Gaps in Merit Based Incentive Payment system measures may reduce its impact on marginalized populations
Eggleton, K., Liaw, W., & Bazemore, A. (2017). Gaps in Merit Based Incentive Payment System Measures May Reduce its Impact on Marginalized Populations. Ann Fam Med, 15(3), 255-7. doi: 10.1370/afm.2075
As the United States enters a new era of value-based payment heavy in emphasis on primary care measurement, careful examination of selected measures and their potential impact on outcomes and vulnerable populations is essential. Applying a theoretical model of health care quality as a coding matrix, we used a directed content analysis approach to categorize individual Merit Based Incentive Payment System (MIPS) measures. We found that most MIPS measures related to aspects of clinical effectiveness, whereas few, if any, related to aspects of access, patient experience, or interpersonal care. These gaps suggest that MIPS may fail to measure the broader aspects of health care quality and even risk worsening existing disparities
Measuring access to routine appointments in general practice.
Our study aims were to determine appointment availability and establish the feasibility of measuring appointment availability through an automated process. An automated electronic query was created, run through a third party software programme, that interrogated Northland general practice patient management systems. The time to third next available appointment (TNAA) was calculated for each general practitioner (GP) and a mean calculated for each practice and across the region. The mean TNAA was 2.5 days. There was a significant relationship between TNAA and increasing number of walk-in clinics. The TNAA of 2.5 days indicates the possibility that routine appointments are constrained in Northland. However, TNAA may not give a reliable measure of urgent appointment availability and the measure needs to be interpreted by taking into account practice characteristics. Walk-in clinics, although increasing the availability of urgent appointments, may lead to more pressure on routine appointments.
Measuring Harm in Primary Care - a Methodology Paper
Dovey SM, Leitch S, Wallis KA, Eggleton KS, Cunningham WK, Williamson MI, . . . Hall JE. (2017). Epidemiology of patient harms in New Zealand: Protocol of a general practice records review study. JMIR Res Protoc, 6(1), 1-11. doi:10.2196/resprot.6696
Knowing where and why harm occurs in general practice will assist patients, doctors, and others in making informed decisions about the risks and benefits of treatment options. Research to date has been unable to verify the safety of primary health care and epidemiological research about patient harms in general practice is now a top priority for advancing health systems safety. We aim to study the incidence, distribution, severity, and preventability of the harms patients experience due to their health care, from the whole-of-health-system lens afforded by electronic general practice patient records. In this paper we discuss the data collection, sampling methods, sampling weights, power analysis and statistical approach of this complex study.
Exploring experiences of general practice waiting rooms through elicited drawings
Eggleton, K., Kearns, R., & Neuwelt, P. M. (2016). Being patient, being vulnerable: exploring experiences of general practice waiting rooms through elicited drawings. Social & Cultural Geography, 1-23. doi:10.1080/14649365.2016.1228114
This article describes a study using participatory visual methodology, in which participants were invited to create drawings to explore their experiences as patients in general practice waiting rooms, and interacting with receptionists. I used a traditional meeting protocol (hui process) as a process for trust building with the participants; most were Māori. As well as explaining the research, the preamble to the interviews also involved making family connections, gift giving and a mutual sharing of ideas. Elicited drawings provided the framework for conversational interviews. Colour, materials, symbols and metaphors were jointly explored through a process of shared analysis of images created. Through this process, participants reflected on, and conceptualised, ideas that addressed disempowerment, discrimination and racism.
Run Charts for Cardiovascular Risk Assessment
Wells, S., Rafter, N., Eggleton, K., Turner, C., Huang, Y., & Bullen, C. (2016). Using run charts for cardiovascular disease risk assessments in general practice. Journal of Primary Health Care, 8(2), 172-178. doi:10.1071/HC15030
Run charts are a quality improvement tool. Within this non-randomised observational study run charts were used to support team processes in reaching CVD risk assessment targets. The study showed that although run charts were easy to use and valued by staff, they did not make a difference in increasing assessment rates. This was likely due to national targets driving performance at the time of the study.
