Measuring Quality in Primary Healthcare – Opportunities and Weaknesses

Abstract

The easy access to data from electronic patient records has made using this type of data in pay-for-performance systems increasingly common. General practitioners (GPs) throughout Europe oppose this for several reasons. Not all data can be used to derive good quality indicators and quality indicators can’t reflect the broad scope of primary care. Qualities like person-centred care and continuity are particularly difficult to measure. The indicators urge doctors and nurses to spend too much time on the registration and administration of required data. However, quality indicators can be very useful as starting points for discussions about quality in primary care, with the purpose being to initiate, stimulate and support local improvement work. This led to The European Society for Quality and Patient Safety in General Practice (EQuiP) feeling the urge to clarify the different aspects of quality indicators by updating their statement on measuring quality in Primary Care. The statement has been endorsed by the Wonca Europe Council in 2018.

1. Introduction

High quality primary care is essential for all stakeholders, e.g. patients, professionals and local and national healthcare authorities. The relatively easy access to data from electronic patient records, which can be combined with information collected from other sources, has made it common to use this type of data both for professional quality improvement and for payment systems like pay-for-performance (1).

In recent years, the use of quality indicators in pay-for-performance systems has increased (2, 3). General practitioners (GPs) throughout Europe oppose the use of quality indicators for pay-for-performance, since the core competences of GP care, like person-centred care, continuity of care or safe prescribing cannot be measured easily. Furthermore, the focus on indicators leads physicians and nurses to spend a substantial part of their time on registration and administration, instead of on the care for patients (4).

In response to this, the European Society for Quality and Patient Safety in General Practice/Family Medicine (EQuiP) decided to clarify the different aspects of quality indicators by developing a statement on measuring quality (5).

2. Main principles on measuring quality in primary healthcare

The following principles concerning measurements of quality in primary healthcare should be taken into account when working with quality indicators: privacy and confidentiality, limitations of quality indicators, quality indicators as a useful tool for quality improvement, and administrative use.

2.1. Privacy and Confidentiality

Personal health data from patient records should always be used in a way that guarantees patients’ privacy and confidentiality in the doctor-patient relationship (6).

2.2. Quality Indicators Have Limitations

Quality indicators reflect simplified measurable dimensions of more complex phenomena. Many of the goals and values in primary care can’t be measured, e.g. ethics and humanism in consultations or if priorities are set right in everyday practice. Quality indicators are useful as starting points for discussions about complex reality as part of a process to initiate, stimulate and support local improvement work.

2.3. Quality Indicators Are Useful Tools for Quality Improvement

Primary care quality depends on each employee’s competence, responsibility, initiative and sense of context. It is therefore important to support internal drivers for improvement. Quality development must be an integrated part of all primary care. GPs are urged to monitor systematically the quality of their own and their team’s work as well as their working environment. The measurements should cover the different aspects of quality, e.g. patient centeredness, access to, equity in and content of care, process and clinical outcome measurements and work satisfaction of physicians and other personnel. Drilling down to individual patients for acting on care gaps should be possible for the GPs caring for the patients in the target population (7).

Comparisons with other primary care settings (benchmarking) can be useful, e.g. by using national quality indicators. Peer group education using benchmark data is a strong educational tool that enables for the discussion of outcomes in their own context between professionals. These comparisons can form the basis for a deeper analysis of reasons for differences in working methods and resource use.

Electronic health records should be developed so that it is easy to extract data for quality work on a local basis or, preferably, electronic health records and quality measurement tools should be integrated.

2.4. Administrative Use of Quality Indicators

Results of quality indicators should not be used as a basis for payment. Payment for quality (payment for performance) has not shown to be beneficial to patients. When payments are made for some aspects of the healthcare, these will be in focus, while other aspects than the measured tend to be ignored while internal motivation for good quality is declining (8).

External reporting should be performed in a way that does not identify individuals, i.e. in an aggregated form. External quality measurements should be limited to a reasonable number of indicators and should concentrate on the aspects of care that contribute most to better and safer patient care.

Data collection should not demand time, staff or financial investment beyond the benefits that may be attained in quality improvement and/or increased patient safety (9). Indicators that are used for any kind of external evaluation should be discussed and approved by health professionals before their use. Several confounding factors may impact more on results than quality in GP practices.

3. Conclusion

Quality indicators can be useful tools for quality improvement, e.g. in peer group education. However, when quality indicators are used to pay primary care providers in pay-for-performance systems, the limitations of indicators tend to end up in the foreground. Quality indicators only reflect simplified measurable dimensions of more complex phenomena. They can be useful as starting points for discussions about complex reality as part of a process to initiate, stimulate, educate and support local improvement work.