidence-based guidelines and identifying barriers to success. In primary care, she says, they’ve often focused on Choosing Wisely recommendations, such as increasing the likelihood these recommendations are followed for cervical cancer screening. They follow up with another audit on the same data six months or a year later, so doctors can see their progress. And they’re working with other groups on a “dashboard” model that would update key figures in real time. Ontario also has a handful of organizations working on primary care audit and feedback, including Health Quality Ontario’s Primary Care Practice Reports. Since its launch in 2014, hundreds of doctors, Family Health Teams and Community Health Centres have volunteered to have their practice analyzed.