The reliability of mini-CEX assessments for medical students in general practice
Eggleton, K., Goodyear-Smith, F., Paton, L., Falloon, K., Wong, C., Lack, L., … Moyes, S. (2016). Reliability of mini-CEX assessment of medical students in general practice clinical attachments. Family Medicine, 48(8), 624–630.
A Mini Clinical Evaluation eXercise (mini-CEX) involves observation of routine clinical encounters, initially developed to assess clinical competencies of postgraduate doctors. This study aimed to measure its inter-rater reliability in assessment of medical students in general practice settings. What we found was that the mini-CEX provided a reliable measure of students performance. However, they may be less reliable in identifying exceptional performance or weaknesses in individual competencies.
A psychometric evaluation of the University of Auckland General Practice Reports of Educational Environment: UAGREE
Eggleton, K., Goodyear-Smith, F., Henning, M., Jones, R., & Shulruf, B. (2016). A psychometric evaluation of the University of Auckland General Practice Report of Educational Environment: UAGREE. Educ Prim Care, 1-8. doi:10.1080/14739879.2016.1268934
The aim of this study was to develop an instrument (University of Auckland General Practice Report of Educational Environment: UAGREE) with robust psychometric properties that measured the educational environment of undergraduate primary care. The questions were designed to incorporate measurements of the teaching of cultural competence. UAGREE is a specific instrument measuring the undergraduate primary care educational environment. Its questions fit within established theoretical educational environment frameworks and the incorporation of cultural competence questions reflects the importance of teaching cultural competence within medicine. The psychometric properties of UAGREE suggest that it is a reliable and valid measure of the primary care education environment.
Using triggers in primary care patient records
Using triggers to identify adverse events is proposed as an efficient means of consistently measuring, and tracking events that result in harm to patients. We aimed to test whether using triggers in a large provincial general practice could provide meaningful directions for improving safety. A literature review identified potential triggers and established the number of patients whose records we should review. Two teams independently reviewed 170 randomly selected patients’ records for trigger presence and for evidence of harm relating to that trigger. All triggers were tested for sensitivity and specificity: triggers with low specificity were removed. Logistic regression was used on both initial and refined trigger sets to measure the odds ratio (OR) of harm occurring if a trigger was present. The results indicate that 8 selected triggers are a useful way of measuring progress towards safer care for patients in primary care practice.
Primary care management of group A streptococcal pharyngitis
The aim of this study was to assess adherence by general practitioners and school-based sore throat programmes to national guidelines for the management of GAS pharyngitis in Northland. Laboratory and pharmaceutical data were obtained for children and young people aged 3-20 years who had GAS positive throat swabs in Northland laboratory services between 1 April and 31 July 2012. One in five of those children presenting to general practice with a positive throat swab and complete prescription data did not receive treatment according to national guidelines, while appropriate treatment was offered to more than 98% of children accessing school-based programmes. A significant proportion of those seen in general practice received antibiotics not recommended by guidelines, an inadequate length of treatment or no prescription. There is room for improvement in general practice management of GAS pharyngitis in Northland. School-based management of sore throat provides high-quality management for children at high risk of rheumatic fever.
Systematic care to reduce ethnic disparities in diabetes care
Kenealy, T. W., Eggleton, K., Robinson, E. M., & Sheridan, N. F. (2010). Systematic care to reduce ethnic disparities in diabetes care. Diabetes Research and Clinical Practice, 89(3), 256-261. doi:10.1016/j.diabres.2010.05.003
We sought to determine whether systematic care can reduce the gap in diabetes control between Maori and non-Maori. A Primary Health Organisation implemented a chronic care management programme for diabetes in 2005. The data constitute an open, prospective cohort followed for approximately two years. Maori started with higher HbA1c (mean 8.1%, SD 1.9) than non-Maori (7.1%, SD 1.4) but over about 2 years HbA1c for Maori improved to that of non-Maori. Improved glucose in Maori was not due to starting insulin or metformin, and rates of sulphonylurea prescription increased in both groups. Likely essential components of the programme were that governance was equally shared between Maori and non-Maori; prolonged nurse consultations were free to the patient; nurses used a formal written wellness plan; nurses were formally trained to support patient self-management; and a computer template supported structured care.