Barriers to “appropriate care” in general practice

The CareTrack study reported by Runciman and colleagues in this issue of the Journal raises serious concerns about the delivery of appropriate health care in Australia.1 Yet we have some of the strongest benchmarks internationally,2 and Australia is one of the world’s healthiest countries.3 How can this hold true?

The CareTrack study founders on its choice of clinical indicators. Of the 522 indicators included, 380 (73%) were based on consensus or expert opinion, with only 76 (15%) having National Health and Medical Research Council grades of recommendation of A or B. That is, only 15% had a “body of evidence [that] can be trusted to guide practice”.4 This is disappointing and calls strongly into question any interpretation of the authors’ finding that adult Australians in their sample received appropriate care at 57% of eligible health care encounters.1

Validity and reliability of clinical practice guidelines are key problems for general practice. Most guidelines are based on evidence not tested in primary care and are rarely prioritised according to the degree to which they improve health. Should every patient who presents with an acute exacerbation of chronic obstructive pulmonary disease receive a chest x-ray and blood gas analysis, as the CareTrack indicators require? Are these actions more important than giving antibiotics?

However, much work has been done on clinical practice guidelines and clinical audit tools for use in general practice in Australia. No single group of indicators will encompass the range of conditions managed in general practice, but a small, manageable group of indicators that covers common presentations, national priorities and community concerns has been established by the Royal Australian College of General Practitioners.5 A supporting information technology tool — the Clinical Audit Tool (PEN Computer Systems, Sydney, NSW) — can be used to implement use of the indicators.6 Additionally, support for health care evaluation efforts is available from the Improvement Foundation, an independent body that uses quality improvement techniques such as the “Collaborative methodology”.7

Guidelines are useful, but the skill lies in implementing the critical elements and options that suit individual patient needs. General practitioners have learnt to take the path of evidence-based medicine, which allows the integration of the best available evidence (clinical practice guidelines) with clinical expertise and patient values. This helps to explain the “paradox of primary care” — where GPs supposedly deliver suboptimal care when assessed against clinical practice guidelines, yet produce superior health outcomes at a population level.8

Aside from the difficulty of how to actually measure care, the problem remains that GPs and patients are regularly exposed to factors that create barriers to appropriate care. Examples of these include:

• Lack of guidelines regarding the complex management of multimorbidity.9

• The pervasive involvement of drug companies in every aspect of practice, from drug trials and education of health practitioners to providing patient support programs — their influence on both doctor and patient decisions is well known.10

• The elevation of non-evidence-based crafts to registration status — this has given credibility where none is justified, resulting in mixed health messages being delivered to the public (eg, the antivaccination lobby, the increasing use of non-evidence-based complementary medicines, and chiropractic involvement in child care).

• Disputes about evidence among learned bodies — for example, advice provided about prostate screening differs widely, despite screening not being supported in independent preventive health guidelines.11

The funding mechanisms of the Australian health system are also not always conducive to appropriate care. For example, the Medicare Benefits Schedule only provides remuneration for a practitioner conducting diabetes screening using the Australian type 2 diabetes risk assessment tool (AUSDRISK) if the screen is positive — both a disincentive to screen and an incentive to overdiagnose. Also, in providing health solutions, it is easier to facilitate patient access to drugs rather than to physical or psychological therapies. The management of chronic pain and alcohol dependence is biased by this. The promotion of pharmacist-led medication review as a quality audit, where evidence consistently reveals no benefit,12 is another example.

Providing systematic responses to remove these barriers is difficult. However, Runciman and colleagues’ call for routine monitoring of care at the facility level, outlined in another article in this issue of the Journal,13 should be supported. It will be necessary to use more creative methods of quality evaluation than those they propose. Benchmarking with clinical practice guidelines is useful, although inadequate to fully evaluate the role, scope and function of general practice.14 It will also be important to maintain privacy and confidentiality of audit data, to overcome GPs’ concerns regarding use of their data.15

Clinical governance at practice level is currently underdeveloped in Australia. If Australia is to continue as one of the healthiest countries, it is imperative that general practices acquire ongoing resourcing to support clinical governance for appropriate evaluation of care. The physical environment of general practice is already tightly regulated through accreditation; consideration now needs to be given to valuing assessment of the quality of care provided.

I support Runciman and colleagues’ proposal for routine monitoring of care in all health facilities. For general practice, the challenge is to build on the work already done and to develop resourcing mechanisms that promote and build quality without perversity, do not restrict patient choice and do not increase administrative burden.